transplantation of heart

1. HEART AND LIVER
TRANSPLANTATION

2. DEFINITION
• A surgical procedure in which a diseased heart is replaced with a
healthy heart from a deceased person.

3. INDICATIONS
NYHA
CLASS
PHYSICAL MANIFESTATION
I No limitation of physical activity, no dyspnea, fatigue or
palpitations with ordinary activity
II Slight limitation of physical activity, patients have fatigue,
palpitations, and dyspnea with ordinary physical but are
comfortable at rest.
III Marked limitation of activity, less than ordinary physical activity
results in symptoms, but patients are comfortable
IV Symptoms are present at rest and any physical exertion exacerbates
the symptoms

4. • Systolic heart failure with severe functional limitations and
/or refractory symptoms despite maximal medical therapy.
• NYHA functional class III-IV
• Maximal oxygen uptake (VO2 max) of < 12-14 ml/kg/min
exercise testing
• Cardiogenic shock not expected to recover
• Ischemic heart disease
• Intractable ventricular arrhythmias
• Severe symptomatic hypertrophic or restrictive
cardiomyopathy
• Congenial heart disease in which severe fixed pulmonary
hypertension
• Cardiac tumors with low likelihood of metastasis

5. CONTRA INDICATIONS
ABSOLUTE
• Elevated pulmonary artery
pressures
• Irreversible severe renal, hepatic
or pulmonary disease
• Kidney dysfunction
• Chronic liver dysfunction
• Recent or un resolved pulmonary
infarction
• Active uncontrolled infection
• Active malignancy or recent
malignancy with high risk or
recurrence
RELATIVE
• Advanced age (> 70 yrs)
• Diabetes mellitus with end organ
damage and/or poor glycemic
control
• Obesity
• Severe cachexia or malnutrition
• Systemic disease with a high
probability of recurrence in the
transplanted heart.
• Severe peripheral vascular
disease or cerebrovascular
disease.
• History of multiple prior
sternotomies
• High level of allo senstization

6. PSYCHOLOGICAL CONTRAINDICATIONS
ABSOLUTE CONTRAINDICATION
•Inadequate social support
•Illicit substance abuse
•Alcohol dependence
•Nicotine abuse
•Active psychotic symptoms
•Dementia
•History of multiple suicide attempts

7. STATUS - 1A
• Mechanical circulatory support such as left and /or right ventricular
assist device(may be listed for 30 days at any point after being
implanted)
• Total artificial heart
• Intra aortic balloon pump
• Extracorporeal membrane oxygenator(ECMO)
• Mechanical circulatory support with objective medical evidence of
significant device infection, mechanical failure or life threatening
ventricular arrhythmias
• Continuous mechanical ventilation
• Continuous infusion of a single high dose intravenous inotrope or
multiple intravenous inotropes, in addition to continuous hemodynamic
monitoring of left ventricular filling pressure

8. STATUS -1B
• Left and/or right ventricular assist device implanted
• Continuous infusion of intravenous ionotropes
STATUS 2
• A candidate who does not meet the criteria for status 1A or 1B

9. CRITERIA FOR DETERMINING BRAIN
DEATH
• Mechanism of brain injury is sufficient to account for
irreversible loss of brain function
• Absence of reversible causes of CNS depression
• CNS depressant drugs
• Hypothermia (<320C)
• Hypotension (MAP < 55mmHg)
• Absence of neuromuscular blocking drugs that may confound
the results of the neurologic exam
• No spontaneous movements, motor responses, or posturing
• No gag or cough reflexes
• No corneal or pupillary light reflexes
• No oculovestibular reflex (cold calorics)

10. Confirmatory test
• Apnea test for minimum of five minutes following:
• No respiratory movements
• Pco2>55 mmHg
• pH <7.40
• No intracranial blood flow

11. DONOR EVALUATION
• Age <55 yrs
• Absence of significant structural abnormalities
• LVH (wall thickness >13mm by echocardiography)
• Significant valvular dysfunction
• Significant congenital cardiac abnormality
• Significant coronary artery disease
• Adequate physiologic function of donor heart
• LVEF>45%
• Achievement of target hemodynamic criteria after hormonal resuscitation and
hemodynamic management
• Negative hepatitis C antibody, hepatitis B surface antigen and HIV
serologies
• Absence of active malignancy or overwhelming infection

12. HEART TRANSPLANTATION SURGICAL
PROCEDURE

13. ORTHOTOPIC HEART TRANSPLANTATION
• The recipient’s diseased heart is removed, and the donor allograft is
inserted anatomically in its place.

