Liver Transplant

Liver Transplant

11/11/10

PY Mindmaps

SP Notes

OHOA pages 544-545 (Part II notes)

DISEASE LEADING TO POSSIBLE TRANSPLANTATION

Acute

- fulminant hepatic failure (paractamol and non-paracetamol)

- trauma

- post-operative

Chronic

- alcoholic liver disease (must be abstinent for > 6 months)

- chronic hepatitis (B, C, autoimmune)

- primary biliary cirrhosis

- primary sclerosing cholangitis

- hepatocellular carcinoma

- liver metastasis (primary tumour fully resected)

Children

- atresia of biliary duct

- metabolic disease (Wilson, alpha 1 anti-trypsin deficiency)

- primary hepatic tumours

- fulminant hepatitis

CRITERIA FOR CHRONIC TRANSPLANTATION (MELD/PELD Scores)

Child Pugh B and C

- bilirubin >3-5mg/dL

- albumin < 28

- INR > 1.7

- hepatic encephalopathy

- refractory ascites

Co-morbidities

- hepatorenal syndrome

- variceal bleeding

- SBP

- hepatocellular carcinoma

CRITERIA FOR ACUTE TRANSPLANTATION (King’s College Criteria)

Paracetamol induced fulminant hepatic failure

- pH < 7.3 or INR > 6 (PT > 100s)

+

- Cr > 300mmol/L

+

- grade III or IV encephalopathy

Non-paracetamol induced fulminant hepatic failure

- INR > 6 (PT > 100s) or any 3 of the following variables:

(1) age < 10 or > 40 yrs

(2) aetiology – non A, non B hepatitis, halothane hepatitis, idiosyncratic drug reactions

(3) duration of jaundice before encephalopathy > 7 days

(4) INR > 3.5 (PT > 50s)

(5) bilirubin > 0.3mmol/L

CONTRAINDICATIONS

Absolute

- severe infections/sepsis

- extra-hepatic malignancy

- severe cardio-respiratory disease

- ongoing ET-OH or drug use

- AIDS

- non-compliance

Relative

- severe chronic renal disease (consider renal + liver transplant)

- previous extensive biliary tract surgery

- HIV positive

- psychosocial issues

COMPATIBILITY WORK UP

- complicated!

- recipient: disease state (urgency and severity), cardio-respiratory function, psychiatrist/social work, nephrologist, infectious diseases, dentist

- weight of donor

- blood compatibility

- investigations: CXR, Doppler sonography, selective angio/MRI, ECHO, cardio-pulmonary testing, ECG, PFT

PREOPERATIVE ASSESSMENT

Clinical Features

- co-morbidities: diabetes, other organ dysfunction

- jaundice

- ascites

- pleural effusions

- cardiac failure

- poor nutritional state

- hepatorenal syndrome

- portopulmonary syndrome (right ventricular failure from severe portal and pulmonary hypertension)

- hepatopulmonary syndromes (hypoxaemia with intrapulmonary shunting)

- cerebral oedema

- bleeding

Investigations

- hyponatraemia

- coagulopathy

- hypoalbuminaemia

- hypoglycaemia

- low platelet count

- fibrinolysis

- anaemia

- blood products; 10U cross-match, 12 FFP

Management

- correct of coagulopathy

- high risk precautions

- altered pharmacology: low first pass, Vd changed, increased free drug, enzyme dysfunction, slow metabolism and clearance

INTRAOPERATIVE

- establish type to surgery: full transplant, sub-total, piggy-back, argon beam (blood sparing)

- establish large bore IV access pre-induction (swan sheath, RICC line) -> expect massive blood loss

- standard induction (RSI)

- soft N/G (beware of varices)

- fulminant liver failure = raised ICP (manage accordingly)

- invasive monitoring

- venovenous bypass lines (femoral and RIJ -> 21Fr)

- actively warm

- transfuse blood:FFP (1:2)

