To determine the need for liver transplantation
1. Liver transplantation (II-3) should be recommended in patients with cirrhosis presenting with evidence of abnormal liver function [Child-Turcotte-Pugh classification ≥7 and Model for End-Stage Liver Disease score ≥10] or first serious complications (e.g., ascites, variceal bleeding, hepatic encephalopathy).
2. Liver transplantation should be recommended when children with chronic liver disease present with growth retardation or abnormal liver function or evidence of portal hypertension (II-3).
3. Patients with type I hepatorenal syndrome should be promptly scheduled for liver transplantation (II-3).
Seek alternative treatment methods.
4. For the treatment of chronic liver disease, each specific treatment option available should be considered: a. Liver transplantation (II-3) should be considered only when no effective alternative therapy is available or when treatment is ineffective. b. However, in patients who are critically ill and whose drug efficacy is uncertain, the patient should be evaluated for liver transplantation in conjunction with disease-specific therapy (III).
To determine the likelihood of successful liver transplantation
5. Patients who are chronic smokers, >50 years of age and have a history or family history of heart disease or diabetes should be evaluated for coronary artery disease (III).
6. In the above cases, dobutamine loading echocardiography is a valid screening test, but a positive result must be confirmed by cardiac catheterization (II-2).
Hepatopulmonary syndrome
7. Patients with sclerosis and hepatopulmonary syndrome have an extremely poor prognosis if they do not receive liver transplantation, so liver transplantation should be expedited and evaluated (II-2).
Portal pulmonary hypertension
8. All patients evaluated for liver transplantation should be screened for pulmonary hypertension (II-3).
9. Doppler ultrasound is an excellent screening method, but positive results must be confirmed by right heart catheterization (II-2).
10. In patients with severe pulmonary hypertension, liver transplantation should be considered only if the condition can be effectively controlled by medication (II-3).
Obesity and smoking
11. Pathological obesity should be considered as a contraindication to liver transplantation (II-3).
12. All patients being considered for liver transplantation should be encouraged to quit smoking (III).
Renal Failure
13. Renal insufficiency is an important predictor of renal failure and death after liver transplantation, so it is important to assess renal function comprehensively before transplantation (II-2).
14. Rapidly progressive hepatorenal syndrome (type I) has a poor prognosis and is often reversed after liver transplantation, so liver transplantation should be evaluated in such patients as soon as possible (II-3).
15. For some patients with chronic kidney and liver disease, combined liver and kidney transplantation can be considered (III).
Extrahepatic malignant tumors
16. Due to the different natural course and recurrence rates of different tumors, the transplantation specialist must consult the oncologist in detail before transplantation evaluation for patients with extrahepatic malignant tumors (III).
Osteoporosis
17. All patients with chronic liver disease should be screened for osteoporosis during the preoperative evaluation of liver transplantation (II-3).
18. For patients with significant bone loss, attempts should be made to increase bone density and prevent pathological fractures before and after liver transplantation (III).
Patients with HIV infection
19. Liver transplantation in HIV-infected patients requires a collaborative multidisciplinary team consisting of transplantation and HIV treatment specialists (III).
Surgical problems
20. Patients with visceral vascular occlusion or dysplasia should undergo careful anatomic evaluation prior to liver transplantation, as these lesions increase the risk of perioperative death and graft failure (II-3).
Psychosocial issues
21. Only patients who can meet reasonable expectations for compliance should be considered for inclusion on the waiting list (II-3).
22. However, when patients do not meet the criteria for liver transplantation, every effort should be made to provide patients with access to expert counseling and to treat conditions that may affect compliance with postoperative therapy (III).
23. Patients receiving methadone maintenance therapy who are not on medication may be good candidates for transplantation and should not be denied consideration for liver transplantation in these patients (II-2).
Specific Indications for Liver Transplantation for Chronic Hepatitis C
24. Liver transplantation should be considered for patients who have developed decompensated cirrhosis after chronic hepatitis C infection (II-3).
25. Antiviral therapy should be considered for patients who are ready to receive liver transplantation by experienced clinicians with close monitoring for adverse events (II-3).
26. Treatment of hepatitis C virus (HCV)-related disease after liver transplantation should be done with caution and under the supervision of a physician experienced in liver transplantation due to the increased risk of adverse events (II-2).
Chronic Hepatitis B
27, For patients with decompensated cirrhosis secondary to chronic hepatitis B, antiviral therapy should be considered in coordination with the transplant center (II-3).
