Liver Transplantation

1
Liver Transplantation

• Philip Goodney, MD
• June 22, 2005

2
Format

• Question and Answer (multiple choice)
• Review of reading in Sabiston Chapter

3
List em

• Name the most common indications for liver
  transplantation, in order, for adults and
  children.

4
List em
TABLE 27-1 -- Indications for Liver
Transplantation

Autoimmune
5
True or False

• The number of cadaveric donors has changed
  dramatically over the last 13 years

6
True or False

• The number of cadaveric donors has changed
  dramatically over the last 13 years
• False

7
Question

• What two kinds of information are used in the
  Child-Turcote-Pugh Score of Severity of Liver
  Disease ?

8
Question

• What two kinds of information are used in the
  Child-Turcote-Pugh Score of Severity of Liver
  Disease ?
• Clinical symptoms (encepholopathy, ascites,
  PSC/PBC)
• Lab data (albumin, PT)

9
Question

• What three variables does the MELD score take
  into account?

10
Question

• What three variables does the MELD score take
  into account?
• Bilirubin
• INR
• Creatinine

11
Question

• If you were going to Foxwoods, and you had to bet
  on a patients survival with end-stage liver
  disease, who would you rather rode shotgun Mr.
  MELD or Mr. CTP? Why?

12
Question

• Mr. MELD, baby ?
• (MELD model of end-stage liver disease)

TABLE 27-3 -- Concordance with 3-Month Mortality
MELD and CTP
13
Question

• Which of the following are absolute
  contraindications to liver transplantation?
• Active sepsis
• Extrahepatic malignancy
• HIV
• Portal vein thrombosis
• HCC

14
Question

• What type of virus is hepatitis B?

15
Question

• What type of virus is hepatitis B?
• hepandnavirus

16
Question

• Which of the following are absolute
  contraindications to liver transplantation?
• Active sepsis
• Extrahepatic malignancy
• HIV
• Portal vein thrombosis
• HCC

17
Question

• Youve had chronic hepatitis B for 25-30 years
  and you have now begun to show clinical symptoms
  of cirrhosis. Imaging demonstrates a nodular
  liver with a mass. What is the likely diagnosis?

18
Question

• Youve had chronic hepatitis B for 25-30 years
  and you have now begun to show clinical symptoms
  of cirrhosis. Imaging demonstrates a nodular
  liver with a mass. What is the likely diagnosis?
• Hepatocellular carcinoma

19
Question

• You go back in time 25 years. You wish to be
  treated for your HBV. What is the treatment, and
  what is the chance that it may lead to remission?

20
Question

• You go back in time 25 years. You wish to be
  treated for your HBV. What is the treatment, and
  what is the chance that it may lead to remission?
• Interferon alpha 2b. 40 remission rate

21
Question

• Because you are a big baseball star, you get a
  liver transplant even though you have chronic
  HBV. What are the treatments to keep you from
  infecting your graft?

22
Question

• Because you are a big baseball star, you get a
  liver transplant even though you have chronic
  HBV. What are the treatments to keep you from
  infecting your graft?
• High titer G /- lamivudine

23
Question

• What infection can accelerrate the cirrhosis that
  accompanies ETOH abuse?

24
Question

• What infection can accelerrate the cirrhosis that
  accompanies ETOH abuse?
• HCV

25
Match em

• PSC
• PBC

• Pruritis
• Jaundice
• Elevated Alk phos
• Damage to large bile ducts
• Damage to small intrahepatic ducts
• Associated with IBD
• Associated with cholangiocarcinoma
• Liver failure
• Does well with transplantation

26
Match em

• Pruritis (both)
• Jaundice (both)
• Elevated Alk phos (both)
• Damage to large bile ducts (PSC)
• Damage to small intrahepatic ducts (PBC)
• Associated with IBD (PSC)
• Associated with cholangiocarcinoma (PSC)
• Liver failure (both)
• Does well with transplantation (both)

27
Question

• What 3 factors make it likely that a patient with
  HCC will benefit from liver transplantation?

28
Question

• What 3 factors make it likely that a patient with
  HCC will benefit from liver transplantation?
• Low grade tumor
• Tumor lt5cm
• Limited multifocality of tumor
• (No macrovascular invasion too)

29
Question

• What are the characteristics of a marginal /
  expanded criteria donor?

30
Question

• What are the characteristics of a marginal /
  expanded criteria donor?
• Older donors (age up to 75!!)
• Hep c , hep B core
• Steatosis of liver graft

31
Question

• What variables are considered when matching donor
  and recipient?

32
Question

• What variables are considered when matching donor
  and recipient?
• ABO (can be crossed if urgent)
• Size
• Age (for pedi patients)

33
True or False

• Dr. Dow will think it is really cool if you take
  the hepatic veins off the donors cava when
  recovering your first liver in our new transplant
  program.

34
True or False

• Dr. Dow will think it is really cool if you take
  the hepatic veins off the donors cava when
  recovering your first liver in our new transplant
  program.
• False

35
Road Map

• Describe the purpose and path of circulation of
  veno-venous bypass

36
Road Map

• Describe the purpose and path of circulation of
  veno-venous bypass
• Inflow portal and femoral veins
• Outflow IJ
• 2.5 L/min
• Control of body temperature (Rewarming)
• Cvvh during the case
• ? If it matters

37
Question

• How long does it take for a recipient of a split
  liver Right lobe to achieve a standard liver
  mass equivalent?

38
Question

• How long does it take for a recipient of a split
  liver Right lobe to achieve a standard liver
  mass equivalent?
• Only 1 month!!

39
Question

• Name the possible operative complications that
  can occur in liver transplantation.

40
Question

• Name the possible operative complications that
  can occur in liver transplantation.
• Bleeding (page me)
• Portal vein thrmobosis (may use collaterals)
• Hepatic artery reconstruction
• Primary nonfunction

41
Question

• How common is primary non-function?

42
Question

• How common is primary non-function?
• 2-3
• Hemodynamic instability
• MSOF
• Encephalopaty
• Rx retransplantation

43
Question

• How is a definitive diagnosis of acute rejection
  made? How is it treated?

44
Question

• How is a definitive diagnosis of acute rejection
  made? How is it treated?
• Liver bx -- demonstrate the presence of
  periportal lymphocytic infiltrate that extends
  into the liver parenchyma, as well as the
  invasion of inflammatory cells into the vascular
  endothelium.
• --corticosteroids. More potent monoclonal or
  polyclonal antiT-cell antibodies are effective
  against corticosteroid-resistant rejection,
  leading to the reversal of the acute episode in
  more than 90 of the recipients

45
Question

• What is vanishing bile duct syndrome?

46
Question

• What is vanishing bile duct syndrome?
• Manifestation of chronic rejection
• Poorly understood
• Candidates for re-transplantation

47
Statistics

• What is the 10 year survival of patients with
  liver transplantation, based on 30,000 UNOS
  patients? Adults vs. Kids?

48
Statistics

• What is the 10 year survival of patients with
  liver transplantation, based on 30,000 UNOS
  patients? Adults vs. Kids?
• Adults 59 px survival, 51 graft survival
• Pedi 78 px survival, 63 graft

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Survival
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Thanks for listening! Have a great day!
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