Indications for Liver Transplant

Acute Liver Failure

1. Definition
   1. Onset of hepatic encephalopathy and Coagulopathy within 12 weeks from the onset of illness
      1. No pre-existing liver disease
      2. ii. Pre-existing liver disease only if asymptomatic
   2. Jaundice to encephalopathy time:
      1. 0-7 days hyperacute
      2. 8-28 days acute
      3. 4-12 weeks subacute
2. Various etiology:
1. Paracetamol overdose
2. Other drug-induced hepatitis
3. Metabolic / autoimmune disorder
4. Vascular disorders
3. Liver failure as the primary problem
   1. Hepatic Encephalopathy a major issue
   2. Not part of a multi-organ failure

Acute on Chronic Liver Failure

1. Pre-existing chronic liver disease
   1. Hepatitis B or C
   2. Alcoholic liver cirrhosis
   3. Autoimmune hepatitis
   4. Primary biliary cirrhosis
   5. Cryptogenic liver cirrhosis
   6. Wilson’s disease
2. Precipitant causing acute severe and irreversible decompensation
3. Behaves clinically as subacute liver failure
4. Urgency in transplantation
5. Cerebral oedema not an issue, unlike in acute liver failure

Liver Transplantion in Cancer

1. Hepatocellular carcinoma
   1. Most are not in severe liver decompensation
   2. Transplant is needed for those not suitable for surgical resection e.g. multifocality, poor liver reserves
2. Assessment criteria for suitability
   1. Milan criteria
      1. Single lesion less than 5 cm or
      2. 3 or less lesions with each less than 3 cm
   2. SF (San Francisco Criteria)
      1. single lesion of </=6.5 cm, or
      2. 3 or less lesions of </=4.5 cm with a total tumour diameter </=8 cm

Transplant outside this criteria in living donor transplants have been performed successfully, the most important criteria being absence of portal vein invasion and hepatic venous involvement.