Pulmonary contraindications, indications and MELD exceptions for liver transplantation: A contemporary view and look forward

Pulmonary concerns in liver transplant candidates have intraoperative and outcome implications. Evolving MELD exception policies address transplant priority for problems such as hepatopulmonary syndrome, portopulmonary hypertension, and hemorrhagic hereditary telangiectasia. Other pulmonary issues such as refractory hepatic hydrothorax, advanced chronic obstructive lung disease (including alpha-1 antitrypsin deficiency) and indeterminate pulmonary nodules may affect liver transplant consideration. Herein, we discuss current pulmonary-related contraindications, indications and MELD exception policies for liver transplantation, suggesting future considerations. Severity and natural history of pulmonary abnormalities may present increased, as well as unacceptable risk for liver transplantation (LT), thus be considered contraindications to LT [1]. However, resolution of certain pulmonary disorders following LT suggests these abnormalities may be appropriate pulmonary indications for LT and should merit higher LT priority to prevent morbidity and mortality [2]. With the inception of the Model of End-Stage Liver Disease (MELD) score in 2002 to prioritize allocation of deceased donor livers, and the recent (December 13, 2012) standardized MELD exception policy (http://optn.transplant.hrsa.gov policy 3.6.4.5), the importance of selected pulmonary issues has been magnified. Therefore, it is instructive to identify the spectrum of pulmonary abnormalities that pose the greatest LT risk and their potential reversibility. The current MELD exception policies (or lack thereof) concerning these pulmonary issues are addressed and future pulmonary considerations are suggested. The major pulmonary concerns that arise in liver transplant candidates discussed in this contemporary view are shown in Table I. (C) 2013 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.