SlideShare a Scribd company logo
1 of 56
Download to read offline
OVERVIEW OF
LIVER
TRANSPLANTATI
ON
Dr. 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 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
Fulminant Hepatic Failure (FHF)
 Synonymous with Acute Liver Failure
 Definition: Development of encephalopathy
within about 8 weeks of the onset of
symptoms or within about 2 weeks of the
onset of jaundice
 Pathology: Pan-lobular or Sub-massive
necrosis
 Classically 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
ph < 7.30 (after hydration and regardless of degree of encephalopathy)
or
INR >6.5
creatinine >3mg/dl
Encephalopathy III-IV
• Non-acetaminophen etiology
•INR >6.5 irrespective of degree of encephalopathy
or 3 of the following five criteria
Age<10, >40
Etiology: nonA-E hepatitis, drugs
Duration of jaundice before encephalopathy >7 days
INR >3.5
Serum bilirubin >17.5 mg%.
CLICHY CRITERIA
• Factor V <20% (age <30 years) or 30% (age >30 years)
• Confusion and/or coma
Acute Liver failure (PGIMER criteria –
Clinical prognostic Indicators)
 age ≥50 yr,
 JEI >7 days,
 grade 3 or 4 encephalopathy,
 presence of cerebral edema,
 prothrombin time ≥35 seconds, and
 creatinine ≥1.5 mg/dL.
Presence of any 3 of 6 CPI was optimum in
identifying survivors and nonsurvivors
Chronic Liver disease : Cirrhosis
 All patients with cirrhosis do not qualify for liver
transplantation.
 Transplantation is generally considered when a
patient has suffered from either a complication of
portal hypertension.
 The onset of decompensation is associated with
significantly impaired survival.
 The development of hepatorenal syndrome is an
ominous marker that signals the need for
immediate transplant evaluation.
Chronic Liver Disease — Signs of
decompensation
 Ascites
 Encephalopathy
 Portal Hypertensive Bleeding
 Hepatocellular Carcinoma in the setting of
Cirrhosis
Chronic Liver Disease—Indications for
Transplantation
 Ascites
 Ascites has a two-year mortality of 50%
 SBP has a two-year mortality of 80%
 Hepato-Renal Syndrome :
- 2 types, type 1 has very poor prognosis,
>50% mortality at 2 weeks, and type 2 has 50%
mortality at 1 year.
 Variceal bleed and hepatic encephalopathy:
difficult to quantify the effect on mortality as they
are a mechanical result of portal hypertension
When?
Quality of life issues
– Severe lethargy
– Intractable itching
– Recurrent bile duct infections
– Intractable ascites
– Severe bone thinning
– Pain
Liver Transplantation
Question 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.
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.
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 score
 Introduced in Feb 2002.
 The MELD score originally was developed and
validated to assess the short-term prognosis of
patients with cirrhosis undergoing TIPS.
 Developed by the Mayo Clinic.
 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%.
Chronic Liver Disease—Indications for
Transplantation
 Ultimately, the decision to transplant is based
upon the patient’s likelihood of survival
 Survival with transplantation:
 One-year ~85-90%
 Two-year ~80-88%
 Five-year ~65-75%
 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%.
Patient Survival After Primary Liver
Transplantation
0
10
20
30
40
50
60
70
80
90
100
0 12 24 36 48 60
Time (months)
Survival(%)
1984-2001 n=384
1991-2001 n=299
1995-2001 n=186
Guidelines for Organ Allocation
 Organs should be allocated to transplant
candidates in the order of medical urgency
 The role of waiting times in determining
allocation order should be minimized
 Every attempt should be made to promote
efficient use of donor organs
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
Contra-indications
 Cardiopulmonary disease that cannot be corrected and is a
prohibitive risk for surgery.
 Malignancy outside of the liver within five years of
evaluation (not including superficial skin cancers) or not
meeting oncologic criteria for cure.
 Active alcohol and drug use. Minimum period of abstinence
of at least six months (+/- participation in a structured
rehabilitation program) may be needed.
 Advanced age and AIDS are examples of relative
contraindications.
 Liver transplantation can be performed in those older than
65 provided that there has been a comprehensive search
made for co-morbidities
Liver Transplantation
Evaluation
 Determine cause of liver disease
 Document severity of liver disease
 Determine survival and functional ability
 Concomitant medical problems
 Psychiatric evaluation
 Social Evaluation
LTx Evaluation
• Medical history
– Symptoms such as fatigue, itching, swelling,
changes in mental status and GI bleeding
– Other medical problems
– Medications
– Includes alcohol use and drug use history
• Physical examination
• Blood tests
– Determine underlying cause of liver disease
– Determine current functional status of the liver
LTx Evaluation
 Liver Ultrasound/CT scan/MRI
 Liver biopsy
 ERCP/ MRCP – Cholangiogram – examines
bile ducts if cirrhosis is otherwise
unexplained
 PET scan and other inv for cancer
Evaluation of psychosocial support for
LTx
 Psychosocial evaluation
– Support systems
– Compliance with post transplant
immunosuppression medication protocol
after transplantation
 Social and family support around the
transplant
Limitations of MELD
• Patients with liver cancer
• Bile duct infections
• Itching
• Disabling mental status changes (hepatic
encephalopathy)
• ? Criteria for living donors
Other conditions like : HPS, metabolic diseases,
congenital errors of metabolism, fulminant
liver failure, graft non-function, etc
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
Donor selection
 Cadaveric/ 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 canulation
 Portal canulation
Donor liver
Donor Liver
 Cadaveric
donor liver
after back
table
preparation
Donor Liver
 Same cadaver
liver with the
hepatic hilum
displayed
Anesthesia
 Physiological processes, biological function, and drug
disposition, renal function, RBF
 Interpretation of liver function study results
 Portal hypertension and complications: variceal hemorrhage,
SBP, sepsis, ascites, hepatorenal syndrome, encephalopathy
 Cardiac and circulatory effects: hyperdynamic circulation,
vasodilatation.
 Portopulmonary hypertension
 Coagulopathy
 Cholestasis, jaundice
Impact of anesthesia on liver function
 Limited functional reserve
 Hepatic blood flow
 Drug clearance
 Anesthesia-induced hepatitis
 Postoperative jaundice
 Risk factors for decompensation in patients with cirrhosis
Implantation of the new liver.
 Orthotopic/ auxillary
 begins with a controlled
recipient hepatectomy
 formidable task in individuals
with severe portal
hypertension and extensive
collateral
 Role of temporary porta-caval
shunt..
 Engraftment with venous,
arterial and then biliary
anastomoses.
 Classic v/s piggy back
implantation.
Overview of liver transplantation
Classical v/s piggy back technique
 Classical or cava
replacement
Piggy-back technique
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
Overview of liver transplantation
After reperfusion.
Immediate outcome
What factors:
 Organ harvesting.
 Organ preservation.
 Warm and cold ischemia times.
 Graft selection/ graft quality.
 Donor-recipient matching.
 Surgical problems.
 Medical issues.
Post-op monitoring
 Monitor hemodynamics, vitals, and blood tests.
 Blood tests: LFTs, lactate, ABG, CBC, and coagulation
parameters.
 Monitor immunosuppression.
 rising transaminases and bilirubin in the 48 h immediately
after transplantation may not be ominous signs as long as
the prothrombin time, serum lactate, bile production, or
other measures of hepatic function are stable or improving
 Usually anesthesia is not reversed and patients are kept
intubated for upto 48 hours.
 Doppler examination of the transplanted liver.
 Medication: immunosuppression, antibiotics, antiplatelets,
analgesics, and PPIs.
Immunosuppression
 CNIs: tacrolimus/ cysclosporine
 mTOR inhibitors: Sirolimus, everolimus
 Steroids
 Mycophenolate
 Azathioprine
 Antibodies: daclizumab, basiliximab, ATG, ALG,
OKT3
 Newer agents: Efalizumab, Enlimomab, Campath
(Alemtuzumab), Natalizumab, Betalacept,
abatacept, etc.
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.
Complications
 Early:
- Infections
- Rejection
- Surgical/ wound complications.
- Biliary problems
- Vascular complications
- Recurrent disease
Complications
 Late 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 hypertension
 Renal function
 Hepatic encephalopathy
 General health and activity
 Treatment of viral disease
 Vaccination
 Prevention 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
Usual model for
LDLT
Living donor firsts
 • LD Kidney - 1954
 • LD Intestine - 1988
 • LD Liver (pediatric) - 1990
 • LD Pancreas - 1992
 • LD Lung - 1994
 • LD Liver (adult) - 1997
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
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 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.
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.
THANK YOU!

