A liver transplant is often the last hope for people with end stage liver disease. However, getting listed for a transplant and undergoing the procedure itself requires that the patient be relatively healthy and able to withstand the rigors of surgery. So when is someone considered too sick for a transplant? There are a number of factors that go into this determination.
What makes someone a candidate for a liver transplant?
In general, someone may be a candidate for a liver transplant if they have irreversible, end stage liver disease and are expected to live less than a year without a new liver. Some common conditions leading to liver failure and transplant include:
– Cirrhosis from hepatitis C or alcohol abuse
– Nonalcoholic fatty liver disease (NAFLD)
– Primary biliary cholangitis
– Primary sclerosing cholangitis
– Inherited diseases like alpha-1 antitrypsin deficiency and hemochromatosis
However, having one of these conditions does not automatically make someone eligible. Doctors will thoroughly assess the patient to determine if they are sick enough to need a transplant but well enough to undergo the procedure and recover successfully.
What factors make someone too ill for a transplant?
There are a number of medical and lifestyle factors that may exclude someone from receiving a donor liver. These include:
– Heart, lung, or kidney failure – Other vital organ failure may be too high risk for surgery.
– Active alcohol/substance abuse – Ongoing abuse can damage a new liver. A period of sobriety is usually required.
– Active infections – Severe infections need to be treated and resolved before transplant.
– Cancer spread beyond the liver – Metastatic cancer has poor outcomes after transplant.
– Advanced age and frailty – Recovery is more difficult for older, weaker patients.
– Inability to adhere to demanding post-transplant regimen – Strict medication and follow-up required.
– Psychiatric or neurologic issues – Includes dementia, psychosis, suicidal ideation.
– Lack of adequate social support system – Help needed with post-op care.
– Severely low MELD score – Indicating liver disease not advanced enough to warrant transplant.
– Morbid obesity – Greatly increases surgical risks and complicates recovery.
Doctors use great discretion when deeming someone too ill for a transplant. The risks must outweigh the potential benefits for that individual.
What is the liver transplant evaluation process?
Getting listed for a liver transplant involves an extensive medical and psychosocial evaluation to determine if it can be done safely. This comprehensive process includes:
– Detailed review of entire medical history.
– Physical exam and lab testing.
– Imaging scans to view liver anatomy and look for tumors.
– Cardiac testing like echocardiogram, EKG, cardiac stress test.
– Pulmonary function tests.
– Kidney tests like GFR.
– Endoscopy procedures if needed.
– Evaluation of any substance abuse issues.
– Mental health assessment.
– Discussion of social support system.
– Review of insurance coverage and financial resources.
This exhaustive evaluation helps determine if the patient is sick enough for a transplant while still having adequate health and support to tolerate the process.
What is the MELD score?
The MELD score is an important factor during liver transplant evaluation. MELD stands for Model for End-Stage Liver Disease. This scoring system was designed to assess the severity of chronic liver disease. It was implemented in 2002 to help prioritize allocation of donor livers to the sickest candidates.
The MELD score ranges from 6 to 40. It is calculated using three laboratory values:
– Bilirubin – Measures liver ability to clear bile.
– Creatinine – Kidney function.
– INR – Blood clotting tendency.
Higher scores indicate more severe liver disease. For example:
– MELD of 6 to 9 is considered mild liver disease. Transplant may not be indicated yet unless other complications present.
– MELD of 10 to 19 is moderately severe disease. These patients may be considered for transplant evaluation.
– MELD of 30 to 40 represents critical end-stage disease. Transplant is imminent at these levels.
However, some patients with low MELD scores may still be too ill for transplant if they have other organ failure or severe complications. MELD is just one factor in the decision.
When is a person considered too ill for transplant?
There are a number of scenarios where a patient with liver failure may be deemed ineligible for a transplant procedure. For example:
– The patient develops multisystem organ failure affecting the heart, lungs, or kidneys. This tremendously raises surgical risk.
– The patient has severe cardiac dysfunction like heart failure or pulmonary hypertension that makes them too unstable for transplant surgery.
– The patient has uncontrolled sepsis or repeated infections indicating an inability to fight infection. A transplant would be life-threatening.
– The patient has metastatic cancer beyond the liver that would likely recur and spread after transplant.
– The patient has advanced neurologic issues like dementia or psychosis that would interfere with recovery.
– The patient is in extremely frail health due to old age and malnutrition. Even early post-op care could be fatal.
– The patient has a severed lack of adequate family/social support at home after discharge.
– The patient refuses to address an active addiction issue that would damage a new liver.
– The patient is severely non-compliant and unwilling to follow post-transplant requirements.
In these situations, the transplant center’s selection committee decides it is in the best interest of the patient to avoid the very high risks of proceeding further.
What happens if a person is declined for transplant?
When someone is considered too ill for a liver transplant, the transplant physicians explain this decision to the patient and family. They discuss the specific factors that make risks outweigh benefits of transplant for this individual. The team then focuses on making the patient as comfortable as possible and discusses alternative palliative treatments. This may include:
– Medications to help manage pain and symptoms.
– Therapies to reduce fluid retention and swelling.
– Nutrition advice to stay nourished and avoid protein depletion.
– Referral to hospice care if appropriate.
– Mental health support for the patient and family.
The person will continue to be monitored by their regular liver doctor and specialists. If their situation stabilizes enough in the future, transplant may be reconsidered. But further declines in health usually lead to end-of-life care planning.
Can being too ill be temporary?
In some cases, a person may be declined for transplant due to a temporary medical issue that eventually resolves. Examples include:
– A bacterial or fungal infection that responds well to antibiotic or antifungal treatment.
– An acute illness like pneumonia that gets better with treatment.
– A flare up of hepatic encephalopathy that improves back to baseline with medication adjustment.
– Development of a portal vein blood clot that is managed with blood thinners.
– An episode of variceal bleeding that is stabilized with endoscopic banding.
– A bout of acute kidney failure that resolves after a short period of dialysis.
Once these complications are under control and health stabilizes again, the patient can be re-evaluated for transplant listing. Their case will be reviewed again by the selection committee for reconsideration.
Conclusion
Being declined for a life-saving liver transplant can be devastating news for patients and families. However, transplant centers must make the difficult decision to protect patients too ill for the surgery from perioperative death or poor outcomes afterwards. A variety of medical and psychosocial factors guide whether the benefits outweigh the substantial risks. Patients who are currently too ill for transplant receive supportive palliative care and symptom management. If their health improves, they may be reassessed for transplant eligibility in the future. Close communication between doctors, patients, and families can help make these difficult decisions easier.