Liver transplantation in adults: Choosing the appropriate timing

Table 1 General indications for liver transplantation

Acute liver failure

Complications of cirrhosis

Ascites

Encephalopathy

Synthetic dysfunction

Liver cancer

Refractory variceal hemorrhage

Chronic gastrointestinal blood loss due to portal hypertensive

gastropathy

Hepatopulmonary syndrome

Portopulmonary hypertension

Hepatorenal syndrome

Recurrent cholangitis

Intractable pruritus

Malnutrition

Hepatic myelopathy

Quality of life impairment

Metabolic disorders causing cirrhosis

Alpha-1-antitrypsin deficiency

Wilson disease

Nonalcoholic steatohepatitis and cryptogenic cirrhosis

Hereditary hemochromatosis

Tyrosinemia

Glycogen storage disease type IV

Metabolic disorders causing severe extrahepatic morbidity

Amyloidosis

Hyperoxaluria

Urea cycle defects

Disorders of branch chain amino acids

Miscellaneous conditions

Budd-Chiari syndrome

Metastatic neuroendocrine tumors

Polycystic disease

Biliary atresia

Alagille syndrome

Nonsyndromic paucity of the intrahepatic bile ducts

Cystic fibrosis

Progressive familial intrahepatic cholestasis

Table 2 Contraindications to liver transplantation

Absolute

Extrahepatic malignancy

Hepatic malignancy with macrovascular or diffuse tumor invasion

Active and uncontrolled infection outside of the hepatobiliary system

Active substance or alcohol abuse

Severe pulmonary hypertension uncontrolled with medical therapy

Obesity (BMI > 40 kg/m2)

Advanced cardiopulmonary disease

Psychosocial factors that would likely preclude recovery after

transplantation

Technical and/or anatomical barriers

Brain death

Acquired immune deficiency syndrome

Relative

Age

Cholangiocarcinoma

Portal vein thrombosis

Chronic or refractory infections

Human immunodeficiency virus infection

Previous malignancy

Active psychiatric illness

Poor social support

Age restriction varies by centers and its limit is not universally agreed. However, it is generally approved that transplantation should not be performed in patients older than 70 years, unless in highly selected cases. BMI: Body mass index.

Table 3 Main causes of acute liver failure

Infective

Virus

Hepatotropic: HAV, HBV, HBV + HDV, HEV

Non-hepatotropic: Adenovirus, Epstein-Barr, Cytomegalovirus,

Echovirus, Varicella Zoster virus, Yellow fever, Herpes simplex ,

Parvovirus B19, Coxsackie

Rarely virus: Lassa, Ebola, Marburg e Toga Virus

Bacteria: Salmonellosis, Tuberculosis, Septicemia

Others: Malaria, Bartonella, Leptospirosis

Drugs

Dose dependent: Paracetamol, Halothane

Idiosyncratic reactions: Isoniazid, Nonsteroidal anti-inflammatory

drugs, Phenytoin, Sodium valproate, Carbamazepine, Ecstasy,

Tioglitazone, Antibiotics, Allopurinol, Propylthiouracil, Amiodarone,

ketoconazole, Antiretroviral drugs

Synergistic drug interactions:

Isoniazid + Rifampicin

Trimethoprim + Sulfamethoxazole

Barbiturates + Paracetamol

Amoxycillin + Clavulanic Acid

Toxins

Amanita phalloides (mushroom poisoning), Herbal medicines, Carbon

tetrachloride, Yellow phosphorus, Industrial solvents, Chlorbenzenes

Metabolic disease

Galactosemia, Tyrosinemia, Hereditary fructose intolerance, Neonatal

hemochromatosis, Niemann-Pick disease type C, Wilson’s disease,

Mitochondrial cytopathies, Congenital disorder of glycosylation,

Acute fatty liver of pregnancy

Autoimmune hepatitis

Type 1 autoimmune hepatitis, Type 2 autoimmune hepatitis, Giant cell

hepatitis with Coomb’s positive hemolytic anemia

Vascular disease

Budd-Chiari syndrome, Acute circulatory failure, Heat stroke,

Acute cardiac failure, Cardiomyopathies

Oncology disease

Hemophagocytic lymphohistiocytosis, Leukemia, Lymphoma

HAV: Hepatitis A virus; HBV: Hepatitis B virus; HDV: Hepatitis delta virus; HEV: Hepatitis E virus.