Liver transplant patients &
rehabilitation concerns
Jen Hokanson PTA
Trish Beck PT
Anatomy
Largest organ in the body (weighs 3-4
pounds-size of a football)
 Located in right upper quadrant
 Connected to diaphragm by ligaments
 Within 1/2 inch of pericardium
 Connected to small intestine via bile duct
 Filters about 1450ml of blood per minute
 Contains 10% of body’s blood volume
 Capable of 80-90% regeneration
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Functions of the Liver
Blood flow through the liver (29% of
total cardiac output)
 Reservoir function (able to store up to 1
extra liter of blood)
 Lymph function(1/2 of lymph is made
by the liver)
 Hepatic macrophage system (resists
infections)
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Metabolic functions of the
liver
Carbohydrate metabolism
 Fat metabolism
 Manufactures proteins
 Storehouse for vitamins, minerals &
sugars
 Blood coagulants
 Iron
 Metabolizes drugs, hormones, toxins
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Excretory and Secretory Functions
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Bile:
– aids production of an
alkaline reaction
– absorption of fats
– breakdown of
cholesterol
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Substances excreted
into bile
– bilirubin: endproduct
of hemoglobin
degradation
– 95% of the bilirubin
ends up in the gut
and 5% goes into
the urine
Symptoms of liver dysfunction
and their causes
Confusion caused by increased
ammonia
 Bleeding due to prolonged clotting time
 Itching/jaundice due to increased
bilirubin
 Fluid retention caused by low albumin
 Kidney damage shown by elevated
creatinine
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Liver Pathologies
TYPES OF HEPATITIS
 Hepatitis A-infectious hepatitis
 Hepatitis B-most common form
 Hepatitis C-most transplants
 Hepatitis D- IV drug users
 Hepatitis E
Cirrhosis
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Alcoholic cirrhosis
Chronic Hepatitis B, C,
or D
Hemochromatosis
Wilson’s disease
Alpha-1, antitrypsin
deficiency
Glycogen storage
disease
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Bile duct obstruction
(PSC, PBC)
Prolonged exposure to
environmental toxins
Cardiac cirrhosis
Severe reaction to
drugs
Parasitic infections
Symptoms of Cirrhosis
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Loss of appetite
Nausea & vomiting
Loss of weight
Increased liver size
Itching
Ascites
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Jaundice
Esophageal varices
Encephalopathy
Sensitivity to toxins
(drugs & alcohol)
Liver Pathologies cont.
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Jaundice
– Obstructive
– Hemolytic
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Ascites
Pruritis
Hepatic
Encephalopathy
Portal Hypertension
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Xanthomas
Poor Clotting
Vit K malabsorption
Fatigue
Muscle Loss
Tumors
Trauma
Bone Mineral Density
taken by photon absorptomety
 Measured in gm/cm2
 usually lumbar or femur
 Normal loss of BMD is 1-2%/yr after
age 25 (accelerate in women after 50)
 In chronic liver disease:
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– decrease in osteoblastic function
– increase osteoclastic function
– loss continues up to 3 mo after transplant
Liver diseases
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Primary Biliary
Cirrhosis(PBC)destroys the ducts that
drain bile in the liver
destruction of the ducts
makes it difficult for the
liver to perform its
normal tasks
affects the middle-aged
PBC affects women 10
times more then men
Conditions associated with
PBC
– Osteoporosis
– Inflammatory
Arthritis
– Thyroid disorders
– Sicca syndrome(tear
glands and salivary
glands fail to
produce enough
moisture)
Liver Diseases
cont.
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Primary
Sclerosing
Cholangitis(PSC)the ducts inside and
outside the liver are
narrowed
most often affects
people in their 30’s,
40’s and 50’s
more common in
men
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Symptoms:
– fatigue
– itching (pruritis).
– jaundice(due to
buildup of bilirubin)
– diarrhea
– fever & chills.
