Transplant Benefit Score

This webapp allows the calculation of a number of tools used in liver transplantation. Click the menu button above for options.

The Transplant Benefit Score (TBS) is a national set of rules used in the UK to offer livers to named adult patients on the elective liver waiting list.

  • Livers are offered nationally to named patient predicted to gain the most survival benefit from receiving the particular liver graft on offer.
  • Utility - Need = Transplant benefit
  • The benefit score is calculated by measuring the difference between the area under the waiting list survival curve and the area under the post-transplant survival curve over a 5-year interval.
  • The information in this app is provided as an information resource only, and is not to be used alone for any diagnostic or treatment purpose.

Recipient

Recipient

Cancer

Donor

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Examples: recipient

Examples: donor

Examples: change over time

Selection criteria for adult elective transplantation

  • Selection will be based primarily on risk of death without a transplant. Patients can be considered for elective transplantation if they have an anticipated length of life or survival in the absence of transplantation that is less than that obtained with a liver transplant.
  • All patients selected for the elective adult liver transplant list must have a projected 5-year survival after transplantation of >50%. That figure may change in the future if/when donor numbers alter.
  • Selection will be assessed secondarily on ability of transplantation to improve quality of life.
  • All patients will need to be regularly reviewed to ensure that they continue to meet criteria and have not improved or become too sick to benefit from transplantation.
  • When the clinical situation alters such that a patient no longer meets these criteria, the patient’s name must be removed from the national list.

Selection criteria for chronic liver disease

Patients can be selected if they fulfil one of the following criteria:

  • Projected 1-year liver disease mortality without transplantation of >9%, predicted by a United Kingdom Model for End-Stage Liver Disease (UKELD) score of ≥49. The UKELD score is derived from the patient’s serum sodium, creatinine and bilirubin and International Normalised Ratio (INR) of the prothrombin time.
  • Patients with porto-pulmonary hypertension (mean PAP >25 mmHg, <50 mmHg; PVR >120 dynes/s/cm-5; PCWP <15 mmHg) should have had a clinically significant response to one of long-acting prostacyclin (or analogues), sildenafil, or bosentan.

References

Version 0.11
Code on Github
Bugs / feature requests
NHSBT Liver selection policy 18/07/2018
MELD
UKELD
MELD-Na

The information in this app is provided as an information resource for clinicians, and is not to be used for any diagnostic or treatment purposes.

© Surgical Informatics, University of Edinburgh | Scottish Liver Transplant Unit 2022

Acute liver failure

ALD selection criteria

Category 1

  • Aetiology: Paracetamol poisoning:
    • pH <7.25 more than 24 hours after overdose and after fluid resuscitation.

Category 2

  • Aetiology: Paracetamol poisoning: Co-existing:
    • Prothrombin time >100 seconds or INR >6.5, AND
    • Serum creatinine >300 μmol/l or anuria, AND
    • Grade 3–4 encephalopathy

Category 3

  • Aetiology: Paracetamol poisoning:
    • Significant liver injury and coagulopathy following exclusion of other causes of hyperlactatemia (e.g. pancreatitis, intestinal ischemia) after adequate fluid resuscitation.
    • Arterial lactate >5 mmol/l on admission, AND
    • Arterial lactate >4 mmol/l 24 hours later, AND
    • Presence of clinical hepatic encephalopathy.

Category 4

  • Aetiology: Paracetamol poisoning: Two of the following three criteria (category 2) AND clinical evidence of deterioration (e.g. increased ICP, FiO2 >50%, increasing inotrope requirements) in the ABSENCE of clinical sepsis.
    • Prothrombin time >100 seconds or INR >6.5, AND
    • Serum creatinine >300 μmol/l or anuria, AND
    • Grade 3–4 encephalopathy

Category 5

  • Aetiology: Favourable non-paracetamol aetiologies such as acute viral hepatitis or ecstasy/cocaine induced ALF:
    • Clinical hepatic encephalopathy is mandatory AND
    • Prothrombin time >100 seconds, or INR >6.5, OR
    • Any three from the following:
      • Age >40 or <10 years
      • Prothrombin time >50 seconds or INR >3.5
      • Any grade of hepatic encephalopathy with jaundice to encephalopathy time >7 days
      • Serum bilirubin >300 μmol/l.

Category 6

  • Aetiology: Unfavourable non-paracetamol aetiologies such as seronegative or idiosyncratic drug reactions:
    • Prothrombin time >100 seconds, or INR >6.5, OR
    • In the absence of clinical hepatic encephalopathy:
      • INR >2 after vitamin K repletion is mandatory AND any two from:
        • Age >40 or <10 years
        • Prothrombin time >50 seconds or INR >3.5
        • If hepatic encephalopathy is present then jaundice to encephalopathy time >7 days
        • Serum bilirubin >300 μmol/l.

Category 7

  • Aetiology: Acute presentation of Wilson’s disease, or Budd-Chiari syndrome.
    • A combination of coagulopathy, and any grade of encephalopathy.

