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Liver Transplantation for Alcoholic Liver Disease. Liver Transplantation . David Orr Hepatologist NZLTU. Milestones in Transplantation. 1948 ACTH and Corticosteroids 1953 6-mercaptopurine 1957 Kidney Transplantation (Murray) 1963 Liver Transplantation (Starzl)

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liver transplantation for alcoholic liver disease

Liver Transplantation for Alcoholic Liver Disease

Liver Transplantation

David Orr

Hepatologist

NZLTU

milestones in transplantation
Milestones in Transplantation
  • 1948 ACTH and Corticosteroids
  • 1953 6-mercaptopurine
  • 1957 Kidney Transplantation (Murray)
  • 1963 Liver Transplantation (Starzl)
  • 1967 Successful Liver Transplanatation (Starzl)
  • 1979 Cyclosporine (Calne)
  • 1982 50% 1 year survival (Calne)
  • 1988 Living Related Liver transplant (Raia)
  • 1994 Living donor R lobe (Yamaoka)
  • 1997 Monosegmental Liver transplants (Rela)
indications for lt
Indications For LT
  • Acute hepatic failure
  • Early graft failure (PGNF, HAT)
  • Late graft failure (CR, biliary cirrhosis, HAT, recurrent disease)
  • Chronic Liver disease

CPS>9 Severe bone disease (esp PBC/PSC)

Uncontrolled variceal bleeding Hepatopulmonary syndrome

Diuretic resistant ascites Portopulmonary hypertension

Chronic hepatic encephalopathy Hepatorenal syndrome

SBP HCC

Severe malnutrition Intractable pruritis

  • Metabolic liver disease
acute liver failure
Acute Liver Failure
  • Paracetamol Listing Criteria

(Poor prognosis criteria: survival <5%)

pH < 7.3 (after fluid resus)

Or

Grade III – IV HE

INR > 8

Serum Cr > 300

acute liver failure5
Acute Liver Failure
  • Non Paracetamol

INR > 8 (irrespective of HE grade)

Or

3 of 5 Criteria

1. INR > 4

2. Age < 10 or >40

3. Aetiology: Drug induced or Non-A, Non-B

4. Bilirubin > 300

5. Jaundice to encephalopathy > 7 days

acute liver failure6
Acute Liver Failure
  • Aetiology

Viral: Hep A, B, E

(Rare: HSV, EBV, CMV)

Drug: Paracetamol, Isoniazid/rifampicin,

NSAIDs, Valproate, carbamazepine,

Ecstasy, anaesthetic, phenytoin,

MAOIs

acute liver failure7
Acute Liver Failure
  • Aetiology

-AFLP, HELLP

-Wilson’s: Coombes neg hemolytic

anaemia, KF rings

-Amanita phalloides: severe diarrhoea

5 hr post ingestion, ALF 4-5/7

-AIH

-BCS

-Lymphoma

-Ischaemic hepatitis

cadaveric organ donor shortage
CADAVERIC ORGAN DONOR SHORTAGE

Waiting List Registrants

Donors

UNOS July 2001

current allocation schema
Current Allocation Schema
  • Severity of Illness (Status)
  • Allocation determined by:
    • Blood Type
    • Waiting time
    • Size
living related liver transplant donor requirements
Living related liver transplant : Donor requirements
  • Unsolicited volunteer
  • Family member (not necessarily blood relative)
  • No clear medical contra-indications
  • Size appropriate
  • ABO matched
  • Age <50
  • Normal liver, HIV negative
donor problems
Donor problems
  • Biliary complications 6%
  • Re-operation 5%
  • Death <0.3%
  • Mean ICU Stay 0.5 days
  • Hospital Stay 6.4 days

Brown et al. AASLD 2001

recipient issues
Recipient Issues
  • Retransplant rate 2.5%
  • Acute liver Failure 2%
  • Biliary complications 23%
  • Arterial complications 8%

