Liver transplantation: Difference between revisions

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Liver transplantation is applicable to any acute or chronic condition resulting in irreversible [[liver]] dysfunction, provided that the recipient does not have other conditions that will preclude a successful [[Organ transplant|transplant]]. Most liver transplants are performed for [[Chronic liver disease|chronic liver diseases]] that lead to irreversible scarring of the [[liver]], or [[cirrhosis]].
Liver transplantation is applicable to any acute or chronic condition resulting in irreversible [[liver]] dysfunction, provided that the recipient does not have other conditions that will preclude a successful [[Organ transplant|transplant]]. Most liver transplants are performed for [[Chronic liver disease|chronic liver diseases]] that lead to irreversible scarring of the [[liver]], or [[cirrhosis]].
* The most common indications for liver transplantation in the United States are:
* The most common indications for liver transplantation in the United States are:
** [[Hepatitis C virus]]  
** [[Hepatitis C]]
** [[Alcoholic liver disease]]  
** [[Alcoholic liver disease]]  
** Idiopathic/autoimmune liver disease  
** Idiopathic or autoimmune liver disease  
** [[Primary biliary cirrhosis]]
** [[Primary biliary cirrhosis]]
** [[Primary sclerosing cholangitis]]  
** [[Primary sclerosing cholangitis]]  
** [[Hepatitis B virus]]  
** [[Hepatitis B]]
** Metabolic [[liver]] disease (eg, inborn errors of [[metabolism]])  
** Metabolic [[liver]] disease (e.g. inborn errors of [[metabolism]])  
** [[Cancer]]  
** [[Carcinoma]]  
** [[Biliary atresia]]
** [[Biliary atresia]]
** [[Acute liver failure]]:  
** [[Acute liver failure]]:  
*** Severe acute [[liver]] injury with impaired synthetic function of the [[liver]](INR ≥1.5) and [[encephalopathy]] in the absence of pre existing [[liver]] disease or cirrhosis
*** Severe acute [[liver]] injury with impaired synthetic function of the [[liver]] (INR ≥1.5) and [[encephalopathy]] in the absence of pre existing [[liver]] disease or cirrhosis
*** Common causes:
*** Common causes:
**** [[Virus|Viral]]
**** [[Virus|Viral]]
**** Drug-induced
**** Drug-induced
*** [[Acute liver failure]] has the highest priority for liver transplantation, and warrants immediate referral to [[Organ transplant|transplantation]] centre  
*** [[Acute liver failure]] has the highest priority for liver transplantation and warrants immediate referral to [[Organ transplant|transplantation]] centre  
*** In the absence of [[Organ transplant|transplantation]], [[Patient|patients]] may recover or die  
*** In the absence of [[Organ transplant|transplantation]], [[Patient|patients]] may recover or die  
** [[Cirrhosis]]:
** [[Cirrhosis]]:
*** Only in cases of complications such as [[portal hypertension]], or compromised [[Liver|hepatic]] function (marker for impaired survival)
*** Cirrhosis is an indication only in the presence of complications such as [[portal hypertension]] or compromised [[Liver|hepatic]] function (marker for impaired survival)
*** Signs of decompensated [[cirrhosis]] include:
*** Signs of decompensated [[cirrhosis]] include:
**** [[Ascites]]
**** [[Ascites]]
**** [[Encephalopathy]]
**** [[Encephalopathy]]
**** [[Esophageal varices|Variceal]] [[Bleeding|hemorrhage]]
**** [[Esophageal varices|Variceal hemorrhage]]
**** [[Hepatorenal syndrome]]
**** [[Hepatorenal syndrome]]
*** Transplantation evaluation is commenced in patients with [[MELD Score|MELD score]] >10:
*** Transplantation evaluation is commenced in patients with [[MELD Score|MELD score]] >10:
*** This gives the [[patient]] time for pretransplantation evaluation
*** This gives the [[patient]] time for pre transplantation evaluation (as a [[MELD Score|MELD score]] ≥15 is an indication for transplantation)
*** [[Patient]] has ample time for education, before the development of symptoms of [[hepatic encephalopathy]] that may impair cognition  
*** [[Patient]] has ample time for education, before the development of symptoms of [[hepatic encephalopathy]] that may impair cognition  
*** [[Patient|Patients]] with [[cirrhosis]] are candidates for liver transplantation in the following scenarios:
*** [[Patient|Patients]] with [[cirrhosis]] are candidates for liver transplantation in the following scenarios:
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**** Cases of Child B cirrhosis with [[portal hypertension]] but a low [[MELD Score|MELD score]]  
