Liver Transplant Criteria and Needs for Donor & Recipient

The liver is a vital organ as it performs more than 500 functions for properly working the human body. The liver functioning may get altered due to several reasons, such as acute (immediate) causes like poisoning or chronic (long-term) causes like hepatic cirrhosis. A person may need a liver transplant if there is improper liver functioning in conditions such as:

1. Hepatitis (B or C)
2. Liver failure
3. Primary liver cancer 
4. Biliary atresia (a rare condition of the bile ducts and liver in newborns)
5. Acute hepatic necrosis (liver tissue dies)
6. Autoimmune hepatitis

The right candidate for receiving a liver transplant is a patient who is:

1. Healthy enough to recover after the transplant surgery.
2. Showing clinical signs of primary liver cancer or liver failure.
3. Not considered at risk of future drug or alcohol abuse.

The candidates who are not appropriate for a liver transplant are patients with:

1. Cancer, that has spread to other parts of the body.
2. Chronic or current infection that limits short-term life expectancy.
3. Heart condition.
4. Another serious disease besides liver condition that will not get better after a liver transplant.
5. A history of non-compliance and being unable to follow a treatment plan.
6. A habit of Active drug and/or alcohol abuse

1. King’s College Criteria for Liver Transplant: Various factors are used to diagnose patients with AHF (acute hepatic failure). Many predictive models have been established to check when a liver transplant is suggested for a person. The most widely accepted one is the King’s College criteria. The King’s College criteria for liver transplant include:

   APAP (acetaminophen)-associated AHF	All other AHF causes
   pH < 7.3	INR > 6.5
   Or	Or
   International normalised ratio (INR) >6.5, Serum creatinine > 3.4 mg/dl, Grade III-IV encephalopathy	Three of the following variables: INR > 3.5 Age < 10 or > 40 years Serum bilirubin > 17.5 mg/dl Duration of jaundice before encephalopathy > 7 days The cause is non-A, non-B hepatitis or idiosyncratic drug reaction

2. Milan criteria for Liver Transplant: The Milan criteria help determine whether a patient with hepatocellular carcinoma (HCC) can opt for liver transplantation. These criteria have been adopted by several transplant societies worldwide. The following table elaborates on the Milan criteria.

   Criteria	Description	Tissue/biopsy needed?
   Milan criteria	1 lesion ≥ 2 cm and ≤ 5 cm OR up to 3 lesions, Each ≥ 1 cm and ≤ 3 cm, No evidence of extrahepatic metastases or vascular invasion	No

3. MELD/PELD system: The Model for End-Stage Liver Disease (MELD) and Paediatric End-Stage Liver Disease (PELD) system was set up to predict risk of death in patients with chronic liver disease. It is good at predicting outcomes in both children and adults with AHF. It is a scoring system for chronic liver diseases and is calculated using blood test results.The test measures:
   1. Bilirubin: an elevated level of bilirubin shows that the bile is leaking into the bloodstream
   2. Creatinine: shows the proper functioning of the liver and kidney
   3. Albumin: measures the functioning of the kidney
   4. Prothrombin time: the time taken by the blood to clot which indicates the production of blood clotting factors by the liver. The MELD and PELD characteristics used in calculating the scores for determining prognoses are:​​​​​

      MELD	PELD
      Bilirubin (mg/dl)	Bilirubin (mg/dl)
      Serum creatinine (mg/dl) *	Albumin (g/dl)
      INR	INR
      	Age at listing
      	Growth failure (based on height, gender, and weight)

      * Patients who had dialysis twice in the past week are automatically set to a creatine level of 4 mg/dl3The patients are rated on a scale of 6 (least severe) to 40 (most severe). Further, the MELD scores are paired with other factors, such as the chance of survival and the patient’s distance from the donor hospital, to decide the priority.The MELD score is continuously measured to ensure accuracy. The frequency of testing depends on how high the scores are:

