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 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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BCC4: Jon Gatward on Liver Transplantation

  1. 1. Critical Care Hepatology Dr.  Jon  Gatward   Staff  Specialist   Royal  Prince  Alfred  Hospital   Sydney  
  2. 2. 0   10   20   30   40   50   60   70   England   N.Ireland   Scotland   Wales  
  3. 3. Critical Care Hepatology Dr.  Jon  Gatward   Staff  Specialist   Royal  Prince  Alfred  Hospital   Sydney  
  4. 4. Case Study! 45M   Primary  Sclerosing  CholangiLs  /  Crohn’s   Recurrent  cholangiLs   OLT  
  5. 5. 171  to  end  Aug  13  
  6. 6. 4.5L  ascites  and  free  pus  in  abdomen   Massive  transfusion   Liver  looked  grey  
  7. 7. Vasodilatory shock Rising lactate Rising K Hypoglycaemia DIC……
  8. 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. 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. 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. 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. 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. 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. 14. acute rejection • 5-­‐7  days   • Fever   • DeterioraLon  in  graY  funcLon   • AST/ALT   • Biopsy  (percutaneous  or  trans-­‐jugular)   • Pulsed  methylprednisolone   • Re-­‐transplantaion  
  15. 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. 16. Liver  congested,  non-­‐homogenous  perfusion   Duplex:  arterial  flow,  no  portal  or  hepaLc  venous  flow   Liver  removed    
  17. 17. the anhepatic phase
  18. 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. 19. 84ml.kg.h-­‐1   Vs.  Na  150  (12.5ml  23.4%  Saline  per  5L  Hemasol  B0)    
  20. 20. re-transplantation Extended  criteria  BD  donor  (fapy  liver)    
  21. 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. 22. F R O M D E M I – G O D S TO G o d s . . .!
  23. 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. 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. 25. Single Pass Albumin Dialysis!
  26. 26. Sauer.  Hepatology  2004;  39:  1408  
  27. 27. re-transplantation
  28. 28. (=7.5% of all grafts)
  29. 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. 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. 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. 32. slow uptake of dcd livers W.I.T.  
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onclusions   Good  outcomes  with  strict  ANLTU  criteria   Donor  age  increased  to  50yrs   Verran  MJA  2013;  199:  104   high numbers declined or not retrieved
  34. 34. ECMO circuit 2nd roller pump for HA PN Insulin
  35. 35. conclusions

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