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Perioperative Management Of Liver Tranplant Patients1
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  • 1. Perioperative Management of Liver Transplant Patients January 22/ 2010 Dr.Husni Ajaj Tripoli
  • 2. Topic Objectives
    • 1. Overview of indications & selection for liver transplantation.
    • 2. Identification & treatment of complications associated with liver disease in the preoperative period.
    • 3. Identification & treatment of complications following orthotopic liver transplantation.
    • 4. Induction of immunosuppressive pharmacotherapy following transplantation.
    • 5. Diagnosis & treatment of graft rejection.
  • 3. Orthotopic Liver Transplantation
    • 1 st orthotopic liver transplantation 1963.
    • Approximately 5,000 orthotopic liver transplantations annually for 17,000 in need.
  • 4. Indications for Liver Transplantation in Adults: Etiologies of End-Stage Liver Disease
    • 1. Fulminant Hepatic Failure
    • 2. Alcoholic Liver Disease
    • 3. Chronic Hepatitis C
    • 4. Chronic Hepatitis B
    • 5. Non-alcoholic steatohepatitis
    • 6. Autoimmune Hepatitis
    • 7. Primary Biliary Cirrhosis
    • 8. Primary Sclerosing Cholangitis
    • 9. Hepatic tumors
    • 10. Metabolic and genetic disorders
  • 5. Indications for Liver Transplantation in Adults
    • Presence of irreversible liver disease and a life expectancy of less than 12 months with no effective medical or surgical alternatives to transplantation
    • Chronic liver disease that has progressed to the point of significant interference with the patient's ability to work or with his/her quality of life
    • Progression of liver disease that will predictably result in mortality exceeding that of transplantation (85% one-year patient survival and 70% five-year survival)
  • 6. Manifestations of End-Stage Liver Disease
    • Progressive jaundice
    • Intractable ascites
    • Spontaneous bacterial peritonitis
    • Hepatorenal Syndrome
    • Encephalopathy
    • Variceal bleeding
    • Intractable pruritus
    • Chronic fatigue (such as resulting in loss of gainful employment)
    • Bleeding diathesis or coagulopathy
  • 7. Selection Criteria for Organ Allocation
    • United Network for Organ Sharing (UNOS) governing body for organ allocation utilizes MELD score.
    • Model for End Stage Liver Disease (MELD) Score
      • 0.957 x loge (creatinine) + 0.378 x loge (bilirubin mg/dL) + 1.12 x loge (INR) + 0.643 x 10
      • Range from 10 to 40
      • Special considerations, amendments for HCC, renal failure.
  • 8. Preoperative management of complications associated with hepatic failure & decompensated cirrhosis
    • Hepatic Encephalopathy
    • Cerebral Edema
    • Acute Renal Failure
    • Infection & Sepsis
    • Metabolic Derangements
    • Malnutrition
    • Coagulopathy
    • Portal Hypertension
  • 9. Hepatic Encephalopathy
    • Etiology: Attributed to increased serum ammonia levels secondary to metabolism of nitrogenous substances in the gut.
    • Symptoms: Range from euphoria to coma.
    • Treatment: lactulose, decreased intake of nitrogen containing compounds, oral neomycin.
  • 10. Cerebral Edema
    • Etiology: Unknown
    • Swelling of brain results in increased ICP & herniation.
    • Invasive monitoring with goal of ICP < 20 mmHg & CPP > 50 mmHg.
    • Treatment: Anxiolysis, HOB elevation, hyperventilation, avoidance of overhydration, mannitol diuresis, HD if compromised renal function.
  • 11. Acute Renal Failure
    • Etiology: Toxin induced, Derangements in systemic & intrarenal hemodynamics.
    • Treatment: Prevention of hypotension, treatment of infection, avoidance of nephrotoxic agents.
    • Once established, renal failure in this setting is often irreversible. Early utilization of renal replacement therapy is indicated.
  • 12. Infection & Sepsis
    • Etiology: Immunologic derangements including complement deficiency, reduced opsonins, WBC dysfunction.
    • Treatment: Frequent cultures, including ascites. Broad spectrum antibiotics, including anti-fungals.
  • 13. Metabolic Derangements
    • 1. Hypokalemia
      • Increased sympathetic tone promotes cellular uptake of K. Decreased serum K promotes production of ammonia by the kidney.
    • 2. Hyponatremia
    • 3. Hypoglycemia
      • Secondary to decreased hepatic glycogen stores & decreased gluconeogenesis.
