Information for Clinical Staff

Medical, surgical and anaesthetic advice for patients with liver disease available 24 hours a day.

If you wish to discuss any cases, please ring the main switchboard and ask for the operator to contact the appropriate registrar.

Criteria to be fulfilled to be accepted on a UK Liver Transplant Programme:

Liver failure due to cirrhosis continues to be the commonest indication for transplant. Statistical analysis of the UK experience to date resulted in a mathematical formula using INR, sodium, creatinine and bilirubin to give a score termed UKELD. UKELD score > 49 is required for listing as this indicates > 9% mortality from liver disease within 12 months which equates to the 91% survival at 12 months following liver transplantation in the UK. The criteria for listing can be viewed on the UK Blood and Transplant website (see link below *), and include variant syndromes where the UKELD score may be < 49 but transplantation is still appropriate, e.g. polycystic liver disease and hepatopulmonary syndrome.

Acute liver failure listing criteria have been altered slightly with respect to paracetamol poisoning but the original Kings College Hospital criteria remain the mainstay of listing.

Hepatocellular Carcinoma (HCC):

The criteria for liver transplant for HCC have been revised because the Milan criteria which have been adopted in the UK for many years excluded some patients with a greater than 50% chance of survival at 5 years following transplantation, the benchmark used for transplantation for benign disease. The lesions require to be identified on both MDCT and MRI scanning and have typical characterisation to count as HCC. This means an arterialized focal abnormality with portal phase washout on MDCT or Gd-enhanced MRI. Tumour rupture, extrahepatic spread, AFP >10,000 and macrovascular invasion are absolute contra-indications to transplant. The new listing criteria are as follows:

1. a single tumour ≤ 5cms diameter.
2. up to 5 tumours all ≤ 3cms.
3. a single tumour 5-7cms which shows no significant progression (volume increase

HIV:

The outcome for liver transplantation in HIV has improved over the past 5 years and HIV disease is therefore no longer an absolute contra-indication to liver transplantation, provided anti-retroviral therapy (ART) is fully suppressing the HIV virus. ART does interact significantly with tacrolimus and ciclosporin and close links with HIV specialists are required.

Listing Criteria for elective liver transplant in UK: www.organdonation.nhs.uk/ukt/about_transplants/organ_allocation/pdf/adult_protocols_guidelines.pdf

---

The following are broad guidelines when to consider referral for liver transplantation. However, each case is considered individually by a multi-disciplinary team and if a general practitioner or referring consultant is unsure if referral of a particular patient is appropriate, the consultants on the Scottish Liver Transplant Unit welcome discussion of any case.

Acute Liver Failure

• Discuss if: PT >20 seconds or INR >2.0
• pH < 7.3 or [ H+] > 50
• Hypoglycaemia
• Conscious level impaired
• Creatinine > 200 mmol/l
• Any patient with encephalopathy, coagulopathy or renal impairment complicating acute liver injury should be discussed with the liver transplant unit.

Chronic Liver Failure

• Significantly impaired quality of life due to itch.
• If albumin < 28 g/l or prothrombin time > 6 seconds prolonged (INR > 1.5) or bilirubin > 50 mmol/l (>100 mmol/l if biliary cirrhosis) i.e. Child Pugh score >7 or Child Class B or C cirrhosis. MELD will also be considered.
• Ascites, particularly if poor response to diuretics
• Spontaneous bacterial peritonitis
• Renal failure
• Gastrointestinal bleeding due to portal hypertension especially if associated with encephalopathy
• Spontaneous hepatic encephalopathy

Hepatic Malignancy

• Tumours must be confined to the liver
• Avoid biopsy if considering potential therapeutic treatment.
• Consider even in well compensated cirrhosis
• Single hepatocellular carcinoma less than 5cm in diameter (assessed by CT scan) or less then 3 tumours each 3cm or less in diameter
• Other tumours will be discussed on an individual basis (Fibrolamellar carcinoma , Metastatic neuro-endocrine). Currently they are not accepted as a formal indication.

Cirrhosis

• All patients with advanced cirrhosis without contraindications should be considered for liver transplant.
• Advanced cirrhosis is reflected by ascites, encephalopathy, variceal bleeding, ↓ albumin, ↑ INR, ↑ bilirubin, and ↑ creatinine
• Even a single episode of ‘decompensation’ indicates poor prognosis.
• Transplant should be considered before development of renal impairment or malnutrition, which carries a high short-term mortality.
• Contraindications include active alcohol and substance misuse, major cardiorespiratory co-morbidity, morbid obesity and extra-hepatic malignancy.
• It is better to refer too early than too late.

Hepatocellular Carcinoma

• Patients with cirrhosis should undergo 6 monthly ultrasound and AFP measurement as HCC surveillance.
• Liver transplant should be considered for early HCC (single lesion ≤ 5 cm; up to 5 lesions all ≤ 3 cm; single lesion 5 – 7 cm which remains stable over 6 months; no vascular invasion or extrahepatic spread; AFP < 10,000)

In order to provide a national service for liver transplantation, the SLTU accepts referrals of the following patients:

• Patients with chronic liver disease for assessment for liver transplantation
• Patients who have undergone liver transplantation and are resident in Scotland
• Patients with acute liver failure whether or not they are candidates for transplantation
• Patients with chronic liver disease for assessment; those who require re-admission following liver transplantation are covered by the National Contract between the Scottish Liver Transplantation Unit and the Scottish Office.
  Patients with acute liver failure are admitted and funded as unplanned activity (UNPAC’s) with the patient’s health boards.