LIVER TRANSPLANTATION

SUBMITTED TO: SUBMITTED BY:

Mrs. Navjot kaur SHIVANGI
Assistant professor M.SC. (N) 2nd yr.
Deptt. Of pediatric nsg.
 Introduction
Liver transplantation has been very successful in treating children with end-stage liver disease,
and offers the opportunity for a long healthy life.
• Organ scarcity is the main limitation to the full exploitation of transplantation- Split-liver and
living-donor transplantation have contributed to reversing a situation
• During early periods the 1st year survival is used to be less than 25% which is improved to
near 90% with the present surgical expertise and the available immunosuppressive drugs and
better understanding of different disease processes.
• Combined organ transplantations is recent improvement and still future improvements are
awaiting.
 WHAT IS LIVER
TRANSPLANTATION?
Liver transplantation is a surgery to remove a diseased liver and replace it with a healthy one.
Many people have had liver transplants and now lead a normal lives. When a patient receives a
liver transplant his or her entire liver is removed. It is then replaced by either a complete new
liver or a portion of healthy liver.
 Potential Members of the Pediatric
Liver Transplant Team
General
• Transplant Surgeon
•Hepatologist /gastroenterologist with expertise in pediatric liver disease
•Infectious disease specialist
•Social worker
•Psychologist/ neuropsychologist /child development specialist
•Dietician
•Physical/ occupational therapist
•Pharmacist
•Psychiatrist
•Transplant coordinator
•Anaesthesiologist
•Patient educator
Components of the Pediatric Liver
Transplantation Evaluation
1. Secure all prior records to identify relevant diagnostic, management and clinical information
2. Establish appropriate indications for referral
3. Construct a patient and disease specific appointment itinerary
4. Confirm or affirm the diagnosis, associated systemic manifestations, and management plan
5. Assess disease severity and urgency for liver transplantation
6. Identify opportunities to maximize current medical therapy
7. Determine if non-transplant surgical options are available
8. Identify contraindications for liver transplantation
9. Consider appropriateness of a live donor option
10. Confirm immunization status; if incomplete, establish a strategy to complete immunizations
11. Establish a trusting relationship among the child, family and transplant team
12. Ensure finances are available
13. Anticipate potential complications following transplant
14. Develop a management and communication plan with the local managing physician
15. Clarify logistics when a potential donor liver is available
INDICATIONS FOR LIVER
TRANSPLANTATION
Chronic liver failure

– Neonatal liver disease

• Biliary atresia

• Idiopathic neonatal hepatitis

– Cholestatic liver disease

• Alagille’s syndrome

• Familial intrahepatic cholestasis (FIC)

-Inherited metabolic liver disease -Other
• a1-Antitrypsin deficiency • Cryptogenic cirrhosis
• Fibropolycystic liver disease +/– Caroli syndrome
• Cystic fibrosis
• Glycogen storage type IV
• Tyrosinaemia type I
• Wilson’s disease
– Chronic hepatitis
• Autoimmune
• Idiopathic
• Post viral (hepatitis B, C, other)
•Acute liver failure

– Fulminant hepatitis

– Autoimmune

– Halothane exposure

– Paracetamol poisoning

– Viral hepatitis (A, B, C, E)

• Metabolic liver disease

– Neonatal haemochromatosis
•Inborn errors of metabolism
– Crigler–Najjar type I
– Familial hypercholesterolaemia
– Urea cycle defects
• Liver tumours
– Benign tumours
– Unresectable malignant tumours
Contraindications for liver
transplantation
Absolute
•Hepatocellular carcinoma with extra hepatic disease and rapid progression
• Generalized extra hepatic malignancy
• Exception: Hepatoblastoma with isolated pulmonary metastases
• Uncontrolled systemic infection
• Severe multisystem mitochondrial disease
• Valproate induced liver failure
• Niemann-Pick Disease Type C
• Severe Porto pulmonary hypertension not responsive to medical therapy
Relative

•Hepatocellular carcinoma with Venous invasion/ Rapid progression despite chemotherapy

•High certainty of non adherence despite multidisciplinary interventions and support

•Critical circumstances not amenable to psychosocial intervention

PREPARATION FOR
TRANSPLANTATION
Immunization
• Live vaccines are usually contraindicated in the immunosuppressed child, and so it is important
to ensure that routine immunizations are complete.

Management of hepatic complications

• Variceal bleeding should be managed with oesophageal banding or sclerotherapy, vasopressin
infusion.
• Oesophageal banding is preferred to injection sclerotherapy for children on the active liver
transplant list.
• In children with uncontrolled Variceal bleeding, the insertion of TIPSS (trans jugular intrahepatic
porto systemic stent-shunt) has proved an effective management strategy in older children
•Sepsis, particularly ascending cholangitis and spontaneous bacterial peritonitis, requires
effective treatment with appropriate broad-spectrum antibiotics.

• Salt and water retention leading to ascites and cardiac failure should be effectively managed
with diuretics and salt and water restriction.

