간이식의 적응증은 크게 2가지로 분류된다.

(1) Symptomatic liver failure (만성 간부전, 급성 전격성 간부전)

(2) Hepatocellular carcinoma

만성 간부전
- non-cholestatic liver cirrhosis (alcoholic LC, NAFLD, hepatitis B/C, autoimmune cirrhosis, drug induced cirrhosis)
- cholestatic cirrhosis (PBC, PSC, caroli disease, choledochal cyst)
- Budd-chiari syndrome
- 소아: Biliary atresia (m/c cause), 선천대사질환, 대사성간질환
→ 기존 치료법으로 간질환의 진행을 멈출 수 없고, 간이식을 하지 않으면 남은 생존 기간이 1년 미만인 진행을 보이는 비가역적 만성 간질환에서 간이식을 진행

급성 전격성 간부전 (viral hepatitis, acetaminophen overdose, Wilson disease)

grade II이상을 보이는 경우 간이식을 고려해야하며, King’s college criteria를 만족하는 경우 간이식이 필요

8.34 Grading of hepatic encephalopathy (West Haven)
Stage	State of consciousness
0	No change in personality or behaviour No asterixis (flapping tremor)
1	Impaired concentration and attention span Sleep disturbance, slurred speech Euphoria or depression Asterixis present
2	Lethargy, drowsiness, apathy or aggression Disorientation, inappropriate behaviour, slurred speech
3	Confusion and disorientation, bizarre behaviour Drowsiness or stupor Asterixis usually absent
4	Comatose with no response to voice commands Minimal or absent response to painful stimuli

Acetaminophen-induced ALF	Nonacetaminophen-induced ALF
Arterial pH <7.30 after fluid resuscitation	Prothrombin time >100 sec (INR >6.5)
Or all of the following: • Prothrombin time >100 sec (INR >6.5) • Serum creatinine >3.4 mg/dL • Grade 3 or 4 hepatic encephalopathy	Or any 3 of the following: • Non-A, non-B viral hepatitis, drug-induced or indeterminate etiology of ALF • Time from jaundice → encephalopathy >7 days • Age <10 years or >40 years • Prothrombin time >50 sec (INR >3.5) • Serum bilirubin >17.4 mg/dL

Acetaminophen-induced ALF

Nonacetaminophen-induced ALF

Arterial pH <7.30 after fluid resuscitation

Prothrombin time >100 sec (INR >6.5)

Or all of the following:

• Prothrombin time >100 sec (INR >6.5)

• Serum creatinine >3.4 mg/dL

• Grade 3 or 4 hepatic encephalopathy

Or any 3 of the following:

• Non-A, non-B viral hepatitis, drug-induced or indeterminate etiology of ALF

• Time from jaundice → encephalopathy >7 days

• Age <10 years or >40 years

• Prothrombin time >50 sec (INR >3.5)

• Serum bilirubin >17.4 mg/dL

→ 여명이 1주 이내로 예상되는 급성 간부전 환자에서 응급 간이식 필요

[1] Sabiston, 21e. pg. 614-619