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PRINCIPLES OF LIVER

TRANSPLANTATIONSouvik Adhikari

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TYPES OF LIVER TRANSPLANTS

Cadaveric liver transplants

Living donor liver transplant

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PRE-TRANSPLANT

ASSESSMENT: PHASES

Phase 1: General assessment ofpatients medical state.

Phase 2: Assessment of patientssuitability for transplantation &identification of any problems.

Phase 3: Logistics of the procedureare addressed: includes all necessarytalks and visits.

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TIMING OF LISTING

UNOS modification of MELD Score:

MELD Score = 3.8 * loge(bilirubin inmg/dL) + 11.2 * loge(INR) + 9.6 *loge(creatinine mg/dL) + 6.4

* PELD Score: based on bilirubin, INR,albumin, growth failure, and age.

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WORKUP: PHASE I

Full clinical and appropriatebiochemical evaluation

Other investigations: CXR, ECG,USG, review of liver histology andother investigations.

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WORKUP: PHASE II

Hepatic & renal USG; MRIangiogram/CT imaging withcontrast/angiography in few cases.

Lung function tests.

USG of great vessels of neck.

Echocardiogram. Anesthetic opinion.

Social worker.

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PHASE II: OTHER TESTS

CMV, VZV, HCV, HBV status.

Blood group.

HLA typing & cross-matching.

HIV. Serum creatinine >150 umol/l: full urinary

evaluation, creatinine clearence, USG,renal biopsy, isotopic GFR.

Diabetic: HbA2, fundoscopy, ECG before &after Valsalva.

Dentition.

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VACCINATION

Hepatitis A

Hepatitis B

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WORKUP: PHASE III:

DISCUSSIONS

Nurses

Dieticians

Social worker Pharmacist

Visit to ITU

Final discussion with transplant co-ordinator

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CARDIOPULMONARY

ASSESSMENT: GROUPS

? Abnormal heart function

? Parenchymal chest disease

Hepatopulmonary syndrome ? Portopulmonary hypertension

Normal

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DONOR OPERATION

Long midline laparotomy.

Rapid cannulation/perfusion.

Median Sternotomy. Warm phase dissection.

Dissection by cardiac team.

Cannulation, Perfusion & Bleed-out:removal of thoracic organs, aortic &portal perfusion.

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DONOR OPERATION: CONTD.

Cold dissection.

Back-table perfusion: removal ofliver.

Kidney removal.

Vessels, spleen & lymph nodes: long

splenic art. & SMA retrieval for SLT. Closure.

Operation note.

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SPLIT-LIVER

TRANSPLANTATION

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LIVE DONOR LIVER

TRANSPLANTATION (LDLT)

Done because of shortage ofcadaveric organs.

Entails considerable risk to the

donor. Donors with BMI >28 are excluded.

Graft volume must be at least 1% of

the recipients body weight. Results for LDLT probably not as

good as cadaveric transplantation.

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BENEFITS OF LDLT

Shorter waiting time.

Performed as elective surgery.

An organ from a healthy donor is of abetter quality.

Donor liver experiences minimal cold

ischemic time. Allows a cadaveric liver to go to

another recipient.

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TRANSPLANT OPERATION

Induction of anesthesia. Laparotomy & dissection phase: veno-

venous bypass established. Anhepatic phase: IVC clamped, liver

removed, IVC & portal vein anastomosed. Graft flushed, liver perfused, infrahepatic

IVC & hepatic art anastomoses done. Gall bladder anastomosed/biliary

drainage. Skin closure. Transfer to ITU.

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POST-TRANSPLANT CARE: ITU

Sleep induction: Temazepam.

Sedation: Propofol/Midazolam.

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IMMUNOSUPPRESSION: TRIPLE

THERAPY

Corticosteroids

Azathioprine

Tacrolimus Mycophenolate in those intolerant to

azathioprine.

Sirolimus in cases of recurrent acuterejection and chronic ductopenicrejection.

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PROPHYLACTIC DRUGS

Perioperative antibiotics

Pneumocystis & antifungalprophylaxis

Peptic ulcer prophylaxis

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COMMON PROBLEMS POST OLT

Hypokalemia

High glucose levels

Low ionised calcium levels Hypovolemia associated with

rewarming

Bleeding secondary to coagulopathy Oliguria associated with calcineurin

inhibitors (Tacrolimus/Cyclosporin)

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OTHER PROBLEMS POST OLT

Rejection

Post-transplantation leucopenia

Post TransplantationLymphoproliferative Diseases (PTLD)

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