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Associated Diseases
– Osteoporosis
– Inflammatory Bowel
Disease.
Liver Diseases
cont.
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FHF-Fulminant
Hepatic failure
Wilson’s Disease
Budd Chiari
ALD-alcoholic liver
disease
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HCC-hepatocellular
carcinoma
polycystic disease
Familial amyloidosis
primary oxalosis
Hemochromatosis
Preventing Liver Disease
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Limit alcohol intake
Avoid exposure to man-made chemicals
Maintain adequate personal hygiene
Avoid excessive intake of cholesterol and saturated
fats.
Limit use of drugs(acetaminophen, antibiotics, sulfa
drugs) that can be harmful to the liver.
Be careful with questionable bacteria (“herbal” tea).
Psychosocial Issues
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Patient experiences a
roller coaster of
emotions in the
transplant sequence
Patients need to be
taught consistent and
appropriate information
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Psychosocial Eval
(performed by S.W.)
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referral
relationship
reactions
roles
resources
recommendations
Pre transplant teaching
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Medical history
Lab findingsespecially (BMD and
hemoglobin)
x-rays resultslooking for
osteoporosis,
compression
fractures, etc.
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Examination
posture
strength
current activity level
ROM
mental status
PT program for pre liver
transplant patient
Spinal protection education and
performance
 Strengthening
 Cardiovascular activity as able (walking,
bike, stair climbing)
 AVOID: lifting, twisting, high impact
sports/activities, joint jarring activities
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Precautions for posttransplant patients
Do not treat the patient if you have a
cold, cough, etc.
 Wash hands prior to entering the room
and put gloves on.
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Post-Op Liver Transplant
Evaluation
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History
Laboratory results
Medications
Examination
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edema
ascites
mental status
jaundice
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PT program
includes:
– AROM & CKC
exercises
– stretches
– stair climbing
– avoid lifting over 10
pounds, twisting,
kyphosis
– body mechanics
instruction
Post transplant back pain
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Caused by:
– prolonged position
during surgery
– loss of abdominal
strength
– increased weight due
to fluid retention
– continued loss of
bone mineral density
for 3 months post-op
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Treatment:
– superficial heat
– mild extension
exercise (upper back
extension in sitting
position)
– proper body
mechanics
– log rolling and
proper positioning
Post Transplant
Osteoporosis
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FACTORS
Original disease
decreased physical
activity
diuretic use
decreased estrogen in
women
hyperparathyroidism
smoking
TREATMENT
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1200-1500mg calcium
per day
adequate vitamin D
minimal steroid use
hormone replacement
exercise & avoid
smoking
moderate sodium intake
Diabetes Mellitus and Post
Transplant Patients
Post transplant risk factors for DM
include positive family history, cadaveric
transplant recipient, older age, African
American or Hispanic ethnicity
 Cadaveric transplant recipients are more
prone to DM due to steroids used vs.
living related donor
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Post Transplant DM
Treatment
Self monitoring of blood sugar
 weight maintenance
 exercise
 diet
 insulin or an oral agent
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Perceived exertion scale
Use it instead of target heart rate graph
as patient’s medications can increase
heart rate
 encompasses sensation of exertion,
physical stress, and fatigue
 have patient stay around 11 or 12 on
the scale
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Perceived exertion scale
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6 (minimal effort: relaxing in a chair)
7 very, very light
8
9 very light
10
11 fairly light
12
13 somewhat hard
14
15 hard
16
17 very hard
18
19 very, very hard
20 (maximal effort: jogging up a steep hill)
Exercises
Warm-up exercises
 Conditioning Phase(walking, bicycling)
 Cool-down exercises
 Warm-up and cool-down exercises are
important to allow for gradual raising or
slowing down of the heart rate thus
preventing dizziness
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Immunosuppressive
Pharmacology
Tacrolimus “FK506” (Prograf)
 Cyclosporine (Sandimmune, Neoral)
 Corticosteroids(prednisone,
methylprednisone)
 Azathioprine (Imuran)
 ATGAM and Thymoglobulin
 Mycophenolate Mofetil (Cellcept)
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Tacrolimus”FK506”(Prograf)
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Cardiovascular
– Hypertension
– Myocardial hypertrophy
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CNS,Musculoskeletal,Misc.