28.Interferon alpha should not be used to treat patients with decompensated cirrhosis because of the risk of worsening liver disease (II-3).
29. The management of patients with hepatitis B virus (HBV) infection after liver transplantation should include antiviral therapy (II-3).
Autoimmune hepatitis
30.Liver transplantation should be considered for patients with decompensated autoimmune hepatitis who cannot tolerate drug therapy, or for whom drug therapy is ineffective (II-3).
31.Patients with autoimmune hepatitis may require more immunosuppressive agents than patients with other indications for liver transplantation because of the risk of disease recurrence and rejection after transplantation (II-3).
Alcoholic cirrhosis
32. Patients with alcoholic liver disease who are being considered for liver transplantation should be evaluated in detail by a health care professional experienced in treating addictive behaviors (III).
33. For alcoholics, liver transplantation should be considered after at least 3-6 months of abstinence to avoid unnecessary surgery for patients who do not need liver transplantation (II-2).
Primary biliary cirrhosis
34, For liver failure due to primary biliary cirrhosis, liver transplantation is the only effective treatment (II-2).
35. Patients with uncontrollable pruritus are, with appropriate selection, also indications for liver transplantation (III).
Primary sclerosing cholangitis
36.For decompensated cirrhosis due to primary sclerosing cholangitis, liver transplantation is the only effective treatment (II-2).
37.Liver transplantation should not be considered for patients with combined cholangiocarcinoma, unless a clinical trial is performed (II-3).
38. Given the high incidence of colon cancer, all patients with comorbid inflammatory bowel disease should receive regular colonoscopy before and after liver transplantation (II-3).
Cholestatic disease in children
39. Children with biliary atresia who have unsuccessful hepatoportal anastomosis or uncontrolled portal hypertension, or who develop liver failure despite successful hepatoportal anastomosis, may undergo liver transplantation after reasonable selection (III).
40. In children with syndromic or non-syndromic intrahepatic cholestasis, liver transplantation can significantly prolong survival and improve quality of life (by reducing pruritus), so liver transplantation should be considered (III).
41. Pre-operative evaluation should be performed in children with Alagille’s syndrome, as the combination of precordial disease is common (III).
42.Lung disease should be carefully evaluated for liver transplantation in patients with concomitant pancreatic cystic fibrosis (III).
α1 antitrypsin deficiency
43.For decompensated cirrhosis due to α1 antitrypsin deficiency, liver transplantation is the only effective treatment (II-3).
44. In patients with cirrhosis due to α1 antitrypsin deficiency, lung disease should be evaluated in detail prior to liver transplantation (although coexisting lung disease is uncommon) (III).
Wilson’s disease
45, Emergency liver transplantation is the only effective treatment for fulminant liver failure due to Wilson’s disease (II-3).
46. Chronic decompensated liver disease that has failed to respond to drug therapy is also an indication for liver transplantation (II-2).
47. Liver transplantation is not recommended as the treatment of choice for neurologic Wilson disease because most patients with this disease can remain stable with medically treated liver lesions, and the regression of liver disease after liver transplantation is not always good (III).
Non-alcoholic steatohepatitis and cryptogenic cirrhosis
48. Liver transplantation is an option for patients with decompensated cirrhosis due to nonalcoholic steatohepatitis (NASH). Post-transplantation therapy should include metabolic monitoring (III).
49. Selective liver transplantation in patients with decompensated cryptogenic cirrhosis, but these patients should be screened for metabolic dysregulation because of possible underlying NASH (III).
Hereditary hemochromatosis
50. All patients newly diagnosed with cirrhosis should be screened for hemochromatosis (by serologic testing), and genetic testing should be performed for those patients in whom the diagnosis cannot be confirmed (III).
51. Patients with hereditary hemochromatosis have a lower survival rate after liver transplantation than patients with other liver diseases. Pre-transplant cardiac evaluation is necessary due to the increased risk of cardiac complications (II-3).
52, These patients should undergo prior phlebectomy prior to transplantation (III).
Neonatal hemochromatosis
53, Liver transplantation is the only effective treatment for severe neonatal hemochromatosis, and urgent evaluation at the transplant center is recommended (II-3).
Tyrosinemia and glycogen accumulation disease
54. Children with tyrosinemia presenting with hepatocellular carcinoma (HCC) and meeting the criteria for HCC liver transplantation should be priority candidates (II-3).