• It is essential to consider intervention with hemodialysis and/or hemofiltration if acute renal

failure or hepatorenal failure develop.
LIVER SEGMENTS
LIVER GRAFTS
Cadaveric
– Whole
– Reduced size
– Split size

Living related
Auxiliary LT
CADAVER DONOR
The donor is obtained from a person who is diagnosed as brain dead, whose
family volunteers to donate the organ for transplantation. People who receive
cadaver donors wait on the institutional/ regional list until a suitable donor
becomes available.
Whole liver transplant:
Performed with two different techniques: the classic technique with inferior
vena cava replacement, and the piggyback technique
Piggyback liver transplant
• It is a IVC preserving technique

•Initial steps similar to classic technique

•Hepatic veins divided, stumps joined to form common cloaca- IVC

•Donor infrahepatic IVC is closed with ligatures

•PV, hepatic artery, biliary anastomosis

LIVER TRANSPLANT * 4 main connections
Reduced-size liver transplantation
Consists in the procurement of the whole liver from an adult cadaver donor,
which is reduced in its size
Split Liver Transplantation
Split donation involves transplantation of a liver from a recently deceased
individual to two recipients. This is possible if the next suitable recipients are an
adult and a child. The donated liver will be split into the left and right lobes. The
adult normally receives the larger lobe and the child will receive the smaller left
lobe.
Living Donor
-Living donor liver transplantations are an option for some patients with end stage

liver disease. This involves removing a segment of liver from a healthy living donor
and implanting it into a recipient. Both the donor and recipient liver segments will
grow to normal size in a few weeks.

- The donor, who may be a blood relative, spouse or friend, will have extensive
medical and psychological evaluations to ensure the lowest possible risk. Blood type
and body size are critical factors in determining who is an appropriate donor.
Auxillary Transplantation
•Part of the liver of a healthy adult donor (living or cadaver) is transplanted in
to the recipient.

•The patient’s diseased liver remains intact until the auxiliary piece regenerates
and assumes function.

•The diseased liver may then be removed this technique is rarely used now.
Donor selection
• Commonly accepted donor selection criteria for split liver procurement are: age 15-50 years;
- weight > 40 kg;
-no past history of liver dysfunction/damage;
-liver function tests within normal values;
- normal macroscopic appearance of the graft; and
- hemodynamic stability
• Data from multicenter registries have shown that pediatric patients receiving livers from
pediatric-age donors have significantly better graft survival compared to those receiving livers
from donors aged > 18 years
Living-donor selection
• usually a parent or first-degree relative

• Donors should be 18-55 years of age, and

• have an ABO-compatible blood type

EARLY POSTOPERATIVE PERIOD
•consists of managing problems related to technical complications and to the
prevention, diagnosis, and treatment of acute rejection and infection episodes.

• usually present with a combination of cholestasis, rising hepatocellular enzyme

levels, and variable fever, lethargy and anorexia
Primary non-function
• Can be seen in the first hours following transplantation, with
– high lactate levels
– increased prothrombin time and partial thromboplastic time
– failure of the patient to wake despite sedation suspension.
• Extremely serious complication - must be treated aggressively and immediately by
– infusing prostaglandin E1
– adopting the necessary measures to prevent a brain edema (mannitol infusion,
hyperventilation)
– addressing the effects of the liver failure by infusing plasma and glucose.
• If persist for more than a few hours, the patient needs a new transplant as soon as possible.
Vascular complications
Hepatic artery thrombosis
• hepatic artery anastomosis carries the highest risk of thrombosis (5%-18%) and
leads to massive graft necrosis in cases of early onset
• 3-4 times >adults and occurs most often within the first 30 d after
transplantation and in small babies transplanted with whole livers.
• If identified early, reconstruction can be attempted to avoid allograft necrosis
• When allograft failure develops, urgent retransplantation is the only option.
Portal Vein Thrombosis
• 5%-10%
• more frequent in children transplanted for biliary atresia, because of pre-
existing portal vein hypoplasia
• Early thrombosis -detected by ultrasound screening, requires immediate
anastomotic revision and thrombectomy.
• Later thrombosis is usually detected by decreased platelet counts and
increasing spleen size or gastrointestinal bleeding.
• Interventional radiographic stent placement or balloon dilation has been
successful in patients who have portal anastomotic stenosis.
Acute rejection
20%-50% of patients in the first weeks

• Clinical features- fever, irritability, malaise, leucocytosis, often with

eosinophilia, and increased γ-GT, bilirubin, and transaminases.

• A liver biopsy is required to confirm rejection

• characterized by the histological triad of – endothelialitis, – portal triad

lymphocyte infiltration with bile duct injury, and – Hepatic parenchymal cell
damage
INFECTIONS
Infectious complications now represent the most common source of morbidity and mortality
after transplantation.

• Bacterial infections occur in the immediate post transplantation period and are most often
caused by Gram-negative enteric organisms, enterococci, or staphylococci.

• Fungal infection most often occurs in high-risk patients requiring multiple operative
procedures, retransplantation, hemodialysis or continuous hemofiltration, pre-transplant
chemotherapy, and multiple antibiotic courses - prophylaxis with liposomal amphotericin B.
MANAGING
IMMUNOSUPPRESSIVE THERAPY
Corticosteroids
• First drugs to be used to control rejection
•Act through intracellular receptors expressed in all cells of the body.
• Their immunosuppressive action mechanism, not fully clarified yet, is linked to the – suppression
of antibody production; – inhibition of synthesis of cytokines such as (IL-2) and interferon-γ; –
reduction in the proliferation of helper and suppressor T cells, cytotoxic T cells, and B cells; and –
the migration and activity of neutrophils
• Over immunosuppression is associated with increased incidence of bacterial, fungal and viral
infections
• Detrimental metabolic effects of steroids are wide ranging and are of particular concern for the
pediatric transplant patient.
IL-2 receptor antibodies
• IL-2 receptor antibodies have been used primarily in children as induction
agents in double or triple immunosuppression protocols
• incidence of acute rejection was lower in the induction groups
• pediatric patients less than 35 kg in weight should receive two intravenous 10-
mg doses, and those weighing ≥ 35 kg should receive two 20-mg doses of
basiliximab.
• The first dose should be given within 6 h after organ reperfusion, and the
second on day 4 after transplantation.