**** Cases of Child B cirrhosis with [[portal hypertension]] but a low [[MELD Score|MELD score]]  
**** [[MELD Score|MELD]] exception points are given to patients with pathologies that may impair survival without impacting the [[MELD Score|MELD score]] such as:
**** [[MELD Score|MELD]] exception points are given to patients with pathologies that may impair survival without impacting the [[MELD Score|MELD score]] such as:
***** [[Cancer]]: [[Hepatocellular carcinoma|HCC]], [[Cholangiocarcinoma|Hilar cholangiocarcinoma]]  
***** [[Cancer]]:  
****** [[Hepatocellular carcinoma|HCC]]  
****** [[Cholangiocarcinoma|Hilar cholangiocarcinoma]]  
***** Complications of [[cirrhosis]]:
***** Complications of [[cirrhosis]]:
****** [[Hepatopulmonary syndrome]]
****** [[Hepatopulmonary syndrome]]
Line 66: Line 68:
****** [[Hepatic artery]] [[thrombosis]]  
****** [[Hepatic artery]] [[thrombosis]]  
***** [[Cystic fibrosis]]:
***** [[Cystic fibrosis]]:
****** [[Primary hyperoxaluria]]
***** [[Primary hyperoxaluria]]
****** [[Familial amyloid polyneuropathy]]
***** [[Familial amyloid polyneuropathy]]
***** Other conditions that may also be indications for transplantation that do not qualify for [[MELD Score|MELD]] or [[MELD Score|MELD]] exception points include:
***** Other indications for transplantation that do not qualify for [[MELD Score|MELD]] or [[MELD Score|MELD]] exception points include:
****** Intractable [[Itch|pruritus]] in case of [[primary biliary cirrhosis]]
****** Intractable [[Itch|pruritus]] in case of [[primary biliary cirrhosis]]
****** Refractory [[Esophageal varices|variceal]] [[Bleeding|hemorrhage]]
****** Refractory [[Esophageal varices|variceal hemorrhage]]
****** Refractory [[ascites]]
****** Refractory [[ascites]]
****** Refractory [[hepatic encephalopathy]]
****** Refractory [[hepatic encephalopathy]]
****** [[Portal hypertensive gastropathy]] leading to chronic [[blood]] loss
****** [[Portal hypertensive gastropathy]] leading to chronic [[blood]] loss
****** Recurrent [[cholangitis]] in patients with [[Primary sclerosing cholangitis|PSC]]  
****** Recurrent [[cholangitis]] in patients with [[Primary sclerosing cholangitis|PSC]]  
****** [[Hepatocellular carcinoma|HCC]]: a single lesion ≤5 cm or up to three separate [[Lesion|lesions]] all <3 cm, no evidence of gross [[vascular]] invasion, and no regional [[Lymph node|nodal]] or distant [[metastasis]].
****** [[Hepatocellular carcinoma|HCC]]:  
******* A single lesion ≤5 cm or up to three separate [[Lesion|lesions]] all <3 cm
******* No evidence of gross [[vascular]] invasion, and
******* No regional [[Lymph node|nodal]] or distant [[metastasis]]
****** [[Neuroendocrine tumors]] that have metastasized to the [[liver]]  
****** [[Neuroendocrine tumors]] that have metastasized to the [[liver]]  
****** [[Hepatocellular carcinoma|HCC]] (including fibrolamellar [[Hepatocellular carcinoma|HCC]])  
****** [[Hepatocellular carcinoma|HCC]] (including fibrolamellar [[Hepatocellular carcinoma|HCC]])  
****** Large [[Hepatocellular adenoma|hepatic adenomas]]  
****** Large [[Hepatocellular adenoma|hepatic adenomas]]  
****** Epithelioid hemangioendothelioma  
****** [[Hemangioendothelioma|Epithelioid hemangioendothelioma]]
****** [[Metabolic disorder|Metabolic disorders]]:  
****** [[Metabolic disorder|Metabolic disorders]]:  
******* [[Alpha 1-antitrypsin deficiency|Alpha-1 antitrypsin deficiency]]
******* [[Alpha 1-antitrypsin deficiency|Alpha-1 antitrypsin deficiency]]
******* [[Wilson's disease|Wilson disease]]
******* [[Wilson's disease|Wilson disease]]
******* [[Acute intermittent porphyria]]
******* [[Acute intermittent porphyria]]
******* [[Glycogen storage disease]] (type I and type IV)  
******* [[Glycogen storage disease]] ([[Glycogen storage disease type I|type I]] and type IV)  
******* [[Tyrosinemia]]  
******* [[Tyrosinemia]]  
******* [[Hemochromatosis]]
******* [[Hemochromatosis]]