      1. 6 to 10: remeasured once a year

      2. 11 to 18: remeasured every three months

      3. 19 to 24: remeasured once a month

      4. 25 to 40: remeasured every week

Registration and listing of recipients:

1. The patient should register with the hospital where they want to do the surgery by registering online at "www.notto.gov.in". 
2. The liver advisory committee will approve the registration and urgency criteria.
3. At the time of listing, the patient should be less than 65 years of age.
4. The patient with liver cirrhosis should meet the standard criteria for liver transplant with a MELD score of more than 15 in patients aged 12 and above. 
5. A super-urgent listing is done in the following situations:
   1. Early hepatic artery failure (HAT) needs re-transplant.
   2. Primary non-function (PNF) of liver allograft
   3. Fulminant hepatic failure (FHF) meeting the king’s college criteria
   4. A living liver donor who develops life-threatening liver failure
6. Patients with metabolic disorders who do not have the minimum required MELD score, including intractable pruritus, polycystic liver disease, and chronic hepatic encephalopathy, will not be considered for listing disease donor liver transplant (DDLT) for now.
7. Contraindications to listing for liver transplantation:
   1. AIDS
   2. MELD score < 15
   3. Uncontrolled sepsis
   4. Severe pulmonary or cardiac disease, and who are not fit for general anaesthesia
   5. Intrahepatic cholangiocarcinoma
   6. Hepatocellular carcinoma more than UCSF (University of California, San Francisco) criteria
   7. Extra-hepatic cancer
8. The patient should only be registered in one hospital, which is registered under the Transplantation of Human Organ and Tissue Act (THOTA)
9. The patient should be registered for a deceased donor even when waiting for a living donor.
10. The hospital should update the status each month for the listed patients; for the super-urgent patient, the status should be updated more regularly.

1. The liver allocation is done according to the waiting list. Firstly, it is done based on the state waiting list. Suppose there is no recipient eligible for the state waiting list, in that case, the allocation is done according to the Army hospital Research And Referral (R&R) to a nearby state in the regional organ and tissue transplant organisation (ROTTO), and then to other ROTTO nationally. 
2. The liver from a paediatric donor (< 16 years) will first go to a paediatric recipient. If no paediatric recipient is eligible, it will go to an adult patient.
3. Liver from a donor of blood group O will be allocated to group O recipient and then to any other blood group if no one is eligible.
4. The other blood groups A, B, and AB will be allocated to the same blood group recipient, except AB, which can be donated to all blood groups.

Once consent is received for a donation from a deceased person, the following steps are followed:

1. Step 1: Check the age and blood group of the available deceased donor and follow the allocation principles.
2. Step 2: If a recipient is on the super-urgent list (according to the accepted criteria and registration), the available liver will go to that recipient. If more than two patients are in similar situations, the allocation depends on how long the waiting period has been.
3. Step 3: If there is no super-urgent patient, the liver goes to the recipient who needs a simultaneous multi-organ transplant. In case two patients have a similar situation, the liver goes to the patient who has waited longer.
4. Step 4: If there are no multi-organ recipients and no super-urgent patient, then the allocation depends on the status of the hospital doing the liver retrieval. Status means whether it is a transplant hospital or a Non-Transplant Organ Retrieval Centre (NTORC).
   1. In the case of a transplant hospital: The liver will be given to the local transplant hospital, and the hospital will not lose its turn.
   2. In the case of NTORC: The liver will go to a common pool, and from there, the liver will be allocated to the transplant hospital according to the ROTTO (list).

An individual must fulfil the following criteria to be able to donate a small part of their liver to someone in need.

1. Age between 18 to 60 years
2. Blood type compatibility with the recipient
3. Sound mental and physical health
4. BMI (body mass index) less than 35
5. Free from the following conditions:
   1. Hepatitis 
   2. Ongoing cancer
   3. Active or chronic infection
   4. Significant organ diseases such as kidney or heart diseases
   5. Active substance abuse