Early referral for liver transplantation

For patients whose liver disease is worsening, liver transplant may offer the only option for a return to well-being and survival. Yet as eligibility guidelines and indications for transplant shift over time, it is not always clear which patients to refer, or when.

From a network of advanced hepatology clinics and transplant evaluation clinics spanning the region, Penn Medicine’s liver transplant program works closely with referring providers to answer these questions and ensure their patients are getting the transplant-related care they need, when they need it.

Liver transplant evaluation: When to refer

One of the most common misunderstandings among referring providers involves timing of referral for transplant. A referral doesn’t mean a patient will be listed for transplant immediately—or even that they need one. Rather, referral—and the earlier the better—gives specialists an opportunity to assess the patient’s illness, optimize management, and determine the best time to pursue transplantation when it becomes necessary.

“If a patient is developing any signs of liver failure, it’s the right time to refer them regardless of how advanced their disease is,” says Maarouf A. Hoteit, MD, professor of clinical medicine (gastroenterology) at the Perelman School of Medicine and medical director of liver transplant at Penn Medicine.

Early evaluation for transplant is especially helpful in the context of living donor transplants, which represent an increasingly important treatment option for patients with liver failure.

“Some providers have historically waited to refer patients until the MELD [Model for End-Stage Liver Disease] score is high—which reflects a liver disease that is severe enough to get them ranked high on the deceased donor waiting list,” Dr. Hoteit says. “But in fact, those patients may benefit from a living donor transplant well before they reach that point."

The only reason there’s a wait list for a deceased donor, he adds, is that the number of patients in need of liver transplantation exceeds the number of available donors in the community. “For any individual patient needing a transplant who has a possible living donor, there’s a major advantage in doing the transplant when we all think the time is right, as opposed to having to wait for their turn on the waitlist.”

Who is eligible for liver transplants?

While no single criterion determines transplant eligibility, several clinical indications should prompt referral for evaluation. Some are longstanding, such as decompensating cirrhosis, while others reflect changing practices in liver transplantation.

Decompensating events

Decompensating cirrhosis remains one of the clearest indications for transplant referral. Although individuals may function for years with mild decompensated cirrhosis and few complications, patients who experience events such as ascites or a variceal bleed should begin the evaluation process, says gastroenterologist Steven F. Solga, MD, a professor of clinical medicine at the Perelman School of Medicine.

Alcohol-associated liver disease

Some of the most substantial changes in transplant eligibility over the past decade involve patients with alcohol use disorder. For many years, transplant centers mandated a six-month period of abstinence from alcohol before a patient could be considered for transplant and placed on the transplant list. Now, Penn Medicine and many other centers are evaluating patients much sooner. It’s an important advance, since in many cases patients’ liver dysfunction is severe enough that they may not be able to wait for six months.

To help such patients benefit from transplant, Penn Medicine’s Integrated Liver Transplant Engagement and Recovery Network, or ILEARN clinic, provides multidisciplinary management of alcohol-related liver disease and an integrated relapse prevention program. “Patients who are compliant with instructions, acknowledge alcohol use as a problem, and are willing to make changes and enter into a therapeutic relationship with an addiction specialty program can be evaluated for transplant, even if their alcohol intake is very recent,” Dr. Solga says.

High MELD scores

MELD scores, which are used to objectively measure the severity of chronic liver disease in patients to prioritize them for transplant, continue to be an important factor in determining when patients are wait-listed. However, MELD scores alone should not drive referral decisions, and low MELD scores do not necessarily exclude transplant. Dr. Solga recommends referring patients when scores reach the low teens, if not sooner.

The key factor to consider in referral is the development of symptoms of liver cirrhosis such as ascites, hepatic encephalopathy, variceal bleeding, or jaundice, which indicate signs of liver failure. “Patients may have a MELD score that’s too low to rank high enough on the transplant wait list to get transplanted soon, even though they are experiencing complications of liver disease,” Dr. Solga adds. “They may be good candidates to receive an organ from a living donor before their health deteriorates further.”