Category 8

  • Hepatic artery thrombosis on days 0 to 21 after liver transplantation

Category 9

  • Early graft dysfunction on days 0 to 7 after liver transplantation with at least two of the following:
    • AST >10,000
    • INR >3.0
    • Arterial lactate >3 mmol/l
    • Absence of bile production

Category 10

  • The total absence of liver function (e.g. after total hepatectomy)

Category 11

  • Any patient who has been a live liver donor (NHS entitled) who develops severe liver failure within 4 weeks of the donor operation

Category 20

  • Acute liver failure in children under two years of age:
    • INR >4 OR
    • Grade 3-4 encephalopathy.

References

Version 0.11
Code on Github
Bugs / feature requests
NHSBT Liver selection policy 18/07/2018
MELD
UKELD
MELD-Na

The information in this app is provided as an information resource for clinicians, and is not to be used for any diagnostic or treatment purposes.

© Surgical Informatics, University of Edinburgh | Scottish Liver Transplant Unit 2022

HCC

HCC selection criteria

Radiological assessment should include both MDCT and MRI with size being assessed by the widest dimensions on either scan. A tumour (for the purposes of counting numbers) will require to be identified as an arterialised focal abnormality with portal phase washout on MDCT or Gd enhanced MR. Other tumours are considered indeterminate and do not count.

Tumour rupture and an α-fetoprotein (AFP) >1,000 iu/ml are absolute contraindications to transplantation, as are extra-hepatic spread and macroscopic vascular invasion.

The following are criteria for transplantation listing:

  • A single tumour ≤5cm diameter, OR
  • Up to 5 tumours all ≤3cm, OR
  • Single tumour >5cm and ≤7cm diameter where there has been no evidence of tumour progression, no extra-hepatic spread and no new nodule formation over a 6- month period. Locoregional therapy +/- chemotherapy may be given during that time. Their transplant list place may be considered from the time of their first staging scan.

Locoregional therapy should be considered for all transplant list patients who have a hepatocellular carcinoma.

It is recognised that different imaging modalities may identify differences both in number and size of tumour, but to qualify as an HCC will require a congruent lesion to be seen on a minimum of two different radiological modalities. There must be no radiological evidence of vascular invasion and no distant metastasis.

References

Version 0.11
Code on Github
Bugs / feature requests
NHSBT Liver selection policy 18/07/2018
MELD
UKELD
MELD-Na

The information in this app is provided as an information resource for clinicians, and is not to be used for any diagnostic or treatment purposes.

© Surgical Informatics, University of Edinburgh | Scottish Liver Transplant Unit 2022

Variant syndromes

UKELD score must be <49:

Hepatopulmonary syndrome

Arterial pO2 <7.8, alveolar arterial oxygen gradient >20 mmHg, calculated shunt fraction >8% (brain uptake following TC macroaggregated albumen), pulmonary vascular dilatation documented by positive contrast enhanced transthoracic echo, in the absence of overt chronic lung disease

Persistent and intractable pruritus

Pruritus consequent on cholestastic liver disease, which is intractable after therapeutic trials. Exclude psychiatric co-morbidity that might contribute to the itch. Lethargy is not an accepted primary indication for orthotopic liver transplantation.

Recurrent cholangitis

Recurrent significant cholangitis not responsive to medical, surgical or endoscopic therapy.

Variant syndromes

UKELD score can be greater than 49:

Familial amyloidosis

Confirmed transthyretin gene mutation in the absence of significant debilitating cardiac involvement, or autonomic neuropathy.

Primary hyperlipidaemia

Homozygous familial hypercholesterolaemia.

Polycystic liver disease

Intractable symptom due to mass of liver or pain unresponsive to cystectomy, or severe complications secondary to portal hypertension.

Hepatic epithelioid haemangioendothelioma

Considered for listing for transplantation with:
  1. Histological confirmation
  2. Two or more lesions not amenable to resection
  3. Local, low volume lymph node involvement does not necessarily preclude transplantation
  4. Minimum observation period of three months

Nodular regenerative hyperplasia

Indications similar to end-stage cirrhotic liver disease:
  • Hereditary haemorrhagic telangiectasia
  • Glycogen storage disease
  • Primary hyperoxaluria
  • Ornithine transcarbamylase deficiency
  • Maple syrup urine disease
  • Porphyria
  • Amyloidosis – other

Variant syndrome in context of chronic liver disease

Patients with diuretic resistant ascites and/or chronic hepatic encephalopathy, for whom their UKELD score at registration may be <49. These cases will be registered under the chronic liver disease criterion in the elective liver patient registration form.

Diretic resistant ascites

Ascites unresponsive to or intolerant of maximum diuretic dosage and nonresponsive to TIPS or where TIPS deemed impossible or contraindicated.

Chronic hepatic encephalopathy

Confirmed by EEG or trail-making tests, with at least two admissions in one year due to exacerbations in encephalopathy, not manageable by standard therapy. Structural neurological disease must be excluded by appropriate imaging and, if necessary, psychometric testing.

References

Version 0.11
Code on Github
Bugs / feature requests
NHSBT Liver selection policy 18/07/2018
MELD
UKELD
MELD-Na

The information in this app is provided as an information resource for clinicians, and is not to be used for any diagnostic or treatment purposes.

© Surgical Informatics, University of Edinburgh | Scottish Liver Transplant Unit 2022