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EVALUATION FORLIVER TRANSPLANTATION
L.VENKATAKRISHNANDept of GI Sciences
PSG Institute of Medical Sciences, Coimbatore
INTRODUCTION
• Liver transplantation is currently the treatment of choice for patients with ESLD with complications.
• Most common indications– Complication of ESLD– Acute Liver Failure– Primary Hepatic Malignancy
• Persistent problem – shortage of donor pool
Scope of the Talk
• Indications for transplant• Candidate selection listing• Pre-transplant evaluation• Disease specific issues• Methods of expanding donor pool• Post transplant care and complications
Indications for Liver Transplantation
Alcoholic Cirrhosis
11%
NAFLD9%
Hepatitis B1%
Cryptogenic cirrhosis
3.5%
Indications for Liver Transplantation
• Fulminant hepatic Failure• Complications of cirrhosis– Ascites– Chronic gastrointestinal blood loss caused by
portal hypertensive gastropathy– Hepatic encephalopathy– Liver Cancer– Recurrent variceal bleeding– Synthetic dysfunction
Indications for Liver Transplantation
• Liver based metabolic conditions– Alpha 1 antitryspin deficiency– Familial amyloidosis– Glycogen storage disease– Hemochromatosis– Primary oxaluria– Wilson disease– Tyrosinemia– Urea cycle enzyme deficiencies
• Systemic complications of chronic liver disease– Hepatopulmonary syndrome– Portopulmonary hypertension
Prognostic Models for LT AllocationConditions for which MELD exception may be allocated
• HCC• Cholangiocarcinoma in select cases• Hepatopulmonary syndrome• Portopulmonary hypertension• Recurrent cholangitis• Budd-Chiari syndrome• Primary hyperoxaluria• Familial amloidosis• Cystic fibrosis• Intractable pruritus• Polycystic liver disease• Hereditary hemorrhagic telangiectasia• Small for size syndrome
Transplant Evaluation• Cardiac evaluation• Pulmonary evaluation• Surgical evaluation• Infectious disease evaluation• Nephrology evaluation• Neurologic evaluation• Laboratory studies• Radiology evaluation• Age appropriate cancer screening• Social work evaluation• Financial screening
Transplant Evaluation• Cardiac evaluationNon invasive evaluation with echo cardiographyPatients with advanced liver disease may not get
target heart rate during TMT.Pharmacological stress with adenosine or
dobutamine.Coronary angiogram and appropriate
management of CAD before ALT To rule out valvular heart disease and venticular
dysfunction.
Transplant Evaluation• Pulmonary EvaluationPOPH should be excluded in LT candidates by routine
echocardiography. If RVSP is more than 45 mm of Hg right heart catheterization indicated
Vasodilater therapy should be evaluated by pulmonary cardiac specialists.
LT can be offered to potential recipients who respond to medical therapy.
All patients should be screened for HPS.Presence of severe HPS with increased mortality should
be expedited for LT evaluation.Other associated pulmonary conditions like ILD should be
evaluated before transplant.
Transplant Evaluation• Surgical EvaluationConfirm the need for transplantIdentify technical challengesDiscuss donor options - deceased, living and
extended.
Transplant Evaluation• Infectious Disease EvaluationSerological – HAV, HBV, HCV, HIV, EBV, CMV, RPRInterferon Assay for TB –Quantiferon test or T
spot TBSelected candidates screening for
coccidiomycosis, strongyloides and dental evaluation
Vaccination strategiesTreatment of latent TB
Transplant Evaluation• Nephrology evaluationRecognition of renal dysfunction with cirrhosis has
a dramatic effect on post LT mortality.Death increased by 7 fold in patients who had onset
of renal failure within one month of transplant.DD includes 1-Intercurrent sepsis
2-Hypovolemia 3-HRS 4-Parenchymal renal diseases
Transplant Evaluation• Nephrology evaluationEvaluation will include calculation of GFR and
determination of precise etiology.SLK is indicated
1. End stage renal diseases with cirrhosis2. Liver failure with CKD and GFR < 30 ml/min3. Acute kidney injury or HRS requiring dialysis for more than 8 weeks4. If more than 30% of glomerulosclerosis or fibrosis by renal biopsy.
Transplant Evaluation• Neurological evaluationCarotid doppler if age > 60Neurology consultation as needed.
Transplant Evaluation• Laboratory studiesElectrolytes Hepatic function panelCoagulation panelHepatitis serologiesBlood typing with antibodiesUrine Toxicology
Transplant Evaluation• Radiology evaluationAbdominal sonogram with dopplerTriple phase CT or gadolinium magnetic
resonance imaging for HCC screening or tumor staging.
CT thorax
Transplant Evaluation• Age appropriate cancer screeningPAP SmearMammogramColonoscopy (age > 50 or history of primary
sclerosing cholangitis)Bone DiseaseObesityPrevious extra hepatic malignancy.
Transplant Evaluation• Social work evaluationAssess psychosocial issuesEvaluate support baseFinancial Screening
1. Secure approval for evaluation2. Discuss the cost
Specific Issues in Transplant Evaluation
Patients with HCV diseasePatients with HIV diseasePatients with HBV diseasePatients with Alcohol Liver DiseaseHepatocellularcarcniomaCholangiocarcniomaMELD exceptions