Critical Care Hepatology Dr.  Jon  Gatward  Staff  Specialist  Royal  Prince  Alfred  Hospital  Sydney  

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England   N.Ireland   Scotland   Wales  

Critical Care Hepatology Dr.  Jon  Gatward  Staff  Specialist  Royal  Prince  Alfred  Hospital  Sydney  

Case Study!45M  Primary  Sclerosing  CholangiLs  /  Crohn’s  Recurrent  cholangiLs  OLT  

171  to  end  Aug  13  

4.5L  ascites  and  free  pus  in  abdomen  Massive  transfusion  Liver  looked  grey  

Vasodilatory shock Rising lactate Rising K Hypoglycaemia DIC……

• Occurs  in  7%    • Clinical:  

•  Vasodilatory  shock  oYen  with  bradycardia  

•  Pulmonary  hypertension  •  Hyperkalaemia    

• Cause?  •  Sudden  ↑  venous  return  •  vasoacLve  substances  •  K  rich  preservaLon  fluids  

• Usually  resolves  within  5  minutes  

•  30%  of  paLents  need  inotropes  and/or  vasopressors.    

• Risk  Factors:  Long  WIT  and  CIT  

post-reperfusion syndrome

Agopian.  Annals  of  Surgery  2013;  258:  409  

• Approximately  1%  in  Australia  • Unrecoverable  hepato-­‐cellular  dysfuncLon  à  death  or  re-­‐transplantaLon  within  1  week  NOT  caused  by  

•  vascular  thrombosis  •  biliary  complicaLons  •  rejecLon  •  recurrent  disease  

• Major  risk  factor:  DCD  (WIT  and  CIT  à  ischemia-­‐reperfusion  injury)  

•  Controlled  DCD  0-­‐10%  •  Uncontrolled  DCD  (Spain  –  10-­‐25%)  

Le  Dinh  World  J  Gastroenterol  2012;  18:  4491  

primary non-function

• Common:  5%  within  30days,  15%  overall  • Bile  leakage  • Bile  duct  strictures  

• AnastomoLc  •  Ischaemic  Type  Biliary  Lesions  (ITBL)  

• Risk  Factors  •  Donor  age  >60  à  67%  have  biliary  complicaLons  •  Donor  obesity  •  Autoimmune  disease  in  recipient  

Le  Dinh  World  J  Gastroenterol  2012;  18:  4491  De  Vera  Am  J  Transplant  2009;  9:  773  

biliary complications

Suarez  Transplanta7on  2008;  85:  9  Jay  Ann  Surg  2011;  253:  259  

Agopian.  Annals  of  Surgery  2013;  258:  409  

• DCD  à  10  x  rate  of  ITBL  •  3  x  more  likely  to  lose  graY  

• Prognosis    •  50%  à  death  or  re-­‐transplantaLon  

• Treatment  •  ERCP  

• PrevenLon    •  ECMO,  machine  perfusion,  different  preservaLves,  anLcoagulants,  early  portocaval  shunt    

Le  Dinh  World  J  Gastroenterol  2012;  18:  4491  De  Vera  Am  J  Transplant  2009;  9:  773  

itbl & dcd

Suarez  Transplanta7on  2008;  85:  9  Jay  Ann  Surg  2011;  253:  259  

Agopian.  Annals  of  Surgery  2013;  258:  409  

HAT  (3.1%  paLents)  •  Early  (30  days)  

•  FHF,  duct  necrosis  and  leaks,  sepsis,  graY  loss  •  Risk  factors  

•  Children,  low  recipient  weight  •  ProthromboLc  states  •  Re-­‐transplantaLon,  arterial  variants  •  PSC,  CMV+  graY  into  CMV-­‐  recipient  •  NOT  DCD  

•  DUS  screening  +/-­‐  CT  angio  •  Treatment  

•  Observe  •  Re-­‐vascularize  •  Re-­‐transplant  

 

HAS  • Assoc  with  biliary  strictures,  esp  aYer  DCD  

• Risk  factors  •  Surgical  trauma  •  RejecLon  •  Recurrent  disease  

DCD is not a risk factor!