  • 14. Coagulopathy
    • Etiology: Compromised synthetic function, deficiency of coagulation factors, platelet dysfunction.
    • Contribute to GI bleeding in conjunction with portal hypertension.
    • Treatment: Prevention with H2 blockers, PPI. Judicious use of Factor VIIa & FFP.
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  • 18. Post-operative complications & management of liver transplant patients
    • Right pleural effusion
      • May affect ventilation, necessitating drainage.
    • Hepatic edema secondary to aggressive resuscitation & increased intravascular volume.
      • Goal CVP 6-10. Minimize increased hepatic vein pressures, sinusoidal congestion that impair graft perfusion & exacerbate reperfusion injury.
  • 19. Post-operative complications & management of liver transplant patients
    • Renal failure
      • Elevation of creatinine & BUN observed in nearly all transplant patients secondary to ATN, hepatorenal syndrome. Usually self-limiting. May necessitate therapy with loop diuretics, renal replacement therapy.
  • 20. Post-operative complications & management of liver transplant patients
    • Electrolyte Derangements
      • Recovering graft increases demand for magnesium & phosphorous.
      • Transfusion of citrate rich blood products results in decreased serum magnesium & calcium.
      • Rapid correction of chronic hyponatremia with isotonic solution can have severe neurological consequence. Judicious use of hypotonic solutions with goal of serum Na 125-130 advised.
  • 21. Post-operative complications & management of liver transplant patients
    • Thrombocytopenia
      • Preoperative portal hypertension results in splenomegaly & platelet sequestration. Generally improves as graft recovers. May necessitate replacement if bleeding is encountered or invasive procedures are planned. Splenectomy is rarely indicated.
      • Platelet dysfunction secondary to renal & hepatic failure may be improved acutely with DDAVP.
  • 22. Post-operative complications & management of liver transplant patients
    • Biliary leak
      • RUQ pain, fever, persistent elevation of bilirubin, liver enzymes. Biloma on CT. Treated with endoscopic stent, percutaneous drainage. Possible surgical revision if duct is ischemic.
    • Hepatic artery thrombosis
      • Persistent elevation or increasing liver enzymes, poor graft function. Diagnosed with U/S, CT angiography, MRA. Treated with immediate revascularization.
  • 23. Induction of Immunosuppression
    • Triple therapy
      • Calcineurin inhibitor (tacrolimus, cyclosporine), anti-proliferative agent (mycophenolate), corticosteroid taper.
      • Initiated immediately following transplantation.
      • Levels followed daily in immediate post-operative period & with decreasing frequency once stabilized in desired range.
    • Agents vary according to etiology of liver disease.
      • Thymoglobulin & Hb Ig utilized in hepatitis patients along with entecavir & prograf to limit viral replication & to avoid coritocsteroid usage.
  • 24. Allograft rejection
    • Hyperacute rejection
      • Secondary to preformed Ab to graft antigen. Extremely rare. Necessitates retransplantation.
    • Acute Cellular Rejection
      • 70% of patients 5 to 14 days following transplant.
      • Heralded by fever, jaundice, elevation of liver enzymes.
      • Diagnosed by liver biopsy. Demonstrates endothelialitis & non-suppurative cholangitis.
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  • 26.
    • Althaus SJ, Perkins JD, Soltes G, Glickerman D. Use of a Wallstent in successful treatment of IVC obstruction following liver transplantation. Transplantation. 1996 Feb 27;61(4):669-72.
    • Kim BW, Won JH, Lee BM, Ko BH, Wang HJ, Kim MW. Intraarterial thrombolytic treatment for hepatic artery thrombosis immediately after living donor liver transplantation. Transplant Proc. 2006 Nov;38(9):3128-31.
    • Cotler, Scott J , MD UptoDate Treatment of acute cellular rejection in liver transplantation
    • Brown , Robert S., MD, MPH , Dove, Lorna M, MD, MPH UptoDate Patient selection for liver transplantation
    • Eric Goldberg, MD , Sanjiv Chopra, MD UptoDate Overview of the treatment of fulminant hepatic failure
    • Bussutil RW, Klintmalm GB, Transplantation of the Liver, WB Saunders Company, Philadelphia. 1996
    • Peter J. Friend; Charles J. Imber Transplantation Immunology. Current Status of Liver Transplantation pp. 29 – 46, MAR 2006
    • http://med.stanford.edu/shs/txp/livertxp