Clinical Management

Liver Transplant Program

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Clinical Management

Liver Transplant Evaluation Process

Each candidate will be seen by a multi-disciplinary team within the University of Maryland Liver Center, including the liver transplant screening committee. Members of the Liver Center team meet with patients and provide expert input about any pre-transplant concerns or post-op management issues that may affect the outcome from liver transplantation.

Experts from the comprehensive Liver Center represent the following specialties:

• Transplantation surgery
• Hepatology, transplant medicine
• Oncology
• Pathology
• Interventional radiology
• Gastroenterology
• Transplant nurse coordinator
• Financial counseling
• Social service
• Psychiatry
• Anesthesiology
• Nutrition

After the evaluation process is completed, the liver transplant screening committee will meet and review the cumulative data and render a decision as to the appropriateness and timing of liver transplantation for each patient. Decisions include:

• Accepted for transplantation
• Deferred, pending supplemental data
• Not eligible for transplantation

A formal letter will be sent to each patient and the referring physician relaying the decision of the multidisciplinary screening committee. If a patient is deferred, the patient and referring physician will be notified of the additional required data. 

In addition to the thorough evaluation with the multidisciplinary Liver Center screening committee, radiologic and laboratory investigations are performed to elucidate the cause and nature of the liver disease, assess functional capacity, determine patency of hepatic vascular supply, and to exclude co-existing medical conditions that would compromise patient or graft survival.

• Complete biochemical and liver profile, hepatitis serologies, virology studies (including CMV, EBV, HIV), complete blood count and coagulation profile.
• Assessment of blood type and presence of any special transfusion related problems.
• Duplex ultrasound and MRI/MRA of liver to determine portal vein patency and exclude liver masses.
• Pulmonary and cardiac functional studies (if indicated).
• Routine cancer screening.

Some patients will require inpatient evaluation due to decompensated cirrhosis or acute hepatic failure. Their pre-transplant management and evaluation will be led by Transplant Hepatology. Patients may require therapeutic, as well as, diagnostic measures to improve their clinical and functional status. Patients with fulminant liver failure will require expedited evaluation and ongoing joint assessment by transplant hepatology and surgery as to the appropriateness and timing for transplantation.

Pre-Transplant Management

The transplant team works with a patient on the following items during the waiting period leading up to the time of transplantation. Wait-list patients are encouraged to attend the monthly Transplant Patient Education Series to learn more about what to expect before, during and after transplantation. 

• Hepatology/Transplant Surgery follow-up: liaison with patient's primary physician and gastroenterologist
• Management of TIPS
• Management of Complications of End State Liver Disease
• Vaccines
• Signing of Patient's Substance Abuse Policy
• Ongoing substance treatment reports and random screening

Patient Education

Pre-transplant patients are educated about and provided with information regarding:

• The normal functions of the liver
• Common symptoms of liver disease
• Dietary issues
• UNOS and the waiting list
• Organ Donation Process
• The surgical procedure
• Medications post-transplant
• Post-transplant follow-up

Post-transplant patients are educated about and provided with information regarding:

• Infection and rejection
• Dietary issues
• Vital sign monitoring
• Medications and side effects
• Care of the T-tube and wound
• Liver biopsy indications and protocols
• Hygiene and dental care
• Activity and exercise
• Discharge plan and long-term follow-up

Outpatient Post-Transplant Management

Patients are discharged from the hospital eight to fourteen days following liver transplantation. After initial discharge, until three months post-transplant, patients are seen in the transplant surgery clinic. After three months post-transplant, patients transition to the transplant hepatology clinic for continued management. The frequency of clinic visits in the transplant hepatology clinic are as follows:

• Once a month (months 3-6)
• Once every three months (months 6-12)
• Once every six months (months 12-24)
• Once a year after 24 months

Transplant hepatology clinic is designed to do a comprehensive review of laboratory data and diagnostic studies reflective of liver function, manage the immunosuppressive regimen that each patient is following, and monitor for recurrence of viral hepatitis. Each patient will be referred back to the primary care physician or gastroenterologist for routine health maintenance. The University of Maryland transplant team will continue to collaborate with the referring physician to ensure a cohesive patient management plan. 

Routine Outpatient Laboratory Testing

Routine laboratory tests are necessary to monitor for the following: drug toxicity, graft rejection, infection secondary to immunosuppression, and the response of liver enzymes after treatment for graft rejection or after a change in the immunosuppressive regimen. Infection and graft rejection most often occur within six months following transplantation. In the event that one or both of these situations occurs, the frequency for laboratory testing will increase in order to closely monitor the patient's overall response. Our current protocol for laboratory testing is:

• 3-6 months post-transplant - labs every two weeks
• After 6 months - labs every month

Routine laboratory tests include: CBC with differential, standard chemistries with a liver profile (ALT, AST, Alkaline Phosphatase, and bilirubin) and a Cyclosporin (Neoral) or FK506/Tacrolimus (Prograf) level. Patients can have laboratory testing done at Associates in Pathology Laboratory located at University of Maryland Medical Center, at a preferred diagnostic center that is designated by a HMO, or at the referring physician's office.

This page was last updated: April 29, 2013