Makindo Medical Notes

Related Subjects: |Chronic liver disease |Cirrhosis |Alkaline phosphatase (ALP) |Liver Function Tests |Ascites Assessment and Management |Budd-Chiari syndrome |Autoimmune Hepatitis |Primary Biliary Cirrhosis |Primary Sclerosing Cholangitis |Wilson disease |Hereditary Haemochromatosis |Alpha-1 Antitrypsin (AAT) deficiency |Non alcoholic steatohepatitis (NASH) |Spontaneous Bacterial Peritonitis |Alcoholism and Alcoholic Liver Disease |Liver Transplantation

Rate limiting factor is the lack of availability of donated (cadaver) organs. Nowadays living donors can be source usually to other family members

About

• A successful and effective treatment of liver failure
• May be done acutely or electively
• Usually for those under 65
• Model for End-Stage Liver Disease score calculator useful

Source of transplant

• Deceased donor: Orthotopic transplant: Recently deceased person who is donor to one or more people
• Living donor: Partial liver section from living donor
• Both the donor and recipient liver segments will grow to normal size in a few weeks.
• Blood type and body size are critical factors .
• ABO blood type compatibility is preferable
• Donor age less than 60 years of age.

Procedure

• Mercedes Benz rooftop incision
• Liver transplants usually take from 6 to 12 hours.
• During the operation, surgeons will remove the non-functioning liver and will replace it with the donor liver.

Acute Need or Transplant

• Paracetamol overdose
• Fulminant Liver failure from viral infection

Kings College criteria for Liver transplant

• An Arterial pH < 7.3 at 24 hrs after ingestion
• A Prothrombin time > 100 seconds
• Creatinine > 300 umoles/L
• Grade III or IV hepatic encephalopathy

Non Paracetamol induced liver failure

• Prothrombin time > 100 seconds OR 3 of the following
• Drug induced, Age < 10 or > 40
• More than 1 week between jaundice and encephalopathy
• Prothrombin time > 50 seconds
• Bilirubin > 300 umoles/L

Indications

• Fulminant liver failure due to Paracetamol overdose
• End stage Liver failure from Alcohol abuse

Indications in advanced liver disease

• Primary biliary cirrhosis
• Recurrent variceal haemorrhage
• Intractable ascites
• Spontaneous bacterial peritonitis
• Refractory encephalopathy
• Severe jaundice
• Exacerbated synthetic dysfunction
• Sudden deterioration
• Fulminant hepatic failure

Pre op work up

• FBC, LFTS GGT, AST + TP, Full coagulation screen
• Urea, creatinine, sodium, potassium and total C02. Glucose
• Electrocardiogram
• Abdominal ultrasound if not done in previous 4 months
• Cross match 10 units of red blood cell concentrate

Surgical

• Midline incision from the suprasternal notch to the pubis
• Allows full exposure to the abdomen and intrathoracic structures
• Cardiac and pulmonary organ harvest
• Hepatic dissection and extraction for the abdominal surgeon.

Contraindications

• Malignancy outside liver, >Sepsis e.g. active SBP
• Liver metastases

Complications

• Death, Sepsis, Haemorrhage, Acute rejection

Prevention of Rejection

• Ciclosporin, Azathioprine
• Tacrolimus, Steroids

Transplant rejection

• High risk: those with a previous history of rejection, younger patients, females and those transplanted for auto immune diseases eg. autoimmune hepatitis and primary biliary cirrhosis.
• Low Risk : Severely malnourished patients and those with renal failure