14. • After the sternotomy, the ascending aorta is cannulated close to the
aortic arch, venous return cannulae are inserted into both the superior
and inferior cavae, and the patient is placed on CPB.
• The cavae are encircled with tourniquets to isolate all of the venous
return from the heart, the ascending aorta is clamped close to the aortic
arch, and the recipient heart is then excised.

15. BIATRIAL TECHNIQUE
• A standard median sternotomy
is used, the great vessels are
cannulated, and
cardiopulmonary bypass is
instituted after anticoagulation
and standard hypothermia are
achieved

17. BICAVAL TECHNIQUE
• The anastomotic sites of the
bicaval technique include the
left atrial cuff, which contains
the orifices of pulmonary veins,
the superior and inferior vena
cava, as well as the aorta and
the main pulmonary artery.

19. HETEROTOPIC HEART
TRANSPLANTATION
• It is a rarely performed procedure in which the recipient’s heart remains
in place, and the donor heart is attached to its right side so that the flow
in each is in parallel, permitting the recipient’s heart to continue to
pump blood, particularly through the lungs.
• This procedure is primarily reserved for patients with pulmonary
hypertension as a strategy to avoid acute right heart failure in the
unconditioned donor heart and in cases in which there is a marked
difference in size of the donor and recipient

21. IMMUNO SUPPRESSION
• Agents used for induction therapy include cytolytic agents such as
the murine monoclonal antibody, antibody ornithine ketoacid
transaminase (OKT3) or polyclonal antithymocyte agents or
antilymphocyte agents (atgam, thymoglobulin).

22. CALCINEURIN INHIBITORS

23. CYCLOSPORINE
• 4-8mg/kg/d in 2 divided doses,
titrated to keep therapeutic 12
hours trough levels

24. TACROLIMUS
• 0.05-0.1 mg/kg/d in 2 divided
doses, titrated to keep
therapeutic 12 trough level

25. AZATHIOPRINE
• 1.5-3.0mg/kg/d
MAJOR TOXICITIES
• Bone marrow suppression
• Hepatitis
• Pancreatitis
• Malignancy

26. MYCOPHENOLATE MOFETIL
• 1000-3000 mg/kg/d in 2 divided
dose
MAJOR TOXICITIES
• Gastrointestinal
disturbances(nausea, diarrhea)

27. SIROLIMUS
• 1-3mg/d, titrated to keep therapeutic
24h trough level
MAJOR TOXICITIES
• Oral ulcerations
• Hypercholesterolemia and
Hypertriglyceridemia
• Poor wound healing
• Lower extremity edema
• Interstitial pneumonitis
• Leukopenia
• Anemia
• Thrombocytopenia
• Nephrotoxicity when used concurrently
with calcineurin inhibitors

28. EVEROLIMUS
• 1.5-3.0 mg/d in 2 divided doses

29. PREDNISONE
• 1mg/kg/d in divided doses, tapered to 0-
0.5mg/kg/d by 6 -12mg
MAJOR TOXICITIES
• Weight gain
• Hypertension
• Hyperlipidemia
• Osteopenia
• Hyperglycemia
• Poor wound healing
• Salt and water retention
• Proximal myopathy
• Cataracts
• Peptic ulcer disease
• Growth retardation

30. LIVER TRANSPLANTATION

31. DEFINITION
• Liver Transplantation is a procedure where a diseased liver is
removed from a patients body and is replaced with a new liver that is
taken from a deceased donor or a part of the liver is extracted from a
live donor who is considered as a donor after multiple tests.

32. TRANSPLANT TEAM
• Liver specialist (hepatologist)
• Transplant surgeons
• Transplant coordinator, usually a registered nurse who specializes in the
care of liver-transplant patients (this person will be your primary contact
with the transplant team)
• Social worker to discuss your support network of family and friends,
employment history, and financial needs
• Psychiatrist to help you deal with issues, such as anxiety and depression,
which may accompany a liver transplant
• Anesthesiologist to discuss potential anesthesia risks
• Chemical dependency specialist to aid those with history of alcohol or
drug abuse
• Financial counselor to act as a liaison between a patient and his or her
insurance companies

