Liver Transplantation: Adult

Practice Guideline

AASLD AST Practice Guideline on adult liver transplantation: Diagnosis and post-transplant management of non-graft-related complications

Background and aims: Long-term mortality after liver transplantation largely reflects complications of immunosuppression, recurrent disease, and medical and surgical comorbidities including metabolic syndrome, chronic kidney disease, cardiovascular disease, malignancies and hernias. This document aims to provide best practice guidelines for preventative and disease-specific management of non-graft related complications in adult recipients beyond the first 90 days after liver transplant. Methods: A multidisciplinary writing group of transplant experts was tasked to formulate clinical questions (in PICO format) that arise during routine management of adult LT recipients. A systematic literature search was performed by a medical librarian. The expert panel reviewed the literature, generated guideline recommendations and rated the level of evidence for each recommendation based on the Oxford Center for Evidence-Based Medicine. The panel categorized the strength of recommendations based on the level of evidence, risk–benefit ratio, and patient preferences. Conclusions: Multidisciplinary care and partnership between the transplant center and the primary care physician is essential for long-term care of the transplant recipient. Significant components of non-graft management guidelines are derived from retrospective cohort studies, systematic reviews and extrapolation of data from the general population. This gap highlights the unmet need for robust prospective studies addressing long-term care of liver transplant recipients.

AASLD AST Practice Guideline on adult liver transplantation: Candidate evaluation

Background and Aims: Liver transplant is a specialized treatment for a spectrum of indications that use a scarce resource. Transplant is guided by principles of justice, equity and benefit with a constant conflict between competing interests. Organs are a national resource with a goal of equitable distribution across sites. An AASLD guideline for the evaluation and selection of appropriate transplant candidates has been available since 2005. Methods: A multidisciplinary writing group of liver transplant experts and a librarian convened over 24 months. The writing group reviewed the literature, generated guideline recommendations and rated the level of evidence for each recommendation based on the Oxford Center for Evidence-Based Medicine. The group categorized the strength of recommendations based on the level of evidence, risk–benefit ratio, and patient preferences. Conclusions: Liver transplant is a lifesaving procedure that should be offered to selected patients with clear indications and a reasonable prospect of benefit. The evaluation is designed to identify those in need, to outline hurdles to a successful outcome, and to develop an effective transplant plan. The goal of this document is to provide a template for this process.

AASLD AST Practice Guideline on Adult Liver Transplantation: Diagnosis and management of Graft-Related complications

Background and Aim: Advances in immunosuppression and surgical techniques in liver transplantation (LT) have significantly improved patient outcomes, but donor utilization and access to LT remain a challenge. The past decade has seen significant strides in donor pool expansion with acceptable clinical outcomes, while improved patient selection and advances in the management of chronic liver disease and post-LT complications have promoted better allograft health. This document aims to provide an evidence-based guideline on the management of graft complications, immunosuppression, graft rejection and recurrent disease in adult LT recipients. Methods: A multidisciplinary writing group of experts (transplant hepatologists, surgeons, pathologist, and psychiatrist) was tasked to formulate clinical questions (in PICO format) that arise during routine management of adult LT recipients. The writing group reviewed the literature, generated guideline recommendations and rated the level of evidence for each recommendation based on the Oxford Center for Evidence-Based Medicine. The group categorized the strength of recommendations based on the level of evidence, risk–benefit ratio, and patient preferences. Conclusion: While robust clinical trial data provide strong guidance on some aspects of graft management in LT such as machine perfusion and immunosuppression efficacy and safety, a significant component of graft management is derived from retrospective cohort data, extrapolation of data from other solid organ transplants, or expert opinion, including the treatment of antibody-mediated rejection. Finally, further investigation is needed to truly optimize the management of the liver allograft, including the prevention of recurrent alcohol-associated, metabolic dysfunction-associated steatotic and immune-mediated liver diseases.

Evaluation for Liver Transplantation in Adults [updated March 2014]

Liver disease is the twelfth commonest cause of mortality in adults in the United States, resulting in 34,000 deaths annually from cirrhosis. In addition, the rising incidence of HCC in the United States is reflected in an increasing number of deaths from hepatocellular carcinoma (HCC). Access to liver transplants (LT), however, has profoundly altered the management of advanced liver disease.  Management of decompensated cirrhosis and acute liver failure before the advent of LT was limited to attempts to ameliorate complications. In contrast, successful LT extends life expectancy and enhances quality of life. The term orthotopic liver transplantation (OLT) refers to placement of the new organ in the same location as the explanted liver. Although most LT recipients receive a whole organ from a deceased donor, an organ can be “split,” with a pediatric recipient receiving a left lateral segment and an adult recipient the larger right lobe. Live donor transplant using the left hepatic lobe initially introduced for pediatric recipients has been extended into adult recipients using the donor’s right lobe. Although live donor transplant is widely employed, it remains controversial, with continuing concern about potential risks to the donor, especially when right lobe resection is required for an adult recipient. Recipients of live donor transplant have reduced waiting list mortality compared to potential recipients of deceased donor organs. Live donor transplant should only be contemplated when LT with a deceased donor is unlikely to occur within a reasonable time frame given the severity of the potential candidate’s liver disease. Irrespective of the source of the graft, deceased or live, LT is a surgically challenging procedure with dissection and removal of a diseased liver from an abdominal cavity with extensive venous collaterals due to portal hypertension with subsequent implantation of the graft and creation of vascular and biliary anastomoses. Reflecting the complexity of surgery in recipients who are often debilitated because of their advanced liver disease, a number of technical complications can occur as well as a variety of adverse effects from therapeutic immunosuppression. Despite these concerns, however, LT has revolutionized the management of severe liver disease. The United Network for Organ Sharing (UNOS) facilitates organ allocation in the United States and also records graft and recipient outcomes. The UNOS database allows critical evaluation of center- and disease-specific recipient outcomes with LT as well as guiding organ allocation policies. Analogous organizations are involved in organ allocation and data collection in other regions of the world. The greatest challenge in LT remains the inadequate supply of donor organs, limiting access to LT for many potential recipients.