When to Refer Your Patient for a Liver Transplant and the Benefits of Living Donation

In a short period of time, transplantation has progressed from an experimental procedure to the standard of care for patients with end-stage organ failure. With the establishment of the country’s first liver transplant program in 1981, to performing our first adult living-donor liver transplant in 1999, to becoming one of the top and most experienced programs in the country for living donor transplants, physicians and researchers at UPMC have refined new therapies, giving hope to patients across the country and around the world.

Swaytha Ganesh, MD, is the medical director of the Living Donor Program at UPMC. She is renowned for her clinical expertise in treating a wide range of patients with liver disease with a specific interest in living-donor liver transplantation. Her areas of research include evaluating recipients and donors and assessing their ability for living donor surgery and developing disease management protocols in post-liver transplant patients with metabolic syndrome, hyperlipidemia, and systemic hypertension.

A miracle of modern medicine, liver transplantation is the only definitive treatment for patients with end-stage liver disease. The one-year survival rate following a liver transplant ranges from 87 to 93 percent with the five-year survival rate being more than 75 percent. Unfortunately, due to the growing transplant waiting list (Figure 1) and hesitations among referring physicians to refer patients for a living donor transplant, many patients have a 15 to 20 percent chance of succumbing to their disease before making it to transplant. 

Indications for a Liver Transplant 

A patient with liver disease and a high risk of decomposition is a candidate for a liver transplant. At UPMC, we are committed to providing liver transplant services to all patients who will benefit—even those with a low Model for End-Stage Liver Disease (MELD) score or complex cases who have been deemed high-risk and have been turned down for a transplant at another center. 

A candidate for liver transplant may suffer from: 

• Hepatitis C
• Hepatitis B
• Alcoholic liver disease
• Nonalcoholic steatohepatitis or fatty liver disease
• Primary liver cancers
• Primary biliary cirrhosis
• Autoimmune hepatitis
• Primary sclerosing cholangitis
• Acute liver disease from toxins including acetaminophen/Tylenol
• Alpha-1 Antitrypsin deficiency
• A failed prior liver transplant
• Polycystic disease
• Hemochromatosis
• Wilson’s disease

When to Refer for a Liver Transplant

Referral for a liver transplant should be initiated early, before the patient is too sick to be considered an appropriate candidate for transplantation. Early referral allows our team to address and resolve any pretransplant complications while the patient’s liver disease is relatively controlled.

General indications for when to refer include continued progress of the patient’s disease despite maximized medical therapies, development of a life-threatening complication such as hepatocellular carcinoma (HCC), or an increasingly unsatisfactory quality of life. 

The MELD score determines how urgently a patient requires a liver transplant based on the likelihood of death within a three-month period. A MELD score of 10 or higher is a clinical indication of liver dysfunction. Patients with higher MELD scores have worse short-term prognoses and are given higher priority for the next available deceased-donor liver. 

A patient’s MELD score is based on:

• Serum creatinine
• Bilirubin
• International normalized ratio (INR)

Living-Donor Liver Transplant for Patients With Low MELD Scores 

Certain diagnoses or conditions carry a higher risk of death than the patient’s MELD score may indicate. Some aspects concerning medical urgency for liver transplants are not accurately represented by a patient’s MELD score, and the current MELD allocation system greatly underestimates the risk of waiting list mortality. Ongoing symptoms of liver decomposition such as loss of weight and muscle mass and ascites in the chest and limbs can reduce a patient’s quality of life and, in some cases, may be life-threatening. 

While patients with a MELD score less than 15 are often not listed for a liver transplant because their chance of receiving a liver through traditional allocation is so low, a living-donor liver transplant offers a life-saving option and the opportunity to receive a transplant sooner. By exploring a living donor transplant, patients with a low MELD score who should still be considered for a living-donor liver transplant include those with:

• Hepatocellular carcinoma
• Ascites requiring periodic large-volume paracentesis
• Hepatic hydrothorax
• Cholangiocarcinoma
• Significant life-altering HSE
• Multiple admissions for HSE, ascites, or GI bleeding
• Patients with decompensated cirrhosis whose overall health is continuing to decline

Early access to a liver transplant allows patients to avoid the considerable burden of chronic liver disease, which, over time, can lead to deteriorating health, multiple medical interventions, and hospitalizations.

Partnering With Referring Physicians

Our understanding of the field of liver transplantation has allowed us to gain invaluable insight and experience in working with referring physicians. Throughout the transplant process, the referring physician remains an integral part of the patient’s care by:

• Identifying patients with end-stage liver disease who will benefit from transplantation.
• Timely referral of those patients to the transplantation center.
• Assisting in the coordination of specialists in pretransplant evaluation.
• Continuing to medically manage the patient’s care while he or she awaits transplantation.
• Collaborating with the transplant team in the long-term care and posttransplant care of the patient.

As an integral member of the patient care team, the referring physician will be continually updated about the patient’s progress by a member of the transplant team. Continuous interaction with the transplant team can range from in-person and telephone interactions to email communications or teleconference sessions for physicians located remotely.

About UPMC’s Liver Transplant Program 

One of the oldest and largest liver transplant programs in the country, UPMC has performed more than 6,000 adult liver transplants and more than 400 adult living-donor liver transplants. We believe that liver transplantation should be an option for any patient with end-stage liver disease who no longer experiences results with medical therapy. 

Additionally, UPMC works with hospitals that have an existing liver transplant program and want to provide patients the option of a living-donor liver transplant. When partnering with another hospital, UPMC provides pre- and postsurgery consultation and training for clinicians, while the surgery itself occurs at UPMC. 

For more information about our program and how to begin the referral process, visit UPMC.com/LiverTransplantReferral.