33. INDICATIONS
Children
• Biliary atresia
• Neonatal hepatitis
• Congenital hepatic fibrosis
• Byler’s disease
• Alpha -Antitrypsin deficiency
• Inherited disorders of metabolism
• Wilson’s disease
• Tyrosinemia
• Glycogen storage diseases
• Lysosomal storage diseases
• Familial hypercholesterolemia
• Primary hyperoxaluria type I
• Hemophilia
Adults
• Primary biliary cirrhosis
• Secondary biliary cirrhosis
• Primary sclerosing cholangitis
• Autoimmune hepatitis
• Caroli’s disease
• Cryptogenic cirrhosis
• Chronic hepatitis with cirrhosis
• Hepatic vein thrombosis
• Fulminant hepatitis
• Alcoholic cirrhosis
• Chronic viral hepatitis
• Primary hepatocellular malignancies
• Hepatic adenomas
• Nonalcoholic steatohepatitis
• Familial amyloid polyneuropathy

34. CONTRAINDICATION
Absolute
• Uncontrolled extra
hepatobiliary infection
• Active, untreated sepsis
• Uncorrectable, life-limiting
congenital anomalies
• Active substance or alcohol
abuse
• Advanced cardiopulmonary
disease
• Extra hepatobiliary malignancy
(not including nonmelanoma
skin cancer)
• Metastatic malignancy to the
liver
• Cholangiocarcinoma
• AIDS
• Life-threatening systemic
diseases

35. Relative
• Age >70
• Prior extensive hepato biliary
surgery
• Portal vein thrombosis
• Renal failure
• Previous extrahepatic malignancy
(not including nonmelanoma skin
cancer)
• Severe obesity
• Severe malnutrition/wasting
• Medical noncompliance
• HIV seropositivity
• Intrahepatic sepsis
• Severe hypoxemia secondary to
right-to-left intrapulmonary
shunts (PO2 < 50 mmHg)
• Severe pulmonary hypertension
(mean PA pressure >35 mmHg)
• Uncontrolled psychiatric disorder

36. MELD score

37. LIVING DONOR TRANSPLANTATION
• Is a procedure where a part of liver is taken from a living doctor, who is
supposed to be considered after undergoing a large number of medical
and psychological tests in order to avoid any sort of risk.
• The donor can be a blood relative, spouse or a friend who is considered
positive for the procedure. It is necessary that the donor must be
leading a healthy lifestyle and should be a non alcoholic.

39. CADAVERIC TRANSPLANTATION
• Is a procedure where the liver is taken from a deceased individual, in
medical terms an individual whose brain has stopped working is
considered to be dead. After considering certain tests and other
formalities the transplantation procedure is executed. The identity of
the donor and the circumstances under which the donor died are
kept confidential

41. AUXILIARY LIVER
TRANSPLANTATION
• The first is in the cases of patients with acute liver failure in whom a
partial graft is used to provide support to the patient’s diseased liver
while it recovers. Once the native liver returns to normal function, the
graft is removed and immunosuppression is withdrawn.
• The second case is for patients with functional congenital or metabolic
disorders affecting a normal liver. Implanting a partial graft while
preserving the native liver allows correction of the metabolic disorder
while avoiding a full liver transplant

43. PARTIAL GRAFT TRANSPLANTATION
• Partial liver grafts are used at times. It may be necessary to provide
partial support for metabolic needs due to a specific or complete
metabolic deficiency.
• In the latter case, one of the major preconditions is that the volume of
the graft must be sufficient inorder to have the capacity to sustain life in
the patient immediately after transplantation

44. SPLIT LIVER TRANSPLANTATION
• This alternative involves dividing a liver in
two parts and depends on who the
intended recipients are. If those sharing the
graft are an adult and a child, the liver will
be divided into a right lobe that includes
also the segment IV and a partial left graft
that includes segments II and III.
• Whereas, if theliver is to be divided
between two adults, it will be split in two,
the right lobe (segments V to VIII) and the
left lobe (segments Ito IV).

45. RETRANSPLANTATION
•The main causes have to be divided in early
(hepatic artery thrombosis or primary graft
non-function) and late (chronic rejection or
recurrence of the primary liver disease).
•The timing of retransplantation represents a
key point in both patient and graft survival.
•Patients with a retransplantation interval less
than 30 days display lower survival rates
when compared to those with later
retransplantation

46. PRETRANSPLANTATION HISTORY
• Risk factors for viral hepatitis: transfusions, intravenous drug abuse, tattoos,
other parenteral exposure
• Family history of liver disease
• Associated disorders: hypothyroidism, osteoporosis, infertility, arthritis
• Onset, duration, and description of symptoms and complications: jaundice,
lethargy, bleeding disorders, pruritus, confusion, ascites, edema, malenic
stools, abdominal pain, bone pain or fractures, chronic diarrhea,
gynecomastia (in men), amenorrhea (in women)
• Current and past medical history: hospitalizations, surgeries
• Social history: exposure to alcohol, drugs, toxins, tobacco products
• Status of immunizations