Le  Dinh  World  J  Gastroenterol  2012;  18:  4491  Agopian.  Annals  of  Surgery  2013;  258:  409  

hepatic artery thrombosis and stenosis

• Rare  (1.1%  paLents)  • Portal  hypertension….graY  failure    • Risks:  

•  Difficult  surgery  •  Recurrence  of  disease  •  Thrombophilia  

•  Treatment  •  Diuresis  •  Angioplasty  /  re-­‐vascularisaLon  •  Re-­‐transplantaLon  

portal vein thrombosis

DCD is not a risk factor!

Agopian.  Annals  of  Surgery  2013;  258:  409   Le  Dinh  World  J  Gastroenterol  2012;  18:  4491  

acute rejection • 5-­‐7  days  • Fever  • DeterioraLon  in  graY  funcLon  • AST/ALT  • Biopsy  (percutaneous  or  trans-­‐jugular)  • Pulsed  methylprednisolone  • Re-­‐transplantaion  

•  Cardiovascular  failure  •  Underlying  cardiomyopathy,  periop  stress  

•  Respiratory  failure  •  Effusions,  right  diaphragm  palsy,  muscle  weakness  •  HPS,  PPS  •  InfecLon    •  TRALI  

•  CNS  failure  •  Encephalopathy,  oedema,  raised  ICP  •  Seizures  (note  Tacrolimus)  •  ICH  

•  Renal  failure  •  Common  and  mulL-­‐factoral.    •  HRS  usually  improves  with  liver.    •  Consider  IACS    

•  Sepsis  

other badness

Liver  congested,  non-­‐homogenous  perfusion  Duplex:  arterial  flow,  no  portal  or  hepaLc  venous  flow  Liver  removed    

the anhepatic phase

1   2  

0              8              16              24              32              40              48              56              64              72  7.4  

7.3  

Time  (hrs)  

5  

10  

pH  

7.1  

7.2  

Lactate  (mmol.l-­‐1)  Anhepatic

Phase

84ml.kg.h-­‐1  Vs.  Na  150  (12.5ml  23.4%  Saline  per  5L  Hemasol  B0)    

re-transplantation

Extended  criteria  BD  donor  (fapy  liver)    

1   2  

0              8              16              24              32              40              48              56              64              72  7.4  

7.3  

Time  (hrs)  

5  

10  

pH  

7.1  

7.2  

Lactate  (mmol.l-­‐1)  Anhepatic

Phase

F R O M D E M I – G O D S TO G o d s . . .!

• RELIEF  Trial  • 189  pts  vs  standard  care  • Decreased  Cr,  bilirubin  • Decreased  encephalopathy  • No  effect  on  mortality  

Bañares  et  al.  Extracorporeal  liver  support  with  the  molecular  adsorbent  recirculaLng  system  (MARS)  in  paLents  with  acute-­‐on-­‐chronic  liver  failure.  The  RELIEF  Trial  

Blood  circuit  

Albumin  circuit  

Dialysis  circuit  

• HELIOS  Study  • 145  pts  vs  standard  care  • Only  subgroup  HRS  Type  1  plus  MELD  >30  had  survival  benefit  

Rifai  et  al.  Extracorporeal  liver  support  by  fracLonated  plasma  separaLon  and  absorpLon  (Prometheus®)  in  paLents  with  acute-­‐on-­‐chronic  liver  failure  (HELIOS  study):  a  prospecLve  randomized  controlled  mulLcenter  study  

Single Pass Albumin Dialysis!

Sauer.  Hepatology  2004;  39:  1408  

re-transplantation

(=7.5% of all grafts)

risk factors for things going wrong

Factor   RR  Recipient  age  >55     1.5  MELD  score  ≥34       1.4  

AeLology:  malignancy    AeLology:  HCV  

1.8  1.5  

Prior  transplant   2.2  HospitalisaLon   1.3  Donor  age  >55   1.5  WIT  >  48min   1.3  CIT  >8.9h   1.3   Agopian.  Annals  of  Surgery  2013;  258:  409  

dcd and risk of death??

U.S. registry data 96-07 42,254 DBD recipients 1,113 DCD recipients RR of death after DCD1.29

Jay.  J  Hepatol  2011;  55:  808  

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Conclusions  Good  outcomes  with  strict  ANLTU  criteria  Donor  age  increased  to  50yrs  

Verran  MJA  2013;  199:  104  

high numbers declined or not retrieved

ECMO circuit 2nd roller pump for HA PN Insulin

conclusions