Liver Transplantation

‡ It¶s 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 recipient¶s 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; .(883-877 :7 ‡ 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 12months. ‡ 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:
‡ Wilson¶s 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.

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