Revision as of 19:12, 25 January 2018


WikiDoc Resources for Liver transplantation

Articles

Most recent articles on Liver transplantation

Most cited articles on Liver transplantation

Review articles on Liver transplantation

Articles on Liver transplantation in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Liver transplantation

Images of Liver transplantation

Photos of Liver transplantation

Podcasts & MP3s on Liver transplantation

Videos on Liver transplantation

Evidence Based Medicine

Cochrane Collaboration on Liver transplantation

Bandolier on Liver transplantation

TRIP on Liver transplantation

Clinical Trials

Ongoing Trials on Liver transplantation at Clinical Trials.gov

Trial results on Liver transplantation

Clinical Trials on Liver transplantation at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Liver transplantation

NICE Guidance on Liver transplantation

NHS PRODIGY Guidance

FDA on Liver transplantation

CDC on Liver transplantation

Books

Books on Liver transplantation

News

Liver transplantation in the news

Be alerted to news on Liver transplantation

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Commentary

Blogs on Liver transplantation

Definitions

Definitions of Liver transplantation

Patient Resources / Community

Patient resources on Liver transplantation

Discussion groups on Liver transplantation

Patient Handouts on Liver transplantation

Directions to Hospitals Treating Liver transplantation

Risk calculators and risk factors for Liver transplantation

Healthcare Provider Resources

Symptoms of Liver transplantation

Causes & Risk Factors for Liver transplantation

Diagnostic studies for Liver transplantation

Treatment of Liver transplantation

Continuing Medical Education (CME)

CME Programs on Liver transplantation

International

Liver transplantation en Espanol

Liver transplantation en Francais

Business

Liver transplantation in the Marketplace

Patents on Liver transplantation

Experimental / Informatics

List of terms related to Liver transplantation

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]


Overview

When a healthy liver allograft is used in place of damaged liver tissue, it is termed as liver transplantation. Thomas Starzl used dogs as the first animals for research on liver transplantation in the 1960s. In 1963, the first liver transplant in humans was attempted by Dr. Thomas Starzl of Colorado, United States. The most common indications for liver transplantation in the United States are hepatitis C virus, alcoholic liver disease, autoimmune liver disease, primary biliary cirrhosis, primary sclerosing cholangitis, hepatitis B virus, liver disease due to inborn errors of metabolism, cancer, biliary atresia and acute liver failure. On the other hand, absolute contraindications to liver transplantation include hepatocellular carcinoma with metastasis, acute liver failure with persistently elevated intracranial pressure ICP >50mmHg, hemangiosarcoma, hilar cholangiocarcinoma, sepsis, and active alcohol or drug abuse. Pretransplant measures such as cardiopulmonary evaluation, screening for occult cancer, infection, and psychosocial evaluation must be performed prior to surgery. The most commonly used technique employed in patients is orthotopic transplantation. This involves removal of the native liver and placement of the donor organ in the same anatomic location as the original liver. Immunosuppressive agents used after transplantation include cyclosporine, everolimus, mycophenolate, corticosteroids, azathioprine, and tacrolimus in different combinations. The most common causes of death in liver transplant patients are infection, malignancy, and rejection. It is necessary to monitor patients for signs of complications and treat them effectively.

