BCC4: Jon Gatward on Liver Transplantation
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BCC4: Jon Gatward on Liver Transplantation

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Intensivist Jon Gatward speaks at BCC4 about Liver Transplantation. His informative talk covers complications including post-reperfusion syndrome, biliary complications, hepatic artery thrombosis......

Intensivist Jon Gatward speaks at BCC4 about Liver Transplantation. His informative talk covers complications including post-reperfusion syndrome, biliary complications, hepatic artery thrombosis and 'other badness'. It also explores DCD livers and issues for retransplantation. Keep up to date with slides and posts on the intensivecarenetwork.com

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  • 1. Critical Care Hepatology Dr.  Jon  Gatward   Staff  Specialist   Royal  Prince  Alfred  Hospital   Sydney  
  • 2. 0   10   20   30   40   50   60   70   England   N.Ireland   Scotland   Wales  
  • 3. Critical Care Hepatology Dr.  Jon  Gatward   Staff  Specialist   Royal  Prince  Alfred  Hospital   Sydney  
  • 4. Case Study! 45M   Primary  Sclerosing  CholangiLs  /  Crohn’s   Recurrent  cholangiLs   OLT  
  • 5. 171  to  end  Aug  13  
  • 6. 4.5L  ascites  and  free  pus  in  abdomen   Massive  transfusion   Liver  looked  grey  
  • 7. Vasodilatory shock Rising lactate Rising K Hypoglycaemia DIC……
  • 8. •  Occurs  in  7%     •  Clinical:   •  Vasodilatory  shock  oYen  with   bradycardia   •  Pulmonary  hypertension   •  Hyperkalaemia     •  Cause?   •  Sudden  ↑  venous  return   •  vasoacLve  substances   •  K  rich  preservaLon  fluids   •  Usually  resolves  within  5   minutes   •  30%  of  paLents  need  inotropes   and/or  vasopressors.     •  Risk  Factors:  Long  WIT  and  CIT   post-reperfusion syndrome Agopian.  Annals  of  Surgery  2013;  258:  409  
  • 9. •  Approximately  1%  in  Australia   •  Unrecoverable  hepato-­‐cellular  dysfuncLon  à   death  or  re-­‐transplantaLon  within  1  week  NOT   caused  by   •  vascular  thrombosis   •  biliary  complicaLons   •  rejecLon   •  recurrent  disease   •  Major  risk  factor:  DCD  (WIT  and  CIT  à  ischemia-­‐ reperfusion  injury)   •  Controlled  DCD  0-­‐10%   •  Uncontrolled  DCD  (Spain  –  10-­‐25%)   Le  Dinh  World  J  Gastroenterol  2012;  18:  4491   primary non-function
  • 10. • Common:  5%  within  30days,  15%  overall   • Bile  leakage   • Bile  duct  strictures   •  AnastomoLc   •  Ischaemic  Type  Biliary  Lesions  (ITBL)   • Risk  Factors   •  Donor  age  >60  à  67%  have  biliary  complicaLons   •  Donor  obesity   •  Autoimmune  disease  in  recipient   Le  Dinh  World  J  Gastroenterol  2012;  18:  4491   De  Vera  Am  J  Transplant  2009;  9:  773   biliary complications Suarez  Transplanta7on  2008;  85:  9   Jay  Ann  Surg  2011;  253:  259   Agopian.  Annals  of  Surgery  2013;  258:  409  