47. EVALUATION BEFORE
TRANSPLANTATION
• LABORATORY TEST
• URINE ANALYSIS
• STOOL ANALYSIS
• GASTRO INTESTINAL STUDIES
• PULMONARY TEST
• RADIOGRAPHIC STUDIES
• OTHERS

48. CADAVER DONOR SELECTION
• Cadaver donor liver for transplantation are procured primarily from
victims of head trauma.
• Organs from brain-dead donors up to age 60 are acceptable if the
following criteria are met: hemodynamic stability, adequate
oxygenation, absence of bacterial or fungal infection, absence of
abdominal trauma, absence of hepatic dysfunction, and serologic
exclusion of hepatitis B and C viruses and HIV.

49. • Compatibility in ABO blood group and organ size between donor and
recipient are important considerations in donor selection.
• Allocation based on the Child-Turcotte-Pugh (CTP) score, which uses five
clinical variables (encephalopathy stage, ascites, bilirubin, albumin, and
prothrombin time) and waiting time, has been replaced by allocation based
upon urgency alone, calculated by the Model for End-Stage Liver Disease
(MELD) score

50. DETERMINING DONOR SUITABILITY
• The two criteria necessary for matching a donor liver to a recipient are
blood type and body size.
• In very urgent situations, the donor blood type (e.g., type A) may not be
compatible with that of the recipient (e.g., type 0). Despite this
incompatibility, such liver transplantations can be successful. There may
be some early postoperative complications, such as mild hemolysis,
higher incidence of acute cellular rejection, and increased postoperative
hepatic vascular and biliary complications, but innovative use of
immunosuppressive regimens and plasmapheresis have improved graft
survival of patients with recipient-donor ABO incompatibility.

51. LIVING-DONOR TRANSPLANTATION
• Being in good health
• Having a blood type that matches or is compatible with the recipient's
• Having a charitable desire of donation without financial motivation
• Being between 18 and 60 years old
• Being of similar or bigger size than the recipient
• Have no chronic medical problems or history of major abdominal surgery
• The donor must undergo testing to ensure that the individual is physically
fit.
• Driven by the shortage of cadaver organs, living-donor transplantation
involving the more sizable right lobe is being considered with increasing
frequency in adults.
• Living-donor transplantation can reduce waiting time and cold-ischemia
time; is done under elective, rather than emergency, circumstances; and
may be lifesaving in recipients who cannot afford to wait for a cadaver
donor.

52. LIVING LIVER DONOR
COMPLICATIONS
•Grade Icomplications are not life-threatening and do not result in
permanent disability.
•Grade IIcomplications require medications or transfusion.
•Grade IIIcan be potentially life-threatening and require invasive
therapy such as & return to the operating room.
•Grade IVleads to disability or death

53. ORTHOTOPIC TRANSPLANTATION
• A segment of the inferior vena cava attached to the liver is taken from
the donor as well. The same parts are removed from the recipient and
replaced by connecting the inferior vena cava, the hepatic artery, the
portal vein and the bile ducts.
• In the adult procedure, once the right lobe is removed from the donor,
the donor right hepatic vein is anastomosed to the recipient right
hepatic vein remnant, followed by donor-to-recipient anastomoses of
the portal vein and then the hepatic artery. Finally, the biliary
anastomosis is performed, duct-to-duct if practical or via Roux-en-Y
anastomosis.

55. HETEROTOPIC LIVER
TRANSPLANTATION
• In which the donor liver is
inserted without removal of the
native liver, has met with very
limited success and acceptance,
except in a very small number of
centers.

56. REDUCED-SIZE LIVER
TRANSPLANTATION
• Transplants part of a donor liver
into a patient. It is possible to
divide the liver into eight pieces,
each supplied by a different set
of blood vessels. Two of these
pieces have been enough to
save a patient in liver failure

57. SURGICAL PROCEDURE
Liver transplantation surgery can be divided into three stages:
(1) Recipient hepatectomy,
(2) Vascular anastomoses with donor liver, and
(3) Biliary anastomosis

58. RECIPIENT HEPATECTOMY
•Stage 1 is the longest and most difficult part of the
surgery, because it involves removal of the native
liver.
•It is complicated even more by coagulopathies,
adhesions, portal hypertension, and venous
collaterals.
•A centrifugal pump cycles the blood out through
iliac and portal vein cannulas and returns it to the
central circulation through the axillary or subclavian
vein

