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Liver Transplantation

Liver Transplantation

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Published by drhananfathy

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Published by: drhananfathy on Jan 31, 2010
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11/27/2012

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Hanan Fathy

Problems Faced by Pediatric Liver Tx Programs (Recipient Issues)
Still existing pediatric pre-transplant mortality t Late referrals (fulminant hepatic failure) t Lack of extracorporeal organ support t Relatively high complication rate (biliary strictures) t Strive to accomplish a meaningful life longevity of pediatric recipients (87.8% - 3 yrs)
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Indications for liver transplantation in infants and children include
t Acute

liver failure (ALF), t Chronic liver failure, t Complications of cholestasis t In young children, the most common liver disease leading to transplantation is biliary atresia and it accounts for at least 50 percent of all liver transplants in children

Frequency (% of transplants) Biliary atresia a-1-Antitrypsin deficiency Familial cholestasis Chronic active hepatitis Fulminant hepatic failure Neonatal hepatitis and perinatal hemochromatosis Wilson's disease Tyrosinemia Glycogen storage disease Primary sclerosing cholangitis Other 50 10 9 6 5 4 3 2 2 2 7

Biliary atresia
a. Status post failed Kasai procedure b. Recurrent ascending cholangitis c. Complications of cirrhosis as listed below

Cirrhosis of any etiology with the following complications
b. Ascites that is refractory to medical management c. Episodes of variceal bleeding that are refractory to sclerotherapy and/or TIPS d. Hypersplenism causing thrombocytopenia e. Liver synthetic failure f. Other major systemic complications
a. Growth failure

• Fulminant hepatic failure • Neonatal liver failure • Inborn errors of metabolism a. Tyrosinemia b. Glycogen storage disease c. Crigler-Nijjar syndrome d. Ornithine transcarbamylase deficiency e. Other defects with the potential to cause neurologic or other major systemic complications • Unresectable hepatic tumors without extension

Assessing Severity: MELD
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Mayo (Model) End Stage Liver Disease
Bilirubin t Creatinine t INR
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Extra points for incidental hepatic tumor t Deceased donor allocation by MELD score t Mean MELD at transplant 26 (UVA)
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PELD scoring: This system is based on the risk or probability of death within 3 months if the patient does not receive a transplant. t The PELD score is calculated based on laboratory data and growth parameters. t The laboratory values used are a patient's albumin, bilirubin, and INR t These values are used together with the patient's degree of growth failure to determine a score that can range from 6 to 40.
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Contraindications to transplant
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Acceptable alternative therapy Expected poor outcome Impairment of other organ systems Cardiac Pulmonary Intestinal Renal Infection Malignancy

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Living Donor Transplantation:
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Donor Advantages
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Emotional Gain

Donor Disadvantages t Psychological stress to donor and family t Inconvenience / risk of evaluation process t Operative mortality ( 1/150 liver) t Major postoperative complications (2-10%) t Minor post operative complications (50%) t Possible long term morbidity t Unrecognized covert liver disease

Living Liver Donor Evaluation
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Donors should be related to recipient Donor: t Age < 55yrs t Compatible blood group t History & physical t Routine labs t Ultrasound of liver t Volumetric analysis by MRA
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R. lobe wt. = 1% recipient total wt

Living Donor Evaluation
Decision to donate must be voluntary t Informed consent t Motivation to donate t Behavioral and psychological health t Donor recipient relationship
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Removal of cirrhotic liver

Implanting the new liver

New liver

Extubate early t Remove lines as soon as possible t Immunosuppression t Replace ascitic losses with albumin t Avoid FFP unless
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Early Post-operative Management

active bleeding t Invasive intervention is required
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Classification of Complications
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Graft dysfuntion or non-function Technical Immunological Infective Extrahepatic Drug effects Medical Recurrent Disease

Immunological
Acute Rejection 5-10 days post transplant but may occur at any time Clinical Elevated LFTS Liver Biopsy Portal tract inflammatory infiltrate Endothelialitis Destruction of biliary epithelium Treatment Steroids

Infective
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Bacterial < 15 days
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Commonly lines /chest /urine Prolonged hospitalization Broad spectrum antibiotics Re transplant Roux loop

Fungal > 15 days
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Viral
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> 4 weeks

CMV – recipients of CMV + organs

Extra-hepatic
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Cardiac failure / infarction Pulmonary Neurological Renal Endocrine
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Diabetes (33%)

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Drug effects Recurrent disease

Causes of liver graft loss in children
Vascular thrombosis t Rejection t Biliary complications t Primary non function
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15% 8% 5% 3%

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