What to look for when advising for a liver What to look for when advising for a liver transplant.transplant.

4 things are necessary in perspective when a patient is listed for a transplant.1. need for a transplant.2. safety of the transplant.3. ability to comply with lifestyle changes after transplant. (financial and social support)4. acceptable quality of life after transplant.

Need: Investigations for the diagnosis, severity, etiology, and L/F complications.

Safety: Assess whether the patient will be able to tolerate a transplant. Cardio-resp fitness, ability to tolerate major surgery, etc.

Test for post transplant compliance, psycho-social and financial issues, and commitment issues.

And investigations that will govern and determine quality of life and medical decisions after tx.. i.e. chances of infection and need for prophylaxis, malignancy, CMV, other systemic problems and reversibility or correctibility.

Cadaveric donor assessment

A complete medical and surgical history is taken.

Laboratory testing generally includes ABO blood type, CBC, chemistries (LFT, RFT, Elec), PT, PTT, HBsAg, and anti-HBc, anti-HCV, anti-HIV, VDRL or RPR, and anti-CMV.

Blood and urine cultures are performed if the prospective donor was hospitalized for more than 72 hours.

Role of Biopsy..

LDLT - Why choose a living donor transplant?

LDLT has 2 main advantages: 1. The availability of a donor liver without the need to wait until the patient's name arrives at the top of the waiting list for cadaveric organ, and

2. The ability to thoroughly evaluate the donor 3. The recipient need not get too sick to get a transplant.

Evaluating a potential donor

Donor safety is paramount.

No exceptions to this rule, regardless of the consequences for the recipient, even death.

Identification of contraindications as early as possible and with a minimum of invasive testing.

Medical & psychological fitness of Donor.

Donor evaluation comprises 6 main components(4 Phases):

1. Blood type compatibility; 2. General medical assessment; 3. A more detailed evaluation of the liver, possibly including liver biopsy; 4. A psychological and psychiatric assessment; 5. A look at the donor's family and support system; 6.Financial considerations

Case 1.

62 male. ETOH cirrhosis, diagnosed 14

months ago, after an episode of acute alcoholic hepatitis.

Off ETOH since 14 months. No other addictions.

No DM, No HTN. Performance status good. H/o pulmonary tuberculosis 30

years ago, completed AKT. H/o Upper GI bleed once, has been

on endoscopic surveillance + propranolol.

..contd..

Clinically icteric. Moderate ascites, on diuretics

(aldactone 200mg/d + lasix 40 mg/d). Has had one episode of SBP 4 months

ago. Altered renal function of late (3

weeks), which responds to terlipressin; but gradually worsens.

Creatinine – 2.1mg/dL

..contd..

S. Bil – 2.9 INR – 1.89 Calculated creat clearance = 21.3

ml/min.

MELD score (UNOS) = 25 Should this patient get a

transplant? Does anything need to be done prior to a transplant?

..contd..

..Liver transplant only? Or simultaneous liver + kidney?

Patient is counseled regarding transplantation and undergoes evaluation for listing.

..contd..

Found to be medically fit, with no cardiac or respiratory issues.

Metabolically WNL, and viral studies were all negative for viral hepatitis.

Bone density studies showed marked osteopenia. (what can be done for this? Is it significant?)

Wait listed for transplant.

Management when waiting for a liver transplant.

SBP prophylaxis? Renal function? TIPS? Variceal prophylaxis? Nutrition? Blood tests. How frequent?

..contd..

Underwent LDLT. Received a right lobe graft 710gms,

GRWR of 0.8. Post transplant initial graft function

was satisfactory. Day 4 post LDLT, rise in bilirubin, ALT

and AST elevated, but still improving, Alk phosphate marginally elevated - 340.

Drains draining around 800mL of ascitic fluid daily.

… US + doppler was normal, vessels patent, n

o biliary radicle dilation, no collections. S. Bil. Increased to 6.5 (pred. conjugated), I

NR worsened to 2.2, renal function showed a slightly abnormal creatinine of 2mg/dL; Platelet count was low.

