Managing Transplant Evaluations

---
name: managing-transplant-evaluations
language: en
description: Guides transplant candidacy evaluation with organ-specific criteria and listing documentation. Use when evaluating transplant candidates, documenting listing criteria, or coordinating transplant workups.
tags:
  - management
  - surgery
  - valuation
metadata:
  author: casemark
  practice_areas:
    - General Surgery
    - Surgical Subspecialties
  document_types:
    - Management Report
  skill_modes:
    - Management
    - Coordination
---

# Managing Transplant Evaluations

Guides transplant candidacy evaluation with organ-specific criteria and listing documentation.

## Why This Skill Exists

Organ transplantation is the definitive treatment for end-stage organ failure, but the gap between organ supply and demand means transplant programs must rigorously evaluate candidates to ensure the best use of scarce donor organs. UNOS (United Network for Organ Sharing) and CMS Conditions of Participation for Transplant Programs mandate comprehensive, multidisciplinary evaluation with standardized documentation. CMS conducts outcome-based reviews of transplant programs, and programs with outcomes significantly worse than expected face decertification — removing them from the transplant network.

The transplant evaluation is one of the most complex assessments in medicine, involving cardiology, pulmonology, psychiatry, social work, financial counseling, infectious disease, and the surgical transplant team. Each organ type has specific listing criteria defined by OPTN (Organ Procurement and Transplantation Network) policy. Incomplete evaluations delay listing, and documentation deficiencies can trigger CMS survey findings. This skill structures the evaluation process to ensure comprehensive, timely, and compliant transplant workups.

---

## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What organ is being evaluated for transplantation (liver, kidney, heart, lung, pancreas, multi-organ)? **Default: [VERIFY]**
2. What is the underlying diagnosis causing end-stage organ failure? **Default: [VERIFY]**
3. What is the current severity score (MELD/MELD-Na for liver, EPTS for kidney, status for heart)? **Default: [VERIFY]**
4. Is the patient on dialysis, mechanical support, or inotropes? **Default: [VERIFY]**
5. Has the patient been evaluated at another transplant center? **Default: no**
6. What is the patient's insurance coverage for transplant and immunosuppression? **Default: [VERIFY]**
7. Does the patient have a potential living donor? **Default: unknown**
8. Are there any absolute contraindications identified on initial screen? **Default: none identified**

### Documents to Request

- Referring physician notes and complete medical records
- Organ-specific diagnostic studies (echocardiogram, PFTs, liver biopsy, renal studies)
- Current medication list including dialysis records if applicable
- Oncologic history and surveillance documentation (if applicable)
- Psychiatric/psychological evaluation
- Social work assessment
- Financial/insurance authorization documentation
- Prior transplant records (if re-transplant evaluation)
- Infectious disease serologies
- UNOS/OPTN policy for the relevant organ allocation

---

## Step 1: Organ-Specific Evaluation Criteria

### Liver Transplant Evaluation

**Indications**: Cirrhosis (any etiology), hepatocellular carcinoma (within Milan criteria), acute liver failure, metabolic liver disease.

**Severity scoring:**

| Score | Components | Use |
|---|---|---|
| MELD-Na | Bilirubin, INR, creatinine, sodium | Waitlist priority (higher = sicker = higher priority) |
| MELD 3.0 | MELD-Na + sex, albumin | Implemented 2023 by OPTN; addresses sex-based disparities |
| Child-Pugh | Bilirubin, albumin, INR, ascites, encephalopathy | Class A/B/C; prognostic but not used for allocation |

**Specific workup:**
- Abdominal MRI or CT (triple-phase) for hepatocellular carcinoma screening
- Hepatic hemodynamics (HVPG if portal hypertension assessment needed)
- AFP, AFP-L3, DCP (tumor markers if HCC concern)
- Cardiac evaluation: echocardiogram, stress test (dobutamine or adenosine for patients who cannot exercise), consider cardiac catheterization if CAD risk factors

### Kidney Transplant Evaluation

**Indications**: ESRD (GFR <20 mL/min) or anticipated ESRD, allowing preemptive listing.

**Key criteria:**

| Component | Requirement |
|---|---|
| GFR/dialysis status | GFR <20 or on dialysis; document dialysis vintage |
| EPTS score | Estimated Post-Transplant Survival score (lower = better expected outcome) |
| Sensitization | PRA (panel reactive antibody) level; high PRA (>80%) = difficulty finding compatible donor |
| Crossmatch compatibility | Virtual crossmatch using HLA antibody testing |
| Recurrence risk | Document risk of original disease recurring in allograft |

**Living donor evaluation**: Document blood type, crossmatch result, GFR, anatomic suitability (CT angiogram), and psychosocial assessment of the donor.

