When to Refer a Patient
The decision regarding when to refer a patient for liver transplant evaluation is based upon how advanced the cirrhosis is. Common reasons for referral include:
- Patients with a Model of End-stage Liver Disease score (MELD) of greater than ten. Currently, organs are allocated based upon the MELD score with higher scores receiving greater priority. Total bilirubin, INR, and creatinine are incorporated into a formula that generates the MELD score. Elevations in any of these values in a patient with cirrhosis is a reason for referral. A MELD calculator can be found here.
- Patients who have developed end-stage liver disease of all types and have had evidence of life threatening complications such as:
- Ascites/fluid retention
- Variceal hemorrhage
- Encephalopathy requiring medication (without a precipitating factor, such as a urinary tract infection)
- Spontaneous bacterial peritonitis
- Worsening renal function
- Patients with hepatic decompensation. Once this process begins, a patient's short-term prognosis is dramatically decreased. Decompensation may present either as synthetic dysfunction (in the form of coagulopathy, hypoalbuminemia, or jaundice) or portal hypertension (in the form of ascites, encephalopathy, or variceal hemorrhage.
- Patients with Hepatocellular carcinoma (HCC). Patients with HCC who have three or fewer lesions less than three cm or one lesion up to five cm are potential liver transplant candidates and may receive priority for liver transplantation. These patients should be immediately referred for evaluation
Early referral is essential, allowing for pre-transplant problems to be addressed and resolved while the liver disease is relatively well-compensated. There is no advantage, however, of early referral in terms of waiting time.
Children with liver disease should be referred for liver transplant evaluation when they fall off their growth curve, or when their liver decompensates.
Once a referral is made, patients are evaluated by the Liver Transplant Program. The following issues must be addressed before progressing to transplantation:
- Patient's fitness for surgery
- Psychosocial preparedness
- Potential for recovery
- Adequate social support structure
- Any pre-existing medical conditions unrelated to the liver disease that would make transplantation unnecessarily risky
Common contraindications to liver transplantation:
- Ongoing substance abuse
Liver transplantation is a complicated decision for both physicians and patients. In each case, a terminal illness is being replaced by a new and chronic condition. The transplant team must ensure that patients are neither too ill nor too healthy to warrant a transplant. The patient must have sufficient medical reserve to survive through and thrive after transplantation. Risks are involved not only for the patients undergoing transplantation but also for those remaining on the waiting list. These principles guide our transplant team as decisions are made affecting each patient we care for.
How to Refer a Patient
Patients may be referred to the Transplant Center at Carolinas Medical Center for consideration by their gastroenterologist, primary care physician, hepatologist or insurance carrier. You may contact our program assistant at 704-355-6924 for information regarding the referral process. It is important that the transplant team know as much as possible about each potential candidate for transplantation. For questions or transfers, you may contact the liver transplant coordinator at 704-355-6649 or 800-562-5752.
Referral information should include:
- Patient demographic information
- Insurance information (copies of the front and back of insurance cards)
- Medical records, including blood work, radiology and pathology studies
After a referral is received, the information is given to the certified transplant coordinator who is responsible for contacting the patient and explaining the evaluation process. The patient's information is forwarded to a transplant financial coordinator to verify transplant coverage. Once prior authorization for the evaluation is obtained from insurance, the patient is scheduled for an outpatient evaluation. The evaluation process includes, but is not limited to:
- Education with a certified transplant coordinator
- Psychosocial evaluation with a Master's prepared social worker
- Transplant financial coordinator evaluation and counseling
- Chest X-ray
- Carotid ultrasound
- Abdominal ultrasound
- Triphasic spiral CT / MRI
- EGD / Colon
- Pulmonary functions with ABG's
- Adenosine myoview or cardiac cath
The following are the responsibility of the patient:
- Mammogram within 12 months for females over the age of 40
- Pap smear within 12 months for females over the age of 18
- PSA within 12 months for males over the age of 50
- Colonoscopy for patients over the age of 50
- Dental evaluation within 12 months
At the completion of the evaluation, patients are discussed in a multidisciplinary transplant conference where their acceptance as a candidate for transplantation is determined. Authorization for transplantation is then requested from their insurance carrier. Once this is received, the patient is placed on the United Network for Organ Sharing national waiting list.
Wait List Maintenance
When patients are on the waiting list they will be scheduled for periodic re-evaluation at The Transplant Center/Carolinas Center for Liver Diseases, with the frequency of visits based on their MELD score.
How Organs are Allocated
Organ allocation guidelines are based on United Network for Organ Sharing and Organ Procurement Transplant Network policies that include medical criteria, as well as the equitable utilization of organs. The current liver allocation policy is based upon MELD score and blood type. Patients within a blood group with the highest MELD score receive highest priority. Other factors include age and body size of donor and candidate.
For more information on organ donation and allocation, please visit www.unos.org
For more information regarding center specific data and statistics, please visit www.ustransplant.org
For questions about the Liver Transplant Program or Carolinas Center for Liver Diseases, please call 704-355-6649 or 800-562-5752.