The decision to proceed with transplantation requires a careful assessment of the etiology and staging of liver disease, the complications of cirrhosis, potential contraindications, and a comprehensive psychosocial evaluation. The results of the work-up may not be clear-cut and a determination to exclude a candidate can be difficult, especially when the alternative outcome to the patient is certain death. A Multidisciplinary Transplant Review Board, composed of all individuals involved in the different aspects of care of the transplant recipient, needs to weigh dispassionately the pros and cons of each candidate in order to reach a rational decision. Input from consulting physicians, psychiatry, ethicists and social workers is critical to resolve specific situations. Each candidate must have an advocate who presents his/her case to the selection committee and the vote to proceed must be unanimous.
The patient needs to meet minimal listing criteria before placed in the waiting list (Child-Turcotte-Pugh score of at least 7 for most causes of cirrhosis). Once listing is approved, the patient is awarded a priority based on the current UNOS organ allocation scheme, the Model for End Stage Liver Disease (MELD). This scheme, based on predicted three-month mortality of patients awaiting liver transplant, uses laboratory values to generate a score which determines priority. The MELD equation incorporates serum creatinine, serum bilirubin, and international normalized ration (INR) as illustrated in Table 9.11.
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