Liver Transplantation

History

  • In the 1960s, Thomas Starzl used dogs as the first animals for research on liver transplantation in Boston and Chicago.
  • In 1963, the first liver transplant in humans was attempted by a surgical team led by Dr. Thomas Starzl of Denver, Colorado, United States.[1]
  • Dr. Starzl performed many additional transplants until he was successful in 1967 with the first one-year survival post-transplantation.
  • In 1970, the regimen for immunosuppressive therapy following transplant was introduced, but azathioprine and steroids did not improve survival rates of patients.
  • In the 1980s, with the introduction of cyclosporine by Sir Roy Calne, there was an improvement in rejection rates.
  • In 1983, liver transplantation was no longer an experimental modality, but a clinically acceptable form of therapy for both adult and pediatric patients with appropriate indications.
  • In 1986, the introduction of monoclonal antibodies such as muromonab-CD3 [OKT3] further contributed to improvement of quality of immunosuppressive therapy used in patients, with significant decline in rejection rates.
  • In 1988, University of Wisconsin (UW) solution was developed, which ensured a smooth surgery and longer preservation period.
  • In 1992, the concept of xenotransplantation and cloning techniques were introduced by Starzl.
  • In 1999, approximately 5000 procedures were carried out, in contrast to 100 which had been performed a decade earlier.
  • Recently, the introduction of newer immunosuppressive agents such as IL-2 receptor blockers and tacrolimus, have drastically increased patient survival rates to 1 and 5-year rates of approximately 85 and 70 percent respectively.[2]
  • Liver transplantation is now performed at over one hundred centers in the USA, as well as numerous centers in Europe and elsewhere. One year patient survival is 85-90%, and outcomes continue to improve, although liver transplantation remains a formidable procedure with frequent complications.
  • Unfortunately, the supply of liver allografts from non-living donors is far short of the number of potential recipients, a reality that has spurred the development of living donor liver transplantation.
  • In December 2016, 147,128 liver transplants were performed in the US as compared to 7217 in 1998 based on data from the United Organ Sharing (UNOS) network.

Indications

Liver transplantation is applicable to any acute or chronic condition resulting in irreversible liver dysfunction, provided that the recipient does not have other conditions that will preclude a successful transplant. Most liver transplants are performed for chronic liver diseases that lead to irreversible scarring of the liver, or cirrhosis.

Contraindications

Absolute contraindications: [3]

Relative contraindications:[3][4][5][6][7][8][9][10][11][12][13]

Patient evaluation prior to transplantation

Pre-transplant patient evaluation has the following objectives:

The following evaluations are required:

Laboratory investigations

Laboratory essential for patient evaluation prior to liver transplantation are as follows:

Cardiopulmonary evaluation

This helps in the evaluation of the patient for:[3][14]

Cancer screening

HCC: For tumor staging, investigations include:

Upper GI endoscopy

Purpose: detection of varices

Bone densitometry

Vaccinations and evaluation for infection

Psychosocial evaluation and education

Techniques

{{#ev:youtube|v=hquWw4rRHh8}}

Orthotopic Liver Transplantation

Immunosuppressive management

Results

Living donor transplantation

  • Living donor liver transplantation (LDLT) has emerged in recent decades as a critical surgical option for patients with end stage liver disease, such as cirrhosis and/or hepatocellular carcinoma often attributable to one or more of the following:[29][42][43]
  • The concept of LDLT is based on:
    • Remarkable regenerative capacities of the human liver
    • Widespread shortage of cadaveric livers for patients awaiting transplant
  • In LDLT, a piece of healthy liver is surgically removed from a living person and transplanted into a recipient, immediately after the recipient’s diseased liver has been entirely removed.
  • Historically, LDLT was used as a means for parents of children with severe liver disease to donate a portion of their healthy liver to replace the damaged liver of their children.
  • In 1986, the first successful LDLT was performed at the Universidade de São Paulo (USP) Medical School, by Dr. Silvano Raia.
  • More technically demanding than standard, cadaveric donor liver transplantation
  • Has faced several ethical problems[44]

