Transplant Medicine

March 10, 2023

Referral timing is essential to ensure patients with advanced liver disease experience optimal transplant results. It is important to avoid referring a patient too soon, before transplant evaluation and services are necessary. However, if you refer a patient too late, the patient can miss the transplant window of opportunity. The disease could be too advanced for transplant eligibility, or the patient's stamina may be too poor to proceed with surgery.

When evaluating patients who may need liver transplants, it also is crucial to bear in mind the rapid changeability of advanced liver disease, says Julie K. Heimbach, M.D., a liver transplant surgeon at Mayo Clinic's campus in Minnesota. Stringent disease status monitoring is essential, including regular hepatocellular carcinoma (HCC) screening. This screening is performed via a liver ultrasound or other imaging and an alpha-fetoprotein level blood test measurement every six months.

"A patient can mow the lawn in May and by June have a complication and become bedridden and fatigued with muscle wasting," says Dr. Heimbach, illustrating how drastically and rapidly patients with advanced liver disease can decompensate.

Indications your patient is ready for transplant referral

Dr. Heimbach says that six key signs indicate when it is time to send a patient to a transplant center for evaluation. Watch for the following:

1. Symptom progression despite low MELD scores. At times, patients with advanced liver disease may present with significant symptoms yet have low Model for End-Stage Liver Disease (MELD) scores. Despite this contradictory situation, Dr. Heimbach says that worsening ascites, encephalopathy or sarcopenia require referral.
2. Decompensated liver signs. If ascites, edema, pleural effusions, encephalopathy, gastrointestinal bleeding, disabling itching or muscle wasting appear, refer the patient for a transplant consult. Unexplained dyspnea with low oxygen levels also can represent liver-related pulmonary complications.
3. HCC. Patients diagnosed with cirrhosis require biannual screening for hepatocellular carcinoma (HCC), which is a common liver transplant indication, says Kymberly D. Watt, M.D., a transplant hepatologist at Mayo Clinic in Minnesota. She suggests referral immediately after identifying a concerning lesion, as one may inadvertently follow a tumor until it is too large for liver transplant eligibility.
4. Bacterial cholangitis occurrences. Repeated episodes of bacterial cholangitis in patients with biliary disease also should prompt transplant referral.
5. Poor function in daily life. If a patient struggles to perform everyday tasks and can no longer work, these are signs that referral for a transplant discussion is appropriate.
6. Repeated admissions. Multiple hospital stays are indicators that a patient's disease may benefit from transplant.

Dr. Watt urges physicians to err on the side of referral for transplant sooner rather than later. If patients are eligible for transplant, she says, earlier surgery may offer them greater odds of full function post-transplant.

She also encourages physicians caring for patients with advanced liver disease to contact Mayo Clinic's liver transplant specialists for any questions about a given patient's status, even when it appears the patient may not have viable treatment options.

"Please reach out and ask," says Dr. Watt. "We'd be happy to discuss with you or see the patient in person or by telemedicine."

In Mayo Clinic Gastroenterology and Hepatology, rotating hepatologists take external physician calls all day.

For more information

Refer a patient to Mayo Clinic.