BCC4: Jon Gatward on Liver Transplantation

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


• 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


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

BCC4: Jon Gatward on Liver Transplantation

Health & Medicine

Transcript of BCC4: Jon Gatward on Liver Transplantation