Critical laboratory findings to be cautioned in

durante and post liver transplantation

Dr Patrick HY CHUNG
Department of Surgery
The University of Hong Kong
 Paediatric liver transplant
• An uncommon
operation
• Treatment option
– End-staged liver diseases
• Acute/chronic
– Metabolic diseases
– Unresectable liver tumor

Biliary atresia is the most common indication

 Indications for liver transplant
referral after Kasai operation
• Progressive liver failure

• Growth retardation

• Recurrent cholangitis

• Portal hypertension
 Liver transplant surgery
• Total hepatectomy
– Take away the diseased liver

• Donor hepatectomy
– Deceased donor (total hepatectomy)
– Living donor (partial hepatectomy)

• Implantation
– HV/PV/HA and biliary reconstruction
• Liver transplant in a high risk operation and
requires close monitoring during as well as
after the operation

– Anesthetist
– Paediatric Intensivist
– Nurse
 Intra-operative
• Blood loss
• Bleeding tendency
• Bowel condition
• Renal function
• Ventilation
 Essential blood tests during the
operation
• Complete blood count
– Hb
– Platelet
• PT/INR
• Blood gas
– Acidosis?
– Lactate
• Renal function test
– Na/ K
 Post operative complications
• Bleeding
• Graft dysfunction
• Infection
– Post-surgical infection
– Opportunistic infection
• Bowel injury / leakage
• Malnutrition
 Bleeding
• Causes:
– Vascular
– Liver parenchyma
– Surgical sites
• Peritoneum
• Diaphragm
• Wound
• Haemoglobin
– Observe the trend
• Platelet count
 Graft dysfunction
• Vascular
– HA/PV/HV
• Biliary
– Obstruction /leakage
• Infection
– Bacterial / EBV/CMV
• Immunologic
– Rejection
– Lymphoproliferative changes
 Graft dysfunction
• PT / INR
• Albumin
• Parenchymal enzyme
– AST/ALT
• Bilirubin level
• Ductal enzyme
– ALP/GGT
 Infection
• ?Pneumonia
• ?Urinary tract infection
• ?Peritonitis

• White cell count

– ?Neutrophil / lymphocyte
• Blood culture
• Cytomegalovirus antigen
 Bowel injury / leakage
• Pneumoperitoneum in X ray
• Un-noticed serosal tear during the operation
• Elevated WBC
• Abnormal liver function test
– Increased parenchymal enzyme
– Deranged clotting profile
 Nutrition
• Blood glucose level
– Liver impairment may lead to hypoglycemia

• Serum albumin level

 Immunosuppressants
Past
Steroid, Cyclosporine A, Azathioprine

Present
Steroid (early post-op), Tacrolimus

Need to monitor the IS level by daily blood taking

 Post-Transplant Lymphoproliferative Disease
(PTLD)
• Complication of long term immunosuppresant
– Suppressed T cell from immunosuppresant
– Uncontrolled B cell proliferation
• Spectrum of disorders
– Infectious mononucleosis to lymphoma
• Presentations can be variable
• Incidence
– adult: 1-2%
– children: 5-13% Dhillon et al. The Br J of Radiology. 2007
Ernesto et al. Am J of Transplant. 2001
• Mortality: 12-35% Frenandez et al. Pediatr Transplant. 2009
Cacciarelli et al. Pediatr Transplant. 2001
Paediatric liver transplant in QMH
 History
First paediatric liver
transplant by HKU team
on 28/9/1993
M/7 yr
Diagnosis
Biliary atresia, post-Kasai
operation
Graft
Living donor
Left lateral section graft
 Demographics
From 9/1993 to 9/2015

Total 130 cases (8 cases being re-transplantation)

Age: 47 days to 17 years

Smallest body size: 4.2kg

Male: female = 68:62

 QMH/HKU 1993-2015, n=130

median follow-up period: 8.5 years (range, 3 months to 17 years)

Source of donor
Graft anatomy
HKU-LDLT vs DDLT (overall 10-
year survival ~ 90%)

Chan et al. J Paediatr Surg 2010

Biliary and vascular complications

Chung et al. HK J Paediatr 2009

 Donors’ Complications
No mortality
International standard: 0.1 to 0.5%

Few with minor complications

 Indications for liver transplant
referral after Kasai operation
• Progressive liver failure

• Growth retardation

• Recurrent cholangitis

• Portal hypertension
Demographics (LT receipients, BA
vs non BA, 1993-2014)

* median (range)
Chung et al. J Paediatr Surg 2015
Survival (BA vs non BA)

p=0.9

Chung et al. J Paediatr Surg 2015

Complications (BA vs non BA)

Chung et al. J Paediatr Surg 2015

 Findings
• Liver transplant is effective salvage treatment
for BA patients who fail the Kasai operation

• Previous Kasai operation does not have

adverse effect the outcome of transplant
surgery. Patient with diagnosis made within
an optimal time period should still undergo
Kasai operation
 Acknowledgement
Paediatric Surgery Liver Transplant
 2

Thank you!