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Liver Transplantation for PSC Patients

A Transplant Surgeon’s PerspectiveTiffany Anthony, MDAnnette C. and Harold C. Simmons Transplant InstituteBaylor University Medical Center

+Liver Transplant: The Journey to and Through Liver Transplant

Recipient Selection

Transplant Listing

Donor Selection

Liver Offers

THE LIVER TRANSPLANT EVENT

Post-Op Recovery

Post-Op Complications

Long Term Complications

Outcomes/Survival

+Liver Transplant: When is time to pursue Tranplant Listing?

Cirrhosis Compensated Cirrhosis Decompensated Cirrhosis: Complications of

Portal Hypertension Ascites Encephalopathy Esophageal Varices Hepato-renal

Syndrome/Hepato-pulmonary/Porto-Pulmonary Hepatocellular Carcinoma: HCC

+Liver Transplant: When is time to pursue Transplant Listing?

Indications for Liver Transplant Listing Specific to PSC patientsCholangitisPruritisCholangiocarcinoma: Special

Protocols/Tight Restrictions/Few Centers

+Liver Transplant: Indications for Transplant Listing

Portal Hypertension Fibrotic Stiff Liver Toll Booth Analogy Hormonal Cascade Dilated and “Leaky”

Venous System Causing

Downstream Symptoms

Of Liver Disease

+Liver Transplant: Indications for Transplant Listing

Ascites

+Liver Transplant: Indications for Transplant Listing

Hepatic Encephalopathy

+Liver Transplant: Indications for Transplant Listing

Esophageal Varices: Nadolol and Banding

+Liver Transplant: Indications for Transplant Listing

Hepato-renal Syndrome Reversible kidney failure

caused by worsening liver

failure. Treatment OLT

Hepato-Pulmonary Syndrome Hypoxemia-low blood oxygen levels

Porto-Pulmonary Syndrome Portal Hypertension and Pulmonary Hypertension

+Liver Transplant: Indications for Transplant Listing

Special Considerations for PSC patients Cholangitis: RRB Points Pruritis: RRB Points Cholangiocarcinoma

+Liver Transplant: Indications for Transplant Listing

ERCP/PTC: Two different ways to stent the bile duct.

ERCP

+Liver Transplant: Indications for Transplant Listing

PTC

+Liver Transplant: Transplant Listing Considerations Liver Transplant Evaluation

Risk-Benefit Ratio Contraindications to Liver Transplant

MELD Score: Total Bilirubin INR Creatinine Total Bilirubin

PSC disadvantage Options

The Wait

Alternative to Deceased Donor Transplant/The Wait List Living Donor Liver Transplant

+Liver Transplant: Donor Selection Considerations

Types of Liver Donors Brain Dead Donors-5% DCD (Donor After Cardiac Death)-95% Living Donor

Donor Selection Criteria Age Medical History BMI Laboratory Values Size CDC High Risk What does the Transplant Surgeon think about the liver

about the liver on visualization?

+Liver Transplant: Donor Selection-Visualization

Normal Liver

+Liver Transplant: Donor Selection-Visualization

Cirrhotic Liver

+Liver Transplant: Donor Selection-Visualization

Steatotic “Fatty” Liver

+Liver Transplant: Donor Selection

Fatty Liver: Pathology

+Liver Transplant: Liver Offers

OPO: Organ Procure Organization

+Liver Transplant: Liver Offers

DonorNet: Electronic Notification

Review Donor information in DonorNet

Liver Biopsy

Imaging

Coordination of Donor OR time with OPO, other Transplant Centers and Aviation company

Procurement

Transplant OR timing

+Liver Transplant: Procurement

+Liver Transplant: THE OPERATION

Incisions

+Liver Transplant: THE OPERATION

+Liver Transplant: THE OPERATION

+Liver Transplant: Post Op Recovery

ICU Stay What to expect in the first 24-48 hours.

Regular Ward Stay What to expect the next 5-10 days after ICU stay

Post-Op Clinic Twice Weekly appts Weekly apps 1-3 month stay in close proximity to Transplant Center

+Liver Transplant: Early Complications Operative Death

3-5%

Primary Non-Function 1-3%

Post-op Bleeding 5%

Biliary Complications 10-15

Vascular Complications 2-4%

Post Op Infections

Acute Rejection 10-30%

+Liver Transplant: Early Complications-Vasculcar 2-4%

Hepatic Artery Thrombosis (HAT) Early vs. Late: 4 week cut-off period Surgery Relist patient Status 1 if < 1 week from LT Re-Transplant-Late

Hepatic Artery Stenosis (HAS) Arterial Revision Stent Placement

Portal Vein Stenosis/Thrombosis

+Liver Transplant: Early Complications-Biliary 10-15%

Biliary Anastomotic Strictures Technical problem Dx: rising canalicular enzymes, PTC/ERCP Operative revision

Biliary Leak Rare, more often seen with split livers Dx: PTC/ERCP Rx:

ERCP/stent with drainage Operative revision

+Liver Transplant: Immunosuppression

Side-Effects/Long Term Effects of Immunosuppression Prograf/tacrolimus Cyclosporine Cell Cept/Myfortic Prednisone

+Liver Transplant: Long Term Complications

Obesity

Diabetes

Hypertension

Hyperlipidemia

Renal Dysfunction

Bone Loss

Cardiovascular Complications

PSC Recurrence

+Liver Transplant: Long Term Complications

PSC Recurrence Estimated to occur in 20-25% of transplant

recipients any where from 5-10 years post transplant.

Largest meta-analysis reported a recurrence of 17% in 940 PSC patients

Can lead to graft failure but this is rare. No proven preventative measures.

+Liver Transplant: Outcomes

1 Year Survival: 90%

5 Year Survival: 75-80%

Very Long Term Survival

Data on PSC Patient Post Transplant Survival Survival

Deceased Donor Living Donor 1 year 93% 97.2% 5 year 87.5% 95%

+Liver Transplant: The Future/Other Technologies

Tissue Engineering Using a scaffold Infusing liver cells Cell signals to differentiate into the different cells/structures ?In my career/lifetime?

Liver Dialysis Bridge to Transplant

Donor Liver Perfusion Machines Extend Time from Procurement to Transplant Salvage “Marginal Livers”

+Liver Transplant: Our patients/Our Friends

+Liver Transplant: Our patients/Our Friends

+The Organ Grinders

+The Organ Grinders

+Questions?