• Pre-Transplant
• Waiting
• Admission
• Post-Transplant

Patients may be referred for consideration as a candidate for liver transplantation, either through self referral or by their physician; which may be a Primary Care Provider (PCP) or a specialist.

To self refer a patient should call 1-800-395-6431, select the option for a liver evaluation appointment, and ask to speak with a transplant coordinator with the Liver Transplant Program. The transplant coordinator will discuss several topics with a potential patient, such as why an evaluation is being requested, the patient's medical and social history. Patients who self-refer are expected to have copies of their medical information sent to the transplant coordinator prior to an appointment being scheduled.

If a physician's office calls to make the referral, they will speak with a transplant coordinator who will request copies of the patient's medical records. The transplant coordinator will then contact the patient to discuss the patient's medical and social history. Once those conversations have occurred and the medical records have been received the patient will be scheduled for an evaluation appointment. Upon the scheduling of an evaluation appointment the Financial Counselor begins the work of verifying insurance coverage, benefit levels and authorization requirements. For an explanation of the insurance and financial aspects of transplantation see Financial Aspects.

Appointments for liver transplant evaluations are scheduled for Monday and Friday mornings. The evaluation appointments take place on the second floor of the outpatient building (Taubman Center) in clinic area F. A map with detailed instructions will be mailed to you prior to your appointment date.

A liver evaluation appointment is actually a series of visits with several specialists and other members of the transplant team, generally all occurring on the same day. During the evaluation appointment the patient generally meets with several members of the transplant team including a transplant coordinator, transplant hepatologist, social worker, transplant nurse, and, perhaps, a surgeon. Each member of the team has a specific role on the team and provides a distinct service for the patient. Please refer to staff teams for a summary of the teams and their roles in the transplant process. During the evaluation many topics are covered with the patient by the various members of the transplant team. The social work team will review with the patient issues such as transportation, substance abuse, and support systems through the transplant process. The patient will be provided with a substance abuse policy and will be asked to sign a contract stating their agreement to abstain from alcohol and illegal drugs.

The testing required to assess whether a patient is an appropriate candidate for a liver transplant is quite extensive, see Medical tests. Many of the initial tests are ordered and performed during the day of evaluation. However, some tests must be scheduled on other dates. Often additional tests are ordered following the physician's review of the initial test findings. Tests that are routinely ordered prior to transplantation may include:

• Chest Xray
• Liver Ultrasound
• CAT Scan
• Dobutamine Echo
• MRI
• PPD and Candida
• Dental Exam
• Pulmonary Function Test (PFT)
• Mammogram (for females)
• Pap Smear (for females)

Patients are expected to take the initiative to complete the testing. Patients are encouraged to complete their testing in medical facilities close to their homes. The results of tests performed at non-UMHS facilities can be sent to the transplant coordinator who will coordinate getting the result reviewed.

Following the transplant evaluation visit, the transplant coordinator gathers the information collected through the evaluation process and prepares to present the data at a multidisciplinary conference where all potential transplant patients are reviewed. The multi-disciplinary team consists of representatives from each of the staff and faculty teams the patients see during the evaluation appointment. The committee reviews the information gathers, determines whether any further testing or preparatory actions are necessary, and whether the specific conditions meet the criteria for the patient to be listed for an organ. The committees recommendations may include: a) defer listing at this time, usually to require additional medical testing, b) defer listing at this time due to substance abuse history and need for substance abuse education, c) to proceed with listing a patient for an organ, or d) to decline to list the patient for an organ, usually due to the severe health of the patient.

If a patient is to be listed for an organ, they will be assigned a (Model for End Stage Liver Disease) MELD score. This score encompasses certain laboratory tests and is designed to provide livers to those patients who are in the most need. Patient MELD scores fluctuate based on the patient's current lab values. Patients with the highest MELD are allocated livers first in this system. Since the national transition to the MELD system in 2002, the amount of time spent waiting on the list for a liver is not as crucial as it once was.

Once the multi-disciplinary transplant team determines that a patient is approved to be listed for a transplant, the coordinator begins the process of placing the patient on the wait list. Throughout the pre-transplant process the Financial Counselor has been working with the patient and the insurance carrier(s) to obtain the necessary authorizations for transplantation. Generally, the goal is to have the steps outlined in Financial Aspects finalized at the same time as the committee decision to list. Occasionally, listing is delayed somewhat pending approval from the patient's insurance carrier. The patient will receive notification of the transplant team's decision by mail. Each patient needs to identify at least one or two support persons to assist them through the transplant process.

Once the evaluation is complete and the patient has been cleared for listing by the transplant team, the patient will be placed on the wait list with their personal MELD score. While wait time is no longer a determining factor in allocating livers to potential recipients; it is true that wait time varies based on factors of blood type, MELD scores and body size. Patients with blood group B generally wait longer than those with blood group A or O. This is due to the lower frequency of these blood groups in the donor pool.

While awaiting transplant, patients are seen in the UMHS liver clinic at least every 3 to 6 months. The frequency of these visits will vary based on active medical issues and complications of liver failure. Blood work will also be obtained every 1 to 3 months to assess liver disease severity and to recalculate MELD scores. During these visits it is important to provide the liver transplant team with any changes in your contact information (including home address and telephone number), insurance or caregivers.