More Related Content

What's hot

liver transplant
liver transplantliver transplant
liver transplantSumer Yadav
 
Preoperative Evaluation For Living Donor Liver Transplantation
Preoperative Evaluation For Living Donor Liver TransplantationPreoperative Evaluation For Living Donor Liver Transplantation
Preoperative Evaluation For Living Donor Liver TransplantationAhmed Adel
 
Biliary stricture ppt
Biliary stricture pptBiliary stricture ppt
Biliary stricture pptSumer Yadav
 
Liver transplantation current status, controversies and myths
Liver transplantation current status, controversies and mythsLiver transplantation current status, controversies and myths
Liver transplantation current status, controversies and mythsAbhishek Yadav
 
Gall bladder cancer management
Gall bladder cancer managementGall bladder cancer management
Gall bladder cancer managementRomil Jain
 
Liver resection indications &amp; methods
Liver resection   indications &amp; methodsLiver resection   indications &amp; methods
Liver resection indications &amp; methodsDr Harsh Shah
 
MANAGEMENT OF HEPATOCELLULAR CARCINOMA
MANAGEMENT OF HEPATOCELLULAR CARCINOMAMANAGEMENT OF HEPATOCELLULAR CARCINOMA
MANAGEMENT OF HEPATOCELLULAR CARCINOMAIsha Jaiswal
 
Liver transplantation; notes of DM/DNB/Specialists
Liver transplantation; notes of DM/DNB/SpecialistsLiver transplantation; notes of DM/DNB/Specialists
Liver transplantation; notes of DM/DNB/SpecialistsPratap Tiwari
 
Obstructive jaundice management
Obstructive jaundice managementObstructive jaundice management
Obstructive jaundice managementAhmed Almumtin
 
