Author(s): Andres F Carrion [*] 1 , Lydia Aye 2 , Paul Martin 3
acute liver failure; alcoholic liver disease; cirrhosis; hepatitis B; hepatitis C; hepatocellular carcinoma; liver transplantation; patient selection
Liver transplantation remains the only therapeutic option offering definitive treatment for end-stage liver disease (ESLD) and acute liver failure (ALF), regardless of the etiology. Current post-liver transplantation survival rates (80-90% after 1 year and 60-75% after 5 years) reflect major advances in surgical technique, post-operative intensive care, immunosuppression as well as better selection of candidates.
Evaluation of potential liver transplant candidates includes assessment of severity of and complications of the patient's liver disease, confirmation of lack of other therapeutic options and likelihood of a good outcome with transplantation in view of the risk of surgery and long-term immunosuppression. An adequate evaluation requires a multidisciplinary team that includes hepatologists, transplant surgeons, anesthesiologists, psychologists and psychiatrists, nurse coordinators, social workers and nutritionists. In addition, other key specialists, most notably cardiologists, evaluate adult candidates.
Indications for liver transplantation
The diagnosis of cirrhosis per se is not an indication for liver transplantation; however, patients should be referred for evaluation if an index complication of cirrhosis occurs (i.e., ascites, variceal hemorrhage or hepatic encephalopathy)  . In addition, patients with cirrhosis and evolving hepatic dysfunction, as reflected in a rising Model for End-stage Liver Disease (MELD) score [greater than or equal]15, should also be referred for liver transplantation evaluation, although this may be appropriate at a lower MELD score if major complications have already occurred. Disease-specific prognostic models for primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) had been developed by combining readily available variables known to independently affect survival of patients with cholestatic disease. However, these models were imprecise in predicting outcomes for individual patients and no consensus exists about the optimal model; therefore, the American Association for the Study of Liver Disease (AASLD) recommends against using disease-specific models for predicting clinical outcomes  . In any event, the MELD score has become the standard method to assess severity in all etiologies of cirrhosis.
Overall, the most common hepatic malignancies are metastatic from extrahepatic sites. Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy in adults; however, only a subset of patients with HCC are suitable for surgical resection or liver transplantation. The majority of cases of HCC in western populations (95%) occur in the setting of cirrhosis, which contrasts to only 60% in eastern populations [2,3] . Surgical resection is the first-line therapeutic option for individuals with a single nodule in a suitable location for resection and in the absence of cirrhosis or in selected individuals with cirrhosis and well-preserved liver function (normal serum bilirubin level and either platelet count [greater than or equal]100,000/mm3 or hepatic venous pressure gradient [less than or equal to]10 mmHg) [4,5] . Surgical resection of HCC can typically be performed without delay, which is a significant advantage compared with liver transplantation. Liver transplantation after initial resection of HCC has been used as a strategy to 'gain' some time until...