Complications of Liver Transplantation

  • Immediate postoperative complications of liver transplantation include:
  • The most common causes of death in liver transplant patients are as follows:
  • To monitor the patient for complications, the following investigations are used:

Laboratory investigations

Imaging studies

Acute and chronic graft rejection

Acute graft rejection:[45]

Chronic graft rejection:

Infection

Infections may be classified based on the duration post transplantation.

  • After the first 6 months, risk of infection in transplant patients is equal to that of the population.

Cytomegalovirus (CMV)

  • Most common viral infection (affects 25-85% patients)
  • Occurrence: Between posttransplant months 1 and 3
  • Infection may be:
    • Primary
    • Reactivated

Pneumocystis carinii pneumonia (PCP)

Other less common organisms causing infection include:

External Links


References

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  2. Kanwal F, Dulai GS, Spiegel BM, Yee HF, Gralnek IM (2005). "A comparison of liver transplantation outcomes in the pre- vs. post-MELD eras". Aliment. Pharmacol. Ther. 21 (2): 169–77. doi:10.1111/j.1365-2036.2005.02321.x. PMID 15679767.
  3. 3.0 3.1 3.2 3.3 3.4 Martin P, DiMartini A, Feng S, Brown R, Fallon M (2014). "Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation". Hepatology. 59 (3): 1144–65. PMID 24716201.
  4. Mathurin P, Moreno C, Samuel D, Dumortier J, Salleron J, Durand F, Castel H, Duhamel A, Pageaux GP, Leroy V, Dharancy S, Louvet A, Boleslawski E, Lucidi V, Gustot T, Francoz C, Letoublon C, Castaing D, Belghiti J, Donckier V, Pruvot FR, Duclos-Vallée JC (2011). "Early liver transplantation for severe alcoholic hepatitis". N. Engl. J. Med. 365 (19): 1790–800. doi:10.1056/NEJMoa1105703. PMID 22070476.
  5. Cooper C, Kanters S, Klein M, Chaudhury P, Marotta P, Wong P, Kneteman N, Mills EJ (2011). "Liver transplant outcomes in HIV-infected patients: a systematic review and meta-analysis with synthetic cohort". AIDS. 25 (6): 777–86. doi:10.1097/QAD.0b013e328344febb. PMID 21412058.
  6. Mindikoglu AL, Regev A, Magder LS (2008). "Impact of human immunodeficiency virus on survival after liver transplantation: analysis of United Network for Organ Sharing database". Transplantation. 85 (3): 359–68. doi:10.1097/TP.0b013e3181605fda. PMID 18301332.
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  9. Prachalias AA, Pozniak A, Taylor C, Srinivasan P, Muiesan P, Wendon J, Cramp M, Williams R, O'Grady J, Rela M, Heaton ND (2001). "Liver transplantation in adults coinfected with HIV". Transplantation. 72 (10): 1684–8. PMID 11726833.
  10. Wreghitt T (2001). "Liver Transplantation in Adults Coinfected With HIV. Transplantation 2001; 72: 1684". Transplantation. 72 (10): 1594–5. PMID 11726816.
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  14. Zoghbi GJ, Patel AD, Ershadi RE, Heo J, Bynon JS, Iskandrian AE (2003). "Usefulness of preoperative stress perfusion imaging in predicting prognosis after liver transplantation". Am. J. Cardiol. 92 (9): 1066–71. PMID 14583357.
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  17. Colle IO, Moreau R, Godinho E, Belghiti J, Ettori F, Cohen-Solal A, Mal H, Bernuau J, Marty J, Lebrec D, Valla D, Durand F (2003). "Diagnosis of portopulmonary hypertension in candidates for liver transplantation: a prospective study". Hepatology. 37 (2): 401–9. doi:10.1053/jhep.2003.50060. PMID 12540791.
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