Hilar Cholangiocarcinoma
Hilar Cholangiocarcinoma Hilar Cholangiocarcinoma
Hilar Cholangiocarcinoma Dr Harsh Shah
 
Management of acute pancreatitis
Management of acute pancreatitisManagement of acute pancreatitis
Management of acute pancreatitisBashir BnYunus
 
Hepatocellular carcinoma 2020
Hepatocellular carcinoma 2020Hepatocellular carcinoma 2020
Hepatocellular carcinoma 2020AbrahamGenetu
 
Kidney Transplantation
Kidney TransplantationKidney Transplantation
Kidney TransplantationMohammed Rajab
 
Non cirrhotic portal hypertension- role of shunt surgery
Non cirrhotic portal hypertension- role of shunt surgery Non cirrhotic portal hypertension- role of shunt surgery
Non cirrhotic portal hypertension- role of shunt surgery Dr Harsh Shah
 

What's hot (20)

Liver transplantation
Liver transplantationLiver transplantation
Liver transplantation
 
Liver Transplantation present scenario in India
Liver Transplantation present scenario in IndiaLiver Transplantation present scenario in India
Liver Transplantation present scenario in India
 
liver transplant
liver transplantliver transplant
liver transplant
 
Preoperative Evaluation For Living Donor Liver Transplantation
Preoperative Evaluation For Living Donor Liver TransplantationPreoperative Evaluation For Living Donor Liver Transplantation
Preoperative Evaluation For Living Donor Liver Transplantation
 
Liver dialysis
Liver dialysisLiver dialysis
Liver dialysis
 
Biliary stricture ppt
Biliary stricture pptBiliary stricture ppt
Biliary stricture ppt
 
Liver transplantation current status, controversies and myths
Liver transplantation current status, controversies and mythsLiver transplantation current status, controversies and myths
Liver transplantation current status, controversies and myths
 
Gall bladder cancer management
Gall bladder cancer managementGall bladder cancer management
Gall bladder cancer management
 
Liver resection indications &amp; methods
Liver resection   indications &amp; methodsLiver resection   indications &amp; methods
Liver resection indications &amp; methods
 
MANAGEMENT OF HEPATOCELLULAR CARCINOMA
MANAGEMENT OF HEPATOCELLULAR CARCINOMAMANAGEMENT OF HEPATOCELLULAR CARCINOMA
MANAGEMENT OF HEPATOCELLULAR CARCINOMA
 
Liver transplantation; notes of DM/DNB/Specialists
Liver transplantation; notes of DM/DNB/SpecialistsLiver transplantation; notes of DM/DNB/Specialists
Liver transplantation; notes of DM/DNB/Specialists
 
Obstructive jaundice management
Obstructive jaundice managementObstructive jaundice management
Obstructive jaundice management
 
Hepatectomy
HepatectomyHepatectomy
Hepatectomy
 
Overview on bariatric surgery
Overview on bariatric surgeryOverview on bariatric surgery
Overview on bariatric surgery
 
Hilar Cholangiocarcinoma
Hilar Cholangiocarcinoma Hilar Cholangiocarcinoma
Hilar Cholangiocarcinoma
 
Management of acute pancreatitis
Management of acute pancreatitisManagement of acute pancreatitis
Management of acute pancreatitis
 
Hepatocellular carcinoma 2020
Hepatocellular carcinoma 2020Hepatocellular carcinoma 2020
Hepatocellular carcinoma 2020
 
Liver Transplant in India
Liver Transplant in IndiaLiver Transplant in India
Liver Transplant in India
 
Kidney Transplantation
Kidney TransplantationKidney Transplantation
Kidney Transplantation
 
Non cirrhotic portal hypertension- role of shunt surgery
Non cirrhotic portal hypertension- role of shunt surgery Non cirrhotic portal hypertension- role of shunt surgery
Non cirrhotic portal hypertension- role of shunt surgery
 

Viewers also liked

Liver Transplantation
Liver TransplantationLiver Transplantation
Liver Transplantationlevouge777
 
Organ transplant ppt
Organ transplant pptOrgan transplant ppt
Organ transplant pptRichard Frank
 
Ultrasound & doppler ultrasound in liver transplantation
Ultrasound & doppler ultrasound in liver transplantationUltrasound & doppler ultrasound in liver transplantation
Ultrasound & doppler ultrasound in liver transplantationSamir Haffar
 
Principles of organ transplant
Principles of organ transplantPrinciples of organ transplant
Principles of organ transplantBashir BnYunus
 
Liver Transplant in India
Liver Transplant in IndiaLiver Transplant in India
Liver Transplant in IndiaHarshit jain
 
Liver transplantation - case studies
Liver transplantation - case studiesLiver transplantation - case studies
Liver transplantation - case studieshr77
 
Liver transplantation & its anaesthetic management
Liver transplantation & its anaesthetic managementLiver transplantation & its anaesthetic management
Liver transplantation & its anaesthetic managementSwadheen Rout
 
Hepatocellular carcinoma
Hepatocellular carcinomaHepatocellular carcinoma
Hepatocellular carcinomayinnshang
 
Human organ transplantation
Human organ transplantationHuman organ transplantation
Human organ transplantationheerkhant
 
