Dr lvk liver transplpantation l.venkatakrishan

1. EVALUATION FOR
LIVER TRANSPLANTATION
L.VENKATAKRISHNAN
Dept of GI Sciences
PSG Institute of Medical Sciences,
Coimbatore

2. INTRODUCTION
• Liver transplantation is currently the
treatment of choice for patients with ESLD
with complications.
• Most common indications
– Complication of ESLD
– Acute Liver Failure
– Primary Hepatic Malignancy
• Persistent problem – shortage of donor pool

3. Scope of the Talk
• Indications for transplant
• Candidate selection listing
• Pre-transplant evaluation
• Disease specific issues
• Methods of expanding donor pool
• Post transplant care and complications

4. Indications for Liver Transplantation
Alcoholic
Cirrhosis
11%
NAFLD
9%
Hepatitis B
1%
Cryptogenic
cirrhosis
3.5%

5. Indications for Liver Transplantation
• Fulminant hepatic Failure
• Complications of cirrhosis
– Ascites
– Chronic gastrointestinal blood loss caused by
portal hypertensive gastropathy
– Hepatic encephalopathy
– Liver Cancer
– Recurrent variceal bleeding
– Synthetic dysfunction

6. Indications for Liver Transplantation
• Liver based metabolic conditions
– Alpha 1 antitryspin deficiency
– Familial amyloidosis
– Glycogen storage disease
– Hemochromatosis
– Primary oxaluria
– Wilson disease
– Tyrosinemia
– Urea cycle enzyme deficiencies
• Systemic complications of chronic liver disease
– Hepatopulmonary syndrome
– Portopulmonary hypertension

7. Prognostic Models for LT Allocation

8. Prognostic Models for LT
Allocation

9. Prognostic Models for LT Allocation
MELD Score

10. Prognostic Models for LT Allocation
Conditions for which MELD exception may be allocated
• HCC
• Cholangiocarcinoma in select cases
• Hepatopulmonary syndrome
• Portopulmonary hypertension
• Recurrent cholangitis
• Budd-Chiari syndrome
• Primary hyperoxaluria
• Familial amloidosis
• Cystic fibrosis
• Intractable pruritus
• Polycystic liver disease
• Hereditary hemorrhagic telangiectasia
• Small for size syndrome

11. Transplant Evaluation
• Cardiac evaluation
• Pulmonary evaluation
• Surgical evaluation
• Infectious disease evaluation
• Nephrology evaluation
• Neurologic evaluation
• Laboratory studies
• Radiology evaluation
• Age appropriate cancer screening
• Social work evaluation
• Financial screening

12. Transplant Evaluation
• Cardiac evaluation
Non invasive evaluation with echo cardiography
Patients with advanced liver disease may not get
target heart rate during TMT.
Pharmacological stress with adenosine or
dobutamine.
Coronary angiogram and appropriate
management of CAD before ALT
To rule out valvular heart disease and venticular
dysfunction.

13. Transplant Evaluation
• Pulmonary Evaluation
POPH should be excluded in LT candidates by routine
echocardiography. If RVSP is more than 45 mm of Hg
right heart catheterization indicated
Vasodilater therapy should be evaluated by pulmonary
cardiac specialists.
LT can be offered to potential recipients who respond to
medical therapy.
All patients should be screened for HPS.
Presence of severe HPS with increased mortality should
be expedited for LT evaluation.
Other associated pulmonary conditions like ILD should be
evaluated before transplant.

14. Transplant Evaluation
• Surgical Evaluation
Confirm the need for transplant
Identify technical challenges
Discuss donor options - deceased, living and
extended.

15. Transplant Evaluation
• Infectious Disease Evaluation
Serological – HAV, HBV, HCV, HIV, EBV, CMV,
RPR
Interferon γ Assay for TB –Quantiferon test or T
spot TB
Selected candidates screening for
coccidiomycosis, strongyloides and dental
evaluation
Vaccination strategies
Treatment of latent TB

16. Transplant Evaluation
• Nephrology evaluation
Recognition of renal dysfunction with cirrhosis has
a dramatic effect on post LT mortality.
Death increased by 7 fold in patients who had
onset of renal failure within one month of
transplant.
DD includes 1-Intercurrent sepsis
2-Hypovolemia
3-HRS
4-Parenchymal renal diseases

17. Transplant Evaluation
• Nephrology evaluation
Evaluation will include calculation of GFR and
determination of precise etiology.
SLK is indicated
1. End stage renal diseases with cirrhosis
2. Liver failure with CKD and GFR < 30 ml/min
3. Acute kidney injury or HRS requiring dialysis
for more than 8 weeks
4. If more than 30% of glomerulosclerosis or
fibrosis by renal biopsy.

18. Transplant Evaluation
• Neurological evaluation
Carotid doppler if age > 60
Neurology consultation as needed.

19. Transplant Evaluation
• Laboratory studies
Electrolytes
Hepatic function panel
Coagulation panel
Hepatitis serologies
Blood typing with antibodies
Urine Toxicology

20. Transplant Evaluation
• Radiology evaluation
Abdominal sonogram with doppler
Triple phase CT or gadolinium magnetic
resonance imaging for HCC screening or
tumor staging.
CT thorax

21. Transplant Evaluation
• Age appropriate cancer screening
PAP Smear
Mammogram
Colonoscopy (age > 50 or history of primary
sclerosing cholangitis)
Bone Disease
Obesity
Previous extra hepatic malignancy.

22. Transplant Evaluation
• Social work evaluation
Assess psychosocial issues
Evaluate support base
Financial Screening
1. Secure approval for evaluation
2. Discuss the cost

23. Specific Issues in Transplant
Evaluation
Patients with HCV disease
Patients with HIV disease
Patients with HBV disease
Patients with Alcohol Liver Disease
Hepatocellularcarcnioma
Cholangiocarcnioma
MELD exceptions

24. Absolute Contraindication for
Transplant