ALT, AST stopped improving and worsened to 3 X ULN.

S. albumin was persistently low <3g/dL. Drains still draining 800-900 mL ascitic flui

d on POD 7. No fever, TLC normal, cultures negative. Tac level 10.8.

What next? Rejection? SFSS? Biliary problem?

Case 2.

46, male. jaundice, abdominal distension, and pedal

edema. Known to have HCV cirrhosis. Known alcoholic but has been sober for more

than a year. Currently listed for liver transplant with a

MELD score of 26. No fever, chills, weight loss or abdominal pain,

GI bleeding, or encephalopathy. H/o spontaneous bacterial peritonitis in the

past. Non bleeder.

…

The past medical history is significant for diabetes and hypertension since the last 8 years.

Current medications include metoprolol, metformin, and norfloxacin.

Presently not working, performance status average. There is no family history of liver disease

… On exam: alert and oriented. Vital signs normal.. Icterus +, pedal edema +, multiple spider nevi. CVS, RS – wnl. Ascites + splenomegaly.

Labs :- Hb 8.2, Plat 39000, WBC 14300, INR 1.9, Creat 2.8, bili 13.9, AST 47, ALT 49, GGTP 103, ALP 127, Albumin 2.1

Ultrasound shows a patent portal vein and ++ascites.

Diagnostic tap confirms SBP with 350 neutrophils.

Inactived for transplant and is started on broad spectrum antibiotics and albumin.

The infection improves but his renal function worsens requiring renal replacement therapy.

… He is reactivated for transplant after 7 days with a

MELD score of 38.

3 donor offers come in simultaneously. Offer 1: 73-year-old male donor who died in a

motor vehicle accident. Biopsy shows 30% steatosis and the cold ischemia time (CIT) will likely be less than 12 hours.

Offer 2: 22-year-old male, found unconscious, and likely died of a drug overdose. HCV positive and is in a neighboring state. The Na+ was 159 mmol/l.

Offer 3: 51-year-old septic, diabetic male who is a non-heart-beating donor in a local hospital. Biopsy shows 20% steatosis.

1. Which organ should be used? 2. Is there a way of quantifying the risk

of graft failure?

What is DRI? Donor Risk index.- Incorporates Age, cause of death, race, BDD or NHBD, Split liver, height, cold ischemia time and location of organ. DRI < 1.7 is low risk and DRI > 1.7 is high risk.

DRI and patient MELD are important determinants of the outcome. (Organ Patient Index).

Case 3.

61-year female, post liver transplant 6 weeks ago, for HCV cirrhosis complicated by HCC.

She received TACE prior to transplant and was within Milan criteria (2 lesions less, 2.6 cm and 2.9 cm; without vascular invasion).

Received a 57-year-old allograft with 20–30% macrosteatosis. Post OLTx - uneventful and symptomatically she felt well.

Imunosuppression consisted of tacrolimus, mycophenolate mofetil, and a tapering dose of prednisone.

Clinical exam was unremarkable. Ultrasound and MRI/MRCP of the abdomen

demonstrated patent vessels; and no evidence of any biliary ductal dilation.

… Hb 9.9 Platelets 173000 INR 1.1 WBC 9300 (normal differential) T bili 2.7 AST 316 ALT 377 ALP 446 Albumin 3g/dL Creatinine 1.2 Tacrolimus level 12.8 ng/ml

D/D? ACR/ HCV/ CMV/ Biliary/ drug induced?

… liver biopsy that demonstrates mild

chronic portal inflammation with rare eosinophils and lobular activity including scattered acidophilic bodies.

There is mild macrovesicular steatosis with ballooning degeneration.

In 4 days time the blood tests – T bil 20.2 mg/dl (direct 19.0 mg/dl)AST 756, ALT 385ALP 451Tacrolimus level 18.1ng/ml

Liver biopsy: Trichome – periportal fibrosis.H&E – hepatic cholestasis with feathery degenerationVessels normal.No e/o rejection

What test will clinch the diagnosis? How will you treat?

THANK YOU