Who should get a transplant?

[diane227, LPN, RN]

Where is the cut off for a transplant? We have a guy in our unit right now, 54 year old alcoholic who has end stage liver disease. He continues to smoke and I suspect he is still drinking. Do you think he should be able to get a transplant?

[WalkieTalkie, RN]

No, if he is still smoking or drinking. Has he been evaluated yet?

[NotReady4PrimeTime, RN]

I think you'll find that most tranpslant centres wouldnot refuse him a transplant. The University of Maryland's take is:

Alcoholic Cirrhosis: Patients with alcoholic cirrhosis are considered for transplant if they meet current criteria for abstinence and rehabilitation.

• Abstinence of alcohol for six months.
  
• Ongoing participation in formal alcohol treatment program.
  
• Presence of adequate psychosocial supports as determined by social service and psychiatry consultants.
  

Patients who do not meet the above criteria at the time of referral will be given the opportunity to fulfill these criteria and undergo re-evaluation. Formal input from the psychiatry staff is required to assess the risk of return to alcohol use following liver transplantation.

Contraindications to Liver Transplantation

While each patient is evaluated on an individual basis, the presence of one or more of the following will frequently preclude acceptance as a candidate for liver transplantation

• HIV infection
  
• Active alcohol or substance abuse
  
• Systemic infections
  
• Life limiting co-existing medical conditions: advanced heart, lung or neurologic conditions.
  
• Uncontrolled psychiatric disorder
  
• Inability to comply with pre- and post-transplant regimens
  

This is pretty standard around the world.

[RN1982]

Yeah, don't think he'll get a new liver if he continues on with his bad habits.

[blondy2061h, MSN, RN]

I did a clinical rotation on a kidney and pancreas transplant floor. We had a patient who came in s/p kidney transplant with an FK506 (Prograf level) of 0. When questioned on it, he admitted to not having taken his Prograf in 2 weeks. He was asked if he was having trouble affording the meds or getting to the pharmacy. Nope- Medicare pays for the meds, and the pharmacy delievers. He admitted he "just didn't feel like taking them." They did a biopsy to determine if he was rejecting the kidney. Lucky him, he wasn't. That was suppose to be an outpatient procedure, but while there it was discovered that he had a gangrenous foot, probably related to his a1c of 14%. He said he wasn't taking his diabetes medications because "he doesn't have diabetes." He absolutely maintained that he wasn't diabetic and didn't need diabetes medications.

The part that floored me about all this, was that the man was listed for a pancreas transplant shortly after all of this.

[itsmyturn]

No, sorry I can't agree with this.

IMO, I think that people who inflict diseases on themselves as a result of something they knew would do it and ARE still doing it should be denied.

If this man had this problem as a result of smoking/drinking when he was younger and has spent the last twenty years staying away from these bad habits and later on has problems, I would say yes because he reformed and should not be punished because he acted negligent at one time.

But, if I was sitting in front of him and a person that needed the same transplant but had no responsibility for the reason he needed it, then I would give the organ to that person.

All I know is I am thankful I don't have this job and I praise those who work in the ethics departments. Tuff, tuff work.

[Medic2RN, BSN, RN, EMT-P]

What makes you suspect he's still drinking?

[core0]

I think you'll find that most tranpslant centres wouldnot refuse him a transplant. The University of Maryland's take is:

Alcoholic Cirrhosis: Patients with alcoholic cirrhosis are considered for transplant if they meet current criteria for abstinence and rehabilitation.

• Abstinence of alcohol for six months.
  
• Ongoing participation in formal alcohol treatment program.
  
• Presence of adequate psychosocial supports as determined by social service and psychiatry consultants.
  

Patients who do not meet the above criteria at the time of referral will be given the opportunity to fulfill these criteria and undergo re-evaluation. Formal input from the psychiatry staff is required to assess the risk of return to alcohol use following liver transplantation.

There is no absolute standard for alcohol. Most centers use the six month rule but there is actually little evidence to support this. A few centers use one year and some use a short as three months. The support issue is probably the best predictor of recidivism. A number of studies have shown that patients with strong family support systems have higher likelihood of abstaining from alcohol. On the other hand there are almost no programs that would transplant someone who is actively drinking.

Contraindications to Liver Transplantation

• While each patient is evaluated on an individual basis, the presence of one or more of the following will frequently preclude acceptance as a candidate for liver transplantation
  

• HIV infection
  
• Active alcohol or substance abuse
  
• Systemic infections
  
• Life limiting co-existing medical conditions: advanced heart, lung or neurologic conditions.
  
• Uncontrolled psychiatric disorder
  
• Inability to comply with pre- and post-transplant regimens
  

This is pretty standard around the world.

PTs with HIV are being transplanted at a number of centers with good results.

Listing a patient for transplant is a long process. There are a number of hoops to jump through. These hoops become barriers for patients that would not do well after transplant. For example if someone is unable to keep appointments or follow instructions before transplant then they probably can't after transplant. Most programs have a pretty extensive system for assessing the patient prior to transplant and deciding which one will be a good candidate.

David Carpenter, PA-C

[tlh65]

My brother had alcoholic cirrhosis. He met all the requirements for transplant, was in an ICU bed for 2 months before a liver was found for him. He had a successful transplant (liver) almost 5 years ago. He has not had a single drop of alcohol since then and is doing wonderfully. I thank God everyday that he wasn't denied because he had had an alcoholic history only 6 months before that.

[BabyLady, BSN, RN]

I personally do not believe in drug addicts and alcoholics receiving organ transplants unless in the very rare case that the organ would otherwise go to waste.

That is where they sure as heck wouldn't want to put me in charge of a program like that.

[tencat]

I have to agree that if you trash your liver with alcohol and/or drug use, it is very sad, but in NO way should an organ go to such a person. The reason why I think this is because the organs are so precious and few and should be saved for those who have had no control over the diseases that have ruined their own organs. If there were more available, then I'd have no problem with an alcoholic/drug user getting a new liver.

[diane227, LPN, RN]

Because he comes into the hospital with a positive alcohol level.