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Perioperative Management of Liver Transplant Patients

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Perioperative Management of Liver Transplant Patients January 22, 2007 Geoffrey Schultz, MD Topic Objectives 1. Overview of indications & selection for liver ... – PowerPoint PPT presentation

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Title: Perioperative Management of Liver Transplant Patients


1
Perioperative Management of Liver Transplant
Patients
  • January 22, 2007
  • Geoffrey Schultz, MD

2
Topic Objectives
  • 1. Overview of indications selection for liver
    transplantation.
  • 2. Identification treatment of complications
    associated with liver disease in the preoperative
    period.
  • 3. Identification treatment of complications
    following orthotopic liver transplantation.
  • 4. Induction of immunosuppressive pharmacotherapy
    following transplantation.
  • 5. Diagnosis treatment of graft rejection.

3
Orthotopic Liver Transplantation
  • 1st orthotopic liver transplantation 1963.
  • Approximately 5,000 orthotopic liver
    transplantations annually for 17,000 in need.

4
Indications for Liver Transplantation in
Adults Etiologies of End-Stage Liver Disease
  • 1. Fulminant Hepatic Failure
  • 2. Alcoholic Liver Disease
  • 3. Chronic Hepatitis C
  • 4. Chronic Hepatitis B
  • 5. Non-alcoholic steatohepatitis
  • 6. Autoimmune Hepatitis
  • 7. Primary Biliary Cirrhosis
  • 8. Primary Sclerosing Cholangitis
  • 9. Hepatic tumors
  • 10. Metabolic and genetic disorders

5
Indications for Liver Transplantation in Adults
  • Presence of irreversible liver disease and a life
    expectancy of less than 12 months with no
    effective medical or surgical alternatives to
    transplantation
  • Chronic liver disease that has progressed to the
    point of significant interference with the
    patient's ability to work or with his/her quality
    of life
  • Progression of liver disease that will
    predictably result in mortality exceeding that of
    transplantation (85 one-year patient survival
    and 70 five-year survival)

6
Manifestations of End-Stage Liver Disease
  • Progressive jaundice
  • Intractable ascites
  • Spontaneous bacterial peritonitis
  • Hepatorenal Syndrome
  • Encephalopathy
  • Variceal bleeding
  • Intractable pruritus
  • Chronic fatigue (such as resulting in loss of
    gainful employment)
  • Bleeding diathesis or coagulopathy

7
Selection Criteria for Organ Allocation
  • United Network for Organ Sharing (UNOS) governing
    body for organ allocation utilizes MELD score.
  • Model for End Stage Liver Disease (MELD) Score
  • 0.957 x loge (creatinine) 0.378 x loge
    (bilirubin mg/dL) 1.12 x loge (INR) 0.643 x
    10
  • Range from 10 to 40
  • Special considerations, amendments for HCC, renal
    failure.

8
Preoperative management of complications
associated with hepatic failure decompensated
cirrhosis
  • Hepatic Encephalopathy
  • Cerebral Edema
  • Acute Renal Failure
  • Infection Sepsis
  • Metabolic Derangements
  • Malnutrition
  • Coagulopathy
  • Portal Hypertension

9
Hepatic Encephalopathy
  • Etiology Attributed to increased serum ammonia
    levels secondary to metabolism of nitrogenous
    substances in the gut.
  • Symptoms Range from euphoria to coma.
  • Treatment lactulose, decreased intake of
    nitrogen containing compounds, oral neomycin.

10
Cerebral Edema
  • Etiology Unknown
  • Swelling of brain results in increased ICP
    herniation.
  • Invasive monitoring with goal of ICP lt 20 mmHg
    CPP gt 50 mmHg.
  • Treatment Anxiolysis, HOB elevation,
    hyperventilation, avoidance of overhydration,
    mannitol diuresis, HD if compromised renal
    function.

11
Acute Renal Failure
  • Etiology Toxin induced, Derangements in systemic
    intrarenal hemodynamics.
  • Treatment Prevention of hypotension, treatment
    of infection, avoidance of nephrotoxic agents.
  • Once established, renal failure in this setting
    is often irreversible. Early utilization of renal
    replacement therapy is indicated.

12
Infection Sepsis
  • Etiology Immunologic derangements including
    complement deficiency, reduced opsonins, WBC
    dysfunction.
  • Treatment Frequent cultures, including ascites.
    Broad spectrum antibiotics, including
    anti-fungals.

13
Metabolic Derangements
  • 1. Hypokalemia
  • Increased sympathetic tone promotes cellular
    uptake of K. Decreased serum K promotes
    production of ammonia by the kidney.
  • 2. Hyponatremia
  • 3. Hypoglycemia
  • Secondary to decreased hepatic glycogen stores
    decreased gluconeogenesis.

