A strategy for performing early transplantation in PSC patients would be difficult, if not impossible, to enact. The current waiting list is based on a ‘point’ system. Priority is given to patients according to accrued waiting time and the severity of liver disease. Exceptions to the rules do occur, and are usually based on the presence of hepatocellular carcinoma or other complications that could potentially shorten the patient’s life span without transplantation. For example, patients with polycystic liver disease often have nearly normal hepatic synthetic function at the time of transplantation, but are placed at a similar priority level as patients with decompensated cirrhosis (Child-Turcotte-Pugh class C) because they suffer from such massive abdominal distension that they have difficulty maintaining an adequate nutritional intake.
One could similarly give special consideration to patients with PSC, such that they could be advanced to a higher priority level due to the risk of cholangiocarcinoma. No study, however, has proven that this is an effective way to avert this complication. Although some studies have suggested that patients with severely decompensated PSC are at a greater risk of cholangiocarcinoma, it has not been shown that fewer patients would develop malignancy if transplantation were performed earlier.
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How often is a listed patient with PSC removed from the waiting list due to the development of cholangiocarcinoma? I can recall only a single case. Likewise, the presence of ‘incidental’ cholangiocarcinoma in the explanted liver is a relatively uncommon finding, occurring in 1.5% to 8% of cases in three large series. These data indicate that relatively few PSC patients would benefit from a policy of early transplantation.