Metástases hepáticas tratamento atual
Metástases hepáticas tratamento atualMetástases hepáticas tratamento atual
Metástases hepáticas tratamento atualCirurgia Online
 
Transplantacija organa
Transplantacija organaTransplantacija organa
Transplantacija organaBruno Bašić
 
Treatment of liver tumours current trends
Treatment of liver tumours current trendsTreatment of liver tumours current trends
Treatment of liver tumours current trendsChandramohan K
 
Acs0710 Injuries To The Great Vessels Of The Abdomen
Acs0710 Injuries To The Great Vessels Of The AbdomenAcs0710 Injuries To The Great Vessels Of The Abdomen
Acs0710 Injuries To The Great Vessels Of The Abdomenmedbookonline
 

Viewers also liked (17)

Liver Transplantation
Liver TransplantationLiver Transplantation
Liver Transplantation
 
Liver transplant
Liver transplantLiver transplant
Liver transplant
 
Liver transplantation
Liver transplantationLiver transplantation
Liver transplantation
 
Imaging in Liver Transplant
Imaging in Liver Transplant Imaging in Liver Transplant
Imaging in Liver Transplant
 
Organ transplant ppt
Organ transplant pptOrgan transplant ppt
Organ transplant ppt
 
Ultrasound & doppler ultrasound in liver transplantation
Ultrasound & doppler ultrasound in liver transplantationUltrasound & doppler ultrasound in liver transplantation
Ultrasound & doppler ultrasound in liver transplantation
 
Principles of organ transplant
Principles of organ transplantPrinciples of organ transplant
Principles of organ transplant
 
Liver Transplant in India
Liver Transplant in IndiaLiver Transplant in India
Liver Transplant in India
 
Liver transplantation - case studies
Liver transplantation - case studiesLiver transplantation - case studies
Liver transplantation - case studies
 
Liver transplantation & its anaesthetic management
Liver transplantation & its anaesthetic managementLiver transplantation & its anaesthetic management
Liver transplantation & its anaesthetic management
 
Hepatocellular carcinoma
Hepatocellular carcinomaHepatocellular carcinoma
Hepatocellular carcinoma
 
Human organ transplantation
Human organ transplantationHuman organ transplantation
Human organ transplantation
 
Metástases hepáticas tratamento atual
Metástases hepáticas tratamento atualMetástases hepáticas tratamento atual
Metástases hepáticas tratamento atual
 
Tx metástases
Tx metástasesTx metástases
Tx metástases
 
Transplantacija organa
Transplantacija organaTransplantacija organa
Transplantacija organa
 
Treatment of liver tumours current trends
Treatment of liver tumours current trendsTreatment of liver tumours current trends
Treatment of liver tumours current trends
 
Acs0710 Injuries To The Great Vessels Of The Abdomen
Acs0710 Injuries To The Great Vessels Of The AbdomenAcs0710 Injuries To The Great Vessels Of The Abdomen
Acs0710 Injuries To The Great Vessels Of The Abdomen
 

Similar to Overview of liver transplantation

Anaesthesia for liver transplantation
Anaesthesia for liver transplantationAnaesthesia for liver transplantation
Anaesthesia for liver transplantationisakakinada
 
IndicationsLivertransplantation.ppt
IndicationsLivertransplantation.pptIndicationsLivertransplantation.ppt
IndicationsLivertransplantation.pptmousaderhem1
 
Selection of patient for liver transplant
Selection of patient for liver transplantSelection of patient for liver transplant
Selection of patient for liver transplantApollo Hospitals
 
Dr lvk liver transplpantation l.venkatakrishan
Dr lvk   liver transplpantation  l.venkatakrishanDr lvk   liver transplpantation  l.venkatakrishan
Dr lvk liver transplpantation l.venkatakrishanrrsolution
 
5_6125448697896502769.pptx
5_6125448697896502769.pptx5_6125448697896502769.pptx
5_6125448697896502769.pptxDeepshikhaKar1
 
ANAESTHESIA FOR PATIENT WITH LIVER DISEASE.pdf
ANAESTHESIA FOR PATIENT WITH LIVER DISEASE.pdfANAESTHESIA FOR PATIENT WITH LIVER DISEASE.pdf
ANAESTHESIA FOR PATIENT WITH LIVER DISEASE.pdfSabariKreeshan
 
8. liver-transplant- Dr harsimran walia
8. liver-transplant- Dr harsimran walia8. liver-transplant- Dr harsimran walia
8. liver-transplant- Dr harsimran waliaharry11818a
 
Renal transplantation -friday_prof_ayman refaei
Renal transplantation -friday_prof_ayman refaeiRenal transplantation -friday_prof_ayman refaei
Renal transplantation -friday_prof_ayman refaeiFarragBahbah
 
Acute Liver Failure
Acute Liver Failure Acute Liver Failure
Acute Liver Failure AnandNaik65
 
Fulminant Hepatic Faliure
Fulminant Hepatic Faliure Fulminant Hepatic Faliure
Fulminant Hepatic Faliure Aftab Siddiqui
 
Core series: Acute Kidney Injury part 1
Core series: Acute Kidney Injury part 1 Core series: Acute Kidney Injury part 1
Core series: Acute Kidney Injury part 1 Adeel Rafi Ahmed
 