– HA, tremor, paresthesias, seizures,coma
and encephalopathy.
Acute nephrotoxicity
 Hepatotoxicity
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Cyclosporine
(Sandimmune,Neoral)
Acute and chronic nephrotoxicity
 Hypertension (65-85% of patients)
 hepatotoxicity
 CNS-seizures, paresthesias, HA,tremor,
shaking
 GI,dermatologic(gingivitis),endocrine.
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Corticosteroids
(prednisone)
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Cardiovascular
– hypertension,cardiomyopathy
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CNS
– tremors, neuritis, psychosis
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Musculoskeletal
– Cushing’s Syndrome,osteoporosis
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Endocrine
– increases blood sugar
Misc. Pharmacology
Antibiotics
 Pain medications
 Antihypertensive medications
 Oral bowel decontamination solution
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Routine Lab Tests
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Alkaline Phosphatase
– normal range: male 98-251 U/L,female 81-312 U/L
Bilirubin
– normal range: total=less than 1.1 mg/dL,
direct=0.0-0.3
Serum Asparate Aminotransferase (SGOT, AST)
– normal range: 12-31 U/L
Serum Alanine Aminotransferase (SGPT, ALT, GPT)
– normal range: male 10-45 U/L, female 9-29 U/L
Routine Lab Tests
cont.
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Blood glucose
– normal range 70-100mg/dL
Creatinine
– normal range: male 0.8-1.2 mg/dL,female 0.60.9mg/dL
Cyclosporine
– normal range will vary with each person,
depending on the combination of
immunosuppressant medications and the length of
time since the transplant
Routine Lab Tests
cont.
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Hemoglobin (Hgb)
– normal range: male 12.9-16.6g/dL,female 11.614.9g/dL
Potassium (K+)
– normal range: 3.6-4.8mEq/L
White Blood Count
– normal range: male 4.1-10.9x10(9)/L,female 4.010.4x10.9(9)/L
Child-Turcotte-Pugh
Scoring System
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This scoring system (which is also called
CTP score) is based on the following:
– level of encephalopathy
– amount of ascites
– labs work (bilirubin, INR, and albumin
levels)
Status of people who need a
liver transplant
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Status 1 fulminant hepatic failure, primary
graft non-function, pediatrics
Status 2A in ICU with <7 days life expectancy
Status 2B 10pts on CTP or 7pts with
refractory ascites, refractory variceal
bleeding, hepatorenal syndrome, or history
of spontaneous bacterial peritonitis
MEDICAL URGENCY 1>2A>2B>3
Low Bacteria Diet
No fresh fruit and vegetables except:
Thick skinned fruits that can be washed
and peeled can be eaten.
 Avoid all cheese products.
 No yogurt.
 Pasteurized fruit juices only.
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Liver Transplant Statistics
13,749 waiting for a liver transplant as
of 9/99.
 In 1998, 4,450 liver transplants were
performed
 Currently there are 126 liver transplant
centers
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Improvements in Liver
Transplants
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1) Split: The 2 lobes go to 2 different
recipients (20% of donors meet criteria for
split liver)
2)Live donor: Parent or genetic match gives
left lobe. Within 2 weeks the donors residual
liver grows to size needed. Recipients liver
also grows to size needed.
3)use of marginal donors (for example: using
older donors)
Donor Assessment
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Clinical findings
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age
precipitating event
physical exam
past history
hospital course
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Lab Values
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blood group, HLA+/aminotransferases
billirubin
coagulation profile
serology
cultures
blood gases