The indications for and timing of liver transplantation

Since the 1970s, there has been dramatic growth in the annual number of liv er transplants, with improving survival. We review indications for liver tr ansplantation for fulminant hepatic failure (FHF), cholestatic liver diseas e, and hepatocellular liver disease. A decreased factor V level appears to be a sensitive indicator of FHF requiring transplantation, with a factor V level of less than 20% (less than 30% for age greater than 30 years) sugges ted as the main indication in encephalopathic patients. The King's criteria are also useful for identifying patients with FHF who require transplantat ion. FHF from Wilson's disease is universally fatal without transplantation . Anp patient with FHF who is unlikely to recover spontaneously should be r eferred to a transplant center. In patients with primary biliary cirrhosis (PBC), the Mayo Clinic model is widely used to calculate a risk score (base d on age, bilirubin, albumin, prothrombin time, and edema). PBC patients wi th a rapidly rising Mayo risk score and/or a rising bilirubin should be lis ted for transplantation The Mayo Clinic survival model for primary sclerosi ng cholangitis is based on bilirubin, histological stage, age, and presence or absence of splenomegaly, but this model is limited by the emergence of recurrent bacterial cholangitis, dominant strictures, and cholangiocarcinom a. Patients with hepatitis C should be referred for transplantation upon on set of ascites, variceal bleeding, encephalopathy, and/or jaundice with dec reasing synthetic function. In patients with autoimmune hepatitis, prognost ic indicators that herald the need for transplantation include variceal ble eding, encephalopathy, ascites, hyperbilirubinemia, and worsening synthetic function. Patients with Budd-Chiari syndrome who have end-stage complicati ons of cirrhosis are candidates for transplantation, but clotting disorders must be treated to minimize the risk of recurrent thrombosis. Although hep atocellular carcinoma was once a contraindication, the presence of a small tumor without vascular or distant metastasis is now an indication for liver transplantation. Zn summary, liver transplantation remains a lifesaving pr ocedure for individuals with end-stage liver disease due to a variety of ca uses.