liver transplantation
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Introduction
Cadaveric & living donor liver* transplants.
* Transplant of left lateral segment, left lobe or right lobe of the liver obtained from a living donor (> 90% of donors are relatives)
Indications
- patients with complications from end-stage liver disease
- hepatic encephalopathy
- hepatorenal syndrome
- esophageal varices
- variceal hemorrhage
- uncontrolled ascites, complications from ascites
- spontaneous bacterial peritonitis
- unresponsive coagulopathy
- profound fatigue
- hepatic osteodystrophy
- recurring bacterial cholangitis
- diseases
- fulminant hepatic failure
- drug or toxin-induced
- viral hepatitis
- end-stage liver disease
- selected malignant disorders
- hepatocellular carcinoma
- cholangiocarcinoma (clinical protocols)
- fulminant hepatic failure
* Early referral
# alcoholic cirrhosis has surpassed hepatitis C infection as most common indication for liver transplantation[8]
Contraindications
- AIDS, at some transplantation centers[1]
- continuing alcohol or drug abuse
- severe, uncontrolled cardiac or pulmonary disease
- most extra-hepatic malignancies
- some islet cell tumors & carcinoid tumors can be exceptions
- advanced hepatocellular carcinoma
- cholangiocarcinoma (exception of clinical protocols)
- uncontrolled sepsis
- morbid obesity
- hepatocellular carcinoma exceeding Milan criteria limits
- severe psychiatric disorder
- inability to comply with medical management
- lack of social support
- advanced age
Advanced age is a relative contraindication[1]
Laboratory
- MELD score predicts prognosis, urgent need for transplantation
- MELD score >= 15 indication for liver transplantation[1]
Complications
- systemic hypertension
- obesity
- azotemia from immunosuppressive agents
- infection
- allograft rejection
- recurrence of original disease
- for example: hepatitis C
- malignancies
- squamous cell carcinomas
- adenocarcinomas
- lymphoproliferative disorders
- lung cancer[6]
Management
- many patients deteriorate or die while on waiting lists
- transplantation centers monitor intracranial pressure for cerebral edema due to hepatic encephalopathy[1]
- post liver transplant
- prophylaxis for:
- immunosuppression for transplant rejection
- use of tacrolimus associated with improved outcomes
- consider early taper of tacrolimus to decrease risk of de novo cancer[9]
- avoid excessive sun exposure; use sun screen (risk of skin cancer)
- cancer screening
More general terms
Additional terms
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018.
- ↑ Journal Watch 21(20):62, 2001 Miller CM et al, One hundred nine living donor liver transplants in adults and children: a single-center experience. Ann Surg 234:301, 2001 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11524583
- ↑ Engels EA et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA 2011 Nov 2; 306:1891. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22045767
- ↑ Ahmed A, Keeffe EB. Current indications and contraindications for liver transplantation. Clin Liver Dis. 2007 May;11(2):227-47. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17606204
- ↑ Moini M, Mistry P, Schilsky ML. Liver transplantation for inherited metabolic disorders of the liver. Curr Opin Organ Transplant. 2010 Jun;15(3):269-76 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20489626
- ↑ 6.0 6.1 Dutkowski P et al. Challenges to liver transplantation and strategies to improve outcomes. Gastroenterology 2015 Feb; 148:307 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25224524
- ↑ Sharma S, Gurakar A, Jabbour N. Avoiding pitfalls: what an endoscopist should know in liver transplantation--part 1. Dig Dis Sci. 2008 Jul;53(7):1757-73. Epub 2007 Nov 9. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17990105
Sharma S, Gurakar A, Camci C, Jabbour N. Avoiding pitfalls: what an endoscopist should know in liver transplantation--part II. Dig Dis Sci. 2009 Jul;54(7):1386-402. Epub 2008 Dec 17. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19085103 - ↑ 8.0 8.1 Cholankeril G, Ahmed A. Alcoholic liver disease replaces hepatitis C virus infection as the leading indication for liver transplantation in the United States. Clin Gastroenterol Hepatol 2017 Nov 30; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29199144 <Internet> http://linkinghub.elsevier.com/retrieve/pii/S1542356517314180
- ↑ 9.0 9.1 European Association for the Study of the Liver EASL Clinical Practice Guidelines: Management of alcohol- related liver disease. J Hepatol. 2018 Apr 5. pii: S0168-8278(18)30214-9 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29628280 https://www.journal-of-hepatology.eu/article/S0168-8278(18)30214-9/fulltext
- ↑ Krowka MJ, Fallon MB, Kawut SM et al International Liver Transplant Society Practice Guidelines: Diagnosis and Management of Hepatopulmonary Syndrome and Portopulmonary Hypertension. Transplantation. 2016 Jul;100(7):1440-52. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27326810
- ↑ National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Liver Transplantat https://www.niddk.nih.gov/health-information/liver-disease/liver-transplant