Liver Transplantation History
• 1958 Research programs on liver replacement at
Northwestern and Harvard
• 1963 First liver transplant (Univ. of CO)
• 1967 First long survival
• 1979 Cyclosporine
• 1987 Univ. of WI solution for improved organ
• 1989 FK 506
• 1999 Living donor liver transplantation
Liver transplantation is the OPTIMAL treatment
for end stage liver disease (ESLD)
ESLD has 2 forms: Acute and Chronic
- Acute = Fulminant Hepatic Failure
- Chronic = Cirrhosis
Fulminant Hepatic Failure (FHF)
Synonymous with Acute Liver Failure
Pathology: Pan-lobular or Sub-massive necrosis
Classically seen in Paracetamol poisoning. In
India – commonest cause is HEV, HAV and drug
Criteria for transplantation of acute liver failure
KING’S COLLEGE CRITERIA
Chronic Liver disease : Cirrhosis
All patients with cirrhosis do not qualify for liver
Transplantation is generally considered when a
patient has suffered from a complication.
The onset of decompensation is associated with
significantly impaired survival.
Chronic Liver Disease — Signs of decompensation
Portal Hypertensive Bleeding
Hepatocellular Carcinoma in the setting of
Question for Transplant Team
• When to list for liver transplantation?
• When to perform the liver transplant?
Patients who are too well should not be transplanted.
Likewise, transplantation of patients who are too sick
is associated with poor outcomes.
The goal of transplantation is to prolong survival.
Thus, liver transplantation should be performed at
the time point when the patient is expected to have
greater survival with a liver transplant than without.
Survival of a patient with ‘‘Child’s C cirrhosis’’ is about 20–
30% at 1 year and less than 5% at 5 years.
In contrast, the survival rate after transplantation is 85–
90% at 1 year and over 70% at 5 years.
By the time the patient has evidence of advanced clinical
liver disease (Child’s C cirrhosis), the patient may not
survive long enough to get a transplant.
• MELD -- Model for End-Stage Liver Disease
Scoring System – MELD Score
= 0.957 x Loge(creatinine mg/dl)
+ 0.378 x Loge(bilirubin mg/dl)
+ 1.120 x Loge(INR)
• MELD score depends upon kidney function,
bilirubin level and clotting factor levels
Introduced in Feb 2002 (Mayo).
The MELD score originally was developed and
validated to assess the short-term prognosis of
patients with cirrhosis undergoing TIPS.
Using the MELD model, patients are assigned a score
from 6 to 40.
Estimated 3-month survival for a score of 6 is 90%,
and for a score of 40 is 7%.
Ultimately, the decision to transplant is based upon
the patient’s likelihood of survival
Usually a patient will be listed for liver tx at a MELD
of 10 or more, when the expected 3 month survival is
less than 90%.
Requirements for Transplantation
End stage liver disease
Physiologic ability to tolerate surgery: Cardiac,
pulmonary, renal, cerebral function
Anatomy – status of vessels (PV/HA/HV)
Social support/ psychological support
No extra-hepatic infection or malignancy
Alcohol abstinence for 6 months/ no substance abuse
Cardiopulmonary disease that cannot be
Malignancy outside of the liver.
Active alcohol and drug use. Minimum period
of abstinence of at least six months is required.
Advanced age and AIDS are examples of
Immediate function of a transplanted liver is essential. Unlike in
kidney, pancreas, or, to some extent, heart transplantation,
there is no effective artificial support for a hepatic patient in the
event of graft failure.
A complex surgical exercise in a severely physiologically
compromised patient –
- major surgery
- blood loss – portal hypertension
- risk of infection
- necessity of liver function
Cadaveric/ living donor.
Blood group match. (HLA not required/ cross
matching not required).
HTK solution (custodiol)
Goal: Cool the organs and
perfuse with preservative
exsanguinating the organs.
- cardiopulmonary instability,
- Portopulmonary hypertension,
- Cholestasis, jaundice,
- blood loss, volume status.
