Liver Transplantation

Liver Transplantation


LIVER TRANSPLANTATION

  • Split liver transplantation: liver of deceased donor split into two (right lobe for an adult and left lobe is usually used for a child)
  • In adult-to-adult living donor liver transplantation, the right lobe of the liver is usually transplanted

 Indications for liver transplantation

Cirrhosis (Most common indication)

Acute fulminant liver failure

Metabolic liver disease

Primary hepatic malignancy

Adults

  • Alcoholic liver disease
  • Viral hepatitis B and C
  • Primary biliary cirrhosis
  • Sclerosing cholangitis
  • Children: Biliary atresia
  • Viral
  • Drug induced
  • (paracetamol)
  • Wilson’s disease
  • Oxalosis
  • α-1-antitrypsin deficiency
  • Viral induced cirrhosis
     
  • v  Cholangiocarcinoma has a high recurrence rate and is not an indication for transplantation
  • v  Other important contraindications: liver metastases, AIDS

 Outcome after liver transplantation

  • Best results following chronic liver disease
  • Following acute liver failure
  • High mortality in the early post-transplant period because of multi-organ failure
  • Those who recover have a very good long term allograft survival
  • Following tumor: very good early outcome, but recurrence later
  • Following viral hepatitis B or C: graft failure, but now it has decreased due to improved anti-viral therapy

 King’s college criteria for orthotopic liver transplantation in acute liver failure

Paracetamol induced

Non-paracetamol induced

  • pH < 7.30 irrespective of grade of encephalopathy OR
  • Prothrombin time(PT) > 100 s
  • +
  • Serum creatinine > 300μmol/L
  • PT > 100 s OR any three of the following
  • PT > 50 s
  • Age < 10 years or > 40 years
  • Etiology: non-A, non-B, halothane or idiosyncratic drug reaction
  • More than 7 days jaundice before encephalopathy
  • Bilirubin > 300μmol/L
 

 

Transplantation

Surgeon

Kidney

Murray (1954)

Liver

Starzl (1963)

Pancreas (Whole organ)

Lillehei and Kelly (1966)

Heart

Bernard (1967)

Lung

Derom (1968)

Pancreatic Islets

Sutherland and Najarin (1974)

Heart-Lung

Reitz and Shumway (1981)

Exam Question

  • In orthotropic liver transplantaion, the bile duct between recipent and donor liver are repaired in end to end fasion or else  Roux en Y choledochojejunostomy.
  • Biliary atresia is an indication for Liver transplantation in children while primary Biliary Cirrhosis, Sclerosing cholangitis and Hematochromatosis an established indications for Liver transplantation in adults

Indication for Liver Transplantation:

Children

  • Biliary atresia
  • Neonatal hepatitis
  • Congenital hepatic fibrosis
  • Alagille’s disease”
  • Byler’s disease
  • a 1 -Antitrypsin deficiency
  • Inherited disorders of metabolism
  • Wilson’s disease
  • Tyrosinemia
  • Glycogen storage diseases
  • Lysosomal storage diseases
  • Protoporphyria
  • Crigler-Najjar disease type I
  • Familial hypercholesterolemia
  • Primary hyperoxaluria type I
  • Hemophilia

