Dr. Harshal RajekarDr. Harshal Rajekar

Cirrhosis – HCV related

Cirrhosis- Hemochromatosis

Cirrhosis – Alcohol induced

Liver Transplantation History

• 1958 Research programs on liver replacement at Northwestern and Harvard

• 1963 First liver transplant (Univ. of CO)• 1967 First long survival• 1979 Cyclosporine• 1987 Univ. of WI solution for improved

organ preservation• 1989 FK 506• 1999 Living donor liver transplantation

Liver TransplantationLiver transplantation is the OPTIMAL

treatment for end stage liver disease (ESLD)

ESLD has 2 forms: Acute and Chronic- Acute = Fulminant Hepatic Failure- Chronic = Cirrhosis

Fulminant Hepatic Failure (FHF)Synonymous with Acute Liver FailurePathology: Pan-lobular or Sub-massive

necrosisClassically seen in Paracetamol poisoning.

In India – commonest cause is HEV, HAV and drug induced.

Criteria for transplantation of acute liver failure

KING’S COLLEGE CRITERIA

Acetaminophen toxicity

Non-acetaminophen etiology

CLICHY CRITERIA

PGIMER criteria

Chronic Liver disease : Cirrhosis

All patients with cirrhosis do not qualify for liver transplantation.

Transplantation is generally considered when a patient has suffered from a complication.

The onset of decompensation is associated with significantly impaired survival.

Chronic Liver Disease — Signs of decompensationAscitesEncephalopathyPortal Hypertensive BleedingHepatocellular Carcinoma in the setting

of Cirrhosis

Liver TransplantationQuestion for Transplant Team

• When to list for liver transplantation?

• When to perform the liver transplant?

When….?Patients who are too well should not be

transplanted. Likewise, transplantation of patients who are

too sick is associated with poor outcomes. The goal of transplantation is to prolong

survival. Thus, liver transplantation should be

performed at the time point when the patient is expected to have greater survival with a liver transplant than without.

PrognosticationSurvival of a patient with ‘‘Child’s C cirrhosis’’ is

about 20–30% at 1 year and less than 5% at 5 years.

In contrast, the survival rate after transplantation is 85–90% at 1 year and over 70% at 5 years.

By the time the patient has evidence of advanced clinical liver disease (Child’s C cirrhosis), the patient may not survive long enough to get a transplant.

MELD score

• MELD -- Model for End-Stage Liver Disease Scoring System – MELD Score

= 0.957 x Loge(creatinine mg/dl)

+ 0.378 x Loge(bilirubin mg/dl)

+ 1.120 x Loge(INR)

+ 0.643

• MELD score depends upon kidney function,bilirubin level and clotting factor levels

MELD scoreIntroduced in Feb 2002 (Mayo).The MELD score originally was developed

and validated to assess the short-term prognosis of patients with cirrhosis undergoing TIPS.

Using the MELD model, patients are assigned a score from 6 to 40.

Estimated 3-month survival for a score of 6 is 90%, and for a score of 40 is 7%.

When…?

Ultimately, the decision to transplant is based upon the patient’s likelihood of survival

Usually a patient will be listed for liver tx at a MELD of 10 or more, when the expected 3 month survival is less than 90%.

Requirements for TransplantationEnd stage liver diseasePhysiologic ability to tolerate surgery: Cardiac,

pulmonary, renal, cerebral functionAnatomy – status of vessels (PV/HA/HV)Social support/ psychological supportNo extra-hepatic infection or malignancyAlcohol abstinence for 6 months/ no substance

abuse

Contra-indicationsCardiopulmonary disease that cannot be

corrected.

Malignancy outside of the liver.

Active alcohol and drug use. Minimum period of abstinence of at least six months is required.

Advanced age and AIDS are examples of relative contraindications.

Surgical perspectiveImmediate function of a transplanted liver is essential.

Unlike in kidney, pancreas, or, to some extent, heart transplantation, there is no effective artificial support for a hepatic patient in the event of graft failure.

A complex surgical exercise in a severely physiologically compromised patient – - major surgery- blood loss – portal hypertension- immunosuppression- risk of infection- necessity of liver function

Donor selectionCadaveric/ living donor.Blood group match. (HLA not required/ cross

matching not required).Size match.Marginal donors.Split liver.

Organ harvesting/ procurement

HTK solution (custodiol)

UW (Viaspan)Goal: Cool the organs

and perfuse with preservative solution while exsanguinating the organs.

Aortic canulationPortal canulation

AnesthesiaMultiple issues:

- cardiopulmonary instability, - Portopulmonary hypertension, - Coagulopathy, - Cholestasis, jaundice, - blood loss, volume status.

Impact of anesthesia on liver functionLimited functional reserve, Drug clearance,

Anesthesia-induced hepatitis, Postoperative jaundice, Risk factors for decompensation in patients with cirrhosis.

Implantation of the new liver.Orthotopic/ auxillarybegins with a controlled

recipient hepatectomy formidable task in

individuals with severe portal hypertension and extensive collateral

Engraftment with venous, arterial and then biliary anastomoses.

