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Evaluation for Liver Transplantation in Adults: PRACTICE GUIDELINE 2013 Practice Guideline by AASLD and AST

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Evaluation for Liver Transplantation in Adults: PRACTICE GUIDELINE 2013 Practice Guideline by AASLD and AST © 2013 The American Association for the Study of Liver Diseases, All rights reserved. rights All Diseases, Liver of Study the for Association American The 2013 © FORWARD REFERENCES FULL TEXT FULL RECOMMENDATIONS CONTENTS Jump to: Jump PRACTICE GUIDELINE PRACTICE Michael Fallon Michael Robert Brown, Jr. Jr. Brown, Robert Sandy Feng Sandy Andrea DiMartini Andrea Paul Martin Paul Transplantation and the American Society of of Society American the and Practice Guideline by the AASLD AASLD the by Guideline Practice Transplantation in Adults: 2013 2013 Adults: in Transplantation Liver for Evaluation AASLD Evaluation for Liver Transplantation in Adults: PRACTICE GUIDELINE 2013 Practice Guideline by AASLD and AST CONTENTS RECOMMENDATIONS FULL TEXT REFERENCES WEB SITE Contents (click section title or page number) Recommendations and Rationales ............................................ 3 Full-text Guideline ....................................................... 63 Abbreviations .......................................................... 64 Preamble ............................................................. 65 Literature Review and Analysis / Funding / Introduction ............................. 66 Indications for Liver Transplant .............................................. 67 The Evaluation Process ................................................... 68 Medical Comorbidities Including Obesity, Older Age, and Cardiac Disease ................ 71 Pulmonary Hypertension .................................................. 72 Hepatopulmonary Syndrome ............................................... 73 Renal Dysfunction / Tobacco Consumption ..................................... 74 Extrahepatic Malignancy / Infectious Diseases ................................... 75 Nutrition / Bone Disease .................................................. 76 HIV / Psychosocial Evaluation .............................................. 77 Disease-Specific Indications for LT ........................................... 78 Autoimmune Hepatitis / Primary Biliary Cirrhosis (PBC) ............................. 79 Primary Sclerosing Cholangitis (PSC) / Alcoholic Liver Disease (ALD) ................... 80 Acute Liver Failure ....................................................... 81 Hepatocellular Carcinoma / Cholangiocarcinoma ................................. 82 Metabolic Diseases / NASH ................................................ 83 α-1-Antritrypsin Deficiency / Hereditary Hemochromatosis ........................... 84 Wilson’s Disease / Hereditary Amyloidosis ...................................... 85 Primary Hyperoxaluria .................................................... 86 MELD Exceptions ....................................................... 87 References ............................................................ 89 USING, SEARCHING, AND PRINTING GUIDELINES This document was designed for use on a variety Use the top menu to return to the list. This file reflects of devices using Adobe Acrobat Reader.® Smaller the most recently approved language of the published screens should be held horizontally. You may search guideline. Your feedback is welcome on the design and or print using your PDF viewer. Menu hyperlinks allow usability and will help guide future publications. movement between sections and to the guidelines on Please email your comments the AASLD site. In Recommendations and Rationales, to [email protected] click on individual items to review specific rationales. or visit our social media pages. BACK 2 FORWARD © 2013 The American Association for the Study of Liver Diseases, All rights reserved. AASLD Evaluation for Liver Transplantation in Adults: PRACTICE GUIDELINE 2013 Practice Guideline by AASLD and AST CONTENTS RECOMMENDATIONS FULL TEXT REFERENCES WEB SITE Recommendations and Rationales This guideline includes 56 specific recommendations. Please click on a recommendation to review the related rationale and supporting evidence. See Table 1 for an explanation of the grading system for recommendations. 1. Evaluation for liver transplant (LT) should be 9. Portopulmonary hypertension should considered once a patient with cirrhosis has be excluded in LT candidates by routine experienced an index complication such as echocardiography. For RVSP ≥45 mm ascites, hepatic encephalopathy, or variceal Hg right heart cardiac catheterization is hemorrhage or hepatocellular dysfunction indicated. (1-B). results in a MELD Score ≥15 (1-A). 