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O Lt Eval Houston Grand Rounds

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O Lt Eval Houston Grand Rounds

  1. 1. Liver Transplantation and Hepatitis C A Clinical Update Joseph S. Galati, M.D Medical Director St. Luke’s Texas Liver Institute
  2. 2. Liver Transplant Evaluation Goals <ul><li>Systematic team approach </li></ul><ul><li>Fairness among patients </li></ul><ul><li>Protect a scarce resource </li></ul><ul><li>Establish a relationship </li></ul><ul><li>Assure patient understanding </li></ul><ul><li>Meet the patient’s support system </li></ul><ul><li>Improve outcome of liver transplantation! </li></ul>
  3. 3. Liver Transplant Evaluation RISK BENEFIT
  4. 5. Components of the Evaluation Liver Transplant Surgery Medical evaluation Psycho-social Evaluation Financial Evaluation Nutritional Evaluation Radiology Pharmacy
  5. 6. Liver Transplant Evaluation Transplant Nurse Coordinator Medical Evaluation Financial evaluation Psychosocial evaluation
  6. 7. Evaluation for Liver Transplantation <ul><li>What is the cause of the patient’s liver disease? </li></ul><ul><li>Does the patient need a liver transplant evaluation at this time? </li></ul><ul><li>Is the patient a good candidate for liver transplantation? </li></ul>
  7. 8. Medical Evaluation for Liver Transplantation Severity of Liver Disease <ul><li>Absolute indications: </li></ul><ul><li>Hepatic synthetic dysfunction </li></ul><ul><li>Peritonitis </li></ul><ul><li>Hepatorenal syndrome </li></ul><ul><li>Fulminant hepatic failure </li></ul><ul><li>Relative indications : </li></ul><ul><li>Refractory encephalopathy </li></ul><ul><li>Refractory variceal bleeding </li></ul><ul><li>Refractory ascites </li></ul><ul><li>Refractory pruritus </li></ul><ul><li>Disabling fatigue </li></ul><ul><li>HCC </li></ul>
  8. 9. Medical Evaluation Assessment of Extrahepatic Diseases <ul><li>Cardiac evaluation: age, risk factors, symptoms </li></ul><ul><li>Pulmonary evaluation: risk factors, symptoms </li></ul><ul><li>Gastrointestinal evaluation: age, risk factors, symptoms </li></ul><ul><li>Renal evaluation: abnormal renal function </li></ul><ul><li>Neuro-psychiatric evaluation: ? encephalopathy </li></ul><ul><li>Cancer assessment: extent of current disease, screening </li></ul>
  9. 10. Evaluation for Liver Transplantation Surgical Assessment <ul><li>Portal vein thrombosis </li></ul><ul><li>Prior surgeries </li></ul><ul><li>Obesity </li></ul><ul><li>Surgical risk </li></ul><ul><li>Assess suitable size of donor liver </li></ul>
  10. 11. Psycho-Social Evaluation <ul><li>Social Worker </li></ul><ul><li>Social support </li></ul><ul><li>Medical compliance </li></ul><ul><li>Sobriety </li></ul><ul><li>Psychiatrist </li></ul><ul><li>Psychiatric disorders </li></ul><ul><li>Personality disorders </li></ul>
  11. 12. Evaluation for Liver Transplantation Assessment of Compliance <ul><li>Clinic visits </li></ul><ul><li>Instructions </li></ul><ul><li>Medications </li></ul><ul><li>Sobriety contract </li></ul><ul><li>Diet </li></ul>
  12. 13. Patients with History of Substance Abuse <ul><li>Abstinence for at least 6 months </li></ul><ul><li>Assess need for sobriety contract </li></ul><ul><li>Random alcohol and drug screens </li></ul><ul><li>Watch for narcotics abuse potential </li></ul><ul><li>Appropriate medical work up based on nature of substance abuse history </li></ul>
  13. 14. Psychosocial Assessment <ul><li>Sobriety contract: </li></ul><ul><li>AA attendance x 6 mo </li></ul><ul><li>Random blood alcohol levels </li></ul><ul><li>Random urine drug screens </li></ul><ul><li>Continued sobriety </li></ul>I will not drink I will not smoke pot I will take my pills X___________