Aduts

  • Primary biliary cirrhosis
  • Secondary biliary cirrhosis
  • Primary sclerosing cholangitis
  • Autoimmune hepatitis
  • Carob’s disease’
  • Cryptogenic cirrhosis
  • Chronic hepatitis with cirrhosis
  • Hepatic vein thrombosis
  • Fulminant hepatitis
  • Alcoholic cirrhosis
  • Chronic viral hepatitis
  • Primary hepatocellular malignancies
  • Hepatic adenomas
  • Nonalcoholic steatohepatitis
  • Familial amyloid polyneuropathy
  • “Arteriohepatic dysplasia, with paucity of bile ducts, and congenital malformations, including pulmonary stenosis.
  • “Intrahepatic cholestasis, progressive liver failure, mental and growth retardation
  • `Multiple cystic dilatations of the intrahepatic biliary tree.
  • Hematochromatosis is also an indication for Liver Transplantation
  • ‘Among genetic and metabolic conditions, Hematachroatosis is the most common reason for Liver Transplantation’
  • The first human liver transplant was performed in 1963 by Dr. Thomas Starzl.
  • Caval, portal vein, hepatic artery, and bile duct anastomoses are performed in succession, the last by end-to-end suturing of the donor and recipient common bile ducts or by choledochojejunostomy to a Roux-en- Y loop if the recipient common bile duct cannot be used for reconstruction (e.g., in sclerosing cholangitis).”- Harrison 17/e p

Bile duct anastomosis in orthotopic liver transplant is done by

  1. Choledochocholedochostomy or
  2. Roux-en-Y choledochojejunostomy

Choledochocholedochostomy

  • end to end anastomosis between donor CBD and the recipient CBD
  • used when the recipient bile duct is not diseased
  • preferred method of bile duct anastomoses
  • Roux-en-Y choledochojejunostomy
  • alternative bile duct anastomosis when choledochocholedocostomy is not possible, that is when recipient extrahepatic bile duct is diseased (eg. sclerosing cholangitis), or small or when there is significant recipient donor duct size mismatch.
  • Liver transplantation is indicated for those children and adults, who in the absence of contraindications suffer from severe, irreversible liver disease for which alternative medical or surgical treatments have been exhausted or are unavailable.

Most common indication

  • in children→ Biliary atresia
  • in adults  → Cirrhosis
  • Harrison 17/e writes- “Currently, chronic hepatitis C and alcoholic liver disease are the most common indications for liver transplantation, accounting for over 40% of all adult candidates who undergo the procedure.”

Indications for         ver Transplantation

Adults

Children

Biliary atresia

Primary biliary cirrhosis

Neonatal hepatitis

Secondary biliary cirrhosis

Congenital hepatic fibrosis

Primary sclerosing cholangitis

Alagille’s disease

Autoimmune hepatitis

Byler’s disease

Caroli’s disease

al- antitrypsin deficiency

Cryptogenic cirrhosis

Inherited disorders of metabolism

Chronic hepatitis with cirrhosis

Wilson’s disease

Hepatic vein thrombosis

Tyrosinemia

Fulminant hepatitis

Glycogen storage diseases

Alcoholic cirrhosis

Lysosomal storage diseases

Chronic viral hepatitis

Protoporphyria

Primary hepatocellular malignancies

Crigler-Najjar disease type I

Hepatic adenomas

Familial hypercholesterolemia

Nonalcoholic steatohepatitis

Primary hyperoxaluria type I

Familial amyloid polyneuropathy

Hemophilia

 

 

Contraindications to Liver Transplantation

Absolute

Relative

Uncontrolled extrahepatobiliary infection

Age >70

Active, untreated sepsis

Prior extensive hepatobiliary surgery

Uncorrectable, life-limiting congenital anomalies

Portal vein thrombosis

Active substance or alcohol abuse

Renal failure

Advanced cardiopulmonary disease

Previous extrahepatic malignancy (not

including nonmelanoma skin cancer)

Extrahepatobiliary malignancy (not including

nonmelanoma skin cancer)

Severe obesity

Metastatic malignancy to the liver

Severe malnutrition/wasting

Cholangiocarcinoma

Medical noncompliance

AIDS

HIV seropositivity

Life-threatening systemic diseases

Intrahepatic sepsis

Severe hypoxemia secondary to right-to-left

intrapulmonary shunts (P02 < 50 mmHg)

Severe pulmonary hypertension (mean PA

pressure >35 mmHg)

Uncontrolled psychiatric disorder

Don’t Forget to Solve all the previous Year Question asked on Liver Transplantation

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