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
Jeremy Fernando (2011)
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)
(2)
(3)
(4)
(5)
age < 10 or > 40 yrs
aetiology – non A, non B hepatitis, halothane hepatitis, idiosyncratic drug reactions
duration of jaundice before encephalopathy > 7 days
INR > 3.5 (PT > 50s)
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
Jeremy Fernando (2011)
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
Jeremy Fernando (2011)
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
Jeremy Fernando (2011)
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
Jeremy Fernando (2011)
-
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)