Evaluation Process for Liver Transplant Candidates

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2 Evaluation Process for Liver Transplant Candidates 2

3 Objectives Identify components of the liver transplant referral to evaluation Describe the role of the liver transplant coordinator Describe selection committee criteria Discuss the MELD system and organ allocation 3

4 Goals of the Evaluation Determine if the patient needs a liver transplant Are they a good surgical candidate for transplant Will they have a good outcome Will they take care of themselves and their new liver 4

5 Liver Transplant Evaluation Volume Chart Title evaluations 2017 evaluations 2018 inpatient outpatient 5

6 Causes of Liver Failure Common causes in adults Viral Hepatitis A, B and/ or C Alcoholic Cirrhosis Fatty Liver Disease Liver Tumors Autoimmune Hepatitis Primary Biliary Cirrhosis Primary Sclerosing Cholangitis Acute Liver Failure Drug ingestion/ toxins 6

7 About the Liver It helps digest food It metabolizes waste, medications and toxins from your blood It makes proteins that help your blood to clot It makes chemicals that protect the body 7

8 Symptoms of Liver Disease When the liver is damaged it cannot grow enough new liver tissue to heal itself. This can lead to cirrhosis which is severe chronic liver damage. Common Symptoms Encephalopathy Bleeding from the nose, esophagus, stomach or rectum Muscle loss Ascites Itching Jaundice Fatigue 8

9 Treatment of Chronic Liver Disease Medical management Nutritional support Medications Procedures Paracentesis EGD with banding Blood transfusions Transplant from a deceased or living donor 9

10 Liver Transplant Process Transplant phases: Referral Evaluation Waiting List Transplant Surgery Post-Transplant recovery

11 Referral Process New transplant referral A physician or case manager calls in, faxes or s the referral to the transplant office to the referral coordinator. Role of referral coordinator Completes an intake, reviews records and reviews clinical with a liver transplant physician for medical acceptance or denial. Requests financial clearance for the evaluation. Reviews records to determine necessary testing needed to complete the evaluation. The transplant team and patient placement are notified for inpatient evaluations. Assists with triaging transfer priority with the transplant fellow when there are multiple referrals pending bed placement. 11

12 Referral Process Role of referral coordinator When financially clear for transplant evaluation and the bed becomes available the patient is transported to UCLA from an outside hospital. Once admitted evaluation orders are placed and the consulting teams are notified. Bedside RN reviews orders and ensures that all orders are completed in a timely manner. 12

13 Liver Transplant Evaluation Consultations for transplant evaluation Transplant Hepatologist Transplant Surgeon Transplant Coordinator Transplant Social Worker Transplant Psychiatrist Transplant Cardiologist Transplant Pulmonologist Transplant Dietitian Other consults may be required due to diagnosis or assessment findings. 13

14 Liver Transplant Evaluation Evaluation workup: Blood Work Serologies Type and screen X 2 Hematology and chemistry panels Drug toxicology screens Imaging Studies Abdominal Ultrasounds, CAT scan or MRI Chest X-ray and/ or CAT scan chest Cardiac and Pulmonary Tests Echocardiogram, Stress test or cardiac angiogram Pulmonary Function Tests 14

15 Liver Transplant Evaluation Evaluation workup: Routine testing is performed per US preventive task force guidelines Mammogram or bilateral breast ultrasound PAP Smear Colonoscopy 15

16 Evaluation Process Role of the evaluation coordinator Reviews and obtains consents for the evaluation from the patient and/or caregivers. Interviews the patient and caregivers. Provides liver transplant education. Pre-transplant alternatives to transplant, evaluation process, selection committee, UNOS, organ allocation, waitlist maintenance, drug and alcohol abstinence Transplant surgery About the procedure, potential medical and surgical complications Post-transplant potential psychological concerns, post-transplant medications, patient responsibilities 16

17 Evaluation Process Role of the evaluation coordinator Reviews diagnostic testing results and consultants recommendations. Prepares patient case for presentation at the selection committee meeting. 17

18 Liver Transplant Evaluation Patient Transplant Selection Committee (PSCM) All patients are presented at the PSCM after the workup has been completed and the results are available. Acceptance criteria No significant comorbidities that would preclude a satisfactory outcome Patient s ability to function normally is severely compromised by their liver disease Social support and compliance 18

19 Liver Transplant Evaluation Patient Transplant Selection Committee (PSCM) Contraindications Advanced cardiopulmonary disease Uncontrolled infection outside of the liver Psychological instability Lack of social support Recent alcohol or substance use Cancer outside of the liver Large tumor burden or portal vein thrombosis with hepatocellular carcinoma 19

