Sunday 17 October 2021  

1 Criteria for establishment of a liver transplant center


The SCOT through its specialized committees has laid down certain criteria for establishment of liver transplant centers in Saudi Arabia. They include:

 

1.1 Working staff:

1.1.1 Consultants in liver transplantation:

1.1.1.1 Surgeons.

At least one consultant transplant surgeon experienced in hepatobiliary surgery with a minimum of one year’s experience from a recognized liver transplant center internationally.

1.1.1.2 Hepatologists.

At least one consultant hepatologist with a minimum of one year’s experience from a recognized liver transplant center internationally.

1.1.1.3 Pediatric gastroenterologists.

At least one consultant pediatric gastroenterologist with a minimum of one year’s experience from a recognized liver transplant center internationally.

1.1.2 Anesthesia consultant.
At least one consultant anesthesiologist with a minimum of 6 months experience from a recognized liver transplant center.
1.1.3 An ICU consultant.
1.1.4 A dietitian.
1.1.5 An infectious disease consultant.
1.1.6 A transplant coordinator.
9.1.1.7 Nursing staff.

They should be well trained with experience in taking care of patients during and after liver transplantation.

1.2 Technical equipment:
1.2.1 The hospital in which the liver transplant center will be established should have the following departments:
Cardiology, Endoscopy, Radiology, Hematology and blood bank, Pathology, Biochemistry laboratory, Nephrology with hemodialysis unit, ICU facility, Immunology, Chest diseases, Psychiatry, Physio-therapy, Microbiology laboratory.

1.2.2 The hospital should contain two operating rooms containing all the necessary equipment for liver transplantation and especially:
Thromboelastrogram, Cell saver machine, Rapid infusion system, Venevenous by-pass machine, Infra-red coagulator or equivalent, Blood warmer, Technicians needed to operate these machines should be available.

 

1.3 Support Services:
1.3.1 Laboratory.
1.3.1.1 Routine laboratory services, including pre- and post-transplant work-up.
1.3.1.2 HLA typing, cytotoxic antibodies, drug levels of cyclosporine and similar drugs.
1.3.2 Radiology.
1.3.2.1 The following tests should be available in the hospital or the center:
Conventional X-ray facility, ultrasound with the availability of a portable machine, Doppler ultrasonography, isotope scan, angio-graphy, CT scan, and percutaneous transhepatic cholangiography.

1.3.3 Endoscopy department.
1.3.3.1 This department should have all diagnostic and therapeutic facilities, including Endoscopic Retrograde Cholangio Pancreateo-graphy (ERCP).

 

1.4 Drugs.

The following drugs should be permanently available in the center:
1.4.1 Immunosuppressive drugs.
· Cyclosporine,
TACROLIMUS (FK 506)
· Azathioprine,
MYCOPHENOLATE MOFETIL (MMF)
· Prednisolone,
· Sirolimus,
(RAPAMYCIN)
· Other similar drugs.

1.4.2 Drugs used to treat acute rejection episodes such as methyl-prednisolone, anti-lymphocyte globulin or anti-thymocyte globulin, and monoclonal antibodies.
1.4.3 Perfusion fluid such as Eurocollins solution or Wisconsin University solution and HTK solution.
1.4.4 Drugs to treat bacterial, viral, fungal, or parasitic infections.

 

2 Indications and contra-indications for liver transplantation

2.1 Indication for liver transplantation

The SCOT, through its scientific committee has established situations in which a liver transplant could be performed.

2.1.1 Fulminant hepatic failure resulting from:
2.1.1.1 Viral hepatitis.
A, B, C, D, EBV, CMV.

2.1.1.2 Drug-induced liver disease (Halothane, Disulfiram, Acetaminophen, Others.
2.1.1.3 Metabolic liver disease.
2.1.1.4 Wilson’s disease.
2.1.1.5 Reye’s syndrome.
2.1.1.6 Massive hepatic trauma.
2.1.1.7 Others.
2.1.2 Advanced chronic liver diseases such as:
2.1.2.1 Primary biliary cirrhosis.
2.1.2.2 Primary sclerosing choloangitis.
2.1.2.3 Biliary atresia.
2.1.2.4 Idiopathic autoimmune hepatitis.
2.1.2.5 Chronic alcoholic cirrhosis.
2.1.2.6 Chronic toxic hepatitis.
2.1.2.7 Chronic viral hepatitis.
2.1.2.8 Vascular disease, e.g. Budd-Chiari syndrome, Veno-occlusive diseases.
2.1.3 Inherited metabolic disorders such as:
2.1.3.1 α-1 antitrypsin deficiency.
2.1.3.2 Wilsons disease.
2.1.3.3 Crigler-Najjar syndrome.
2.1.3.4 Glycogen storage.
2.1.3.5 Protein C deficiency.
2.1.3.6 Oxalosis.
2.1.4 Localized liver tumors such as:
2.1.4.1 Primary hepatocellular carcinoma.
2.1.4.2 Other liver tumors.
2.1.4.3 Isolated hepatic metastatic disease, e.g., Carcinoid.
(Appendix 20: Investigations for evaluation of chronic liver disease for liver transplantation)

 

2.2 Contraindications for liver transplantation
2.2.1 Absolute contraindications:
2.2.1.1 Active extra-hepatobiliary infections.
2.2.1.2 Extra-hepatic malignancy.
2.2.1.3 AIDS.
2.2.1.4 End-stage cardiac or pulmonary failure.
2.2.1.5 Narcotics or alcohol addiction.
2.2.2 Relative contraindications
2.2.2.1 Age of patients less than 4 weeks and more than 65 years.
2.2.2.2 Active hepatitis B infection.
2.2.2.3 Extensive abdominal surgery.
2.2.2.4 Hepatocellular carcinoma more than 5 cm in size or multifocal carcinoma more than 3 cm in size.
2.2.2.5 Cholangiocarcinoma.

 

3 Priority criteria for liver transplantation

 

3.1 The SCOT through its specialized committee has laid down priority criteria for liver transplantation as follows:

3.1.1 An ICU patient who is intubated and on mechanical ventilation (status 4). This patient has absolute priority and the status should be evaluated weekly.
3.1.2 ICU patient, not on ventilator (status 3).
3.1.3 Hospitalized (status 2).
3.1.4 At home (status 1).
3.1.5 If the patient has a relative contra-indication (status 0), his condition should be re-evaluated after the relative contraindication resolves.

 

3.2 Distribution of liver allografts

The liver allografts are distributed as follows:
3.2.1 Each liver transplant center establishes a local waiting list and sends it to the SCOT, which in turn establishes a national waiting list according to the priority criteria mentioned above.
3.2.2 Liver transplant centers should report the names of patients requiring urgent liver transplantation to the SCOT so that they are enlisted on a special urgent waiting list.
3.2.3 The liver is distributed according to priority, period on the waiting list, and blood group according to the preset conditions. The center to which the liver is to be allocated has to reply to the SCOT within two hours its decision to accept the allograft or decline. In case of acceptance, the liver transplant center has the task of performing the retrieval of the liver.

 

4 Criteria for living liver donation

4.1 The donor should be sound physically and stable psychologically.
4.2 Donor age should be not less than 18 years and not more than 45 years.
4.3 Donor and recipient should be blood group (ABO) compatible.
4.4 Liver function should be normal and the donor should be negative for HBs Ag and HCV Ab.
4.5 The donor should not be addicted to narcotics or alcohol and should not be taking drugs that are toxic to the liver.