  • 11. • DCD  à  10  x  rate  of  ITBL   •  3  x  more  likely  to  lose  graY   • Prognosis     •  50%  à  death  or  re-­‐transplantaLon   • Treatment   •  ERCP   • PrevenLon     •  ECMO,  machine  perfusion,  different   preservaLves,  anLcoagulants,  early   portocaval  shunt     Le  Dinh  World  J  Gastroenterol  2012;  18:  4491   De  Vera  Am  J  Transplant  2009;  9:  773   itbl & dcd Suarez  Transplanta7on  2008;  85:  9   Jay  Ann  Surg  2011;  253:  259   Agopian.  Annals  of  Surgery  2013;  258:  409  
  • 12. HAT  (3.1%  paLents)   •  Early  (30  days)   •  FHF,  duct  necrosis  and  leaks,  sepsis,  graY  loss   •  Risk  factors   •  Children,  low  recipient  weight   •  ProthromboLc  states   •  Re-­‐transplantaLon,  arterial  variants   •  PSC,  CMV+  graY  into  CMV-­‐  recipient   •  NOT  DCD   •  DUS  screening  +/-­‐  CT  angio   •  Treatment   •  Observe   •  Re-­‐vascularize   •  Re-­‐transplant     HAS   •  Assoc  with  biliary   strictures,  esp  aYer  DCD   •  Risk  factors   •  Surgical  trauma   •  RejecLon   •  Recurrent  disease   DCD is not a risk factor! Le  Dinh  World  J  Gastroenterol  2012;  18:  4491  Agopian.  Annals  of  Surgery  2013;  258:  409   hepatic artery thrombosis and stenosis
  • 13. •  Rare  (1.1%  paLents)   •  Portal  hypertension….graY  failure     •  Risks:   •  Difficult  surgery   •  Recurrence  of  disease   •  Thrombophilia   •  Treatment   •  Diuresis   •  Angioplasty  /  re-­‐vascularisaLon   •  Re-­‐transplantaLon   portal vein thrombosis DCD is not a risk factor! Agopian.  Annals  of  Surgery  2013;  258:  409   Le  Dinh  World  J  Gastroenterol  2012;  18:  4491  
  • 14. acute rejection • 5-­‐7  days   • Fever   • DeterioraLon  in  graY  funcLon   • AST/ALT   • Biopsy  (percutaneous  or  trans-­‐jugular)   • Pulsed  methylprednisolone   • Re-­‐transplantaion  
  • 15. •  Cardiovascular  failure   •  Underlying  cardiomyopathy,  periop  stress   •  Respiratory  failure   •  Effusions,  right  diaphragm  palsy,  muscle  weakness   •  HPS,  PPS   •  InfecLon     •  TRALI   •  CNS  failure   •  Encephalopathy,  oedema,  raised  ICP   •  Seizures  (note  Tacrolimus)   •  ICH   •  Renal  failure   •  Common  and  mulL-­‐factoral.     •  HRS  usually  improves  with  liver.     •  Consider  IACS     •  Sepsis   other badness
  • 16. Liver  congested,  non-­‐homogenous  perfusion   Duplex:  arterial  flow,  no  portal  or  hepaLc  venous  flow   Liver  removed    
  • 17. the anhepatic phase
  • 18. 1   2   0              8              16              24              32              40              48              56              64              72   7.4   7.3   Time  (hrs)   5   10   pH   7.1   7.2   Lactate  (mmol.l-­‐1)   Anhepatic Phase
  • 19. 84ml.kg.h-­‐1   Vs.  Na  150  (12.5ml  23.4%  Saline  per  5L  Hemasol  B0)    
  • 20. re-transplantation Extended  criteria  BD  donor  (fapy  liver)    
  • 21. 1   2   0              8              16              24              32              40              48              56              64              72   7.4   7.3   Time  (hrs)   5   10   pH   7.1   7.2   Lactate  (mmol.l-­‐1)   Anhepatic Phase
  • 22. F R O M D E M I – G O D S TO G o d s . . .!