Classic v/s piggy back implantation.

Classical v/s piggy back technique

Classical or cava replacement

Piggy-back technique

Graft function Helpful signs of hepatic function in the

immediate postoperative period1. Hemodynamic stability2. Awakening from anesthesia3. Clearance of lactate4. Resolution of hypoglycemia5. Normalization of coagulation profile6. Resolution of elevated transaminases7. Bile of sufficient quantity and golden brown in

color

Immediate outcome

What factors:Organ harvesting.Organ preservation.Warm and cold ischemia times.Graft selection/ graft quality.Donor-recipient matching.Surgical problems.Medical issues.

Medication after transplantImmunosuppression: usually 3 drugs to start, with

rapid withdrawal of steroids.Antibiotics.Antifungals.Antivirals: anti-CMV, HBV.PCP prophylaxis.Anti-platelet agent.Anti-ulcer.Multivitamin.Calcium and magnesium.

ComplicationsImmediate, early and late.Immediate – post-op.

- Bleeding (commonest – 12-15%)- Graft non-function (PNF) [5%] or delayed graft function [6-7%].- Vascular complications: HAT, PVT and venous thrombosis.- Renal dysfunction.- complications related to prolonged and major surgery, blood transfusion.- Infections – viral and bacterial.

Complications

Early: - Infections- Rejection- Surgical/ wound complications.- Biliary problems- Vascular complications- Recurrent disease

ComplicationsLate complications:

- Usually late, after more than a year.- Recurrent disease- Medication adverse effects- Chronic rejection- Infections- Metabolic problems- Recidivism

Infections after a transplant

Waiting for a liver

Management of Ascites.Management of portal hypertensionRenal functionHepatic encephalopathyGeneral health and activityTreatment of viral diseaseVaccinationPrevention of infection.

If waiting is not possible…., getting too late….

LDLT: living donor liver transplant.India: only related/ approved by a ethical

committee.Advantages:

- elective surgery.- healthy known donor- short cold ischemia times- reduced waiting time

Disadvantages:- risk to donor- cost and more resources- higher risk of biliary ad vascular complications- reduced size liver

Essential Concepts for UsingLiving Donors

• No conflict of interest• No coercion• Minimize donor risks• Donors must be given every opportunity

to change their minds• Emphasize alternatives

How Much Liver Do You Need?• Liver = 2% body weight• Optimal: > 1% liver weight/body weight ratio• 70 kg recipient needs at least 700 cc (gm)• Cannot go below 0.7 - 0.8%

- GRWR.- Graft/ SLV ratio- Usually right lobe.- Recently the use of dual grafts has been done

successfully.

LDLT problemsRisk to donor: 0.2 – 0.3% risk of death

- 2-4% risk of major complications- About 15-25% risk of minor complications.

Higher incidence of biliary problemsHigher incidence of vascular problemsSmall for size syndromeEthical issuesInitially had poorer graft survival, but recently

has been equal to DDLT.

Diagnoses indicating potential candidacy for LT include the following:  * 070 Viral hepatitis * 1550-1552 Malignant neoplasm of liver and intrahepatic bile ducts * 2115 Benign neoplasm of liver and biliary passages * 2308 Carcinoma of liver and biliary system * 2353 Neoplasm of uncertain behavior in liver and biliary passages * 2390 Neoplasm of unspecified nature in digestive system * 2710 Glycogenesis * 2720 Pure hypercholesterolemia * 2727 Lipidoses * 2751 Disorders of copper metabolism * 2770-2776 Cystic fibrosis, disorders of porphyrin metabolism, other disorders of purine and pyrimidine metabolism, amyloidosis, disorders of bilirubin excretion (like EHBA as well as Criggler Najar syndrome), mucopolysaccharidosis, other deficiencies of circulating enzymes including urea cycle disorders, an dother metabolic disorders. * 2860 Congenital factor VIII disorder * 2861 Congenital factor IX disorder * 4530 Budd-Chiari syndrome * 570 Acute and subacute necrosis of liver * 5710 Alcoholic fatty liver * 5712 Alcoholic cirrhosis of liver * 5714 Chronic hepatitis * 5715 Cirrhosis of liver without mention of alcohol * 5716 Biliary cirrhosis * 5718 Other chronic nonalcoholic liver disease * 5719 Unspecified liver disease without mention of alcohol * 5728 Other sequelae of chronic liver disease * 5758 Other specified disorders of gallbladder * 5761,5762 Cholangitis, obstruction of bile duct * 75161,75169 Biliary atresia, other anomalies of gallbladder, bile ducts, and liver * 7744 Perinatal jaundice due to hepatocellular damage * 7778 Other specified perinatal disorders of digestive system * 864 Injury to liver * 3483 Encephalopathy, unspecified* 452 Portal vein thrombosis.

Donor liver

Donor Liver

Cadaveric donor liver after back table preparation

After reperfusion.

THANK YOU!