20 Liver Transplant Evaluation Transplant Selection Committee: The patient is notified by the transplant coordinator with the outcome of the selection committee meeting by verbal notification and a letter. Early: transplant is not needed at this time Re-present: Additional testing and information is required Denied: there may be psychosocial or medical barriers to transplant. Accepted: ok to be listed for transplant 20

21 Patient Acceptance Financial clearance for listing If accepted for transplant request for listing authorization is submitted to the insurance company for liver transplant. UCLA then verifies that the patients has adequate benefits for transplant. Once financial clearance is received the patient can be listed for liver transplant by the coordinator. 21

22 Listing Process United Network of Organ Sharing (UNOS) A national organization mandated by the federal government to distribute donated organs. Facilitates all organ allocation in the United States. Monitors every organ allocation to ensure compliance. Patients are listed in the UNOS database and there is one waiting list for our entire country. 22

23 Listing Process Criteria needed to list Recipients first and last name Date of birth Social security number or UNOS assigned patient identifier code if no SS# is available Current height and weight Type and screen (2 required) Up to date serologies hepatitis B, hepatitis C and HIV Most recent listing labs sodium, total bilirubin, creatinine, albumin and INR Had dialysis twice, or 24 hours of CVVHD, within a week prior to the serum creatinine test? yes/ no 23

24 Liver Allocation MELD: Model For End Stage Liver Disease Utilized to allocate donor livers and distribute organs to the sickest patients and is used for candidates who are 12 years and older. It is calculated with the following labs. Sodium Creatinine Total Bilirubin Albumin INR The higher the score the more urgent the need for a transplant. Patients on dialysis receive the equivalent of a creatinine of 4. 24

25 Waiting List MELD Lab Schedule MELD SCORE Recertification Due Lab values must be no older than MELD 25 or higher MELD MELD MELD 6-10 every 7 days every 1 month every 3 months every 6 months 48 hours 7 days 14 days 30 days 25

26 Organ Procurement Process Donor Organ Procurement Agency (OPO) UNOS Organ Center Transplant Center Recipient 26

27 Waiting Time It is not possible for us to predict how long a patient will wait for a donor liver as we are waiting for a random event to occur (death of a potential donor). Some patients wait days while others wait weeks, months or years. Waiting times vary by regions of the country. 27

28 Allocation 28

29 Allocation Adult livers are allocated by the following Status 1A Patients who have sudden onset of liver failure with no known history of liver disease, usually fatal unless transplanted quickly MELD Higher MELD scores have priority over lower scores, ranges 6-40 Blood Type Size The donor must have the same or compatible blood type The donor or segment of the donor s liver must be a comparable size to the recipient 29

30 Allocation In June 2012, the Board passed Share 35, a policy that sought to improve access to transplant for the sickest patients with chronic liver disease through: National sharing for candidates with MELD/PELD scores greater than 15 Regional sharing for candidates with MELD/PELD scores of at least 35 National sharing for liver-intestine candidates 30

31 Allocation Share 35 Two year post-implementation outcome analysis showed: the percentage of transplants was increased from 19%- 27% in patients with a MELD or PELD of at least 35 and increased sharing within each region from 19% to 50% Despite several efforts to expand liver sharing to regional candidates with the greatest medical urgency, the geographic disparity in disease severity at transplant persists. 31

32 Allocation New Allocation Policy 150 nautical mile radius sharing circle around the donor hospital and increased sharing within the region. May include candidates outside of the region. Candidates at transplant hospitals within the circle will receive 3 additional MELD or PELD points. Candidates with a MELD/PELD score 32 or higher will be prioritized for organ offers. 32

33 Allocation New Allocation Policy Before the match run, candidates with a MELD/PELD of at least 15 and who are either within the same DSA as the donor or are within 150 nautical miles of the donor hospital but in a different DSA will receive additional transplant priority (equivalent to 3 MELD/PELD points). Livers from deceased donors who are 70 or older or donation after cardiac death (DCD) donors will be in a separate allocation that gives priority to candidates in the DSA after allocating to Status 1 candidates in the region or circle. The MELD may go above 40 with the inclusion of proximity points. 33

34 Summary Identify the components of the liver transplant evaluation. Describe the role of the liver pre-transplant coordinator. Describe selection committee criteria. Discuss the MELD system and organ allocation. 34

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