Article Text

Review
Adult liver transplantation: A UK clinical guideline - part 1: pre-operation
  1. Charles Millson1,
  2. Aisling Considine2,
  3. Matthew E Cramp3,
  4. Andrew Holt4,
  5. Stefan Hubscher5,
  6. John Hutchinson6,
  7. Kate Jones7,
  8. Joanna Leithead8,
  9. Steven Masson9,
  10. Krish Menon10,
  11. Darius Mirza11,
  12. James Neuberger12,
  13. Raj Prasad13,
  14. Anthony Pratt14,
  15. Wendy Prentice15,
  16. Liz Shepherd16,
  17. Ken Simpson17,
  18. Doug Thorburn18,
  19. Rachel Westbrook19,
  20. Dhiraj Tripathi20
  1. 1 Department of Hepatology, York Teaching Hospitals NHS Foundation Trust, York, UK
  2. 2 Pharmacy department, King's College Hospital NHS Foundation Trust, London, UK
  3. 3 South West Liver Unit, Plymouth Hospitals NHS Trust, Plymouth, UK
  4. 4 Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
  5. 5 Department of Cellular Pathology, University of Birmingham, Birmingham, UK
  6. 6 Department of Hepatology, York Teaching Hospitals NHS Foundation Trust, York, UK
  7. 7 Liver Transplantation Service, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  8. 8 Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  9. 9 Liver Unit, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
  10. 10 Liver Transplantation & HPB Surgery, King's College Hospital NHS Foundation Trust, London, UK
  11. 11 Liver Transplantation & HPB surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
  12. 12 Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
  13. 13 Liver Transplantation & HPB Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  14. 14 Pharmacy department, York Teaching Hospitals NHS Foundation Trust, York, UK
  15. 15 Palliative Care Medicine, King's College Hospital NHS Foundation Trust, London, UK
  16. 16 Liver Transplantation Service, Royal Free London NHS Foundation Trust, London, UK
  17. 17 Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
  18. 18 Department of Hepatology, Royal Free London NHS Foundation Trust, London, UK
  19. 19 Department of Hepatology, Royal Free London NHS Foundation Trust, London, UK
  20. 20 Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birminghams, UK
  1. Correspondence to Dr Charles Millson, Hepatology, York Hospitals NHS Foundation Trust, York YO31 8HE, UK; charlie.millson{at}btinternet.com

Abstract

Liver transplantation is a highly successful treatment for all types of liver failure, some non-liver failure indications and liver cancer. Most referrals come from secondary care. This first part of a two-part guideline outlines who to refer, and how that referral should be made, including patient details and additional issues such as those relevant to alcohol and drug misuse. The process of liver transplant assessment involves the confirmation of the diagnosis and non-reversibility, an evaluation of comorbidities and exclusion of contraindications. Finally, those making it onto the waiting list require monitoring and optimising. Underpinning this process is a need for good communication between patient, their carers, secondary care and the liver transplant service, synchronised by the transplant coordinator. Managing expectation and balancing the uncertainty of organ availability against the inevitable progression of underlying liver disease requires sensitivity and honesty from all healthcare providers and the assessment of palliative care needs is an integral part of this process.

  • liver transplantation
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This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Footnotes