Brown et al. AASLD 2001

common problems after lt
Common Problems after LT

Diabetes NODM 15%

Osteoporosis Increased risk in cholestatic liver diseases, long term steroids

Obesity

Hypertension CNI

Hyperlipidemia Sirolimus

Neurological Headache- CNI

Hematological Anaemia. HCV related

Viruses CMV, EBV, Herpes viruses

Malignancy Skin, all solid tumours, PTLD

Renal Failure CNI

what to watch for within the first week
What to watch for within the first week
  • Hepatic Artery thrombosis
  • Portal Vein thrombosis
  • Infections Bacterial/Viral/Fungal
  • Drug toxicity
  • Renal Impairment
  • Acute cellular rejection
acute cellular rejection
Acute cellular Rejection
  • 40-50% of recipients within 1st year post transplant
  • Mainly in first month
  • High AST/ALT/Alk phos
  • Peripheral eosinophilia
  • Diagnose on liver biopsy
infection post transplant
Infection post Transplant
  • Month 1

Nosocomial infection

Bacteria and fungi

19-28% of patients have bacteremia

Staph, Enterococcus (50-60%)

  • Month 2-6

CMV

slide21
CMV
  • Herpesvirus
  • Highest risk are recipients from CMV mismatch or Recipients of OKT-3/Thymoglobulin
  • Without prophyllaxis (oral Valganciclovir), risk of symptomatic disease 64%
  • Fever, leukopenia, hepatitis in up to 25%

Pneumonitis, GI infection

  • Predisposes: chronic rejection, worse HCV recurrence and fungal superinfection
  • Treat with iv Ganciclovir/oral Valganciclovir for 3 months
biliary complications the achilles heel of liver transplantation
Early (< 30 days)

Anastomotic bile leak

Anastomotic stricture

Bile leak at T tube exit

Obstruction of T tube

Sphincter of Oddi dysfunction

Late (> 30 days)

Anastomotic stricture

Nonanastomotic strictures

Bile leak on T tube removal

Sphincter of Oddi dysfunction

Biliary Complications “The Achilles heel of liver transplantation”
disease recurrence post transplant
Disease Recurrence post transplant
  • HCV 100%

30% cirrhotic at 5 years

  • HBV 100% without prophylaxis
  • AIH/PBC/PSC 20%
  • NASH Up to 80%
  • Cholangiocarcinoma
  • HCC dependant on tumor size
  • Hemochromatosis
patient survival
Patient Survival

Survival (%)

Years post transplant

causes of death
Causes of Death

ANZLT registry 2006.

slide28
Q & A
  • Orthotopic liver transplantation:

a. better prognosis in adults than children

b. contraindicated in cholangiocarcinoma

c. liver not viable >12 hr after harvesting

d. external biliary drainage influences cyclosporin

dosage

e. outcome of Tx is independent of stage of liver

disease

slide29
Q & A
  • A patient presents with hepatitis. ALT 3500
  • The least likely diagnosis

a. panadol od

b. alcohol

c. Budd Chiari

d. viral hepatitis

e. ischaemic hepatitis

slide30
Q & A
  • What is the best predictor for oesophageal variceal bleeding?A. portal venous pressureB. Child Pugh ScoreC. Variceal sizeD. INR
slide31
Q & A
  • Female diacharged home after hemicolectomy. Husband brings her back 48 hours later with abdominal pain, jaundice, and anemia. What is the strongest predictor of increased mortality without liver transplant?A. raised bilirubinB. raised creatininec. Raised ASTd. Raised ALTe. PT 160
slide32
Q & A
  • 50 year old man with chronic liver disease with heaptitis B infection. Recent gastroscopy shows large oesophageal varicies. Alb 32 platelets 70 AFP 300 INR 1.4CT shows localised mass in liverWhat is the best treatment/management?A. ChemoembolisationB. Liver transplantC. RFAD. CryotherapyE. local rescetion