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Liver Transplantation Malay Shah, MD Surgical Director, Liver Transplantation Associate Professor of Surgery University of Kentucky Medical Center
Financial Disclosures
Unfortunately, I have no financial commitments or relationships to disclose
1.Discuss indications & contraindications for liver transplant 2. Review allocation of livers for transplantation 3. Discuss the MELD score and its implications for survival with and without transplant
Objectives
Clinical Features of Cirrhosis
Clinical Features of Cirrhosis
Clinical Features of Cirrhosis
Clinical Features of Cirrhosis
Clinical Features of Cirrhosis
Clinical Features of Cirrhosis
THIS ULTIMATELY LEADS TO…
When is Liver Transplant Indicated?
Liver transplantation is indicated in cirrhotic patients when the risk of death without transplant exceeds the risk of death with transplant
Surgical Complications 1% mortality high morbidity
Infections Drug side effects Recurrence of liver disease: HCC,
HepC
Malignancy Risk: Non-melanoma skin CA: RR 30 Kidney: RR 9 HCC and Gyn cancers: RR 5 Bladder, Thyroid, Melanoma, and NHL:
RR 3 Colorectal, Lung: RR 2 Pancreas: RR 1.5 Breast: RR 1.1
10% one-yr mortality
When is Liver Transplant Indicated? Defining the Risks
• Cirrhosis with hepatic decompensation and MELD score ≥ 15 (or Na-MELD ≥ 15): Hep B/C, EtOH, PBC, PSC, biliary atresia, AIH, NASH
• HCC within Milan criteria
• Fulminant liver failure
• MELD EXCEPTIONS : metastatic neuroendocrine tumor, hepatic hydrothorax, recurrent cholangitis, hepatopulmonary syndrome, etc.
Indications for Liver Transplant
Active EtOH use Illicit drug use
Active smoking Noncompliance
Dishonesty Active Malignancy (non-
HCC)
age > 65 COPD
CAD/CHF ESRD
BMI >35
Contraindications for Liver Transplant
• 1985: European Liver Transplant Registry—38% due to HCC
• 5-year survival only 20%!
• 1996: only 10% due to HCC
Lancet 1999; 353: 1253
Hepatocellular Carcinoma Early Experiences with Transplant
Mezzaferro et al, N Eng J Med 1996
Milan Criteria
Historically, liver transplantation for HCC produced horrible results
Milan Criteria Solitary lesion <5cm Two or three lesions, all <3cm No extrahepatic disease 5 year survival rate equivilant to txp w/o HCC
• 2002: 29 points for patients within Milan, and 24 points for stage I HCC (one tumor < 2cm)
• This was shown to give too high of a priority to HCC patients
and disadvantaged non-HCC patients
• Current policy: Patients listed with their calculated MELD score. After a 6 month wait period after listing, they will receive a score of 28.
MELD Exception Points for HCC
all OLT HCC one year 84% 87%
five year 75% 67%
ten year 52% 49.5%
Hepatocellular Carcinoma Survival Compared to Non-HCC Recipients
V. Mazzaferro et al., Ann Surg Oncol 2008;15(4):1001
Variable HR CI (95%) p-value Overall patient survival Milan criteria (in vs. out) 3.1 1.35-6.93 0.007 Tumor-free survival Milan criteria (in vs. out) 5.5 1.39-21.27 0.01 Microsatellites (yes vs. no) 3.6 1.5-8.71 0.004 Microvascular invasion (yes vs. no) 3.4 1.36-8.76 0.009 Tumor grade (G3 vs. G1-2) 3.4 1.04-11.14 0.04
Hepatocellular Carcinoma Prognostic Factors Affecting Survival
1980s: waiting time and “level of care”
1996: disease severity using CTP
score
2002: disease severity using MELD (Model End-Stage Liver Disease)
score
Liver Allocation
Assessing perioperative morbidity and mortality in patients with cirrhosis
Class correlates with the frequency of post-operative complications: liver failure, worsening encephalopathy, bleeding, infection, renal failure, hypoxia, intractable ascites
Child-Turcotte-Pugh Score
Child-Turcotte-Pugh Score
Operative mortality: Class A: 10% Class B: 30% Class C: ~80%
Emergency surgery associated with higher mortality
General consensus for elective surgery:
Class A: elective surgery well tolerated Class B: permissible with preoperative preparation Class C: contraindicated
Child-Turcotte-Pugh Score
5 factors contribute to score, 3 of which are non-modifiable (bilirubin, INR and albumin)
Great subjectivity in encephalopathy and ascites
Easy to “game the system” and increase your patient’s CTP score
Child-Turcotte-Pugh Score Limitations for Transplant
MELD Score = (0.957 * ln(Serum Cr) + 0.378 * ln(Serum Bilirubin) + 1.120 * ln(INR) + 0.643 ) * 10
• INR • Creatinine • Total Bilirubin
• Range: 6 – 40
Model for End Stage Liver Disease Score (MELD)
Goal = determine mortality rates for candidates compared to recipients
Liver Recipient Outcomes
12,996 patients listed from 2001 – 2003
Liver Recipient Outcomes
Liver Recipient Outcomes
Overall, recipients had 79% lower mortality risk than candidates waiting on the list MELD 18-20: 38% lower mortality risk MELD 40: 96% lower mortality risk
8X
MELD 6
15
24
33
40
One yr survival without OLT
97%
86%
16%
<2%
<1%
One yr survival with OLT
86%
86%
84%
76%
74%
• Hyponatremia has been shown to be an independent predictor of death
• Na-MELD = MELD + (135 – Na)*1.59
• Example: • MELD 10, Na 129: Na-MELD is 20
“Sodium MELD” Score
Kim WR et al. N Engl J Med 2008;359:1018-1026.
Kim WR et al. N Engl J Med 2008;359:1018-1026.
MELD can quantify mortality risk in cirrhotic patients post-operatively
Applies to abdominal, orthopaedic and cardiovascular operations
Mortality rates: MELD <7: ~6% MELD 8-11: ~10%
MELD 12-15: ~25%
MELD Score Correlation
QUESTIONS?
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