  • 23. • RELIEF  Trial   • 189  pts  vs  standard  care   • Decreased  Cr,  bilirubin   • Decreased  encephalopathy   • No  effect  on  mortality   Bañares  et  al.  Extracorporeal  liver  support  with  the  molecular   adsorbent  recirculaLng  system  (MARS)  in  paLents  with  acute-­‐on-­‐ chronic  liver  failure.  The  RELIEF  Trial   Blood  circuit   Albumin  circuit   Dialysis  circuit  
  • 24. • HELIOS  Study   • 145  pts  vs  standard  care   • Only  subgroup  HRS  Type  1  plus   MELD  >30  had  survival  benefit   Rifai  et  al.  Extracorporeal  liver  support  by   fracLonated  plasma  separaLon  and  absorpLon   (Prometheus®)  in  paLents  with  acute-­‐on-­‐chronic   liver  failure  (HELIOS  study):  a  prospecLve   randomized  controlled  mulLcenter  study  
  • 25. Single Pass Albumin Dialysis!
  • 26. Sauer.  Hepatology  2004;  39:  1408  
  • 27. re-transplantation
  • 28. (=7.5% of all grafts)
  • 29. risk factors for things going wrong Factor   RR   Recipient  age  >55     1.5   MELD  score  ≥34       1.4   AeLology:  malignancy     AeLology:  HCV   1.8   1.5   Prior  transplant   2.2   HospitalisaLon   1.3   Donor  age  >55   1.5   WIT  >  48min   1.3   CIT  >8.9h   1.3   Agopian.  Annals  of  Surgery  2013;  258:  409  
  • 30. dcd and risk of death?? U.S. registry data 96-07 42,254 DBD recipients 1,113 DCD recipients RR of death after DCD1.29 Jay.  J  Hepatol  2011;  55:  808  
  • 31. !" #!" $!!" $#!" %!!" %#!" &!!" &#!" '!!" '#!" ()*" +,-" .)/" 0,1" ,21" 0,3" +4-" +45" ,46" 7)2" 8*9" -8:" ()*" +,-" .)/" 0,1" ,21" 0,3" +4-" +45" ,46" 7)2" 8*9" -8:" ()*" +,-" .)/" 0,1" ,21" 0,3" +4-" +45" ,46" 7)2" 8*9" -8:" ()*" +,-" .)/" 0,1" ,21" 0,3" +4-" +45" ,46" 7)2" 8*9" -8:" ()*" +,-" .)/" 0,1" ,21" 0,3" +4-" +45" ,46" 7)2" 8*9" -8:" ()*" %!!;" %!$!" %!$$" %!$%" %!$&" !"#"$%&'($&)##*+& !"#"$%&,&+"-.#/&)##*)0&1$(#!& 9<=>?" (*(" (/(" Total   DBD   DCD   dbd and dcd
  • 32. slow uptake of dcd livers W.I.T.  
  • 33. ! ! ! ! ! ! ! ! ! ! ! ! ! "#!$%&%$$'()! *+!',,%-.,%/! $%,$0%1'()! #2!/%3(04%/! 5/1'43%/!/646$!'7%!! ! 89! :%/03'(!';46$-'(0,0%)<'7%!! 98! :%/03'(!';46$-'(0,0%)! ! "! =,>%$!! ! ! ! #! ?@!*2<#2!/64',%/!6,>%$!6$7'4)! !8#!464A$%,$0%1'()! B646$!/0%/!C!*D!-04)!! 9#! 5;46$-'(!/646$!(01%$!! "! E670),03'(!.$6;(%-)! 8! ! ! ! 92!(01%$)!6;,'04%/! ?@!82<*+!/64',%/!6,>%$! 6$7'4)! 9#!,$'4).('4,)! @0(%!(%'F!! ! ! 9! 54'),6-6,03!),$03,G$%! ! 9! H6$,'(!1%04!,>$6-;6)0)! ! 9! I%.',03!'$,%$J!),%46)0)! ! 9! Conclusions   Good  outcomes  with  strict  ANLTU  criteria   Donor  age  increased  to  50yrs   Verran  MJA  2013;  199:  104   high numbers declined or not retrieved
  • 34. ECMO circuit 2nd roller pump for HA PN Insulin
  • 35. conclusions