Principal Consultant & Unit Head, Liver Transplant, Fortis Hospital, Shalimar Bagh, New Delhi, India
Part 4 of 12 in Liver Transplant
Contraindications and the MELD-Sodium Score for Timing Transplant
August 11, 2024
Not every patient with liver disease benefits from transplant. Dr. George named the absolute contraindications directly: poor cardiopulmonary reserve that would not tolerate the surgery, cancer outside the liver, and active alcohol or substance abuse.
The MELD-sodium score
Timing matters as much as eligibility. The MELD score (using creatinine, bilirubin and INR) has been extended to the MELD-sodium score, which also factors in serum sodium. A score above 15 means a patient should be offered liver transplant for cirrhosis; below that threshold, the risk of transplant and lifelong immunosuppression outweighs the benefit, and patients are better managed with continued medical therapy and monitoring.
Why the threshold matters
Dr. George pointed to data from more than 16,000 patients: above a MELD-sodium score of 15, more patients survive with a transplant than without one, even accounting for the real risks of surgery and lifelong immunosuppression. Below that score, more patients are better served staying on medical management. Getting this threshold right, not defaulting to either extreme, is the core of correct patient selection.
This article is based on a Jivo Masterclass session conducted by Dr. Ashish George, Principal Consultant & Unit Head, Liver Transplant, Fortis Hospital, Shalimar Bagh, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Ashish George taught doctors across Africa on August 11, 2024.
FROM THE LIVE Q&A
Dr. Abdullahi
How do factors like donor liver quality and recipient health condition impact the success and recovery process after a liver transplant?
Dr. Ashish George
Both donor and recipient undergo extensive two-pronged evaluation: confirming the surgery poses no major risk to the donor, and confirming the liver quality is good enough to function well in the recipient. Primary non-function occurs in under 1-2% of living donor transplants; early allograft dysfunction in about 5-10%. Donors are generally 18-55, and a younger, non-fatty liver has better quality than an older or fattier one.
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Frequently Asked Questions
Who is eligible to donate a liver?▼
Legally, the donor must be a relative of the patient. Medically, the ideal donor is blood-group compatible (A or O for an A recipient, B or O for a B recipient, any group for an AB recipient, only O for an O recipient; Rh status doesn't matter), aged 18 to 55, and free of diabetes or advanced uncontrolled pulmonary disease. An incompatible donor can still be evaluated if no compatible one exists, with longer preparation, higher cost and slightly increased risk.
Is there research correlating liver transplant and COVID-19 survival, and what are the nutritional considerations before, during and after liver transplantation?▼
Post-transplant patients who contract COVID-19 usually develop mild disease since the immunosuppressed body can't mount a severe response, though those who do develop severe COVID-19 can have poorer survival due to vulnerability to secondary infections. On nutrition: patients awaiting transplant should follow a high-protein, high-calorie diet to fight muscle loss (sarcopenia); after transplant, only freshly cooked meals, clean water, and peeled fruits/vegetables eaten immediately are advised, plus reduced red meat, due to immunosuppression and cardiovascular risk.
How long does it take for a donor's liver to regrow after donation, is it true that a donor only has ten years of survival left, and what is the age limit to donate?▼
About 70-80% of eventual growth happens in the first two to four weeks, and 95-97% of original size is reached by six months. The '10 years survival' claim is an absolute myth: once recovered, a donor's life expectancy, work, family and sexual life are completely unaffected. The donation age range is generally 18 to 55, and a person can only donate a liver once.
For someone who already had a liver transplant and requires another one, what are the possibilities, and how many times is it possible to have a repeat transplant?▼
Re-transplant is needed in about 5-7% of patients, due to disease recurrence, chronic rejection, or other causes. It is technically more challenging than a first transplant but achieves equal long-term results when performed by a skilled team; some patients have undergone two, three, or even four transplants over the years.
Is it possible for a healthy person without liver disease to have a partial hepatectomy stored, so that if they develop liver disease later it can be transplanted back to them?▼
No, this has not been thought of or done. Only a very small subset of the general population ever needs a liver transplant, so removing a healthy liver segment as a major surgery isn't advisable, and there is no method to preserve a graft for years, only for hours to a few days using specialised machines.
Who should not receive a liver transplant?▼
Patients with poor cardiopulmonary reserve unable to tolerate surgery, cancer outside the liver, or active alcohol or substance abuse.
What MELD-sodium score indicates a patient should be transplanted?▼
Above 15. Data from over 16,000 patients shows more patients survive with transplant than without one above this threshold; below it, medical management is generally better.
In This Series: Liver Transplant
- 1.Liver Transplant
- 2.Indications for Liver Transplant: Acute and Chronic Liver Disease
- 3.Liver Transplant for Liver Cancer: HCC, the UCSF Criteria and Downstaging
- 4.Contraindications and the MELD-Sodium Score for Timing Transplant
- 5.Survival Rates After Liver Transplant, and Why It's a Cure, Not Just a Therapy
- 6.Living Donor Evaluation: Compatibility, Safety and Liver Regeneration
- 7.Who Can Donate a Liver: Eligibility, Compatibility and the Ten-Year Myth
- 8.Hepatitis B and C in Liver Transplant Candidates
- 9.Re-Transplantation: When and How Often It's Possible
- 10.Nutrition Before and After Liver Transplant
- 11.Immunosuppression After Transplant: COVID-19, Cardiovascular and Renal Risk
- 12.Cold Ischemia Time and Post-Transplant Alcohol Limits