55. Children with tyrosinemia and glycogen accumulation disease should be considered for liver transplantation (II-3) if they have failed to respond to drug therapy.
56. For liver transplant candidates, extrahepatic complications due to possible underlying disease must be taken into account (III).
Amyloidosis and hyperoxaluria
57, Liver transplantation should be considered for patients with amyloidosis in order to correct the underlying metabolic defect before end-stage organ damage occurs (II-3).
58. Liver transplantation is effective in patients with hyperoxaluria with or without concomitant renal transplantation, and therefore should be considered in patients with this disease (II-3).
Urea cycle and branched-chain amino acid disorders
59, Children with metabolic disorders resulting in significantly increased morbidity and mortality from progressive extrahepatic damage may be listed as an indication for liver transplantation if specific drug therapy or dietary modification is ineffective and if liver transplantation can reverse the enzyme deficiency and metabolic disorder (II-3).
60. Living liver transplantation should be considered only if the enzyme activity of the donor can satisfactorily reverse the enzyme deficiency in the recipient (III).
61.The degree of neurological impairment should be considered when selecting patients for liver transplantation (III).
Hepatocellular carcinoma
62.For patients with HCC who are not suitable for surgical resection and whose malignancy is confined to the liver, liver transplantation may be a treatment option (II-2).
63. The best outcome after liver transplantation is achieved in patients with a single lesion ≥2 cm but <5 cm, or no more than three lesions and the largest <3 cm, and no radiological evidence of extrahepatic metastasis (II-2).
64. To achieve a favorable prognosis, patients who meet the above criteria should receive transplantation within 6 months (II-2).
Hepatoblastoma
65. Liver transplantation should be considered for children with hepatoblastoma whose lesions are confined to the liver and cannot be resected (II-3).
Fibrous laminar-like HCC and hemangioendothelioma 66. Liver transplantation may be considered for patients with fibrous laminar-like HCC whose tumors are unresectable and without evidence of extrahepatic metastases (III).
67. Liver transplantation may be considered for patients with unresectable epithelioid hemangioendothelioma (III).
Cholangiocarcinoma
68.Liver transplantation in patients with cholangiocarcinoma should be limited to a limited number of medical centers with well-designed clinical trials (III).
Fulminant Liver Failure
69.Patients with fulminant liver failure should be recommended to the transplant center as soon as possible with a view to receiving close monitoring and treatment (III).
70.For patients with little chance of natural recovery, liver transplantation should be performed as soon as possible (II-3).
Other diseases
71.The need for liver transplantation in patients with Budd-Chiari syndrome should be individualized and alternative therapies should be considered due to the availability of multiple effective therapies (III).
72.For patients with metastatic neuroendocrine tumors, liver transplantation should be limited to those whose tumors cannot be resected and whose symptoms cannot be controlled with optimal drug therapy (III).
73. Patients with polycystic liver disease are occasionally an indication for liver transplantation (III).
Re-transplantation of liver
74. For patients whose first transplant has failed, retransplantation is the only way to prolong survival and improve overall survival. Re-transplantation should be used selectively for those who have failed first transplantation, hepatic artery thrombosis, severe rejection, or recurrent disease (II-3). However, compared with the first time, post-transplantation survival is decreased and costs are increased.
75. Re-transplantation of the liver should be performed before the patient develops severe liver and kidney failure (II-3).
76. Re-transplantation of the liver should be performed with caution in emergency situations and avoided in patients with a low chance of success (III).
Comment: Liver transplantation is the most effective, and sometimes the only effective, treatment for acute liver failure and end-stage liver disease. In recent years, the clinical technology of liver transplantation in China has progressed rapidly, and thousands of liver transplants are performed each year. With this comes the problem of how to address the shortage of donor organs and improve the long-term survival of liver transplant recipients. Although performing liver transplantation is primarily the task of surgeons, patient selection, preoperative evaluation, perioperative and long-term postoperative management are the joint responsibilities of hepatologists and clinicians from other related disciplines who are familiar with the specialty of liver transplantation.
In developed countries, such as Europe and the United States, where liver transplantation was carried out earlier, the management of liver transplantation-related medical problems is an important part of the training of hepatologists and one of the required knowledge and skills. This clinical guideline, published by the American Association for the Study of Liver Diseases, provides a detailed list of patient selection and preoperative evaluation tests for liver transplantation.
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