Cirrhosis and Its Complications
Cirrhosis and Its ComplicationsCirrhosis and Its Complications
Cirrhosis and Its Complicationsozererik
 
HEPATO-RENAL SYNDROME : DEV BUCHE
HEPATO-RENAL SYNDROME : DEV BUCHEHEPATO-RENAL SYNDROME : DEV BUCHE
HEPATO-RENAL SYNDROME : DEV BUCHEDevawrat Buche
 
Preparation for transplantation (mih)
Preparation for transplantation (mih)Preparation for transplantation (mih)
Preparation for transplantation (mih)FarragBahbah
 
Organ donation and transplantation
Organ donation and transplantationOrgan donation and transplantation
Organ donation and transplantationHIRENGEHLOTH
 
Management of cirrhosis for improving survival
Management of cirrhosis for improving survivalManagement of cirrhosis for improving survival
Management of cirrhosis for improving survivalMahendra Debbarma
 
5. perioperative assessment of Hemodialysis patients. Dr. Ahmed Kamal.pptx
5. perioperative assessment of Hemodialysis patients. Dr. Ahmed Kamal.pptx5. perioperative assessment of Hemodialysis patients. Dr. Ahmed Kamal.pptx
5. perioperative assessment of Hemodialysis patients. Dr. Ahmed Kamal.pptxAbdiwahabNoor1
 
AKIforResidentsInternalMedicine2022.pptx
AKIforResidentsInternalMedicine2022.pptxAKIforResidentsInternalMedicine2022.pptx
AKIforResidentsInternalMedicine2022.pptxhcahoustonim
 
Futility in liver transplantation
Futility in liver transplantation Futility in liver transplantation
Futility in liver transplantation Abhishek Yadav
 

Similar to Overview of liver transplantation (20)

Anaesthesia for liver transplantation
Anaesthesia for liver transplantationAnaesthesia for liver transplantation
Anaesthesia for liver transplantation
 
IndicationsLivertransplantation.ppt
IndicationsLivertransplantation.pptIndicationsLivertransplantation.ppt
IndicationsLivertransplantation.ppt
 
Selection of patient for liver transplant
Selection of patient for liver transplantSelection of patient for liver transplant
Selection of patient for liver transplant
 
Dr lvk liver transplpantation l.venkatakrishan
Dr lvk   liver transplpantation  l.venkatakrishanDr lvk   liver transplpantation  l.venkatakrishan
Dr lvk liver transplpantation l.venkatakrishan
 
5_6125448697896502769.pptx
5_6125448697896502769.pptx5_6125448697896502769.pptx
5_6125448697896502769.pptx
 
ANAESTHESIA FOR PATIENT WITH LIVER DISEASE.pdf
ANAESTHESIA FOR PATIENT WITH LIVER DISEASE.pdfANAESTHESIA FOR PATIENT WITH LIVER DISEASE.pdf
ANAESTHESIA FOR PATIENT WITH LIVER DISEASE.pdf
 
8. liver-transplant- Dr harsimran walia
8. liver-transplant- Dr harsimran walia8. liver-transplant- Dr harsimran walia
8. liver-transplant- Dr harsimran walia
 
Renal transplantation -friday_prof_ayman refaei
Renal transplantation -friday_prof_ayman refaeiRenal transplantation -friday_prof_ayman refaei
Renal transplantation -friday_prof_ayman refaei
 
Acute Liver Failure
Acute Liver Failure Acute Liver Failure
Acute Liver Failure
 
Fulminant Hepatic Faliure
Fulminant Hepatic Faliure Fulminant Hepatic Faliure
Fulminant Hepatic Faliure
 
Core series: Acute Kidney Injury part 1
Core series: Acute Kidney Injury part 1 Core series: Acute Kidney Injury part 1
Core series: Acute Kidney Injury part 1
 
Cirrhosis and Its Complications
Cirrhosis and Its ComplicationsCirrhosis and Its Complications
Cirrhosis and Its Complications
 
YASIR PPT (4.1).pptx
YASIR PPT (4.1).pptxYASIR PPT (4.1).pptx
YASIR PPT (4.1).pptx
 
HEPATO-RENAL SYNDROME : DEV BUCHE
HEPATO-RENAL SYNDROME : DEV BUCHEHEPATO-RENAL SYNDROME : DEV BUCHE
HEPATO-RENAL SYNDROME : DEV BUCHE
 
Preparation for transplantation (mih)
Preparation for transplantation (mih)Preparation for transplantation (mih)
Preparation for transplantation (mih)
 
Organ donation and transplantation
Organ donation and transplantationOrgan donation and transplantation
Organ donation and transplantation
 
Management of cirrhosis for improving survival
Management of cirrhosis for improving survivalManagement of cirrhosis for improving survival
Management of cirrhosis for improving survival
 
5. perioperative assessment of Hemodialysis patients. Dr. Ahmed Kamal.pptx
5. perioperative assessment of Hemodialysis patients. Dr. Ahmed Kamal.pptx5. perioperative assessment of Hemodialysis patients. Dr. Ahmed Kamal.pptx
5. perioperative assessment of Hemodialysis patients. Dr. Ahmed Kamal.pptx
 
