4. Clinical Guidelines for Liver Transplantation (PDF) - British ...

Guidebook for the Solid Organ Transplant Programme Chapter 4
4.1.2 INDICATIONS AND REFERRAL GUIDELINES CONT.
Hepatitis B: With the advent of effective strategies for preventing allograft reinfection with
hepatitis B, patients with hepatitis B can now be considered for liver transplantation. The HBV
DNA level must be at the lowest level possible in order to meet transplant criteria. Those who
have high HBV-DNA levels will be treated with Lamivudine at 100 mg daily. This results in
HBV-DNA becoming undetectable after approximately four to six weeks in about 90% of such
patients. Patients who do not respond may be treated with Adefovir, Tenofovir or Entecavir.
Those who remain HBV-DNA at a titer greater than 500,000 copies/mL cannot be activated for
transplantation. Patients with HBV who are identified, as possible transplant recipients should
only be started on Lamivudine or Adefovir, after discussion with the transplant team. Although
Lamivudine is well tolerated, there is a high rate of resistance by the development of mutant
hepatitis B virus. This is approximately 50% per year for the first three years and the emergence
of a mutant virus will render the patient HBV-DNA positive and makes transplantation more
problematic as high-dose HBIG is then required to reduce the risk of allograft reinfection. Even
HBV-DNA negative patients with hepatitis B are at risk of allograft reinfection. Fortunately,
this can be prevented using a combination of antiviral drugs and immunoprophylaxis. We are
currently using long-term prophylaxis with Lamivudine combined with low dose hepatitis B
immune globulin (HBIG). Although patients can also develop HBV escape mutants that are
resistant to the HBIG, at present the combination of Lamivudine and immune globulin appears
to be very effective at preventing HBV recurrence.
Alcoholic Liver Disease: Patients with liver failure due to or associated with alcohol abuse
can be considered for transplantation provided that they have demonstrated full and sustained
rehabilitation from alcohol and other substance abuse and that social supports and an abstinence
maintenance program are in effect. The minimal criteria are at least 6 months verifiable
abstinence, willingness to sign abstinence and monitoring contract, a satisfactory report from an
independent alcohol and drug counsellor and favourable assessments from the transplant
program staff members who have expertise in evaluation of patients with a history of substance
abuse.
Metabolic Diseases: Liver transplantation is occasionally offered as therapy for patients
with genetic disorders that can be corrected by liver transplantation. Examples include familial
amyloidosis, or metabolic conditions such as oxaluria, glycogen storage disease and urea cycle
defects.
Hepatocellular Carcinoma: Patients with hepatocellular carcinoma can be considered for
liver transplantation. However, they must be carefully selected to minimize the chance of
recurrence of metastatic disease, because the progression of hepatoma is accelerated by
immunosuppression. Patients with one lesion at 5 cm or up to 3 lesions, none greater than 3 cm.
Patients with solitary tumors up to 6 cm could be considered if they showed a good response to
pretransplant cytoreduction. All patients with single tumor should be offered pretransplant
cytoreductive therapy. Smaller tumors will be treated with RFA or alcohol ablation and large
ones with chemoembolization or combination therapy. Patients who have larger lesions are
occasionally considered if they have a good response to chemoembolization. A “good response”
is shrinkage of the tumour, with a needle biopsy of the area that is negative and a significant
improvement in the alpha-fetoprotein. Chemoembolization is rarely used in patients who have a
portal vein thrombosis or a previous shunt procedure.
Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 2
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