Cancer indications

For several decades, liver transplants have been performed in patients with liver cancer and, more recently, bile duct cancer and neuroendocrine tumors that have not spread beyond the liver. Now, the indications for transplant oncology are expanding. Today, Penn Medicine offers transplants to appropriate candidates with colorectal cancer that has metastasized to the liver but not beyond it. In carefully selected patients, transplants for each of these conditions can offer a curative treatment option.

Complex comorbidities and diagnoses

Some patients with complicated medical histories may also benefit from a transplant evaluation, including patients with comorbidities such as obesity, heart disease, or cancer. “For example, a patient may have colorectal cancer that can be cured by colon surgery but may also have mild cirrhosis, which increases the risks of complications from abdominal surgery,” Dr. Solga explains. “Therefore, we may consider a transplant evaluation prior to the operation, so we are prepared in the event of need.”

Penn Medicine’s transplant team works closely with colleagues in other fields to optimize patients for transplant—working with oncologists and interventional radiologists to control cancer prior to transplant, for example, or collaborating with cardiologists to treat conditions such as aortic stenosis or valvular disease before a transplant. The liver transplant team is also skilled at managing rare autoimmune liver diseases such as primary sclerosing cholangitis and primary biliary cholangitis. 

From advanced hepatology care to liver transplant: a complete care journey

A successful transplant journey begins well before surgery. After a patient is referred, Penn Medicine’s team evaluates where they are in their disease course and connects them with appropriate resources. Some patients are triaged directly to a full transplant evaluation. Others are connected to advanced hepatology care, which can transition seamlessly to transplant evaluation when the time is right.

To make specialized liver care accessible to as many patients as possible, Penn Medicine has developed a network of advanced hepatology and transplant evaluation clinics throughout the region, with clinics in Pennsylvania, New Jersey, and Delaware. Each region is home to a transplant evaluation hub with a dedicated team of hepatologists, transplant surgeons, social workers, transplant coordinators, and nutritionists. Liver transplant specialists from across those regional hubs meet weekly to discuss evaluations and make recommendations for each patient’s next steps.

While transplants are performed at the Penn Medicine Transplant Institute in Philadelphia, the regional clinic model allows many patients to receive much of their care closer to home while remaining connected to the full transplant team. “In a straightforward case where we don’t have to deal with complex issues, we can get patients listed for transplant without them ever needing to come to Philadelphia,” Dr. Hoteit says.

And those evaluations typically happen swiftly. Most patients referred for transplant evaluation are seen within a week or two. “We understand that the matter is urgent and we make a lot of resources available to assess those patients thoroughly and in a timely manner,” says Dr. Solga.

Referring patients to Penn Medicine: a collaborative approach to care

Referring a patient for transplant evaluation doesn’t mean relinquishing their care. Penn Medicine partners closely with referring physicians throughout the transplant journey, tailoring a shared-care approach that reflects each patient’s needs as well as each provider’s expertise and comfort level.

“Patients often want to continue local care, for reasons of trust as much as geography. That’s a good thing, especially when it comes to receiving routine care like endoscopies and blood testing,” Dr. Solga says. “Our goal is always to work with the patient and referring physician to come up with a shared-care approach that’s best for everyone. If the disease reaches a point where the referring doctor begins to feel it’s outside of their comfort zone, we can shift to taking on that patient’s care.”

Moving forward with a liver transplant is an important decision—and the beginning of an important relationship, Dr. Solga says. “I think of the evaluation process as an engagement and the actual transplant as marriage, since most patients continue to receive long-term care from their transplant center,” he explains. “Given that, it’s important that patients find the right fit.”

The Penn Medicine Transplant Institute (PTI) has performed more than 4,000 liver transplants, with patient survival outcomes that exceed regional and national averages. The PTI also offers one of the largest living donor liver transplant programs in the region.

Referrals and consultations

Learn more about liver transplant at Penn Medicine. To refer a patient or consult with a transplant specialist, please call 877-937-7366, or submit a referral through our secure online referral form.