Liver Transplantation: Contraindication and Ineligibility

Liver transplantation (LT) is a life-saving therapeutic modality for patients with various advanced liver diseases. It crucial to identify that the patient's illness sufficiently and unlikely improve medical management justify need transplantation. At same time, it comorbidities far disease would result in an unacceptable outcome after LT. Specific care also required before deciding on LT elderly, acute chronic disease, comorbidities, hepatocellular carcinoma. Transplantation needs be timed appropriately avoid unnecessary ensure decision not left too late losing patient without transplant. Also, important as when The current review explores some of these issues contraindications ineligibility basic principles selecting are should have irreversible will fatal LT, fit enough survive surgery post-operative period, better quality life survival than considered if advanced, recipient has significant which decrease success donor or graft inappropriate, precluded by logistic reasons. In context transplantation, contraindication, futility, closely overlapping terms. Contraindications generally agreed situations where transplant teams consider despite having disease. most such cases, futile either likely successful poor functioning e.g. cardiopulmonary failure (ALF) brain herniation. Severe uncontrolled sepsis, extrahepatic malignancy, carcinoma (HCC), illicit drug use absolute contraindications. HCC vascular involvement spread may downstaging. Ongoing alcohol misuse been contraindication. duration abstinence only criterion alcoholic (ALD), done psychological assessment commitment family support. Relative include age, obesity body mass index (BMI) >35 kg/m2, extensive abdominal surgeries, thrombosis, challenge surgical procedure. given Table 1.Table 1Contraindications Transplantation.Absolute contraindicationsRelative contraindicationsTemporary contraindicationsSevere diseaseExtensive thrombosisObesity (BMI >40 kg/m2)Hepatocellular invasion, metastasis beyond criteriaExtensive surgeriesPositive culturesExtrahepatic malignancyPoor complianceUntreated HIVActive useAdvanced ageRecent from alcoholOngoing abuse lack abstinenceUncontrolled sepsis multiorgan failureLogistical constraintsSevere psychiatric illnessAbbreviations: BMI, index; HIV, human immunodeficiency virus. Open table new tab Abbreviations: Ineligibility ascertained evaluation referred undergone Ineligible refused listing taken off list. common reported much half patients. Patients ineligible process reversible spontaneously management, requires optimization, becomes outcome. As can seen 1, temporary ineligibilities transplant, reversed optimization. Some reasons found inappropriate premature referral and/or optimization addiction rehabilitation.1Arya A. Hernandez-Alejandro R. Marotta P. Uhanova J. Chandok N. Recipient assessment: single centre experience.Can J Surg. 2013; 56: E39-E43Crossref PubMed Scopus (10) Google Scholar,2Bilato M. Marrone G. Tarli C. et al.Reasons transplantation.Dig Dis. 2018; 50: 1-19PubMed Scholar There different challenges making eligibility, broad groups diseases [i.e., ALF, acute-on-chronic (ACLF), (CLD)] but specific etiologies like ALD, hepatitis B C, autoimmune (AIH), Budd–Chiari syndrome (BCS), etc. Moreover, there special considerations elderly patients, metabolic obesity, cardiovascular renal dysfunction, hepatopulmonary (HPS), HCC, sarcopenia, frailty. aims cover make contraindicated. Despite improvements critical transplant-free ALF remains around 50%, ALF.3Koch D.G. Tillman H. Durkalski V. Lee W.M. 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On other hand, waiting long could becoming sick Patient become develop severe positive blood cultures, hypotension high-dose ionotropic support, herniation, death. natural history cirrhosis characterized asymptomatic compensated phase followed decompensated phase, manifests complications portal hypertension dysfunction. Decompensation form variceal bleeding, ascites, jaundice, occurs 4–12% per year. median varies depending type decompensation. bleeding alone outcomes ascites ascites. five-year mortality risk 18%–20%, while non-bleeding manifestation encephalopathy, range 55–80%. who two more decompensations, combination approach 88%.6D'Amico Garcia-Tsao Pagliaro L. Natural indicators cirrhosis: systematic 118 studies.J 2006; 44: 217-231Abstract (2030) severity had traditionally assessed Child–Turcotte–Pugh (CTP) score, considers presence HE, serum bilirubin, albumin, increase prothrombin time control. 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Kim W.R. al.MELD-GRAIL-Na: glomerular filtration rate liver-transplant list.Hepatology. 2020; 71: 1766-1774Crossref (33) al.14Kim Mannalithara Heimbach J.K. 3.0: End-Stage updated modern era.Gastroenterology. 2021; 161: 1887-1895.e4Abstract (57) revised version 3.0, according affords accurate general addresses determinants waitlist including sex disparity. robust data needed replaces standard allocation. may, however, gastrointestinal bleed listed frequent GI bleeding. certain sicker their exception reduce mortality. 2 below mentions conditions given.15Francoz Belghiti Castaing D. al.Model end-stage exceptions French score-based system.Liver Transpl. 2011; 17: 1137-1151Crossref (67) ScholarTable 2Conditions With Exception.•MELD <15 hypertension:○Chronic recurrent encephalopathy○Recurrent bleeding○Hepatic hydrothorax○Hepatopulmonary syndrome○Portopulmonary hypertension•Related malignant disease:○Perihilar cholangiocarcinoma∗Malignant stricture imaging (biopsy cytology confirmed malignancy aneuploidy carbohydrate antigen 19-9 >100 U/mL absence cholangitis); unresectable solitary tumor <3 cm diameter regional distant administered neoadjuvant chemoradiation staging laparotomy LT.○Hepatic metastases endocrine tumor○Rare tumors: Hepatic epithelioid hemangioendothelioma, hepatic angiosarcoma•Complications cholestatic disease:○Refractory pruritus○Recurrent bacterial cholangitis•Miscellaneous○Polycystic disease○Familial amyloid polyneuropathy○HIV infection○Hereditary haemorrhagic telangiectasiaAbbreviations: virus; MELD, Disease.∗ Malignant Disease. We wish highlight importance palliative substantial population eligible die Palliative provided families focus relief symptoms taking preferences into account. adopt services help terminally ill living well during final months years. consultation goal characterize understanding, providing support high-risk decision, improving his life. ACLF distinct sequela decompensation carries significantly morbidity mortality, driven mainly organ failures. unmet meet doesn't adequately judge non-renal failures systemic inflammation, drivers ACLF. One debatable ascertaining right transplanted. Recent times evolving role ACLF.16Trebicka Sundaram Moreau Jalan Arroyo failure: science fiction?.Liver 26: 906-915Crossref (0) Data UNOS CANONIC study up grade 3 CLIF-C <64 LT.17Gustot T. 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