Contents

Search

liver transplantation

Cadaveric & living donor liver* transplants. * Transplant of left lateral segment, left lobe or right lobe of the liver obtained from a living donor (> 90% of donors are relatives) Indications: 1) patients with complications from end-stage liver disease a) hepatic encephalopathy b) hepatorenal syndrome c) esophageal varices - *variceal hemorrhage d) uncontrolled ascites, complications from ascites e) spontaneous bacterial peritonitis f) unresponsive coagulopathy g) *profound fatigue h) *hepatic osteodystrophy i) recurring bacterial cholangitis 2) diseases a) fulminant hepatic failure 1] drug or toxin-induced 2] viral hepatitis b) end-stage liver disease 1] cirrhosis of any cause# 2] cystic fibrosis 3] arteriohepatic dysplasia 4] Budd-Chiari syndrome 5] veno-occlusive disease 6] polycystic liver disease 7] congenital hepatic fibrosis 8] *metabolic disorders a] tyrosinemia b] glycogen storage disease 9] hemochromatosis c) *selected malignant disorders 1] hepatocellular carcinoma 2] cholangiocarcinoma (clinical protocols) * Early referral # alcoholic cirrhosis has surpassed hepatitis C infection as most common indication for liver transplantation [8] Contraindications: 1) AIDS, at some transplantation centers [1] 2) continuing alcohol or drug abuse 3) severe, uncontrolled cardiac or pulmonary disease 4) most extra-hepatic malignancies a) some islet cell tumors & carcinoid tumors can be exceptions b) advanced hepatocellular carcinoma c) cholangiocarcinoma (exception of clinical protocols) 5) uncontrolled sepsis 6) morbid obesity 7) hepatocellular carcinoma exceeding Milan criteria limits 8) severe psychiatric disorder 9) inability to comply with medical management 10) lack of social support 11) advanced age Advanced age is a relative contraindication [1] Laboratory: - MELD score predicts prognosis, urgent need for transplantation - MELD score >= 15 indication for liver transplantation [1] Complications: 1) systemic hypertension 2) obesity 3) azotemia from immunosuppressive agents 4) infection 5) allograft rejection 6) recurrence of original disease -> for example: hepatitis C 7) malignancies a) squamous cell carcinomas 1] skin 2] lip 3] cervix 4] vulva 5] perineum b) adenocarcinomas 1] breast 2] colon c) lymphoproliferative disorders -> B-cell lymphoma d) lung cancer [6] Management: 1) many patients deteriorate or die while on waiting lists 2) transplantation centers monitor intracranial pressure for cerebral edema due to hepatic encephalopathy [1] 3) post liver transplant a) prophylaxis for: - Pneumocystis carinii pneumonia (PCP) - Herpes simplex virus (HSV) b) immunosuppression for transplant rejection - use of tacrolimus associated with improved outcomes - consider early taper of tacrolimus to decrease risk of de novo cancer [9] c) avoid excessive sun exposure; use sun screen (risk of skin cancer) d) cancer screening - annual fecal occult blood - flexible sigmoidoscopy - mammography - Pap smear

Related

model for end-stage liver disease score (MELD score)

General

organ transplantation

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018.
  2. Journal Watch 21(20):62, 2001 Miller CM et al, One hundred nine living donor liver transplants in adults and children: a single-center experience. Ann Surg 234:301, 2001 PMID: 11524583
  3. Engels EA et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA 2011 Nov 2; 306:1891. PMID: 22045767
  4. Ahmed A, Keeffe EB. Current indications and contraindications for liver transplantation. Clin Liver Dis. 2007 May;11(2):227-47. PMID: 17606204
  5. Moini M, Mistry P, Schilsky ML. Liver transplantation for inherited metabolic disorders of the liver. Curr Opin Organ Transplant. 2010 Jun;15(3):269-76 PMID: 20489626
  6. Dutkowski P et al. Challenges to liver transplantation and strategies to improve outcomes. Gastroenterology 2015 Feb; 148:307 PMID: 25224524
  7. Sharma S, Gurakar A, Jabbour N. Avoiding pitfalls: what an endoscopist should know in liver transplantation--part 1. Dig Dis Sci. 2008 Jul;53(7):1757-73. Epub 2007 Nov 9. Review. PMID: 17990105 - Sharma S, Gurakar A, Camci C, Jabbour N. Avoiding pitfalls: what an endoscopist should know in liver transplantation--part II. Dig Dis Sci. 2009 Jul;54(7):1386-402. Epub 2008 Dec 17. Review. PMID: 19085103
  8. Cholankeril G, Ahmed A. Alcoholic liver disease replaces hepatitis C virus infection as the leading indication for liver transplantation in the United States. Clin Gastroenterol Hepatol 2017 Nov 30; PMID: 29199144 http://linkinghub.elsevier.com/retrieve/pii/S1542356517314180
  9. European Association for the Study of the Liver EASL Clinical Practice Guidelines: Management of alcohol- related liver disease. J Hepatol. 2018 Apr 5. pii: S0168-8278(18)30214-9 PMID: 29628280 https://www.journal-of-hepatology.eu/article/S0168-8278(18)30214-9/fulltext
  10. Krowka MJ, Fallon MB, Kawut SM et al International Liver Transplant Society Practice Guidelines: Diagnosis and Management of Hepatopulmonary Syndrome and Portopulmonary Hypertension. Transplantation. 2016 Jul;100(7):1440-52. PMID: 27326810
  11. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Liver Transplantat https://www.niddk.nih.gov/health-information/liver-disease/liver-transplant