Once the attending physician identifies a patient as a potential candidate for liver transplantation, he or she refers the patient to a transplant center where the patient undergoes a thorough evaluation to satisfy five specific goals:
The establishment of a specific diagnosis.
Documentation of the severity of the disease.
Identification of all complications of the disease or concomitant diseases that might adversely affect the patient’s survival.
Estimation of the long-term prognosis of the disease with or without orthotopic liver transplantation.
Development of a database that allows continual updating of survival and prognosis statistics at the transplant center.
The routine evaluation process involves a number of laboratory tests and x-ray studies. Additional studies are tailored to the individual patient after a thorough review of the patient’s records from the referring physician. All patients undergo Doppler ultrasonography of the portal venous system to measure portal vein flow and to confirm its patency. Adult patients also undergo pulmonary function testing and electrocardiography. In patients suspected of having coronary artery or valvular disease, a stress test or coronary angiography may be required. In addition, patients with significant nutritional deficiencies are identified and treated with an intensive program of nutritional support while they are awaiting a donor liver.
Patients are also evaluated by a psychiatrist, a social worker, and a hospital finance officer. The social worker ensures that all appropriate arrangements have been made to allow the patient to return to the transplantation center when a suitable donor liver is located.
After completion of the evaluation process, each patient’s situation is discussed by a transplantation committee and he or she is placed into one of four categories:
- Active candidate.
- Active candidate pending additional evaluation.
- Inactive candidate (liver disease not far enough advanced for transplantation).
- Unacceptable candidate for transplantation. In addition, a decision is made regarding the urgency of the need for transplantation.
Once accepted as an active candidate for liver transplantation, the patient is placed on the active transplantation list. The waiting period varies widely among transplantation centers. When a potential liver donor is identified and located, all suitable candidates on the active list are reviewed by the transplantation committee and priority is given to the patient with the most urgent need. The chosen recipient is admitted to the transplant hospital on an emergency basis and is surgically prepared to receive the donor organ.
The recipient operation is precisely timed with the donor liver procurement procedure, and the donor and recipient operating teams maintain close communication regarding the progress of the two operative procedures. If the two procedures are performed at different sites, the donor liver is preserved and transported to the recipient team under cold ischemia conditions within 8 to 20 hours of procurement.