EVALUATION FORLIVER TRANSPLANTATION

L.VENKATAKRISHNANDept of GI Sciences

PSG Institute of Medical Sciences, Coimbatore

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

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

Indications for Liver Transplantation

Alcoholic Cirrhosis

11%

NAFLD9%

Hepatitis B1%

Cryptogenic cirrhosis

3.5%

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

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

Prognostic Models for LT Allocation

Prognostic Models for LT Allocation

Prognostic Models for LT AllocationMELD Score

Prognostic Models for LT AllocationConditions 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

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

Transplant Evaluation• Cardiac evaluationNon invasive evaluation with echo cardiographyPatients 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.

Transplant Evaluation• Pulmonary EvaluationPOPH 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.

Transplant Evaluation• Surgical EvaluationConfirm the need for transplantIdentify technical challengesDiscuss donor options - deceased, living and

extended.

Transplant Evaluation• Infectious Disease EvaluationSerological – HAV, HBV, HCV, HIV, EBV, CMV, RPRInterferon Assay for TB –Quantiferon test or T

spot TBSelected candidates screening for

coccidiomycosis, strongyloides and dental evaluation

Vaccination strategiesTreatment of latent TB

Transplant Evaluation• Nephrology evaluationRecognition 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

Transplant Evaluation• Nephrology evaluationEvaluation will include calculation of GFR and

determination of precise etiology.SLK is indicated

1. End stage renal diseases with cirrhosis2. Liver failure with CKD and GFR < 30 ml/min3. Acute kidney injury or HRS requiring dialysis for more than 8 weeks4. If more than 30% of glomerulosclerosis or fibrosis by renal biopsy.

Transplant Evaluation• Neurological evaluationCarotid doppler if age > 60Neurology consultation as needed.

Transplant Evaluation• Laboratory studiesElectrolytes Hepatic function panelCoagulation panelHepatitis serologiesBlood typing with antibodiesUrine Toxicology

Transplant Evaluation• Radiology evaluationAbdominal sonogram with dopplerTriple phase CT or gadolinium magnetic

resonance imaging for HCC screening or tumor staging.

CT thorax

Transplant Evaluation• Age appropriate cancer screeningPAP SmearMammogramColonoscopy (age > 50 or history of primary

sclerosing cholangitis)Bone DiseaseObesityPrevious extra hepatic malignancy.

Transplant Evaluation• Social work evaluationAssess psychosocial issuesEvaluate support baseFinancial Screening

1. Secure approval for evaluation2. Discuss the cost

Specific Issues in Transplant Evaluation

Patients with HCV diseasePatients with HIV diseasePatients with HBV diseasePatients with Alcohol Liver DiseaseHepatocellularcarcniomaCholangiocarcniomaMELD exceptions

Absolute Contraindication for Transplant