I have cirrhosis. At what point do I need to consider a liver transplant?

The mere presence of cirrhosis is not an indication for liver transplantation. Many people with cirrhosis enjoy normal lives without ever developing complications or the need for hospitalization. Others decompensate over time, in which case transplantation may become necessary.

Patients often seek out a liver specialist when they first receive a diagnosis of cirrhosis in an effort to learn more about transplantation. Their initial hope may be to have a liver transplant—that is, to remove the damaged organ and replace it with a new, undamaged one. Although this outcome might, on the surface, seem to be a good solution, several negative factors must be considered before pursuing this option. First, the rate of surgical complications of liver transplantation may be as high as 15% to 20%, including death within the first year after transplantation. You must weigh this risk against the risk of death without transplantation, taking into account quality of life issues. Second, the medications required after transplantation have many side effects. Early exposure to these medications may result in a diminished quality of life for at least some time after the operation. Third, organ availability is limited in many regions of the country. As a consequence the degree of illness necessary to be at the top of the transplant waiting list can be quite high. Patients with compensated cirrhosis will likely remain at the lower end of the waiting list for a long time.

Patients should consider liver transplantation when they have developed complications of liver disease such as ascites, variceal bleeding, hepatic encephalopathy, or jaundice (Table 3). Additionally, even in patients who feel well, a rising MELD score (see Question 46) may be an indication for transplant evaluation. The development of liver cancer may also be an indication for transplantation. Careful monitoring by a physician is necessary in all patients with cirrhosis to look for signs of liver failure so that referral for transplantation occurs at the appropriate time.

The progression of liver disease is often predictable. Most patients with cirrhosis have already developed complications of liver disease such as ascites, variceal bleeding, jaundice, or encephalopathy. These symptoms may come and go, and the patient may sometimes feel quite well. This is an ideal time for liver

transplantation. Unfortunately, because of the system of organ distribution, we rarely have the opportunity to offer liver transplantation at the most opportune time. Livers are distributed according to the MELD scoring system (see Question 46). The MELD scoring system prioritizes patient who are “sicker” based on their laboratory tests (bilirubin, INR, and creatinine). These lab tests may not, however, reflect the true degree of illness in some people, especially those with ascites, bleeding problems, and malnutrition. This situation may lead to a seesaw of emotions—the desire to rise to the top of the list requires increased illness, but this is a condition no one wishes to achieve.

On rare occasions candidates for liver transplantation may become “too sick” to undergo transplantation. This situation occurs most commonly when the candidate develops infection or sepsis. In such a case the infection is often caused by bacteria that enter the urinary bladder, kidneys, ascites fluid, lungs (pneumonia), or bloodstream. Sepsis can lead to failure of organs other than the liver, such as the kidneys, lungs, heart, and blood vessel (vascular) system. When patients have sepsis, liver transplantation cannot be performed for several reasons:

• Immunosuppressive agents are required after transplantation, but they limit the body’s ability to assist in fighting off the infection.

• The patient’s blood pressure may be too low to safely perform surgery.

• The patient’s blood pressure may be too low to adequately supply the new liver with blood.

• If other organs are in failure, a liver transplant may not help the patient achieve total recovery

In this circumstance it is better to attempt to control the infection and then proceed to transplantation, rather than the reverse. Unfortunately, when sepsis is present and the liver is not functioning properly, it is difficult for the body to recover adequately to allow later transplantation. It is therefore important to report all signs of infection to your doctor so that early treatment can be initiated and sepsis prevented.