29920335 Liver Transplantationddd

8/10/2019 29920335 Liver Transplantationddd

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Liver Transplantation

Its the replacement of a diseased liverwith a healthy

liver allograft.

Liver transplantation nowadays is a well accepted

treatment option for end-stage liver disease and acute

liver failure.
http://en.wikipedia.org/wiki/Liverhttp://en.wikipedia.org/wiki/Allografthttp://en.wikipedia.org/wiki/Allografthttp://en.wikipedia.org/wiki/Liver


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Types of L iver Transplant

Whole liver transplant:It involves removal of the recipients entire old diseased liver and

a whole healthy liver from a donor is transplanted.

Split liver transplant.


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Types of L iver Donor

It is possible to transplant livers from the following types of donor:

Living donation:Is a procedure in which a living person donates a portion of hisor her liver to another. The feasibility of LDLT was first

demonstrated in the united states in 1989. The recipient was achild, who received a segment of his mother's liver.Only asmall portion of liver is taken from the donor leaving enoughto keep the donor healthy.

Deceased liver transplantation.

Asystolic liver transplantation.


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I ndications of L iver Transplantation

Basically, all forms of chronic hepatopathy that are irreversible

and potentially curable by transplantation constitute an

indication for liver relacement century.

Only those patients who are considered capable of withstanding

the perioperative period and the intense medical regimen and

follow-up, must be exposed to liver transplantation.

The most common indications are: cirrhosis , alcoholic liver

disease,chronic viral-induced liver disease (hepatitis B, C, D),

chronic drug-induced liver disease, idiopathic autoimmune liverdisease,hepatocellular carcinoma,and primary sclerosing

cholangitis.


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As a general rule, the following complications of ESLDwarrant liver transplantation :

Fulminant hepatic failure:

Acute viral hepatitis (A, B, d,Epstein-Barr virus EBV).

Drug-induced liver toxicity(halothane, gold, Disulfiram,

acetaminophen & others).

Recurrent variceal hemorrhage.

Refractory ascites.
http://emedicine.medscape.com/article/929028-overviewhttp://emedicine.medscape.com/article/170907-overviewhttp://emedicine.medscape.com/article/170907-overviewhttp://emedicine.medscape.com/article/929028-overview


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Complications of ESLD that warrant liver transplantation

(cont,) :

Spontaneous bacterial peritonitis.

Refractory encephalopathy.

Severe jaundice.

Exacerbated synthetic dysfunction.

Sudden deterioration.


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Viral Hepatitis

Hepatitis C: This disease is the first cause of end-stage liver

disease worldwide.

Evaluation requires not only the detection of thosepatients that would benefit from the procedure, butalso the ability to reduce viral load previous to the

procedure, to avoid recurrence.

Some of the risk factors for recurrence are: pre-transplant viral load, advanced age of the receptor,hyperbilirubinemia,advanced-age of the donor.


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Viral Hepatitis (Cont,)

Hepatitis B: Transplantation for Hepatitis B was abandoned due to

recurrence and lack of effective prophylaxis. Recurrence of

HBsAg was associated to liver fibrosis and a loss of the livergraft with a mortality approaching 50%.

This recurrence was dependent on the viral load. Fortunately,

prophylaxis with Hepatitis B immuneglobulin and oral

nucleosides can prevent reinfection of the graft and now post-transplant recurrence is rare.

The use of lamivudine is associated with a recurrence >20%,

that is why most programs use HBIG for at least a year.


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Alcoholic L iver Disease

A prior history of alcoholism is frequent in liver translantcandidates. Alcohol acts as a cofactor in the development of

chronic end stage liver disease.

Obesity, advanced age, and the genetic factors play an

important role. The sickest patients are the most benefitted from liver

transplantation, especially for Child-Pugh B and C patients.

Current recomendations include: Child-Pugh >7, bleeding

secondary to portal hypertension, or an episode of spontaneousperitonitis.

Candidates must receive extensive evaluation for their

addiction, to determine the risk or recurrence.


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Cholestatic Disease

Primary biliary cirrhosis,

Sclerosing cholangitis,

Secondary biliary cirrhosis,

Biliary atresia,

Cystic fibrosis


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Malignant Disease

Liver transplantation constitutes a cure for malignant diseases ofthe liver, because it involves resection of the tumor and thesolution for the main disease of the patient, this because themajority of liver tumors occur in patients with liver cirrhosis.

Unresectable Hepatic Malignancies which needs LT : Hepatocellular carcinoma.

Cholangiocarcinoma (highly selected cases, only under protocol).

Rare nonhepatocellular or bile duct tumors that arise within the

hepatic parenchyma (e.g., epithelioid hemangioendothelioma). Isolated hepatic metastatic disease.

Carcinoid tumor.

Pancreatic islet cell tumor.


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Malignant Disease (Cont,)

Hepatocellular Carcinoma. This tumor frequently coexists with cirrhosis or viral hepatitis.

The actual recommendation is that transplantation should beoffered to those patients with limited tumors (stage I or II, T1

or T2, N0, M0) and that have no evidence of vascular invasionor extrahepatic disease (Liver Transpl 2001; 7: 877-883.)

The prognosis of alpha-fetoprotein is still controversial, eventhough high levels are associated with high recurrence,specially values >1000or 2000.

In general, if patient selection is maintained for patients withtumors


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Malignant Disease (Cont,)

Cholangiocarcinoma. Primary Sclerosing Cholangitis is the main risk factor for the

development of this tumor. Overall survival is 9to 12months.

These tumors reccur frequently, even after resection ,because

often it is a multifocal disease. Liver transplantation has been considered contraindicated in

these patients due to the fact that the overall survival is 20-30%, significantly lower to patients transplanted for cirrhosis.

There are reports of chemoradiotherapy followed by livertransplantation for patients with localized cholangiocarcinomawithout lymph node metastases, that show survival rates of88%at 1year and 82%at 5years.


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Metabolic Diseases

Some of them are:

Wilsons disease,

Hereditary Hemochromatosis,

Alpha-1Antitrypsin:which cause irreversible liver damage and also have systemic

secondary effects.

Tyrosinemia.

The medical team must perform strict evaluation to exclude the

presence of systemic disease in these patients.


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Vascular Disease

Budd-Chiari syndromeor veno-occlusive disease

frquently result in liver failure. All these patients

must be evaluated for hypercoagulable states oroccult malignancy. The majority of these patients

have hematological diseases, such as polycythemia

vera.


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