Liver Transplantation

Philip Goodney, MD

June 22, 2005

Format

• Question and Answer (multiple choice)

• Review of reading in Sabiston Chapter

List ‘em

• Name the most common indications for liver transplantation, in order, for adults and children.

List ‘emTABLE 27-1 -- Indications for Liver Transplantation

Adults Children

Noncholestatic cirrhosis 65 Biliary atresia 58

 Viral hepatitis B and C Inborn errors 11

 Alcoholic Cholestatic 9

 Cryptogenic PSC

Cholestatic 14 Alagille’s sy

 Primary biliary cirrhosis

4

PSC Viral hepatitis 2

Autoimmune 5 Miscellaneous 16

Malignant neoplasm 2

Miscellaneous 14

Autoimmune

True or False

• The number of cadaveric donors has changed dramatically over the last 13 years

True or False

• The number of cadaveric donors has changed dramatically over the last 13 years

• False

Question

• What two kinds of information are used in the Child-Turcote-Pugh Score of Severity of Liver Disease ?

Question

• What two kinds of information are used in the Child-Turcote-Pugh Score of Severity of Liver Disease ?

– Clinical symptoms (encepholopathy, ascites, PSC/PBC)

– Lab data (albumin, PT)

Question

• What three variables does the MELD score take into account?

Question

• What three variables does the MELD score take into account?

– Bilirubin– INR– Creatinine

Question:

• If you were going to Foxwoods, and you had to bet on a patient’s survival with end-stage liver disease, who would you rather rode shotgun: Mr. MELD or Mr. CTP? Why?

Question:

• Mr. MELD, baby

• (MELD = model of end-stage liver disease)

TABLE 27-3 -- Concordance with 3-Month Mortality: MELD and CTP

Score Concordance95% Confidence

Interval

Model for End-Stage Liver Disease (MELD)

0.88 0.85, 0.90

Child-Turcote-Pugh (CTP) 0.79 0.75, 0.83

Question

• Which of the following are absolute contraindications to liver transplantation?

– Active sepsis– Extrahepatic malignancy– HIV– Portal vein thrombosis– HCC

Question

• What type of virus is hepatitis B?

Question

• What type of virus is hepatitis B?

• hepandnavirus

Question

• Which of the following are absolute contraindications to liver transplantation?

– Active sepsis– Extrahepatic malignancy– HIV– Portal vein thrombosis– HCC

Question

• You’ve had chronic hepatitis B for 25-30 years and you have now begun to show clinical symptoms of cirrhosis. Imaging demonstrates a nodular liver with a mass. What is the likely diagnosis?

Question

• You’ve had chronic hepatitis B for 25-30 years and you have now begun to show clinical symptoms of cirrhosis. Imaging demonstrates a nodular liver with a mass. What is the likely diagnosis?

• Hepatocellular carcinoma

Question:

• You go back in time 25 years. You wish to be treated for your HBV. What is the treatment, and what is the chance that it may lead to remission?

Question:

• You go back in time 25 years. You wish to be treated for your HBV. What is the treatment, and what is the chance that it may lead to remission?

• Interferon alpha 2b. 40% remission rate

Question:

• Because you are a big baseball star, you get a liver transplant even though you have chronic HBV. What are the treatments to keep you from infecting your graft?

Question:

• Because you are a big baseball star, you get a liver transplant even though you have chronic HBV. What are the treatments to keep you from infecting your graft?

• High titer G +/- lamivudine

Question

• What infection can accelerrate the cirrhosis that accompanies ETOH abuse?

Question

• What infection can accelerrate the cirrhosis that accompanies ETOH abuse?

• HCV

Match ‘em

• PSC• PBC

• Pruritis• Jaundice• Elevated Alk phos• Damage to large bile ducts• Damage to small

intrahepatic ducts• Associated with IBD• Associated with

cholangiocarcinoma• Liver failure• Does well with

transplantation

Match ‘em

• Pruritis (both)

• Jaundice (both)

• Elevated Alk phos (both)

• Damage to large bile ducts (PSC)

• Damage to small intrahepatic ducts (PBC)

• Associated with IBD (PSC)

• Associated with cholangiocarcinoma (PSC)

• Liver failure (both)

• Does well with transplantation (both)

Question

• What 3 factors make it likely that a patient with HCC will benefit from liver transplantation?

Question

• What 3 factors make it likely that a patient with HCC will benefit from liver transplantation?

• Low grade tumor

• Tumor <5cm

• Limited multifocality of tumor

• (No macrovascular invasion too)

Question

• What are the characteristics of a marginal / expanded criteria donor?

Question

• What are the characteristics of a marginal / expanded criteria donor?

– Older donors (age up to 75!!)– Hep c +, hep B core +– Steatosis of liver graft

Question

• What variables are considered when matching donor and recipient?

Question

• What variables are considered when matching donor and recipient?

• ABO (can be crossed if urgent)

• Size

• Age (for pedi patients)

True or False

• Dr. Dow will think it is really cool if you take the hepatic veins off the donor’s cava when recovering your first liver in our new transplant program.

True or False

• Dr. Dow will think it is really cool if you take the hepatic veins off the donor’s cava when recovering your first liver in our new transplant program.

• False

Road Map

• Describe the purpose and path of circulation of veno-venous bypass

Road Map

• Describe the purpose and path of circulation of veno-venous bypass

– Inflow: portal and femoral veins– Outflow : IJ

• 2.5 L/min

• Control of body temperature (Rewarming)

• Cvvh during the case

• ? If it matters

Question

• How long does it take for a recipient of a split liver Right lobe to achieve a “standard” liver mass equivalent?

Question

• How long does it take for a recipient of a split liver Right lobe to achieve a “standard” liver mass equivalent?

• Only 1 month!!

Question

• Name the possible operative complications that can occur in liver transplantation.

Question

• Name the possible operative complications that can occur in liver transplantation.

– Bleeding (page me)– Portal vein thrmobosis (may use collaterals)– Hepatic artery reconstruction– Primary nonfunction

Question

• How common is primary non-function?

Question

• How common is primary non-function?– 2-3%

– Hemodynamic instability– MSOF– Encephalopaty

– Rx: retransplantation

Question

• How is a definitive diagnosis of acute rejection made? How is it treated?

Question

• How is a definitive diagnosis of acute rejection made? How is it treated?

• Liver bx -- demonstrate the presence of periportal lymphocytic infiltrate that extends into the liver parenchyma, as well as the invasion of inflammatory cells into the vascular endothelium.

• --corticosteroids. More potent monoclonal or polyclonal anti–T-cell antibodies are effective against corticosteroid-resistant rejection, leading to the reversal of the acute episode in more than 90% of the recipients

Question

• What is “vanishing bile duct” syndrome?

Question

• What is “vanishing bile duct” syndrome?

• Manifestation of chronic rejection

• Poorly understood

• Candidates for re-transplantation

Statistics

• What is the 10 year survival of patients with liver transplantation, based on 30,000 UNOS patients? Adults vs. Kids?

Statistics

• What is the 10 year survival of patients with liver transplantation, based on 30,000 UNOS patients? Adults vs. Kids?

• Adults: 59% px survival, 51% graft survival

• Pedi: 78% px survival, 63% graft

Survival

Thanks for listening! Have a great day!