AKIforResidentsInternalMedicine2022.pptx
AKIforResidentsInternalMedicine2022.pptxAKIforResidentsInternalMedicine2022.pptx
AKIforResidentsInternalMedicine2022.pptx
 
Futility in liver transplantation
Futility in liver transplantation Futility in liver transplantation
Futility in liver transplantation
 

More from hr77

Organ donation
Organ donationOrgan donation
Organ donationhr77
 
Nutritional guidelines-for-icu-patients
Nutritional guidelines-for-icu-patientsNutritional guidelines-for-icu-patients
Nutritional guidelines-for-icu-patientshr77
 
How to use medical literature
How to use medical literatureHow to use medical literature
How to use medical literaturehr77
 
liver mass - how to investigate?
liver mass - how to investigate?liver mass - how to investigate?
liver mass - how to investigate?hr77
 
Liver mass
Liver massLiver mass
Liver masshr77
 
Gallbladder and extrahepatic biliary system
Gallbladder and extrahepatic biliary systemGallbladder and extrahepatic biliary system
Gallbladder and extrahepatic biliary systemhr77
 
Blood products in liver transplantation and HPB surgery
Blood products in liver transplantation and HPB surgeryBlood products in liver transplantation and HPB surgery
Blood products in liver transplantation and HPB surgeryhr77
 
Advanced and laparoscopic liver, bile duct and pancreatic surgery
Advanced and laparoscopic liver, bile duct and pancreatic surgeryAdvanced and laparoscopic liver, bile duct and pancreatic surgery
Advanced and laparoscopic liver, bile duct and pancreatic surgeryhr77
 
hepatocellular carcinoma
hepatocellular carcinomahepatocellular carcinoma
hepatocellular carcinomahr77
 
Interventions for clients with liver, gallbladder and pancreas disorders
Interventions for clients with liver, gallbladder and pancreas disordersInterventions for clients with liver, gallbladder and pancreas disorders
Interventions for clients with liver, gallbladder and pancreas disordershr77
 
Organ donation 2013
Organ donation 2013Organ donation 2013
Organ donation 2013hr77
 
recent advances in hepatobiliary and GI surgery
recent advances in hepatobiliary and GI surgeryrecent advances in hepatobiliary and GI surgery
recent advances in hepatobiliary and GI surgeryhr77
 
Liver surgery
Liver surgeryLiver surgery
Liver surgeryhr77
 
Pediatric liver retransplantation
Pediatric liver retransplantationPediatric liver retransplantation
Pediatric liver retransplantationhr77
 
liver transplantation in the morbidly obese
liver transplantation in the morbidly obeseliver transplantation in the morbidly obese
liver transplantation in the morbidly obesehr77
 
HHV-6 viremia in liver transplant recipients
HHV-6 viremia in liver transplant recipientsHHV-6 viremia in liver transplant recipients
HHV-6 viremia in liver transplant recipientshr77
 
Early liver transplantation after resection for hcc
Early liver transplantation after resection for hccEarly liver transplantation after resection for hcc
Early liver transplantation after resection for hcchr77
 
Neoadjuvant therapy for esophageal cancer
Neoadjuvant therapy for esophageal cancerNeoadjuvant therapy for esophageal cancer
Neoadjuvant therapy for esophageal cancerhr77
 
Advancing age in liver transplant recipients
Advancing age in liver transplant recipientsAdvancing age in liver transplant recipients
Advancing age in liver transplant recipientshr77
 
Adjuvant therapy protocols for liver cancer in patients undergoing liver tran...
Adjuvant therapy protocols for liver cancer in patients undergoing liver tran...Adjuvant therapy protocols for liver cancer in patients undergoing liver tran...
Adjuvant therapy protocols for liver cancer in patients undergoing liver tran...hr77
 

More from hr77 (20)

Organ donation
Organ donationOrgan donation
Organ donation
 
Nutritional guidelines-for-icu-patients
Nutritional guidelines-for-icu-patientsNutritional guidelines-for-icu-patients
Nutritional guidelines-for-icu-patients
 
How to use medical literature
How to use medical literatureHow to use medical literature
How to use medical literature
 
liver mass - how to investigate?
liver mass - how to investigate?liver mass - how to investigate?
liver mass - how to investigate?
 
Liver mass
Liver massLiver mass
Liver mass
 
Gallbladder and extrahepatic biliary system
Gallbladder and extrahepatic biliary systemGallbladder and extrahepatic biliary system
Gallbladder and extrahepatic biliary system
 
Blood products in liver transplantation and HPB surgery
Blood products in liver transplantation and HPB surgeryBlood products in liver transplantation and HPB surgery
Blood products in liver transplantation and HPB surgery
 
Advanced and laparoscopic liver, bile duct and pancreatic surgery
Advanced and laparoscopic liver, bile duct and pancreatic surgeryAdvanced and laparoscopic liver, bile duct and pancreatic surgery
Advanced and laparoscopic liver, bile duct and pancreatic surgery
 
hepatocellular carcinoma
hepatocellular carcinomahepatocellular carcinoma
hepatocellular carcinoma
 