59. VASCULAR ANASTOMOSES WITH A DONOR
LIVER
• Stage 2 comprises the four vascular anastomoses: suprahepatic
inferior vena cava, infrahepatic vena cava, hepatic artery, and portal
vein.
• If venovenous bypass is used, it is removed after the intrahepatic vena
cava anastomosis and before the hepatic artery anastomosis

60. BILIARY ANASTOMOSIS
• Stage 3 can be achieved by choledochojejunostomy (bile duct to
jejunum) or by choledochocholedochostomy (bile duct to bile duct).
• Choledochojejunostomy is performed in patients who have diseased
bile ducts, such as those with biliary atresia or sclerosing cholangitis.
It is also known as a Roux-en- Y procedure

62. NON HEPATIC COMPLICATIONS OF
LIVER TRANSPLANTATION
• Fluid overload
• Arrhythmias
• Congestive heart failure
• Cardiomyopathy
CARDIOVASCULAR INSTABILITY

63. PULMONARY COMPROMISE
• Pneumonia
• Pulmonary capillary vascular
permeability
• Fluid overload

64. RENAL DYSFUNCTION
• Prerenal azotemia
• Hypoperfusion injury (acute
tubular necrosis)
• Drug nephrotoxicity
• Renal blood flow secondary to 􀁂
intraabdominal pressure

65. HEMATOLOGIC
• Anemia 2° to gastrointestinal
and/or intraabdominal bleeding
• Hemolytic anemia, aplastic
anemia
• Thrombocytopenia

66. INFECTION
• Bacterial: early, common
postoperative infections
• Fungal/parasitic: late,
opportunistic infections
• Viral: late, opportunistic
infections, recurrent hepatitis

67. NEUROPSYCHIATRIC
• Seizures
• Metabolic encephalopathy
• Depression
• Difficult psychosocial
adjustment

68. MALIGNANCY
• B-cell lymphoma
(posttransplantation
lymphoproliferative disorders)
• De novo neoplasms (particularly
squamous
• cell skin carcinoma

69. HEPATIC COMPLICATIONS OF LIVER
TRANSPLANTATION
Hepatic Dysfunction Common after
Major Surgery
Pigment load
Hemolysis
Blood collections (hematomas,
abdominal
collections)
Intrahepatic
Early
Early Hepatotoxic drugs and anesthesia
Hypoperfusion (hypotension, shock,
sepsis)
Benign postoperative cholestasis

70. Late Transfusion-associated
hepatitis
Exacerbation of primary
hepatic disease
Post hepatic Biliary obstruction
Renal clearance of
conjugated bilirubin
(renal dysfunction)

71. PRIMARY NONFUNCTION
• Is characterized by post transplantation encephalopathy,
coagulopathy, minimal bile output, and progressive renal and
multisystem failure, with increasing serum lactate and rapidly rising
liver enzyme levels and histologic evidence of hepatocyte necrosis in
the absence of any vascular compromise.

72. • With improved donor selection and management, operative techniques,
reducing cold ischemia times, and newer preservative solutions, the risk
of primary nonfunction has decreased.
• Patients with initial dysfunction, also known as primary graft
dysfunction, might recover with support, but those who progress to show
evidence of extrahepatic complications, such as hemodynamic instability,
renal failure, or other organ system dysfunction, can require urgent
retransplantation.

73. HEMORRHAGE AND HYPOVOLEMIC
SHOCK
• Continuous monitoring of coagulation parameters during surgery.
• Use of antifibrinolytic agents
• Decompression of spenchnic circulation by veno-venous bypass or
temporary porto-caval shunt.
• Maintenance of recipient's core temperature
• Assess the patient’s vital signs and other indicators of fluid volume hourly
and note trends indicating hypovolemia; hypotension; weak, rapid, irregular
pulse; oliguria; decreased level of consciousness; and signs of peripheral
vasoconstriction.
• Monitor the patient’s hematocrit and hemoglobin levels daily.
• Maintain patency of all I.V. lines, and reserve 2 units of blood in case the
patient needs a transfusion.
• Accurate measurements of hemodynamic function, such as arterial blood
pressure, peripheral blood pressure, central venous pressure, pulmonary
artery pressure, PAOP or "wedge" pressure, urinary output, patency of drains,
and bile totals are assessed frequently to evaluate true volume status.

