2004 AASLD / ILTS transplant course indications for liver transplantation in the MELD era: Evidence-based patient selection

Nothing of him that doth fade, But doth suffer a sea-change Into something rich and strange. —William Shakespeare, The Tempest. Act i. Sc. 2. Liver transplantation has evolved over the past decade from an experimental, episodic technique, practiced in only a few centers, to a standard, accepted form of therapy for many different types of liver disease. Success rates for liver transplantation have continued to improve due to better surgical techniques, more efficacious and less toxic immunosuppressants, and, most importantly, better selection of candidates for liver transplantation. In the formative years of liver transplantation the procedure was offered mostly to patients with unresectable cancers or extreme liver failure. As experience has accumulated, clinicians have developed a better appreciation of the diagnoses for which liver transplantation is likely to be of benefit and for the optimal timing of treatment for many of these diseases. Recently, with the introduction of mathematical models such as the model for end-stage liver disease (MELD) and pediatric end-stage liver disease (PELD) scores that are accurate predictors of the risk of death for patients with chronic liver disease, liver transplant clinicians have come to understand that the need for liver transplantation can be defined for many types of liver disease. This concept represents a true “sea change” in clinical thinking regarding the referral, timing, and allocation of liver transplantation for waiting candidates. No longer are candidates “put in line to wait” for their transplant. The new risk models such as the MELD and PELD scores use objective patient-specific variables to define the risk of death for patients with chronic liver diseases within 3 months and thus define the need for transplant for a given individual at a given point in time that is objective and precise. However, there are many patients who do not have chronic progressively fatal liver disease for whom liver transplant offers beneficial treatment. For these indications, other end points such as the risk of disease progression and/or deterioration in the quality of life might be alternative measures on which to base new risk models. Even with a paucity of reliable natural history data for many of these conditions, one can begin to conceive of methods for evaluating indications for liver transplantation based on the risk model concept. The goal of the 2004 AASLD / ILTS Liver Transplant Course is to illuminate the indications for liver transplantation with the light of this evidence-based approach to liver disease and transplantation. My fellow course directors and I have assembled an international group of experts in the field of liver transplantation. These presenters have generously donated their time, for which we are thankful. Each will address an area of liver transplantation for which experience has evolved to a degree that allows for an evidence-based approach in evaluating the need for, and results obtainable with, liver transplantation. We have purposely selected areas in which controversy exists regarding the indication for liver transplantation in hopes of generating discussion and illuminating areas for future research. We hope that this syllabus is a helpful document summarizing the data presented during this course and that it will serve as a mental marker for the important exchange that we hope will occur among the attendees after the presentations. On behalf of my fellow course directors, Drs. Robert Merion and Michael Millis, I thank each of the contributors to this dynamic course, welcome all of you, and look forward to your active participation.