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Before Transplant

Pretransplant Referral

Referring physicians, insurance case managers and other transplant centers can make a referral for a patient to be evaluated for transplantation appropriateness at Ohio State’s Medical Center. Here are some of the steps in the pretransplant referral process:

  1. The referring party is responsible for providing the coordinator with all applicable medical information according to the transplant referral protocol provided at time of referral.
  2. You will need to notify your insurance company before making your initial evaluation appointment. Our pretransplant office and hospital business office will work with you to determine insurance availability and precertification requirements.
  3. Pretransplant coordinators and business office staff then work together to meet insurance company requirements for evaluation and transplant procedure approval.
  4. Transplant hepatologists, pretransplant nurse practitioners or coordinators evaluate each patient referred to the Liver Transplant Program to determine how soon you need to be seen for an evaluation. You could be transferred, admitted or scheduled for an outpatient evaluation visit within several days or weeks.

Evaluation

During your outpatient clinic evaluation visit, our goal is to have all the pretransplant initial testing, lab work (including tissue typing) and an array of clinical testing, education, surgeon interview and social work consultation (see Psychosocial Evaluation below) completed in one day.

This patient evaluation is then reviewed at the weekly liver transplant patient selection meeting attended by a multidisciplinary team to include:

  • Transplant hepatologist
  • Transplant surgeon
  • Pretransplant coordinator
  • Pretransplant nurse practitioner
  • Transplant infectious diseases
  • Transplant clinical psychologist
  • Transplant social worker

Psychosocial Evaluation

Every patient being evaluated for liver transplant will have a psychosocial assessment with a social worker. The purpose of this evaluation is to help determine if a transplant candidate has the psychological stability, motivation and personal support to meet the challenges of transplantation. Before the appointment, you will complete a psychosocial survey that will be reviewed during the evaluation.

The assessment will cover:

  • your insurance coverage and ability to afford surgical and medication expenses.
  • your support system, (including primary and secondary caregivers)
  • knowledge of the transplant process and  coping skills required to deal with the stress of the waiting period, hospitalization and recovery
  • psychiatric history  including any current psychiatric problems
  • track record of compliance with medical appointments and medications
  • chemical dependency

All patients must meet the chemical dependency requirements of the State of Ohio Solid Organ Transplant Consortium. The use of tobacco, alcohol and/or illicit drugs is carefully examined. Patients who meet criteria for alcohol or drug dependence must undergo at least three months of rehabilitation and demonstrate three months of abstinence before listing. If further chemical dependency evaluation is warranted it will be conducted by the clinical psychologist, Talbot Hall or another licensed facility.

Sometimes patients are referred to see a transplant psychologist, for further assessment of any psychological factors that may interfere with transplant outcome.

After the psychosocial  evaluation is complete, a report is written and sent to the team with a recommendation about your suitability for transplant from a psychosocial perspective.

Following initial testing, the transplant team evaluates the information gathered and determines whether transplantation is appropriate. We will also determine what additional information is needed prior to placing you on the transplant list. These tests are customized based on your history and conditions, thus avoiding unnecessary testing and costs. It is preferred that these tests be completed at Ohio State’s Medical Center, but depending on your geographic location or payer preference, they may be completed closer to your home.

Education

During the pretransplant clinic visit, you will take part in a comprehensive education program that details the surgical procedure, medications, recovery and rehabilitation associated with the transplant process. The main focus is on educating you and your  family about the following:

  • patients' responsibilities and role in the process
  • what happens clinically during surgery and recovery
  • potential complications
  • lifestyle modifications
  • drug therapy
  • cost factors
  • support groups
  • further evaluation

After your evaluation is complete, we will send follow-up letters to the referring physician and your insurance company. A referral could be made to Cardiology, Pulmonary, Infectious Disease or other services as warranted.

Approval

If approved for transplant listing, the final step involves approval by the Liver Patient Selection Committee and then by Ohio Solid Organ Transplantation Consortium (OSOTC). The OSOTC has a committee comprised of representatives from other transplant programs and other members who approve all patients for liver transplant listing in the state of Ohio. When approved by the OSOTC, you are then listed for liver transplantation on the United Network for Organ Sharing (UNOS) national waiting list. A letter is sent to your insurance company providing recommendations for transplantation and requesting approval.

The process for prioritizing candidates waiting for liver transplant is based on each person’s Model for End Stage Liver Disease (MELD) score. The MELD system, developed by UNOS, gives each person a numeric score based on results of three lab test results:

  • bilirubin (measures how effective the liver excretes bile)
  • INR/prothrombin time (measures the liver’s ability to make blood clotting factors)
  • creatine (measures kidney function)  

While you are waiting for your transplant, your labwork will be done and MELD score calculated weekly to monthly as determined by UNOS requirements.

Waiting

Please be prepared to wait as long as several months, because, although the number of patients waiting for a liver transplant has increased dramatically, the number of available donor livers has not. In addition, the donor must have a blood type compatible with your own and be similar in body weight and size. Each potential donor also must be screened very carefully for disease, infection or trauma to ensure that you receive a healthy liver.

The length of time waiting for a liver transplant depends on your medical condition as evidenced by your MELD score and other factors including your blood type, donor availability and your size.

While waiting, you will be seen in hepatology or the transplant clinic every three to six months depending on your medical condition and MELD score. You will continue to be followed by your primary care physician and other specialists until transplantation takes place.

For more information, please view During Your Transplant.