### Heart Transplant Evaluation

**Indications**: End-stage heart failure (EF <25%, VO2 max <12-14 mL/kg/min on CPET, refractory to medical therapy).

**UNOS Status:**

| Status | Criteria |
|---|---|
| 1 | VA-ECMO, BiVAD, mechanical ventilation, or nondischargeable LVAD with life-threatening arrhythmia |
| 2 | Durable LVAD with device complications, IABP, inotropes |
| 3 | Dischargeable LVAD without complications, inotropes without hemodynamic monitoring |
| 4 | All other active candidates |

**Specific workup**: Right heart catheterization (PVR must be <5 Wood units or responsive to vasodilators), CPET, pulmonary function tests, carotid duplex.

---

## Step 2: Absolute and Relative Contraindications

### Absolute Contraindications (apply to all organs)

| Contraindication | Rationale |
|---|---|
| Active malignancy (most types) | Immunosuppression accelerates cancer progression |
| Active sepsis or uncontrolled infection | Cannot survive surgery; risk of dissemination |
| Active substance abuse (alcohol, illicit drugs) | Risk of non-adherence, recurrence of alcohol-related liver disease |
| Irreversible multi-organ failure (unless multi-organ transplant considered) | Cannot benefit from single-organ transplant |
| Severe irreversible pulmonary hypertension (for heart transplant) | Right heart failure of allograft |
| Documented non-adherence with medical therapy | Predictive of non-adherence with immunosuppression |

### Relative Contraindications (require individual assessment)

| Factor | Consideration |
|---|---|
| Age >70 | Higher perioperative risk; consider DCD kidneys or marginal organs |
| BMI >35-40 | Increased surgical complications; some programs require weight loss |
| HIV positive | Acceptable if well-controlled on ART (CD4 >200, undetectable VL); per HOPE Act |
| Prior malignancy | Requires disease-free interval (2-5 years depending on cancer type; consult ASTS guidelines) |
| Tobacco use | Most programs require 6-month cessation with cotinine verification |
| Limited social support | Social work assessment to identify barriers |
| Active psychiatric illness | Must be stable on treatment; does not preclude transplant |

---

## Step 3: Multidisciplinary Workup Components

### Standard Evaluation Workup (all organs)

| Component | Purpose | Provider |
|---|---|---|
| Transplant surgery evaluation | Surgical candidacy, anatomy, procedure planning | Transplant surgeon |
| Transplant hepatology/nephrology/cardiology | Disease-specific medical management | Medical specialist |
| Cardiac evaluation | Perioperative cardiac risk | Cardiologist |
| Pulmonary evaluation | Perioperative pulmonary risk, PFTs | Pulmonologist |
| Infectious disease evaluation | Serologies, latent infections, vaccination status | ID specialist |
| Psychiatric/psychological evaluation | Adherence prediction, mental health, substance abuse screening | Psychiatrist/psychologist |
| Social work assessment | Support system, transportation, housing, financial resources | Social worker |
| Financial counseling | Insurance coverage for surgery, immunosuppression, follow-up | Financial counselor |
| Nutrition assessment | Nutritional optimization pre- and post-transplant | Registered dietitian |
| Dental evaluation | Clear dental infections before immunosuppression | Dentist |
| Gynecologic/urologic cancer screening | Age-appropriate screening up to date | Specialist |

### Required Serologies

| Test | Purpose |
|---|---|
| HIV 1/2 Ab/Ag | Screening |
| Hepatitis B (HBsAg, HBsAb, HBcAb) | Donor/recipient matching, prophylaxis planning |
| Hepatitis C Ab, HCV RNA | Treatment planning, viremic donor considerations |
| CMV IgG | Donor/recipient matching, prophylaxis determination |
| EBV IgG | PTLD risk stratification |
| Varicella IgG | Vaccination if non-immune |
| Quantiferon/PPD | Latent TB screening |
| Syphilis (RPR) | Screening |
| Toxoplasma IgG | Prophylaxis planning (heart transplant) |
| Strongyloides, Coccidioides (endemic areas) | Regional screening |