74. Hepatic Artery Stenosis and Thrombosis
• Angiography is the gold standard for diagnosis. In cases of early
documentation of the problem (i.e., within 24-48 hours), urgent
revascularization can result in arterial patency. However, a significant
number of patients treated in this manner still require
retransplantation because of biliary complications, persistent biliary
sepsis, and intra-abdominal infection.

75. Portal Vein Stenosis and Thrombosis
• Treatment is by surgical intervention in early post-transplantation
and by percutaneous transhepatic dilation or stenting of the stricture
later after liver transplantation. If left untreated, it can progress to
complete thrombosis of the vein or severe graft dysfunction and
hemodynamic instability secondary to massive ascites

76. Hepatic Outflow Obstruction
• Be alert for signs and symptoms of acute vascular obstruction in the
right upper quadrant
• Cramping pain or tenderness, nausea, and vomiting. Notify the
practitioner immediately if any occur.
• As ordered, prepare for emergency thrombectomy. Maintain I.V.
Infusions, check and document
• The patient’s vital signs, and maintain airway patency.

77. HEPATIC FAILURE
• Monitor nasogastric tube drainage for upper GI bleeding.
• Frequently assess the patient’s neurovascular status.
• Note development of peripheral edema and ascites.
• Monitor the patient’s renal function by checking urine output, blood
urea nitrogen levels, and serum creatinine and potassium levels.
Monitor serum amylase levels daily.

78. WOUND INFECTION OR ABSCESS
• Assess the incision site daily, and report any inflammation,
tenderness, drainage, or other signs and symptoms of infection.
• Change the dressing daily or as needed.
• Note and report any signs or symptoms of peritonitis or abscess,
including fever, chills, leukocytosis(or leukopenia with bands),
and abdominal pain, tenderness, and rigidity.
• Take the patient’s temperature every 4 hours.
• Collect abdominal drainage for culture and sensitivity studies.
Document the color, amount, odor,and consistency of drainage.
• Assess the patient for signs of infection in other areas, such as
the urinary tract, respiratory system, and skin. Document and
report any signs of infection.

79. PULMONARY INSUFFICIENCY OR
FAILURE
• Pleural effusion
•Pulmonary edema
•Pneumonia
•Pneumothorax or hemothorax
•Atelectasis
•Paralysis of right diaphragm

80. • Maintain ventilation at prescribed levels.
• Monitor the patient’s arterial blood gas levels, and change ventilator
settings, as ordered.
• Auscultate for abnormal breath sounds every 2 to 4 hours.
• Suction the patient as needed.
• The patient may require changes in ventilatory settings, suctioning to
remove secretions, or administration of pharmacologic agents to correct
acid-base imbalances.
• While the patient is on ventilatory support, pneumonia can be avoided by
maintaining the head of bed elevated at 30 degrees, turning the patient
frequently, providing good oral care, and brushing the patient's teeth.
• After extubation, patients must be encouraged to perform incentive
spirometry exercises and to turn, cough, and deep-breathe frequently to
help prevent atelectasis and pneumonia.
• Respiratory treatments with bronchodilators, prophylactic antimicrobials,
and chest physiotherapy also may be used

81. ARTERIAL HYPERTENSION
• The general principles of AHT treatment are similar to those
used in the general population, including low sodium diet and
weight loss. Specific measures include the reduction in CNI
doses and early steroid withdrawal within the first 3-6
months post-transplantation.
• Care must be taken in relation to possible drug interactions
between immunosuppressive agents and anti-hypertensive
drugs.
• The drugs of first choice are those that induce vasodilatation
as calcium antagonists. Inhibitors of the angiotensin
converter enzyme and the loop diuretics are also used.

82. NEUROLOGIC COMPLICATIONS
• Most neurologic complications are related to the degree of pre
transplantation encephalopathy caused by hepatic encephalopathy or
electrolyte disturbances, in particular hyponatremia, as well as the
idiosyncratic central nervous system effects of metabolic abnormalities
caused by immunosuppressive agents, most notably the CNIs(calcineurin
inhibitors).
• These drugs can produce a wide clinical spectrum of signs and
symptoms, from mild tremor and acute confusion to status epilepticus.
• CNI-related neurotoxicity occurs in approximately 25% of liver transplant
recipients. These could be dose-related and include impaired mentation
or confusion, psychosis, dysphasia, mutism, cortical blindness,
extrapyramidal syndromes, quadriplegia, encephalopathy, seizures, and
coma.