  14. 15. Survival After Liver Transplantation By Pre-Transplant Length of Abstinence
  15. 16. Evaluation for Liver Transplantation Financial Assessment <ul><li>Pre-approval by patients’ health insurance company for the evaluation and the transplant. </li></ul><ul><li>Assess patients’ support system resources for the expenses of travel and stay during the peri-operative period </li></ul><ul><li>Assess patients’ financial responsibility towards all hospital bills and post transplant medications </li></ul>
  16. 17. Primary Biliary Cirrhosis When to refer to OLT ? <ul><li>Bilirubin rising or approaching 6 mg/dl </li></ul><ul><li>Child-Pugh class B or C cirrhosis </li></ul><ul><li>First variceal bleed </li></ul><ul><li>Refractory pruritus (with good function) </li></ul><ul><li>Disabling fatigue </li></ul>
  17. 18. Primary Sclerosing Cholangitis: When to refer to transplant ? <ul><li>Predictor models not as reliable </li></ul><ul><li>Child-Pugh class B or C cirrhosis </li></ul><ul><li>Recurrent cholangitis </li></ul><ul><li>Refractory pruritus </li></ul><ul><li>Cholangiocarcinoma? </li></ul>
  18. 19. Viral Hepatitis and Liver Transplant <ul><li>Hepatitis C: </li></ul><ul><li>100% serologic recurrence </li></ul><ul><li>60-70% histologic recurrence </li></ul><ul><li>10-15% severe recurrence </li></ul><ul><li>Hepatitis B: </li></ul><ul><li>With no HBIG = 90 % histologic recurrence </li></ul><ul><li>With HBIG 30 % histologic recurrence </li></ul><ul><li>With lamivudine + HBIG = ? </li></ul>
  19. 20. Liver Transplant Evaluation Acceptable candidate P lace on waiting list Unacceptable candidate Able to modify negative factors Unable to modify negative factors Reject for liver transplant
  20. 21. On the “List” <ul><li>Status 3: minimum 7 C-P points </li></ul><ul><li>Status 2b: minimum 10 C-P points </li></ul><ul><li>Status 1: FHF, children, non-function, HA-T </li></ul><ul><li>Status 2a: 10 C-P points, plus be in the ICU with the following </li></ul><ul><ul><ul><li>Variceal hemorrhage (after TIPSS/shunt) </li></ul></ul></ul><ul><ul><ul><li>Hepatorenal </li></ul></ul></ul><ul><ul><ul><li>Encephalopathy (despite therapy) </li></ul></ul></ul><ul><ul><ul><li>Refractory ascites </li></ul></ul></ul><ul><li>Status 1: FHF, children, non-function, HA-T </li></ul>
  21. 22. Deaths on the Waiting List 1990/1995/2000 This accounts for a 25% death rate on the liver list
  22. 23. Cadaveric Donors, Cadaveric Transplants, and Number on Waiting List Source: Donors from OPTN data as of 9/5/00; transplants from Scientific Registry data as of 9/5/00; snapshot of OPTN waiting list on the last day of each year. Donors Transplants Waiting List at Year’s End
  23. 24. Waiting List Characteristics Liver Registrants in 1999 <ul><li>35% Ages 35-49, 44% Ages 50-64 </li></ul><ul><li>78% White, 7% Black, 10% Hispanic </li></ul><ul><li>51% Blood type O </li></ul><ul><li>95% Waiting for first transplant </li></ul><ul><li>56% On waiting list for 1 year or more </li></ul><ul><li>66% Medical urgency status 3 </li></ul>
  24. 25. Liver Graft Survival Rates by Waiting List Status at Transplant Note: Waiting list status for 1-year survival reported for codes 1, 2A, 2B, and 3; 5-year survival reported for codes 1, 2, 3, and 4. Source: Scientific Registry data as of 9/5/00. 1 Year (1998 Cohort) 5 Years (1992-97 Cohort)
  25. 26. So…when is the proper time to refer for transplant?
  26. 27. Never too early

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