overview of liver transplantation

1. Dr. HarsHal rajekarDr. HarsHal rajekar

2. Cirrhosis – HCV related

3. Cirrhosis- Hemochromatosis
Cirrhosis – Alcohol
induced

4. 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

5. Liver Transplantation
Liver transplantation is the OPTIMAL treatment
for end stage liver disease (ESLD)
ESLD has 2 forms: Acute and Chronic
- Acute = Fulminant Hepatic Failure
- Chronic = Cirrhosis

6. Fulminant Hepatic Failure (FHF)
Synonymous with Acute Liver Failure
Pathology: Pan-lobular or Sub-massive necrosis
Classically seen in Paracetamol poisoning. In
India – commonest cause is HEV, HAV and drug
induced.

7. Criteria for transplantation of acute liver failure
KING’S COLLEGE CRITERIA
 Acetaminophen toxicity
 Non-acetaminophen etiology
CLICHY CRITERIA
PGIMER criteria

8. 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.

9. Chronic Liver Disease — Signs of decompensation
Ascites
Encephalopathy
Portal Hypertensive Bleeding
Hepatocellular Carcinoma in the setting of
Cirrhosis

10. Liver Transplantation
Question for Transplant Team
• When to list for liver transplantation?
• When to perform the liver transplant?

11. 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.

12. Prognostication
Survival 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.

13. 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

14. MELD score
Introduced 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%.

15. 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%.

16. Requirements for Transplantation
End stage liver disease
Physiologic ability to tolerate surgery: Cardiac,
pulmonary, renal, cerebral function
Anatomy – status of vessels (PV/HA/HV)
Social support/ psychological support
No extra-hepatic infection or malignancy
Alcohol abstinence for 6 months/ no substance abuse

17. Contra-indications
Cardiopulmonary 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.

18. Surgical perspective
Immediate 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

19. Donor selection
Cadaveric/ living donor.
Blood group match. (HLA not required/ cross
matching not required).
Size match.
Marginal donors.
Split liver.

20. Organ harvesting/
procurement
HTK solution (custodiol)
UW (Viaspan)
Goal: Cool the organs and
perfuse with preservative
solution while
exsanguinating the organs.
Aortic canulation
Portal canulation

21. Anesthesia
Multiple issues:
- cardiopulmonary instability,
- Portopulmonary hypertension,
- Coagulopathy,
- Cholestasis, jaundice,
- blood loss, volume status.
Impact of anesthesia on liver function
Limited functional reserve, Drug clearance,
Anesthesia-induced hepatitis, Postoperative
jaundice, Risk factors for decompensation in patients
with cirrhosis.

22. Implantation of the new liver.
Orthotopic/ auxillary
begins 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.

23. Classical v/s piggy back technique
Classical or cava
replacement
Piggy-back technique

24. Graft function
Helpful signs of hepatic function in the immediate
postoperative period
1. Hemodynamic stability
2. Awakening from anesthesia
3. Clearance of lactate
4. Resolution of hypoglycemia
5. Normalization of coagulation profile
6. Resolution of elevated transaminases
7. Bile of sufficient quantity and golden brown in color

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

26. Medication after transplant
Immunosuppression: 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.

27. Complications
Immediate, 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.

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

29. Complications
Late complications:
- Usually late, after more than a year.
- Recurrent disease
- Medication adverse effects
- Chronic rejection
- Infections
- Metabolic problems
- Recidivism

30. Infections after a transplant

31. Waiting for a liver
Management of Ascites.
Management of portal hypertension
Renal function
Hepatic encephalopathy
General health and activity
Treatment of viral disease
Vaccination
Prevention of infection.

32. 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

33. Essential Concepts for Using
Living Donors
• No conflict of interest
• No coercion
• Minimize donor risks
• Donors must be given every opportunity to change
their minds
• Emphasize alternatives

34. 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.

35. LDLT problems
Risk 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 problems
Higher incidence of vascular problems
Small for size syndrome
Ethical issues
Initially had poorer graft survival, but recently has
been equal to DDLT.

36. 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.

37. Donor liver

38. Donor Liver
Cadaveric
donor liver
after back table
preparation

40. After reperfusion.

41. THANK YOU!