83. BONE COMPLICATIONS
• Osteopenia is a frequent finding in patients with advanced, chronic liver
disease, particularly in those with cholestatic disease.
• Globally, 20-40% of liver transplant recipients present atraumatic bone
fractures; this prevalence rises to 65% in patients transplanted due to
cholestatic disease and in retransplant patients

84. • The most frequent locations are the vertebrae and the ribs. Multiple
factors have been implicated, such as hormonal changes associated with
the pathogenesis of the liver disease, prolonged immobilization, and
immunosuppressive treatment, particularly steroids.
• Indeed, immunosuppression by itself affects bone density through its
influence on the cytokines that intervene in bone metabolism.
• In addition, some of the drugs directly suppress osteoblast function,
inhibit intestinal absorption of calcium, and stimulate its secretion
through the kidneys. Calcium, vitamin D, calcitonine and biphosphonates
have been used to avoid post-transplantation osteoporosis, but no
consensus has been reached yet as to the best approach

85. DYSLIPIDEMIA
•With the exception of patients with cholestatic
disease, who frequently present
hypercholesterolemia tied to bile secretion
alteration, most cirrhotic patients have synthesis-
reduction related hypocholesterolemia.
•The etiology of post-transplantation
hyperlipidemia involves many factors, such as the
diet, genetic predisposition, de novo DM, post
transplantation kidney dysfunction, and
immunosuppressive treatment. In particular,
steroids play a significant role in hyperlipidemia
onset mediated by increased hepatic secretion of
VLDL and of its conversion to LDL.

86. • The use of CNI is also related with the development of
hypercholesterolemia and hyper triglyceridemia. Sirolimus is a relatively
new immunosuppressive drug that has as a major side effect the
development of hyperlipemia.
• Treatment is focused on patients with persistent dyslipidemia,
particularly if they have concurrent cardiovascular risk factors.
Appropriate diet, weight reduction, strict control of DM and arterial
hypertension along with smoking or drinking cessation are initial
measures.

87. ELECTROLYTE IMBALANCES AND
OTHER METABOLIC ABNORMALITIES
• Almost any metabolic imbalance can occur after OLT. This is not
surprising, considering the magnitude of the physiologic stress of
surgery, fluid shifts, multitude of pharmacologic agents administered,
and multisystem complications. The most common imbalances, however,
are hypokalemia, hyperkalemia, hyperglycemia, and hypomagnesemia.
• Hypokalemia can occur as a side effect of potassium-wasting diuretic
therapy, intracellular fluid shifts secondary to metabolic alkalosis,
hypothermia, insulin therapy, and corticosteroid therapy. Rarely, if the
serum potassium level is monitored regularly and supplementation given
when indicated, hypokalemia from any cause is significant enough to
produce physical signs.

88. • Hyperkalemia is more often seen after transplantation, beginning 1 to 2
weeks after OLT. It is caused by renal tubular acidosis secondary to CNI
use. It is easily manageable with a dietary regimen. Rarely, patients need
to be placed on mineralocorticoids or potassium- chelating agents.
• The main cause of hyperglycemia in liver transplant patients is
preexisting diabetes mellitus. Other important causes are corticosteroids
and CNIs. Drug-induced hyperglycemia is usually transient and improves
after discontinuation of steroids and reduction in dosage of CNIs. Less
than 5% of these patients require long-term treatment

89. • Hypomagnesemia is another phenomenon after OLT. Many patients are
hypomagnesemic from malnutrition before transplantation, and the
condition is exacerbated during the postoperative period. The exact
nature of this problem is not completely understood. However,
contributing postoperative factors are believed to include diuretic therapy
and the renal effects of CNIs. Routine monitoring of the serum
magnesium level and supplementation with IV or oral magnesium may
be indicated.

90. TRANSPLANT REJECTION
• Clinical signs suggesting rejection are fever, right upper quadrant
pain, and reduced bile pigment and volume
• Leukocytosis may occur, but the most reliable indicators are increases
in serum bilirubin and aminotransferase levels.
• Radiographic visualization of the biliary tree and/or percutaneous
liver biopsy

91. CAUSES OF GRAFT REJECTION
MEDICAL COMPLICATION
Early (0-90 days after transplantation)
• Hyperacute rejection
• Delayed graft function
• Acute rejection
• Acute calcineurin inhibitor
• Nephrotoxicity
• Dehydration
• Other drug toxicities Infection
Late (>90 days after transplantation)
• Acute rejection
• Calcineurin inhibitor toxicity
• Chronic rejection Dehydration
• Other drug toxicities Infection
• BK virus nephropathy

