Indications and timing for liver transplantation in adults

Introduction. - The shortage of cadaveric organ donors imposes a severe limit to the number of liver transplantations. A selection is thus necessary among patients: should the sickest be selected or those who supposedly have the best chance to survive and recover? Optimizing the timing of transplantation during the course of the disease (not too early, but not too late) is another issue. Current knowledge and key points. - Suitable candidates for transplantation are patients suffering from an irreversible, symptomatic liver disease. The goals of therapy are: firstly, to favorably modify the natural outcome of the disease: and secondly, in an acceptable risk taking manner. Major criterias for indication in the most common liver diseases can be summerized as follows: a) for chronic parenchymal liver diseases, a Child-Pugh score of 9 or 10, or less if complications have already occurred is a mandatory and often sufficient criterion; b) for cholestatic liver diseases, a serum bilirubin level higher than 100-150 mu mol/L is generally required; c) apart from <> hepatocellular carcinomas on cirrhotic parenchyma (less than three tumors of less than 5 cm in diameter), most cancers are considered contraindications, d) acute liver failure requires early referral to a liver transplant center for potential emergency indication. Future prospects and projects. - In an organ shortage situation which is likely to perdue, early consultative contact between the patient and the liver transplant team will allow improvement in the access to transplantation procedure. (C) 1998 Elsevier. Paris.