Historic liver transplant guidelines may result in physicians waiting too long to refer patients to transplant, according to Lindsay Y. King, MD, MPH, medical director of the Duke liver transplant program. Relying solely on the Model for End-Stage Liver Disease (MELD) score may delay referral until patients are too sick to receive a liver, she says.

“Historically, we’ve prioritized allocation based on MELD score, predicting 90-day survival,” King continues. “However, MELD was originally developed to determine how to allocate organs — not to identify which patients need a transplant.”

Early referral gives patients the time to explore options including transplant before they become too ill for such treatments. They can establish a relationship and rapport with transplant teams and prepare for a later transplant. Patients may even improve without the need for transplant with the assistance of a multidisciplinary team focused not only on medical care but also on nutritional and psychosocial care.

This diagnostic use of MELD has led some physicians to delay referring patients for liver transplant. Historically there was a MELD score threshold of 15 where transplant benefit was seen for patients whose MELD score was above 15. However longer-term studies and more recent data have shown that patients with lower MELD scores of 11-12 will benefit from liver transplantation.

Studies have shown that there are also persistent outdated beliefs among providers which delay referrals, especially around contraindications. “Many guidelines for contraindications have been updated recently,” King says. “The six-month rule for alcohol has been updated, and there’s no set BMI limit for liver transplant.”

Contraindications including obesity, age, alcohol and substance use, and other comorbidities should be evaluated on a case-by-case basis. “Other than severe cardiopulmonary disease, contraindications for transplant tend to be relative,” says King.

Rather than basing referral on MELD score, King says, decompensation should be the guideline for determining whether a patient should be referred to evaluation for a transplant. The following conditions can be referred to liver transplant, according to King:

• Cirrhosis with decompensation including ascites, variceal bleeding, hepatic encephalopathy (Recurrent hepatic encephalopathy, recurrent or refractory ascites [spontaneous bacterial peritonitis, hyponatremia, acute kidney injury], and recurrent portal hypertensive bleeding are indications for transplantation regardless of the MELD score)
• Hepatocellular carcinoma
• Perihilar cholangiocarcinoma that is unresectable
• Pulmonary complications of liver disease: hydrothorax, hepatopulmonary, portopulmonary hypertension
• Polycystic liver disease with significant symptoms
• Primary sclerosing cholangitis with recurrent cholangitis episodes
• Alcohol associated hepatitis not responsive to corticosteroids
• Acute liver failure

Other considerations may include select cases of small intrahepatic cholangiocarcinoma, colorectal liver metastases, hepatic epitheloid hemagioendothelioma, hepatic adenomas, and neuroendocrine liver metastases.

“We strive to get everyone who needs a liver transplant into the process,” says King. “We work with the mentality of ‘How do we get to a transplant?’ and focus on opportunities rather than barriers.”