While on the transplant waiting list, patients will continue to be seen by their local doctors for ongoing treatment of general medical problems such as diabetes and high blood pressure. Any major changes in health status including new medical problems, medications, hospitalizations, or test results should be communicated to the transplant team.

To remain active on the list, patients must keep up with the listing requirements. Listing requirements include submission of routine blood samples for antibody monitoring, scheduling visits to the University of Michigan transplant clinic, and follow up testing as requested. If these requirements are not met, the patient's status on the list will be changed to 'inactive'; which will cause a delay in getting a transplant. It is in the patient's best interest to actively participate with the transplant team to ensure their medical results remain current while they are on the wait list. Other situations that may cause a patient to be placed on hold, include, but are not limited to, severe infections, stroke, heart attack, and operations. It is crucial for patients to keep the transplant team informed of any health changes or changes in their insurance.

Liver disease due to alcohol and hepatitis C infection are the leading causes of liver failure in the United States. Not surprisingly, these two diseases are also the most common indications for liver transplantation. Since alcohol and illicit drugs can damage the liver, it is very important that all liver transplant candidates completely abstain from these substances both before and after transplantation. The UMHS Liver Transplant Program has developed a substance abuse policy that all adult patients are required to read, sign, and follow both before and after transplantation regardless of prior use or non-use of alcohol and illicit substances. The written policy is explained to all patients and their families during their pre-transplant evaluation clinic visit. The policy strictly forbids the use of any alcohol and illegal or illicit drugs including cocaine and marijuana both before and after transplantation. In addition, the program reserves the right to randomly screen liver transplant candidates and recipients for illicit substances at any time. Listed patients who violate this program policy will have their listing status immediately changed to "inactive". Upon further investigation, those with documented non-compliance to our written policy will be removed from the list.

Prior to transplant listing, most patients with a history of substance abuse will be required to undergo inpatient or outpatient substance abuse counseling, rehabilitation, or treatment. Specific recommendations and referrals will be made on an individual basis. All patients recommended to undergo these treatments will be responsible for following up with the transplant team to insure that all rehab and treatment goals have been met.

Changes in a patient's medical or social status may result in the patient's status on the list being changed to 'inactive' for liver transplantation. During a period of time being "inactive", patients will temporarily not be eligible to receive a liver until the issues have been resolved. Common reasons for an "inactive" status include development of infections such as pneumonia requiring antibiotics or new medical problems such as a heart condition that may increase the risk of transplantation. In addition, changes in insurance, relocation, travel, or family support may lead to temporary "inactive" status.

Reactivation on the transplant list requires reevaluation by a transplant team member either over the phone or in the clinic. Once the patient has been cleared for reactivation, updated labs will be required to calculate the patient's MELD score. Therefore, it is very important to notify the transplant team immediately of any changes in insurance, medical or social status that may impact transplantation.

The allocation of donor livers is based upon matching a suitable donor organ to a blood type compatible recipient with the highest MELD score. However, a minority of liver transplant candidates with life-threatening complications of liver failure may have a higher risk of death than is reflected in their laboratory MELD score. Under these circumstances, patients may receive a higher "Exception" MELD score if approved by our liver transplant team and members of the UNOS regional review board. Common reasons for petitioning for a higher "Exception" MELD score include the development of liver cancer, low oxygen levels in the blood, and recurrent fluid accumulation in the chest cavity. The transplant team will monitor all listed patients closely for these complications at their clinic visits and petition for a higher "Exception" MELD score when medically indicated. Of note, common complications of liver failure such as fluid retention in the abdomen or legs, confusion, internal bleeding, or infections do not allow for upgrade on the transplant waiting list.

Allocation of donor organs is based on MELD score, blood type, and body size. Once a potential organ donor is identified, a transplant coordinator will contact the recipient by telephone and instruct them not to eat or drink anything. The patient will be advised to come to the University of Michigan Medical Center in Ann Arbor as soon as possible. It is important that patients organize travel plans ahead of time to hasten arrival at the hospital. For patients that live at a great distance from our center, the liver transplant social workers may assist with planning for transportation and nearby housing.

Upon arrival at the hospital, the patient will have a brief examination, blood tests, an EKG and chest X-ray. Research coordinators may discuss with the patient and their family possible enrollment in liver transplant study protocols. Although all patients are encouraged to enroll into studies, participation is entirely voluntary and lack of participation will not impact in any way the quality or type of care a patient receives in our center.

Once the donor liver has been confirmed to be suitable, arrangements will be made to proceed with the recipient operation at the University of Michigan. Most liver transplants take four to six hours to complete, however, some may take longer. The diseased liver along with the gallbladder will be removed in entirety and the new liver is placed in position. Many patients receive transfusions of blood products during and after the surgery. Once the operation is complete, the transplant surgeon will discuss the results with family members.

Family members have several options for housing while in Ann Arbor for the operation and hospitalizations. These options include a hotel located on the medical campus (Med Inn, 800-544-8684) and the nearby Transplant House but reservations need to be arranged through our social workers ahead of time for the Transplant House. The social workers can also provide additional information regarding temporary housing and local hotels in the area.