359.2 🩺 國考版

359.2.1 高頻考點

359.2.1.1 Top Indications

  • ALD (top in many)
  • HCV (declining with DAAs)
  • MASH/MASLD (rising)
  • HBV
  • Cryptogenic
  • Autoimmune
  • HCC

359.2.1.2 Milan Criteria for HCC

  • Single ≀ 5 cm OR
  • ≀ 3 nodules each ≀ 3 cm
  • No vascular invasion
  • No extrahepatic spread

359.2.1.3 UCSF Criteria

  • Extended
  • Single ≀ 6.5 cm OR
  • ≀ 3 tumors each ≀ 4.5 cm
  • Total ≀ 8 cm

359.2.1.4 Allocation

  • MELD-Na (2016) + MELD 3.0 (2023)
  • 90-day mortality
  • Exception points: HCC, HPS, POPH, FAP, CCA

359.2.1.5 Contraindications

  • Active malignancy outside liver
  • Severe cardiopulmonary disease
  • Active substance abuse < 3-6 months
  • Severe psychosocial issues
  • Anatomic
  • Cholangiocarcinoma (except Mayo protocol)

359.2.1.6 Mayo Protocol (Hilar CCA)

  • Early stage I, II
  • Neoadjuvant chemoradiation
  • Strict selection
  • Acceptable outcomes

359.2.1.7 Donor Types

  • Deceased donor (DBD or DCD)
  • Living donor (Taiwan predominant)
  • Split liver
  • Domino (FAP)

359.2.1.8 Immunosuppression

  • Induction: basiliximab or rATG + steroids
  • Maintenance: tacrolimus + MMF + prednisone
  • Tacrolimus-sparing: mTOR inhibitors

359.2.1.9 Common Complications

  • Vascular (HAT — hepatic artery thrombosis, most serious early)
  • Biliary (anastomotic stricture, leak)
  • Rejection (ACR + AMR + chronic ductopenia)
  • Infections (CMV, EBV, PCP, fungal)
  • Malignancy (PTLD, skin)
  • Recurrence

359.2.1.10 Recurrence Rates

  • HCV: now curable post-LT
  • HBV: prevented with antivirals + HBIG
  • HCC: 10-20%
  • PSC: 30%+
  • PBC: 20-30%
  • AIH: common, manage IS

359.2.1.11 Outcomes

  • 1-yr 85-90% graft
  • 5-yr 70-75%
  • 10-yr 55-65%

359.2.1.12 Key Trials

  • Mathurin (2011): early LT for severe AH
  • Mayo protocol for hilar CCA
  • Various MELD updates

359.2.2 易混淆比范

Indication Considerations
Cirrhosis decompensated MELD-based
ALF Status 1A
HCC Milan Exception points
Hilar CCA Mayo protocol only
Acute AH Strict psychosocial
Metabolic Address underlying

359.2.3 Special Topics

359.2.3.1 MELD Exception Points

  • HCC within Milan
  • Hepatopulmonary syndrome
  • Portopulmonary HTN
  • Familial amyloid polyneuropathy (FAP)
  • Cholangiocarcinoma (Mayo)
  • Polycystic liver disease
  • Cystic fibrosis

359.2.3.2 HCV Post-LT

  • Universally recurred pre-DAA
  • Now curable with DAAs
  • Treat after stable LT

359.2.3.3 HBV Post-LT

  • Prevented with antivirals + HBIG
  • Lifelong therapy
  • Excellent outcomes

359.2.3.4 Living Donor LT

  • Right or left lobe
  • Donor evaluation extensive
  • ~ 0.5% donor mortality
  • Common in Taiwan