Expanding eligibility for liver transplant

For many patients, liver transplantation offers hope for a return to well-being. Unfortunately, many patients who might benefit from transplantation are deemed ineligible for the procedure—or succumb to liver disease before a suitable donor organ becomes available. 

At Penn Medicine, the liver transplant team is working to connect more patients with these lifesaving surgeries. “As a high-volume transplant center, Penn Medicine is always looking to push the envelope and expand the reach of patients who may be candidates for transplant,” says Jonathan Nahas, MD, assistant professor of clinical medicine (gastroenterology) at the Perelman School of Medicine. 

New protocols and changes in eligibility mean liver transplants are now an option for many patients with alcohol use disorder (AUD), as well as some patients with certain cancer indications. Meanwhile, advances in technology and technique mean that Penn Medicine’s experienced surgeons can offer transplants to patients with comorbidities that might have previously disqualified them. Those advances, combined with a robust living donation program, are giving many high-risk and previously disqualified candidates a new path forward.

Liver transplants and alcohol use

Alcohol is a major driver of liver-related mortality, in the United States and around the world. “In the U.S., alcohol-related liver disease is the most common indication for liver transplant,” Dr. Nahas says. Dr. Nahas recently joined the Penn Medicine Physician Interviews podcast to discuss the diagnosis and management of alcohol-associated liver diseases.

In the not-so-distant past, patients with alcohol use disorder were not considered for transplant unless they had been abstinent for at least six months. “That was a somewhat arbitrary criterion, determined in the 1980s and 1990s without a lot of real data to support it,” Dr. Nahas says. “That meant a lot of patients with alcohol-related liver disease were deemed ineligible. And the main problem was that more than half of patients with alcohol-associated hepatitis die before six months.”

Over the last 10 or 15 years, however, transplant centers have evolved beyond the so-called “six-month rule,” providing transplants to well-selected candidates even if they have a recent history of alcohol use. “The goal is to identify individuals who may have recent drinking but otherwise have favorable profiles for transplant,” Dr. Nahas explains.

To improve the odds of successful outcomes, the Penn Transplant Institute established the Integrated Liver Transplant Engagement and Recovery Network, or ILEARN clinic. The ILEARN clinic provides multidisciplinary management of alcohol-related liver disease, with an integrated relapse-prevention program and intensive outpatient care that includes individual counseling and group therapy. The ILEARN team includes transplant-specialized hepatologists, psychiatrists, social workers, and providers in addiction medicine who work closely together. The team meets weekly to discuss patient progress, address concerns, and offer extra support as needed. 

“Our goal is to provide patients with a consistent, well-rounded, thoughtful message that covers not only the psychiatry aspect, but also the hepatology,” Dr. Nahas says. “Studies have shown that these types of integrated, multidisciplinary care models can improve outcomes for high-risk patients.” 

Data from Penn Medicine indicate that patients receiving care in the ILEARN clinic show improved abstinence, as measured with PEth (phosphatidylethanol) blood tests that detect alcohol consumption. Clinic participants also have extremely low rates of post-transplant alcohol-related graft injury or death. 

With support from the clinic, some patients may ultimately recover sufficient liver function to avoid a transplant. Many others establish healthy habits that allow them to move forward with transplant. ILEARN serves patients both pre- and post-transplantation, helping them establish abstinence before surgery and supporting their continued sobriety after recovery.

The approach is increasing the number of patients who can benefit from transplants. “A few years ago, a given patient wouldn’t have been eligible. But now we’re able to offer supports to get them through this major surgery and recovery and help them return to a healthy life,” Dr. Nahas says. 

Expanding access with living donor transplants and technological advances

The Penn Transplant Institute is expanding access to transplant in other ways, including in the realm of transplant oncology. Traditionally, liver transplants were a treatment option for some patients with hepatocellular carcinomas that had not spread beyond the liver. More recently, transplants have been extended to patients with cholangiocarcinoma (cancer of the bile ducts), as well as some patients with colorectal cancer that has metastasized to the liver but not beyond it. 

For many patients with cancer, living donation helps make liver transplants possible. Model for End-Stage Liver Disease (MELD) scores are used to objectively measure the severity of chronic liver disease in patients to prioritize them for transplant and are an important factor in determining when patients are wait-listed. “But patients with colorectal cancer metastases, even with exception points, still don’t have a MELD score that’s competitive,” Dr. Nahas says. And some patients with other indications may not have a MELD score that accurately identifies the urgency of their need, he adds. “So we have to think outside the box to get patients that life-saving transplant.” 

The living donation program helps to fill the gap by giving patients the option to move forward with a transplant sooner than they might on the organ waiting list, before their health deteriorates further. Penn Medicine’s living donor program is the largest and most experienced program in the region. Most liver transplant patients still receive organs from deceased donors, but living donation is growing steadily—and Penn Medicine continues to invest in the program to expand access and streamline the donation process. “Instead of waiting on the transplant list for an offer that may never come, patients are able to find options through living donation,” Dr. Nahas adds.

The liver transplant team has also sought ways to expand access through other means. With advanced surgical techniques and new technology that perfuses livers after removal, the team is now able to use some organs that previously were considered unsuitable for transplant, Dr. Nahas says. “We’ve had success in using this type of technology to expand access by successfully transplanting livers that another center may have declined,” he adds. 

That advance relies on Penn Medicine’s experienced organ procurement team, which applies a skilled and critical eye when assessing possible organs for transplant. “They search high and low to give our patients on the list the best chance at a new liver,” he adds. “We’ve had to think outside of the box to get these patients those lifesaving transplants.” 

Referring patients to the Penn Transplant Institute

The Penn Transplant Institute has performed more than 4,000 liver transplants, the highest volume—and with the best patient survival outcomes—in the region. The team is also experienced with complex cases, including treating patients with comorbidities such as heart disease or obesity that might make them risky surgical candidates. When necessary, Penn Medicine’s transplant team works closely with specialists in other fields to manage those conditions and optimize patient health ahead of surgery. 

Referrals and consultations

Penn Medicine’s transplant team welcomes referrals and inquiries from physicians considering whether and when their patients are eligible for transplant. Early referral, when possible, is recommended. 

By referring early, patients can begin establishing evaluations for living donor transplants, even when their MELD scores suggest they are not yet a candidate for the organ donor list. Referrals also help patients connect with opportunities such as clinical trials investigating new treatments for liver diseases—treatments that may delay or even prevent the need for a future transplant. In the case of AUD, early referral allows patients to establish care with the ILEARN clinic to address alcohol use to help them become suitable candidates for transplant. 

“Early referral is always helpful, even when patients have not been abstinent from alcohol. With our support and multidisciplinary care model, we can help patients before they become too sick for transplant or have acute events that lead them to be hospitalized,” Dr. Nahas says. “A patient may not be a candidate today, but we can start an evaluation and maybe help them to become a transplant candidate when the time is right.” 

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