Who is Eligible for a Liver Transplant?

A liver transplant is a surgery in which a diseased, damaged, or failing liver is removed and replaced with a healthy organ. People with acute liver failure, chronic liver disease, end-stage liver disease, or liver cancer may need a liver transplant. Such individuals are usually critically ill and have run out of other treatment options. However, there is a long waiting list for new livers. Around 8,500 people a year receive liver transplants in the US. But approximately 12,500 more people are added to the waiting list each year. Please continue reading to find out the eligibility criteria for a liver transplant.

What are the different types of liver transplantation?

There are two main ways to perform liver transplants:

Deceased organ transplant

This type of liver transplant surgery involves removing a whole liver from a donor who has died recently and transplanting it into a person who needs a new liver. The organs come from bodies that have active blood flow (this is necessary to keep the tissues alive). This is often the case in people who have suffered catastrophic brain injuries but have beating hearts. Sometimes, a deceased person’s liver is split into two sections, and each section is transplanted into a different person. Approximately 95% of all liver transplants in the US are done using a deceased person’s donated liver.

Living donor liver transplant

This surgery involves removing a lobe (section) of liver tissue from a living liver donor, such as a family member with the same blood type. The liver can regenerate itself, so it grows to full size in both the donor and the recipient. The right lobe of the liver is usually used as it is slightly larger, but the left lobe works well too. A child needs about 20% of an adult liver. The advantages of living donor liver transplants are that you get a new liver sooner and a healthier organ. These types of liver transplants are less common but are on the rise (they increased by 30% in 2019 compared to the previous year).

What are the criteria to qualify for a liver transplant?

Every liver transplant candidate cannot get a new liver because the demand exceeds the supply of donated livers. Therefore, doctors must use liver transplant criteria to decide who gets a new liver first. A lot goes into deciding why one person should get a liver transplant sooner than another person.

It’s worth noting that liver transplant recipients undergo a major operation and intensive recovery. Healthcare providers want to give a new liver to a person who has the maximum chance of a successful transplant. For this reason, a transplant recipient must meet certain criteria, including:

Clinical signs of liver failure or primary liver cancer.
Good overall health status to undergo the surgery and recovery.
No anticipated risk of alcohol or drug abuse in the future.

The transplant team performs a thorough liver transplant evaluation of a candidate’s physical and mental health, including any history of substance abuse. If there are any underlying conditions that could compromise the long-term success of the transplant procedure, these need to be addressed first. Once a person meets the minimum requirements for a liver transplant, they are placed on the national waitlist for livers from deceased donors.

Who gets a liver transplant first?

If a person has a matching living donor, they can get the surgery done without waiting. Among the people on the waiting list for a deceased donor liver, a few transplant patients go to the top of the list because they have acute liver failure. Such patients are critical and only have a few days to live if they don’t get a donor's liver. Most people on the transplant waiting list have chronic liver failure and/or liver cancer. They are ranked according to a scoring system to decide their place on the waiting list.

The system used to rank patients for liver transplant urgency is called MELD (Model for End-Stage Liver Disease). In children, the scoring system is called PELD (Pediatric End-Stage Liver Disease). A person’s MELD score is calculated using the results of blood tests, which include:

Bilirubin. People with failing livers have high bilirubin levels due to the leakage of bile into the bloodstream.
Prothrombin time. This test measures how long it takes blood to clot and is an indicator of liver functions.
Creatinine. This is a measure of kidney function in adults.
Albumin. This test is used to measure kidney function in children.

In addition to the above criteria (MELD score), there are exception points for conditions or complications that constitute a higher risk and make the need for a liver transplant more urgent. For example, a child with slowed growth due to liver failure will get exception points. Once the total score is calculated, it is used to determine a person’s position on the list of transplant recipients waiting for a suitable liver.

How is a donor liver matched with a transplant recipient?

As mentioned above, donor livers are given to liver transplant recipients on the basis of their place on the national waiting list. In addition, the following criteria are taken into account:

Matching blood type and other factors, to lower the risk of rejection.
Matching body size, to ensure the donated liver is the right size for the recipient’s body.
Geographical location, to ensure the donated liver reaches the recipient while it is still viable, i.e., within 8-9 hours.

What happens when a donor liver becomes available?

When a donor liver becomes available, the transplant recipient gets a call from their transplant coordinator. They must go to the transplant center right away where they will undergo tests to prepare for the surgery. The surgery itself takes 6-12 hours and is done under general anesthesia. After the operation, the transplant recipient needs to stay in the intensive care unit for a few days and in the hospital for 1-3 weeks. After discharge, the patient must follow up frequently with their liver specialist. A liver transplant patient can lead a normal life; however, they must take immunosuppressant drugs lifelong to prevent rejection of the transplanted liver.

What are the risks of a liver transplant?

A liver transplant is a major surgery that carries several risks, such as bleeding, infection, blood clots in an artery or vein supplying the liver, problems with the bile ducts, poor liver function, and rejection.

Who is not eligible for a liver transplant?

A person may not be a candidate for a liver transplant if they have continued alcohol abuse that may cause liver damage in the new liver. Other reasons for disqualification include a life-threatening disease that will not improve with liver transplantation. This may include chronic infections such as hepatitis C or HIV, certain cancers, heart failure, severely reduced lung function due to chronic obstructive pulmonary disease, and irreversible brain damage.

When is it too late for a liver transplant?

It may be too late for a liver transplant if metastatic cancer has spread from its original location. Other situations where a liver transplant may not be a treatment option include advancing age, sarcopenia (age-related muscle loss), acute on chronic liver failure (sudden liver decompensation in a patient with pre-existing chronic liver failure), and other severe medical conditions unrelated to the liver.

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