Liver Transplantation

Its the replacement of a diseased liver with a healthy

liver allograft.
Liver transplantation nowadays is a well accepted
treatment option for end-stage liver disease and acute
liver failure.

Types of Liver Transplant

Whole liver transplant:
It involves removal of the recipients entire old diseased liver and
a whole healthy liver from a donor is transplanted.

Split liver transplant.

Types of Liver Donor

It is possible to transplant livers from the following types of donor:

Living donation:
Is a procedure in which a living person donates a portion of his
or her liver to another. The feasibility of LDLT was first
demonstrated in the united states in 1989. The recipient was a
child, who received a segment of his mother's liver.Only a
small portion of liver is taken from the donor leaving enough to
keep the donor healthy.

Deceased liver transplantation.

Asystolic liver transplantation.

Indications of Liver Transplantation

Basically, all forms of chronic hepatopathy that are irreversible
and potentially curable by transplantation constitute an
indication for liver relacement century.
Only those patients who are considered capable of withstanding
the perioperative period and the intense medical regimen and
follow-up, must be exposed to liver transplantation.
The most common indications are: cirrhosis , alcoholic liver
disease,chronic viral-induced liver disease (hepatitis B, C, D),
chronic drug-induced liver disease, idiopathic autoimmune liver
disease, hepatocellular carcinoma,and primary sclerosing
cholangitis.

Indications of Liver Transplantation

As a general rule, the following complications of ESLD
warrant liver transplantation :
Fulminant hepatic failure:
Acute viral hepatitis (A, B, d,Epstein-Barr virus EBV).
Drug-induced liver toxicity(halothane, gold, Disulfiram,
acetaminophen & others).

Recurrent variceal hemorrhage.

Refractory ascites.

Indications of Liver Transplantation

Complications of ESLD that warrant liver transplantation
(cont,) :
Spontaneous bacterial peritonitis.
Refractory encephalopathy.
Severe jaundice.
Exacerbated synthetic dysfunction.
Sudden deterioration.

Viral Hepatitis
Hepatitis C:
This disease is the first cause of end-stage liver
disease worldwide.
Evaluation requires not only the detection of those
patients that would benefit from the procedure, but
also the ability to reduce viral load previous to the
procedure, to avoid recurrence.
Some of the risk factors for recurrence are: pretransplant viral load, advanced age of the receptor,
hyperbilirubinemia,advanced-age of the donor.

Viral Hepatitis (Cont,)

Hepatitis B:
Transplantation for Hepatitis B was abandoned due to
recurrence and lack of effective prophylaxis. Recurrence of
HBsAg was associated to liver fibrosis and a loss of the liver
graft with a mortality approaching 50%.
This recurrence was dependent on the viral load. Fortunately,
prophylaxis with Hepatitis B immuneglobulin and oral
nucleosides can prevent reinfection of the graft and now posttransplant recurrence is rare.
The use of lamivudine is associated with a recurrence >20%,
that is why most programs use HBIG for at least a year.

Alcoholic Liver Disease

A prior history of alcoholism is frequent in liver translant
candidates. Alcohol acts as a cofactor in the development of
chronic end stage liver disease.
Obesity, advanced age, and the genetic factors play an
important role.
The sickest patients are the most benefitted from liver
transplantation, especially for Child-Pugh B and C patients.
Current recomendations include: Child-Pugh >7, bleeding
secondary to portal hypertension, or an episode of spontaneous
peritonitis.
Candidates must receive extensive evaluation for their
addiction, to determine the risk or recurrence.

Cholestatic Disease

Primary biliary cirrhosis,

Sclerosing cholangitis,
Secondary biliary cirrhosis,
Biliary atresia,
Cystic fibrosis

Malignant Disease
Liver transplantation constitutes a cure for malignant diseases of
the liver, because it involves resection of the tumor and the
solution for the main disease of the patient, this because the
majority of liver tumors occur in patients with liver cirrhosis.
Unresectable Hepatic Malignancies which needs LT :
Hepatocellular carcinoma.
Cholangiocarcinoma (highly selected cases, only under protocol).
Rare nonhepatocellular or bile duct tumors that arise within the
hepatic parenchyma (e.g., epithelioid hemangioendothelioma).
Isolated hepatic metastatic disease.
Carcinoid tumor.
Pancreatic islet cell tumor.

Malignant Disease (Cont,)

Hepatocellular Carcinoma.
This tumor frequently coexists with cirrhosis or viral hepatitis.
The actual recommendation is that transplantation should be
offered to those patients with limited tumors (stage I or II, T1
or T2, N0, M0) and that have no evidence of vascular invasion
or extrahepatic disease (Liver Transpl 2001; 7: 877-883).
The prognosis of alpha-fetoprotein is still controversial, even
though high levels are associated with high recurrence,
specially values >1000 or 2000.
In general, if patient selection is maintained for patients with
tumors <5 cm, or less than 3 tumors each one less than 3 cm,
survival exceeds 70% and recurrence rates is less than 15%
after transplatation (Ann Surg Oncol 2006; 13: 1500-1510).

Malignant Disease (Cont,)

Cholangiocarcinoma.
Primary Sclerosing Cholangitis is the main risk factor for the
development of this tumor. Overall survival is 9 to 12 months.
These tumors reccur frequently, even after resection ,because
often it is a multifocal disease.
Liver transplantation has been considered contraindicated in
these patients due to the fact that the overall survival is 2030%, significantly lower to patients transplanted for cirrhosis.
There are reports of chemoradiotherapy followed by liver
transplantation for patients with localized cholangiocarcinoma
without lymph node metastases, that show survival rates of
88% at 1 year and 82% at 5 years.

Metabolic Diseases
Some of them are:
Wilsons disease,
Hereditary Hemochromatosis,
Alpha-1 Antitrypsin:
which cause irreversible liver damage and also have systemic
secondary effects.
Tyrosinemia.
The medical team must perform strict evaluation to exclude the
presence of systemic disease in these patients.

Vascular Disease
Budd-Chiari syndrome or veno-occlusive disease
frquently result in liver failure. All these patients
must be evaluated for hypercoagulable states or
occult malignancy. The majority of these patients
have hematological diseases, such as polycythemia
vera.

Contraindications
to Liver Transplantation
While each patient is evaluated on an individual basis, the
presence of one or more of the following will frequently
preclude acceptance as a candidate for liver transplantation.
HIV infection.
Active alcohol or substance abuse.
Systemic infections.
Life limiting co-existing medical conditions: advanced heart,
lung or neurologic conditions.
Uncontrolled psychiatric disorder.
Inability to comply with pre- and post-transplant regimens.