When to consider liver transplant during the management of chronic liver disease.

The decision to perform liver transplantation for a particular patient is never the decision of one single individual, although a single individual could preclude transplant as an option if the opportunity for referral is missed. Every physician treating patients with cirrhosis, including primary care physicians and primary gastroenterologists, should watch for the essential turning points at which a patient may become eligible for a transplant referral. Timing of referral could be assessed according to either the type of liver disease or non–disease-specific measures of disease severity. Although the MELD score is an easily accessible and convenient tool it is not as well known as CTP classification, and many cirrhotic patients under long-term management may not be being allocated a MELD score regularly calculated by their primary physicians. Because a slow progression in MELD score may occur without a change in symptoms, reaching the MELD score acceptable for transplant referral may go unrecognized. As generalists face the rising prevalence of NAFLD and the rising prevalence of cirrhosis and HCC from HCV, there will be an increasing need for education in the management of liver disease. It will be necessary for specialists and health care systems to better inform primary care physicians about the recommendations on criteria for transplant referral and the critical windows of opportunity within which they can act. Although there is a recognized knowledge gap that needs to be addressed, once a patient is in medical care, inadequate physician knowledge should never be the cause for late timing or missing the opportunity for referral.