Liver disease is any disturbance of liver function that causes illness. Liver disease is a broad term that covers all the potential problems that cause the liver to fail to perform its designated functions. Usually, more than 75% or three quarters of liver tissue needs to be affected before decrease in function occurs. The liver is a prolific organ, and has the unique characteristic of regeneration.
Liver disease manifests itself from a number of different factors. Alcohol and drugs (even herbal remedies (kava kava, ma-huang) can cause Cirrhosis. Hepatitis A (virus from fecal matter), Hepatitis B, C and D (body fluid exposure) and Hepatitis E (food and water) cause liver disease. Other virus and diseases can also cause liver disease, such as Mononucleosis, fatty liver, Hemochromatosis, Wilsons or Gilberts Diseases, and others.
When the liver is failing, and its decline exceeds its ability to regenerate, a transplant, or death become the only possible outcomes. Liver transplants are performed in a transplant hospital specializing in Liver transplants. There are 139 transplant centers, in 11 regions of the United States.
Two types of Liver Transplant are possible: Living transplant and a deceased transplant. As those names suggest, a living transplant comes from a live donor and a deceased transplant from someone who has passed. A live donor donates a portion of their liver, and it is then placed in the recipient. A deceased transplant places the whole liver from the deceased in the recipient.
In 2013, 6,455 transplants occurred, with 253 live transplants and 6,203 deceased transplants. 16,372 people were on the transplant waitlist. 39% of those on the transplant list received a liver, 4% from a live donor, and 96% from a deceased donor. Since the risk to the donor is so high, few liver transplants come from live donors.
The criteria for those on the liver transplant waiting list, include:
- First off, your Hepatologist has to recommend you for a transplant, and a transplant center has to accept you.
- The acceptance is based upon your health condition, and your MELD (Model of End-stage Liver Disease – PELD is the pediatric version) score.
- If you are an alcoholic, you will have to be free from any alcohol use for 1 year, be subject to random drug and alcohol tests, and attend some sort of rehabilitation or AA program.
- In general, you must be free of cancer or any other life threatening disease.
- Your MELD score generally must be 15 or higher.
A MELD, coupled with age and blood type determines priority for a liver transplant (a few other medical conditions can also obtain bonus points in the MELD calculations). The MELD score is determined through an algorithm that takes into account your INR (International Normalized Ration measures blood clotting, higher scores meaning blood is not clotting) score, your Bilirubin (yellow breakdown product of blood, high scores meaning it is not being excreted in the bile) score and your Creatinine (breakdown product of creatine, higher scores meaning kidney failure) score.
The MELD Score formula looks like this:
MELD = (0.957 * ln(Serum Cr) + 0.378 * ln(Serum Bilirubin) + 1.120 * ln(INR) + 0.643 ) * 10
(if the patient is on dialysis, the value for Creatinine is automatically set to 4.0).
A MELD calculator can be found at the MAYO clinic website. The Mayo clinic pioneered liver transplant methodologies, and originally came up with the MELD formula (it was originally named the MAYO end-stage Liver Disease). If you would like a MELD calculator in MS Excel format, send me a note and I will send it to you.
The MELD score ranges from a low of 0 to a high of 40. A MELD score for a healthy person is under 5. Any MELD above 6 is an indication of liver disease. A MELD of 15 indicates that a patient has liver disease, and the risk of transplant is equal to the risk of the liver disease itself. The risk of death due to transplant is 15%. A MELD score of 40 indicates a patient has a 98% mortality rate in the next 12 months. The graphic below illustrates the MELD score and its corresponding mortality rates at both 90 days and 1 year. This mortality is averaged over the transplant population, and can vary with time and location.
Ideally, a liver transplant happens with a MELD score somewhere between 15 and 25, although this can be rare. In the Midwest, the average score for a transplant is around 22. However, in high-density cities, such as New York or Los Angeles, the average transplant is more like 32.
Liver transplants tend to be very safe, and because of the MELD scoring system, very objective. The higher the MELD score, the higher the probability of a patient getting a transplant. Of course, the higher the MELD, the sicker a patient tends to be also.
In our case, Vicki’s Hepatologist referred her in February 2012 for transplant, but only after she survived her ankle surgery. Vicki first interviewed at the University Of Kentucky Medical Center, where they have a Liver Transplant Center in Region 11. She was accepted onto the liver transplant list at UK in May 2012. Later, she also interviewed at the University of Cincinnati Medical Center in Region 10. She was accepted onto the list at UC in February 2013.
During these times, Vicki’s MELD score ranged from a low of 14 to a high of 26. For the first year the range was 14 to 18. Later in 2013, especially after complications from dangerously low Sodium levels, her MELD score fluctuated from 22 to 26; the low Sodium scores provided some bonus points. On January 28, 2014 Vicki finally received her liver transplant.
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