Interventions for clients with liver, gallbladder and pancreas disorders
Interventions for clients with liver, gallbladder and pancreas disordersInterventions for clients with liver, gallbladder and pancreas disorders
Interventions for clients with liver, gallbladder and pancreas disorders
 
Organ donation 2013
Organ donation 2013Organ donation 2013
Organ donation 2013
 
recent advances in hepatobiliary and GI surgery
recent advances in hepatobiliary and GI surgeryrecent advances in hepatobiliary and GI surgery
recent advances in hepatobiliary and GI surgery
 
Liver surgery
Liver surgeryLiver surgery
Liver surgery
 
Pediatric liver retransplantation
Pediatric liver retransplantationPediatric liver retransplantation
Pediatric liver retransplantation
 
liver transplantation in the morbidly obese
liver transplantation in the morbidly obeseliver transplantation in the morbidly obese
liver transplantation in the morbidly obese
 
HHV-6 viremia in liver transplant recipients
HHV-6 viremia in liver transplant recipientsHHV-6 viremia in liver transplant recipients
HHV-6 viremia in liver transplant recipients
 
Early liver transplantation after resection for hcc
Early liver transplantation after resection for hccEarly liver transplantation after resection for hcc
Early liver transplantation after resection for hcc
 
Neoadjuvant therapy for esophageal cancer
Neoadjuvant therapy for esophageal cancerNeoadjuvant therapy for esophageal cancer
Neoadjuvant therapy for esophageal cancer
 
Advancing age in liver transplant recipients
Advancing age in liver transplant recipientsAdvancing age in liver transplant recipients
Advancing age in liver transplant recipients
 
Adjuvant therapy protocols for liver cancer in patients undergoing liver tran...
Adjuvant therapy protocols for liver cancer in patients undergoing liver tran...Adjuvant therapy protocols for liver cancer in patients undergoing liver tran...
Adjuvant therapy protocols for liver cancer in patients undergoing liver tran...
 

Recently uploaded

AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologyDeepakDaniel9
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 

Recently uploaded (20)

AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacology
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 

