Liver Transplantation

INDICATIONS:

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(Hepatitis C)
• Secondary biliary cirrhosis
• Primary sclerosing cholangitis(PSC)
• 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
• Portal hypertensive gastropathy 
• 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.
• Unresectable disease
• Hematochromatosis is also an indication for Liver Transplantation
• ‘Among genetic and metabolic conditions, Hematachroatosis is the most common reason for 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
• Child-Pugh’s classification is used to assess the status of pt. of liver cirrhosis.
• A liver cirrhotic pt. having variceal bleeding or ascites can be controlled by shunt surgery only if he falls in Child­Pugh’s ‘A’ class (or some pts. of B class). Moderate to severe grade liver insufficiency can only be managed by liver transplantation.

CONTRAINDICATIONS:

• Cholangiocarcinoma has a high recurrence rate and is not an indication for transplantation
  
• 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
• Chronic rejection of any solid organ entails cellular injury to endothelial cells, resulting in intimal proliferation, fibrosis, and eventually, ischemic injury to the graft. 
• Immunosuppressive therapy is directed at controlling lymphocyte activity and minimizing cellular rejection.
• King’s college criteria for orthotopic liver transplantation in acute liver failure

•  Donor bile duct with recipient bile duct or Roux en Y choledochojejunostomy is the best way to get bile drainage in donor liver In orthotropic liver transplantation

Exam Question

• Hepatitis C  is the Most common indication for Liver transplantation
• Patient of hepatitis C treated with orthotopic liver transplantation which shows  rising transaminase and bilirubin levels after an year should be given immunosuppresent to prevent T-lymphocyte mediated  rejection injury to hepatic endothelial cells
• Liver transplantation offers the only chance of cure in those with unresectable hepatocellular carcinoma
• Donor bile duct with recipient bile duct or Roux en Y choledochojejunostomy is the best way to get bile drainage in donor liver In orthotropic liver transplantation
• The best available treatment for portal hypertensive gastropathy is Liver transplantation
• Indications of Liver transplantation are Biliary atresia,Sclerosing cholangitis & Cirrhosis
• According to Pugh’s classification moderate to severe hepatic insufficiency is managed by liver transplantation
• Liver transplantation was first done by Starzl 
• In late stage of PSC treatment is liver transplantation