92. CAUSES OF GRAFT REJECTION
MECHANICAL COMPLICATION
Early (0-90 days after transplantation)
• Lymphocele
• Ureteric obstruction
• Urine leak
• Vascular thrombosis
Late (>90 days after transplantation)
• Renal artery stenosis
• Ureteric obstruction
• Urine leak
• Vascular thrombosis

93. TYPES OF ALLOGRAFT REJECTION
• a) Hyperacute rejection:
• Occur within minutes to days after transplantation
• Primarily mediated by ABO or preformed
• anti-HLA antibodies
• Characterised by intravascular thrombosis and
• interstitial haemorrhage
• Liver transplants are relatively resistant

94. b)Acute rejection
• Usually occurs during first six months
• T cell dependent
• May be cell-mediated, antibody-mediated or both
• Usually reversible with additional immunosuppressive Therapy.

95. c) Chronic rejection
• Most common cause of long-term allograft loss
• Occurs over months to years
• Secondary to T and B cell processes
• Characterised by myointimal proliferation in graft
• arteries leading to ischaemia and fibrosis
• Vanishing bile duct syndrome

96. NURSING MANAGEMENT
Before liver transplantation
• Instruct the patient and his family about the transplant, necessary
diagnostic tests, immunosuppressant medications, and rejection risk.
• Review information about the equipment and procedures, such as
cardiac monitoring, ET tube, NG tube, abdominal drainage tubes,
indwelling urinary catheter, and arterial lines.
• Reassure the patient that discomfort should be minimal and that the
equipment will be removed as soon as possible.
• Administer ordered medications such as immunosuppressant agents.
• Review incentive spirometry and range of motion (ROM) exercises with
the patient.
• Make sure that an informed consent form has been signed.
• Instruct family members in measures to control infection and minimize
rejection after transplantation and advise them to have all their
immunizations up to date.
• Provide emotional support to the patient and his family.

97. After liver transplantation
• Assess the patient’s cardiopulmonary and hemodynamic status, including vital
signs, oxygen saturation, and cardiac rhythm, at least every 15 minutes in the
immediate postoperative period and then hourly or as indicated by his condition.
• Mean arterial and pulmonary artery pressures are monitored continuously.
Cardiac output, central venous pressure, pulmonary capillary wedge pressure,
arterial and mixed venous blood gases, oxygen saturation, oxygen demand and
delivery, urine output, heart rate, and blood pressure are used to evaluate the
patient’s hemodynamic status and intravascular fluid volume.
• Liver function tests, electrolyte levels, the coagulation profile, chest x-ray,
electrocardiogram, and fluid output, including urine, bile, and drainage from
Jackson-Pratt tubes, are monitored closely.

98. • Monitor the patient’s temperature frequently, at least every hour initially
and then every 2 to 4 hours. He may be hypothermic in the initial
postoperative phase, and it’s important to reestablish normal body
temperature.
• Later in the postoperative phase, monitor the patient for fever and signs
of infection.
• Monitor laboratory tests, especially liver enzymes, bilirubin, electrolytes,
coagulation studies, and CBC.
• Assess insertion sites for indications of bleeding. Assess the incision site
closely for oozing or active bleeding. If the patient has an NG tube,
assess drainage color at least every 2 hours
• Institute strict infection control precautions.
• Administer prophylactic antibiotics and postoperative drugs, such as
corticosteroids and immunosuppressants, as ordered.
• Assist with extubation as soon as possible (usually within 4 to 6 hours),
and administer supplemental oxygen as needed. Encourage coughing,
deep breathing, and incentive spirometry.

99. • Monitor the patient’s intake and output at least hourly, and
notify the practitioner if output is less than 30 ml/hour. Maintain
fluids at 2,000 to 3,000 mL/day, or as ordered, to prevent fluid
overload.
• Maintain the patient on nothing by mouth status with NG
decompression, and attach the NG tube to low intermittent
suction until bowel sounds return.
• Change the patient’s position at least every 2 hours, getting him
out of bed and to the chair within 24 hours if his condition is
stable.
• liver is responsible for the storage of glycogen and the synthesis
of protein and clotting factors, these substances need to be
monitored and replaced in the immediate postoperative period.

100. • Continually assess the patient for signs and symptoms of acute rejection,
such as malaise, fever, graft enlargement, and diminished graft function
(typically 7 to 14 days after the transplant.
• To ease emotional stress, plan care to allow rest and provide as much
privacy as possible. Allow family members to visit and comfort the
patient as much as possible.
• Teach the patient and his family about danger signs and symptoms and
the need to report these immediately.