10. Potential recipients with portopulmonary 2. In a liver transplant candidate potentially hypertension (POPH) should be evaluated treatable etiologies and components of by a pulmonary or cardiac specialist for hepatic decompensation such as ascites, vasodilator therapy (1-A). hepatic encephalopathy, or variceal hemorrhage should be treated (1-B). 11. LT can be offered to potential recipients with portopulmonary hypertension (POPH), 3. Potential liver transplant candidates with which responds to medical therapy with a worsening renal dysfunction or other mean pulmonary artery pressure (MPAP) evidence of rapid hepatic decompensation ≤35 mmHg (1-B). should have prompt evaluation for liver transplant (2-B). 12. Hepatopulmonary syndrome (HPS) is relatively common in patients evaluated for 4. Obese patients (WHO class 1 and greater) LT and should be screened for by pulse require dietary counseling prior to LT (1-C). oximetry (1-A). 5. Class 3 obesity (BMI ≥40) is a relative 13. The presence of severe hepatopulmonary contraindication to LT (2-B). syndrome (HPS) is associated with increased mortality and affected individuals 6. Cardiac evaluation needs to include should undergo expedited LT evaluation (1-B). assessment of cardiac risk factors with stress echocardiography as an initial 14. Renal dysfunction requires vigorous screening test with cardiac catheterization evaluation prior to LT to determine etiology as clinically indicated (1-B). and prognosis (1-A). 7. Cardiac revascularization should be 15. Simultaneous liver-kidney transplantation considered in LT candidates with significant is indicated for LT candidates in whom coronary artery stenosis prior to transplant renal failure reflects chronic kidney disease (2-C). (CKD) with GFR <30 mL/min or acute kidney injury with dialysis >8 weeks or if extensive 8. In the absence of significant comorbidities, glomerulosclerosis is present (1-B). older recipient age (>70 years) is not a contraindication to LT (2-B). 16. Tobacco consumption should be prohibited in LT candidates (1-A). BACK 3 FORWARD © 2013 The American Association for the Study of Liver Diseases, All rights reserved. AASLD Evaluation for Liver Transplantation in Adults: PRACTICE GUIDELINE 2013 Practice Guideline by AASLD and AST CONTENTS RECOMMENDATIONS FULL TEXT REFERENCES WEB SITE 17. LT candidates with a prior extrahepatic 28. Patients should have adequate social/ malignancy should have received definitive caregiver support to provide the necessary treatment with adequate tumor-free survival assistance both while waitlisted and prior to listing for LT (1-B). until independently functioning in the postoperative period (1-B). 18. Candidates should undergo age and risk factor-appropriate cancer screening, e.g., 29. LT transplant candidates with HCV have colonoscopy, mammography, Papanicolaou the same indications for LT as for other smear (1-A). etiologies of cirrhosis (1-A). 19. LT candidates should be screened for 30. Antiviral therapy pre-LT should be bacterial, viral, and fungal infections prior contemplated to reduce the risk of recurrent to LT (1-A). HCV post-LT (1-B). 20. Treatment for latent TB should be initiated 31. Patients with HBV liver disease should pre-LT (1-B). receive antiviral therapy to suppress HBV replication pretransplant and continued 21. Vaccination should be encouraged against surveillance for hepatocellular carcinoma pneumococcus, influenza, diphtheria, (HCC) (1-A). pertussis, and tetanus (1-A). 32. LT should be considered in patients with 22. Live vaccines (mumps, measles, rubella, decompensated autoimmune hepatitis who and varicella), if indicated, should be admin- do not respond to or are not appropriate istered early in the evaluation process (1-B). candidates for medical therapies (I-A). 23. Nutritional assessment should be performed 33. LT is indicated in autoimmune hepatitis in every LT candidate (1A). presenting as acute liver failure if recovery 24. Bone densitometry should be obtained as is unlikely (1-B). part of transplant evaluation and treatment 34. LT is indicated for decompensated primary of osteoporosis initiated prior to LT (1-A). biliary cirrhosis (PBC) (I-A). 25. Patients with HIV infection are candidates 35. Severe pruritus, refractory to medical for LT if immune function is adequate and therapy, may also be an indication for LT the virus is expected to be undetectable by (I-B). the time of LT (1-A). 36. LT is an effective therapy for 26. Patients should be evaluated for and meet decompensated liver disease due to primary reasonable expectations for adherence sclerosing cholangitis (PSC), including bouts to medical directives and mental health of recurrent cholangitis and sepsis (I-A). stability as determined by the psychosocial evaluation (1-A). 37. Colonoscopy should be performed annually in patients with primary sclerosing 27. Methadone-maintained patients should not cholangitis (PSC) and inflammatory bowel be denied transplantation based on disease (IBD) both before and after methadone use alone, and expectations transplantation due to the high incidence
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