Overview of liver transplantation

  • 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  Definition: Development of encephalopathy within about 8 weeks of the onset of symptoms or within about 2 weeks of the onset of jaundice  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 ph < 7.30 (after hydration and regardless of degree of encephalopathy) or INR >6.5 creatinine >3mg/dl Encephalopathy III-IV • Non-acetaminophen etiology •INR >6.5 irrespective of degree of encephalopathy or 3 of the following five criteria Age<10, >40 Etiology: nonA-E hepatitis, drugs Duration of jaundice before encephalopathy >7 days INR >3.5 Serum bilirubin >17.5 mg%. CLICHY CRITERIA • Factor V <20% (age <30 years) or 30% (age >30 years) • Confusion and/or coma
  • 8. Acute Liver failure (PGIMER criteria – Clinical prognostic Indicators)  age ≥50 yr,  JEI >7 days,  grade 3 or 4 encephalopathy,  presence of cerebral edema,  prothrombin time ≥35 seconds, and  creatinine ≥1.5 mg/dL. Presence of any 3 of 6 CPI was optimum in identifying survivors and nonsurvivors
  • 9. Chronic Liver disease : Cirrhosis  All patients with cirrhosis do not qualify for liver transplantation.  Transplantation is generally considered when a patient has suffered from either a complication of portal hypertension.  The onset of decompensation is associated with significantly impaired survival.  The development of hepatorenal syndrome is an ominous marker that signals the need for immediate transplant evaluation.
  • 10. Chronic Liver Disease — Signs of decompensation  Ascites  Encephalopathy  Portal Hypertensive Bleeding  Hepatocellular Carcinoma in the setting of Cirrhosis
  • 11. Chronic Liver Disease—Indications for Transplantation  Ascites  Ascites has a two-year mortality of 50%  SBP has a two-year mortality of 80%  Hepato-Renal Syndrome : - 2 types, type 1 has very poor prognosis, >50% mortality at 2 weeks, and type 2 has 50% mortality at 1 year.  Variceal bleed and hepatic encephalopathy: difficult to quantify the effect on mortality as they are a mechanical result of portal hypertension
  • 12. When? Quality of life issues – Severe lethargy – Intractable itching – Recurrent bile duct infections – Intractable ascites – Severe bone thinning – Pain
  • 13. Liver Transplantation Question for Transplant Team • When to list for liver transplantation? • When to perform the liver transplant?
  • 14. 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.
  • 15. 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.
  • 16. 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
  • 17. MELD score  Introduced in Feb 2002.  The MELD score originally was developed and validated to assess the short-term prognosis of patients with cirrhosis undergoing TIPS.  Developed by the Mayo Clinic.  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%.
  • 18. Chronic Liver Disease—Indications for Transplantation  Ultimately, the decision to transplant is based upon the patient’s likelihood of survival  Survival with transplantation:  One-year ~85-90%  Two-year ~80-88%  Five-year ~65-75%  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%.
  • 19. Patient Survival After Primary Liver Transplantation 0 10 20 30 40 50 60 70 80 90 100 0 12 24 36 48 60 Time (months) Survival(%) 1984-2001 n=384 1991-2001 n=299 1995-2001 n=186
  • 20. Guidelines for Organ Allocation  Organs should be allocated to transplant candidates in the order of medical urgency  The role of waiting times in determining allocation order should be minimized  Every attempt should be made to promote efficient use of donor organs
  • 21. 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
  • 22. Contra-indications  Cardiopulmonary disease that cannot be corrected and is a prohibitive risk for surgery.  Malignancy outside of the liver within five years of evaluation (not including superficial skin cancers) or not meeting oncologic criteria for cure.  Active alcohol and drug use. Minimum period of abstinence of at least six months (+/- participation in a structured rehabilitation program) may be needed.  Advanced age and AIDS are examples of relative contraindications.  Liver transplantation can be performed in those older than 65 provided that there has been a comprehensive search made for co-morbidities
  • 23. Liver Transplantation Evaluation  Determine cause of liver disease  Document severity of liver disease  Determine survival and functional ability  Concomitant medical problems  Psychiatric evaluation  Social Evaluation
  • 24. LTx Evaluation • Medical history – Symptoms such as fatigue, itching, swelling, changes in mental status and GI bleeding – Other medical problems – Medications – Includes alcohol use and drug use history • Physical examination • Blood tests – Determine underlying cause of liver disease – Determine current functional status of the liver
  • 25. LTx Evaluation  Liver Ultrasound/CT scan/MRI  Liver biopsy  ERCP/ MRCP – Cholangiogram – examines bile ducts if cirrhosis is otherwise unexplained  PET scan and other inv for cancer
  • 26. Evaluation of psychosocial support for LTx  Psychosocial evaluation – Support systems – Compliance with post transplant immunosuppression medication protocol after transplantation  Social and family support around the transplant
  • 27. Limitations of MELD • Patients with liver cancer • Bile duct infections • Itching • Disabling mental status changes (hepatic encephalopathy) • ? Criteria for living donors Other conditions like : HPS, metabolic diseases, congenital errors of metabolism, fulminant liver failure, graft non-function, etc
  • 28. 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
  • 29. Donor selection  Cadaveric/ living donor.  Blood group match. (HLA not required/ cross matching not required).  Size match.  Marginal donors.  Split liver.
  • 30. 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
  • 32. Donor Liver  Cadaveric donor liver after back table preparation
  • 33. Donor Liver  Same cadaver liver with the hepatic hilum displayed
  • 34. Anesthesia  Physiological processes, biological function, and drug disposition, renal function, RBF  Interpretation of liver function study results  Portal hypertension and complications: variceal hemorrhage, SBP, sepsis, ascites, hepatorenal syndrome, encephalopathy  Cardiac and circulatory effects: hyperdynamic circulation, vasodilatation.  Portopulmonary hypertension  Coagulopathy  Cholestasis, jaundice Impact of anesthesia on liver function  Limited functional reserve  Hepatic blood flow  Drug clearance  Anesthesia-induced hepatitis  Postoperative jaundice  Risk factors for decompensation in patients with cirrhosis
  • 35. Implantation of the new liver.  Orthotopic/ auxillary  begins with a controlled recipient hepatectomy  formidable task in individuals with severe portal hypertension and extensive collateral  Role of temporary porta-caval shunt..  Engraftment with venous, arterial and then biliary anastomoses.  Classic v/s piggy back implantation.
  • 37. Classical v/s piggy back technique  Classical or cava replacement Piggy-back technique
  • 38. 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
  • 41. Immediate outcome What factors:  Organ harvesting.  Organ preservation.  Warm and cold ischemia times.  Graft selection/ graft quality.  Donor-recipient matching.  Surgical problems.  Medical issues.
  • 42. Post-op monitoring  Monitor hemodynamics, vitals, and blood tests.  Blood tests: LFTs, lactate, ABG, CBC, and coagulation parameters.  Monitor immunosuppression.  rising transaminases and bilirubin in the 48 h immediately after transplantation may not be ominous signs as long as the prothrombin time, serum lactate, bile production, or other measures of hepatic function are stable or improving  Usually anesthesia is not reversed and patients are kept intubated for upto 48 hours.  Doppler examination of the transplanted liver.  Medication: immunosuppression, antibiotics, antiplatelets, analgesics, and PPIs.
  • 43. Immunosuppression  CNIs: tacrolimus/ cysclosporine  mTOR inhibitors: Sirolimus, everolimus  Steroids  Mycophenolate  Azathioprine  Antibodies: daclizumab, basiliximab, ATG, ALG, OKT3  Newer agents: Efalizumab, Enlimomab, Campath (Alemtuzumab), Natalizumab, Betalacept, abatacept, etc.
  • 44. 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.
  • 45. Complications  Early: - Infections - Rejection - Surgical/ wound complications. - Biliary problems - Vascular complications - Recurrent disease
  • 46. Complications  Late complications: - Usually late, after more than a year. - Recurrent disease - Medication adverse effects - Chronic rejection - Infections - Metabolic problems - Recidivism
  • 47. Infections after a transplant
  • 48. 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.
  • 49. 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
  • 51. Living donor firsts  • LD Kidney - 1954  • LD Intestine - 1988  • LD Liver (pediatric) - 1990  • LD Pancreas - 1992  • LD Lung - 1994  • LD Liver (adult) - 1997
  • 52. 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
  • 53. 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.
  • 54. 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.
  • 55. 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.