  • Contributors There were 20 authors involved in the production of these two articles concerning liver transplantation. The original project was divided into an introduction, nine sections and a conclusion. From that original outline, the sections were written by writing groups and then collated. The nine sections were then divided into two halves for the purposes of publication, after discussion with the editor of FG. Each contributor provided editing input, to the project, as the manuscript went through its many iterations. The specific contribution/participation of each contributor are as follows: CM (consultant hepatologist in a DGH): senior author. Initiated section divisions, collected manuscripts. Contributed to writing by adding DGH aspects to all part 1 and management of post-transplant patient section. Edited all tables and oversaw the process. CM is responsible for overall content as guarantor. A Considine is a consultant pharmacist. She co-wrote the section on the Immunosuppression agents in Part 2 with Prof Neuberger and gave input into Part 1 particularly with the ‘disease specific considerations’ and where medication interactions can occur. MC (consultant transplant hepatologist): Co-authored the section on 'Management of the patient on the waiting list' and then read both Part 1 and 2 of final submission as an additional critique for all sections. Critical role in planning and acquisition of data for inclusion into guideline, along with evaluation of relevance to project. Final manuscript editing and approval. AH (consultant transplant hepatologist): Co-authored the section on 'How to refer', and then drew up the tables and added valuable additional input, as well as re-write participation for the sections, when the original submission was too lengthy. Critical role in planning, final manuscript editing and approval. SH is a consultant histopathologist and wrote the section on cellular rejection in Part 2. He added valuable oversight in Part 1, particularly as both parts were too lengthy and required significant reduction in word count. JH (consultant hepatologist in a DGH) wrote the section on Transplant assessment and with KJ refined this section, to focus on the DGH referrer. JH also read both completed parts to provide the DGH perspective on these elements of liver transplantation and ensure focus was correct for that audience. Critical role in planning and acquisition of data for inclusion into Part 1 of guideline, along with evaluation of relevance to project. Part 1 and 2 final manuscript editing and approval. KJ (Transplant co-ordinator) provided section on the Transplant co-ordinator and then gave critical input for aspects on process of organ selection along with RP (below). Critical role in planning and acquisition of data for inclusion into guideline, along with evaluation of relevance to project. Final manuscript editing and approval JL (consultant transplant hepatologist) co-authored the section on 'How to refer' and provided editorial input for part 2. Critical role in planning and acquisition of data for inclusion into guideline, along with evaluation of relevance to project. Final manuscript editing and approval SM (consultant transplant hepatologist) co-authored the section on 'How to manage the patient on the waiting list' bringing together the co-ordinators input with the transplant centre and the interaction with secondary care referring centre. Providing insights from both sides of the secondary/tertiary care interaction and then editing the initial contribution of the section to a more manageable section. Ensuring relevance of data collected for the project along with final manuscript editing and approval KM (consultant transplant surgeon) contributed to the section in part 2 on Transplant surgery and outcomes. KM also provided input in Part 1 into section on Transplant assessment and previous surgery. Critical role in planning and acquisition of data for inclusion into guideline, along with evaluation of relevance to project. Final manuscript editing and approval DM (consultant transplant surgeon) co-authored the section on Transplant surgery with KM and post-transplant surgical complications. He also provided input in Part 1 into section on Transplant assessment and previous surgery. Critical role in planning and acquisition of data for inclusion into guideline, along with evaluation of relevance to project. Final manuscript editing and approval JN (consultant transplant hepatologist) wrote the section on Post-Transplant Immunosuppression with the aid of A Considine. Prof Neuberger also contributed to the Part 1 in editorial role, when he helped with the original concept, he provided a critical role following the original guideline production and prior to it’s splitting into two halves (Part 1 and 2) and ensuring correct focus was maintained when the manuscript was reduced in size. RP (consultant transplant surgeon) wrote the section on organ allocation and donation. He also made a significant contribution to the post-operative care and complications sections and the pre-op evaluation (Part 1). Critical role in planning and acquisition of data for inclusion into guideline, along with evaluation of relevance to project. Final manuscript editing and approval AP (Liver Pharmacist) contributed to Part 2 immunosuppression section, but also gave useful input into Part 1 and 2 from point of view of medication and drug interactions, particularly with viral hepatitis treatment. Critical role in evaluating data for inclusion into guideline, along with maintain relevance to project. Final manuscript editing and approval WP (Consultant in Palliative Care) authored the section on Palliative Care and Transplantation in Part 1. Her contribution in Part 2 was proof-reading and providing critical input. Critical role in planning and acquisition of data for inclusion into guideline, along with evaluation of relevance to project. Final manuscript editing and approval LS is a Transplant co-ordinator. She contributed to the section on How to refer a patient for liver transplant (Part 1) and gave input into section on Organ allocation (Part 2). Critical role in planning and acquisition of data for inclusion into guideline, along with evaluation of relevance to project. Final manuscript editing and approval KS (consultant transplant hepatologist) wrote the section on 'When to refer' in Part 1, but also gave significant editorial input to entire project, at the time of the section merge and subsequent division into two halves. Critical role in planning and acquisition of data for inclusion into guideline, along with evaluation of relevance to project. Final manuscript editing and approval DT and RW (consultant transplant hepatologists) co-authored the section on Transplant outcomes. They provided critical input into Part 1 as well, with respect to referral process. Critical role in planning and acquisition of data for inclusion into guideline, along with evaluation of relevance to project. Final manuscript editing and approval. DT (consultant transplant hepatologist) co-authored the section on Postoperative care and complications (non-surgical). DT also supported the entire process by helping the lead author with editing sections and discussion of tables, pictures, deciding on section inclusion, data relevance and final manuscript editing and approval.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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