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Liver Transplant Referral Criteria

Condition

The Liver Transplant Program assesses children and youth who may require liver transplantation. The program provides transplant assessment, wait-list management and post-transplant follow-up care.

Who can refer

Physicians 

Patient age

18 years and under

Patient acceptance

Patients may be referred for assessment if they meet one or more of the following criteria.
  1. End-stage chronic liver disease
    Consider referral for patients with end-stage chronic liver disease who have one or more of the following:
    • Persistent cholestasis
    • Uncorrectable coagulopathy
    • Growth failure or severe malnutrition
    • Refractory ascites
    • Recurrent cholangitis
    • Refractory pruritus
    • Severe portal hypertension or signs of intractable portal hypertension with low bilirubin related to cirrhosis caused by parenteral nutrition-associated liver disease
    • Recurrent encephalopathy
    • Hepatopulmonary syndrome
    • Reduced quality of life due to liver disease
  2. Liver tumours (for example, hepatoblastoma)
    Referral may be appropriate when:
    • The tumour is considered unresectable (for example, PRETEXT IV)
    • Vascular invasion or extrahepatic metastases are present
      Vascular invasion and extrahepatic metastases are not absolute contraindications for transplantation. The extent of disease and response to systemic therapy should be considered when assessing suitability for transplantation.
  3. Fulminant hepatic failure
    Referral may be appropriate for patients who meet the King's College Criteria or other validated criteria for liver transplantation.
  4. Metabolic diseases
    Liver transplantation may be considered for patients with certain metabolic diseases and a limited life expectancy without transplantation, including:
    • Urea cycle defects
  • Organic acidemias
  • Primary hyperoxaluria type I
Patients with methylmalonic acidemia (MMA) or primary hyperoxaluria type I may be considered for combined liver-kidney transplantation.
5. Re-transplantation
Patients whose previous liver transplant has failed may be considered for re-transplantation, including:
  • Primary graft non-function within seven days of transplant
  • Hepatic artery thrombosis occurring within 24 hours to seven days after transplant
6. Other conditions
Referral may be appropriate for patients with selected rare conditions, including:
  • Rare tumours
  • Vascular abnormalities

Clinical criteria

Please note patients must have provincial health care or interm federal health. 

Out of province patients with a transplant centre in their province must first be assessed by that program before referral to the Sickkids program.

Rejection criteria

1) Co-Morbidities: Patients with any co-morbidity, including extrahepatic comorbidities (e.g. severe heart  or brain abnormalities, mitochondrial diseases), that decreases the likelihood of surviving 5 years post-  transplant to below 60% or whom which the peri-operative risk is deemed unacceptably high, are not  candidates for liver transplantation.  

2) Infections: Patients are not candidates for liver transplantation if they display the following:  • Active extrahepatic infection (including sepsis)  • Uncontrolled HIV infection (i.e. detectable viral load and/or CD4 count <100) or AIDS.  

3) Malignancy: Patients with extrahepatic primary malignancies are not candidates for liver  transplantation. In general, patients must be disease free for 2-5 years after curative therapy but  this rule may be discussed on an individual patient basis depending on the type and stage of  malignancy.  

4) Vascular Abnormalities: Patients with extensive thrombosis of the portal vein, superior mesenteric vein  and splenic vein, or other extensive vascular anomalies or pathologies precluding sufficient  revascularization of the graft are not candidates for liver transplantation. These patients can be  considered for a multivisceral transplant.  

5) Medical instability: Clinically unstable patients that are unlikely to survive the transplant surgery.  These conditions may include situations like – active sepsis, uncontrolled brain edema, uncontrolled GI,  CNS or pulmonary hemorrhage, need for high dose pressors and unstable ventilation.  

6) Psychosocial Considerations: Patients must undergo a complete psychosocial evaluation prior to listing  for transplant. Patients who display the following are not candidates for liver transplantation:  • Unstable psychiatric disorder, especially one likely to interfere with compliance;  • Unwillingness or inability to follow the advice of health professionals;  • Social support/compliance issues prohibiting adherence to post-operative medications and/or  follow-up care.  

7) Blood Transfusions: Patients who are unwilling to accept transfusions of blood or blood products are  not candidates for liver transplantation. 

Notes

For acute liver failure referrals, requiring emergent assessment please call the liver transplant fellow on call at 416-813-7500.

Required supporting documentation

Required documentation will depend on reason for referral - in general, summary of patient's clinical history, recent labs, clinic notes, all imaging (both reports and images), social worker contact and medications.

Additional resources

More information can be found on the Liver Transplant Program webpage.

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