---

## Step 4: Selection Committee Presentation and Listing

### Selection Committee Format

Present each candidate to the multidisciplinary selection committee:

1. **Case summary**: Diagnosis, disease severity, functional status
2. **Workup results**: Each component summarized with normal/abnormal flagged
3. **Risk assessment**: Operative risk, expected survival, quality of life improvement
4. **Contraindication screen**: Address each absolute/relative contraindication
5. **Psychosocial assessment**: Support system, adherence prediction, financial coverage
6. **Recommendation**: Approve for listing / Defer with required actions / Decline with rationale

### UNOS Listing Requirements

When approved, complete the UNOS Waiting List Registration Form (OPTN Candidate Registration form):
- Patient demographics and insurance
- Diagnosis and disease severity score (MELD, status)
- Blood type and HLA typing
- Sensitization (PRA for kidney)
- Acceptable donor criteria (age range, DCD acceptance, extended criteria)
- Listing date (accrual of waiting time begins at listing)

---

## Step 5: Waitlist Management and Updates

### Required Monitoring While Listed

| Organ | Monitoring Frequency | Key Updates |
|---|---|---|
| Liver | MELD recertification per OPTN schedule (Q7d if MELD ≥25, Q30d if 19-24, Q90d if 11-18) | Update labs, HCC surveillance Q3 months, update status |
| Kidney | Annual re-evaluation | PRA updates, crossmatch panels, health status |
| Heart | Periodic (varies by status) | Hemodynamics, LVAD function, status update |
| Lung | Q6-12 months | PFTs, 6-minute walk, oxygen requirements |

### Reasons for Delisting

- Clinical improvement (no longer needs transplant)
- Development of absolute contraindication (new malignancy, active substance abuse)
- Patient choice (withdrawal of candidacy)
- Non-adherence with medical therapy or follow-up
- Too sick to transplant (multi-organ failure not amenable to transplant)
- Death while on waitlist

Document the reason for any status change in the OPTN system.

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Has the organ-specific severity score been calculated and documented (MELD, EPTS, UNOS status)?
2. Has every absolute contraindication been evaluated and either excluded or addressed?
3. Has the multidisciplinary workup been completed with all required evaluations (including psychosocial and financial)?
4. Has the selection committee reviewed and documented the listing decision?
5. Are waitlist monitoring intervals established per OPTN requirements?

---

## Quality Audit

- [ ] Organ-specific indication documented with severity scoring
- [ ] Disease etiology documented with supporting evidence
- [ ] Absolute contraindications screened and documented
- [ ] Relative contraindications addressed with risk-benefit analysis
- [ ] All required serologies obtained and resulted
- [ ] Cardiac evaluation completed (ECG, echo, stress test as indicated)
- [ ] Pulmonary evaluation completed (PFTs, imaging)
- [ ] Psychiatric/psychological evaluation completed with adherence assessment
- [ ] Social work assessment completed with support plan
- [ ] Financial counseling completed with insurance verification for immunosuppression
- [ ] Dental clearance obtained
- [ ] Age-appropriate cancer screening up to date
- [ ] Nutritional assessment completed
- [ ] Selection committee review documented with rationale
- [ ] UNOS listing form completed (if approved)
- [ ] Waitlist monitoring schedule established per OPTN policy

---

## Guidelines

1. Transplant evaluation must be multidisciplinary. No single provider can determine transplant candidacy — the selection committee reviews all evaluations collectively.
2. Absolute contraindications are non-negotiable unless the underlying condition resolves (e.g., malignancy in remission beyond required disease-free interval, substance abuse with documented sustained recovery).
3. For alcohol-related liver disease, most programs require 6 months of documented sobriety. However, early transplant protocols (Lille score responders with ALD-specific evaluation) are emerging with equivalent outcomes — follow institutional protocol and document the rationale.
4. Never list a patient without confirming insurance coverage for immunosuppression drugs. Non-adherence to immunosuppression due to inability to afford medications is a leading cause of graft loss.
5. MELD recertification must be performed on schedule per OPTN policy — late recertification results in MELD score reverting to a lower value, potentially delaying transplant.
6. Document all waitlist status changes (activation, inactivation, removal) in the OPTN system with clinical rationale. Unexplained status changes trigger CMS survey attention.
7. Living donor evaluation is governed by separate OPTN policy with strict informed consent, independent donor advocate, and medical workup requirements — never evaluate a living donor using the recipient team alone.