Impact of anesthesia on liver function
Limited functional reserve, Drug clearance,
Anesthesia-induced hepatitis, Postoperative
jaundice, Risk factors for decompensation in patients
Implantation of the new liver.
begins with a controlled
formidable task in individuals
with severe portal hypertension
and extensive collateral
Engraftment with venous,
arterial and then biliary
Classic v/s piggy back
Classical v/s piggy back technique
Classical or cava
Helpful signs of hepatic function in the immediate
1. Hemodynamic stability
2. Awakening from anesthesia
3. Clearance of lactate
4. Resolution of hypoglycemia
5. Normalization of coagulation profile
6. Resolution of elevated transaminases
7. Bile of sufficient quantity and golden brown in color
Medication after transplant
Immunosuppression: usually 3 drugs to start, with rapid
withdrawal of steroids.
Antivirals: anti-CMV, HBV.
Calcium and magnesium.
Immediate, early and late.
Immediate – post-op.
- Bleeding (commonest – 12-15%)
- Graft non-function (PNF) [5%] or delayed graft
- Vascular complications: HAT, PVT and venous
- Renal dysfunction.
- complications related to prolonged and major
surgery, blood transfusion.
- Infections – viral and bacterial.
Waiting for a liver
Management of Ascites.
Management of portal hypertension
General health and activity
Treatment of viral disease
Prevention of infection.
If waiting is not possible….,
getting too late….
LDLT: living donor liver transplant.
India: only related/ approved by a ethical
- elective surgery.
- healthy known donor
- short cold ischemia times
- reduced waiting time
- risk to donor
- cost and more resources
- higher risk of biliary ad vascular complications
- reduced size liver
Essential Concepts for Using
• No conflict of interest
• No coercion
• Minimize donor risks
• Donors must be given every opportunity to change
• Emphasize alternatives
How Much Liver Do You Need?
• Liver = 2% body weight
• Optimal: > 1% liver weight/body weight ratio
• 70 kg recipient needs at least 700 cc (gm)
• Cannot go below 0.7 - 0.8%
- Graft/ SLV ratio
- Usually right lobe.
- Recently the use of dual grafts has been done
Risk to donor: 0.2 – 0.3% risk of death
- 2-4% risk of major complications
- About 15-25% risk of minor complications.
Higher incidence of biliary problems
Higher incidence of vascular problems
Small for size syndrome
Initially had poorer graft survival, but recently has
been equal to DDLT.
Diagnoses indicating potential candidacy for LT include the following:
* 070 Viral hepatitis
* 1550-1552 Malignant neoplasm of liver and intrahepatic bile ducts
* 2115 Benign neoplasm of liver and biliary passages
* 2308 Carcinoma of liver and biliary system
* 2353 Neoplasm of uncertain behavior in liver and biliary passages
* 2390 Neoplasm of unspecified nature in digestive system
* 2710 Glycogenesis
* 2720 Pure hypercholesterolemia
* 2727 Lipidoses
* 2751 Disorders of copper metabolism
* 2770-2776 Cystic fibrosis, disorders of porphyrin metabolism, other disorders of purine and pyrimidine metabolism,
amyloidosis, disorders of bilirubin excretion (like EHBA as well as Criggler Najar syndrome), mucopolysaccharidosis, other
deficiencies of circulating enzymes including urea cycle disorders, an dother metabolic disorders.
* 2860 Congenital factor VIII disorder
* 2861 Congenital factor IX disorder
* 4530 Budd-Chiari syndrome
* 570 Acute and subacute necrosis of liver
* 5710 Alcoholic fatty liver
* 5712 Alcoholic cirrhosis of liver
* 5714 Chronic hepatitis
* 5715 Cirrhosis of liver without mention of alcohol
* 5716 Biliary cirrhosis
* 5718 Other chronic nonalcoholic liver disease
* 5719 Unspecified liver disease without mention of alcohol
* 5728 Other sequelae of chronic liver disease
* 5758 Other specified disorders of gallbladder
* 5761,5762 Cholangitis, obstruction of bile duct
* 75161,75169 Biliary atresia, other anomalies of gallbladder, bile ducts, and liver
* 7744 Perinatal jaundice due to hepatocellular damage
* 7778 Other specified perinatal disorders of digestive system
* 864 Injury to liver
* 3483 Encephalopathy, unspecified
* 452 Portal vein thrombosis.