- monitoring coag’s frequently and TEG

- maintain glucose with IV dextrose

- monitor Ca2+ closely

- use cell salvage

- use anti-fibrinolytic (transexamic acid 15mg/kg bolus -> 5mg/kg/hr)

- haemodynamic instability from:

1. cardiac involvement (alcoholic cardiomyopathy)

2. pericardial effusion

3. systemic vasodilation

Stage 1 (Preparation)

- prophylactic antibiotics

- start SDD

- TXA2 (plasmin inhibitor)

- laparotomy

- dissection

- slings placed around major vessels

Stage 2 (Anhepatic)

- division of hepatic artery, portal vein, hepatic vein, bile duct

- removal of liver and part of IVC -> anastomoses of donor and recipient vena cava and portal vein

- VR severely compromised -> haemodynamic instability

- keep Hb 60-80g/L

- venovenous bypass (femoral to RIJ) to help

- in acute hepatic failure patients may become hypoglycaemic

- prednisolone 500mg IV

Stage 3 (Reperfusion)

- re-establishment of blood flow through liver (portal vein to IVC)

- reperfusion syndrome -> cytokine release, complement activation, hypothermia, arrhythmias, hypotension, hyperkalaemia, bradycardia

- hepatic artery re-anastomosis and bile duct reconstruction

- will need inotropes

POST OPERATIVE

General

- consider protective isolation (immunosuppressed)

- aim for early enteral nutrition if no bowel anastomosis

Cardiovascular

- keep 60-80g/L

- judicious fluid management (avoid hepatic oedema, impaired graft function)

- inotropic support

- avoid lactate containing fluids

Respiratory

- aim for extubation early

- pneumonia and TRALI common

Renal

- optimal renal perfusion

- urinary output measurement

Analgesia

- PCA

- RSC

- paracetamol 0.5g QID

Medications

Cefuroxime 1.5g TDS – 3/7

Metronidazole 500mg TDS – if bilio-intestinal anastomosis

SSD regime

PPI

Immunosuppression (methylprednisolone, cyclosporine A, azathioprine, tacrolism/sirolimus, monoclonal antibody therapy)

Haematology

- platelets >50

- heparin to APTT 40-60

- blood products if bleeding

Graft Function

- improving coagulation profile

- decreasing transaminases

- normal glucose

- haemodynamic stability

- adequate urine output

- bile production (via T drain)

- daily U/S to look for patency of blood flow

- if concern about rejection -> liver biopsy

COMPLICATIONS

Early

- bleeding/coagulopathy -> massive transfusion, hypocalcaemia

- hypothermia

- respiratory: hypoxia, pleural effusions, atelectasis, right hemidiaphragm palsy, TRALI, infections, pulmonary oedema

- cardiovascular: haemorrhage, vasodilation, 3rd spacing

- electrolytes and acid-base derangements

- neurological: encephalopathy, cerebral oedema, central pontine myelinolysis

- renal: may require RRT

- small for size syndrome: hyperbilirubinaemia, graft dysfunction, ascites, portal hypertension, end-organ dysfunction

- primary graft failure: fast decompensation, SIRS -> MODS

- biliary leak/stricture: require OT or ERCP

- hepatic artery thrombosis: high fever, elevated LFT’s, graft failure, coagulopathy -> US/angio -> thrombectomy, retransplant, angioplasty

- portal vein thrombosis: hepatic dysfunction, massive ascites, renal failure, portal hypertension -> thombectomy, thrombolysis, endoscopic therapy

- sepsis

- hyperacute (rare) or acute rejection (day 7)

Late

- sepsis c/o immunosuppression (bacterial, viral, fungal, protozoal)

- HT

- renal failure

- chronic rejection

- disease recurrence

- DM

- lymphoproliferative disease

- malignancies

- require immunisations: tetanus, diphtheria, influenza, pneumococcal, hepatitis A and B

Jeremy Fernando (2011)