14
Coagulopathy
  • Etiology Compromised synthetic function,
    deficiency of coagulation factors, platelet
    dysfunction.
  • Contribute to GI bleeding in conjunction with
    portal hypertension.
  • Treatment Prevention with H2 blockers, PPI.
    Judicious use of Factor VIIa FFP.

15
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16
Post-operative complications management of
liver transplant patients
  • Right pleural effusion
  • May affect ventilation, necessitating drainage.
  • Hepatic edema secondary to aggressive
    resuscitation increased intravascular volume.
  • Goal CVP 6-10. Minimize increased hepatic vein
    pressures, sinusoidal congestion that impair
    graft perfusion exacerbate reperfusion injury.

17
Post-operative complications management of
liver transplant patients
  • Renal failure
  • Elevation of creatinine BUN observed in nearly
    all transplant patients secondary to ATN,
    hepatorenal syndrome. Usually self-limiting. May
    necessitate therapy with loop diuretics, renal
    replacement therapy.

18
Post-operative complications management of
liver transplant patients
  • Electrolyte Derangements
  • Recovering graft increases demand for magnesium
    phosphorous.
  • Transfusion of citrate rich blood products
    results in decreased serum magnesium calcium.
  • Rapid correction of chronic hyponatremia with
    isotonic solution can have severe neurological
    consequence. Judicious use of hypotonic solutions
    with goal of serum Na 125-130 advised.

19
Post-operative complications management of
liver transplant patients
  • Thrombocytopenia
  • Preoperative portal hypertension results in
    splenomegaly platelet sequestration. Generally
    improves as graft recovers. May necessitate
    replacement if bleeding is encountered or
    invasive procedures are planned. Splenectomy is
    rarely indicated.
  • Platelet dysfunction secondary to renal hepatic
    failure may be improved acutely with DDAVP.

20
Post-operative complications management of
liver transplant patients
  • Biliary leak
  • RUQ pain, fever, persistent elevation of
    bilirubin, liver enzymes. Biloma on CT. Treated
    with endoscopic stent, percutaneous drainage.
    Possible surgical revision if duct is ischemic.
  • Hepatic artery thrombosis
  • Persistent elevation or increasing liver enzymes,
    poor graft function. Diagnosed with U/S, CT
    angiography, MRA. Treated with immediate
    revascularization.

21
Induction of Immunosuppression
  • Triple therapy
  • Calcineurin inhibitor (tacrolimus, cyclosporine),
    anti-proliferative agent (mycophenolate),
    corticosteroid taper.
  • Initiated immediately following transplantation.
  • Levels followed daily in immediate post-operative
    period with decreasing frequency once
    stabilized in desired range.
  • Agents vary according to etiology of liver
    disease.
  • Thymoglobulin Hb Ig utilized in hepatitis
    patients along with entecavir prograf to limit
    viral replication to avoid coritocsteroid
    usage.

22
Allograft rejection
  • Hyperacute rejection
  • Secondary to preformed Ab to graft antigen.
    Extremely rare. Necessitates retransplantation.
  • Acute Cellular Rejection
  • 70 of patients 5 to 14 days following
    transplant.
  • Heralded by fever, jaundice, elevation of liver
    enzymes.
  • Diagnosed by liver biopsy. Demonstrates
    endothelialitis non-suppurative cholangitis.

23
                                               
                       
24
  • Althaus SJ, Perkins JD, Soltes G, Glickerman D.
    Use of a Wallstent in successful treatment of IVC
    obstruction following liver transplantation.
    Transplantation. 1996 Feb 2761(4)669-72.
  • Kim BW, Won JH, Lee BM, Ko BH, Wang HJ, Kim MW.
    Intraarterial thrombolytic treatment for hepatic
    artery thrombosis immediately after living donor
    liver transplantation. Transplant Proc. 2006
    Nov38(9)3128-31.
  • Cotler, Scott J, MD UptoDate Treatment of acute
    cellular rejection in liver transplantation
  • Brown, Robert S., MD, MPH, Dove, Lorna M, MD, MPH
    UptoDate Patient selection for liver
    transplantation
  • Eric Goldberg, MD, Sanjiv Chopra, MD UptoDate
    Overview of the treatment of fulminant hepatic
    failure
  • Bussutil RW, Klintmalm GB, Transplantation of the
    Liver, WB Saunders Company, Philadelphia. 1996
  • Peter J. Friend Charles J. Imber Transplantation
    Immunology. Current Status of Liver
    Transplantation pp. 29 46, MAR 2006
  • http//med.stanford.edu/shs/txp/livertxp
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