Liver transplantation pre-surgical management

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

Liver trasnsplantation Microchapters
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Patient Information
Overview
Historical Perspective
Indications
Pre-surgical management
Choice of donor
Epidemiology and Demographics
Techniques
Complications
Acute rejection
Immune therapy
Post-surgical infection
Prognosis

Overview

Pre-surgical management for liver transplantation includes laboratory testings such as ABO-Rh blood typing, Liver biochemical and function tests (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, bilirubin, international normalized ratio, Complete blood count, Creatinine clearance,serum sodium, serum alpha-fetoprotein, and Calcium and vitamin D levels. Cardiological testings include electrocardiogram, cardiac stress testing, Echocardiography , Pulse oximetry and ABG.

Liver transplantation pre-surgical management

Laboratory testing 

• ABO-Rh blood typing
• Liver biochemical and function tests (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, bilirubin, international normalized ratio
• Complete blood count
• Creatinine clearance
• Serum sodium
• Serum alpha-fetoprotein
• Calcium and vitamin D levels
• Serologies for cytomegalovirus, Epstein-Barr virus, varicella, human immunodeficiency virus, hepatitis A, hepatitis B, hepatitis C, rapid plasma reagin
• Urinalysis
• Urine drug screen

Cardiopulmonary evaluation 

• Electrocardiogram
• Cardiac stress testing 
• Noninvasive stress testing is suggested in liver transplantation candidates with no active cardiac conditions if there are multiple risk factors for coronary artery disease present.
• If initial noninvasive testing is abnormal, cardiac catheterization is indicated.
• If clinically significant coronary artery stenosis are present, patients should be evaluated for revascularization prior to transplantation.
• Echocardiography 
•  We obtain transthoracic contrast-enhanced echocardiography to look for evidence of valvular heart disease or portopulmonary hypertension.
• Pulse oximetry and ABG
• Patients should undergo pulse oximetry to screen for hepatopulmonary syndrome.
• Patients should have a blood gas obtained while breathing room air and undergo transthoracic contrast-enhanced echocardiography.
• Testing to rule out other causes includes a chest radiograph, pulmonary function tests, and chest computed tomography.

Cancer screening

• Abdominal CT scanning or magnetic resonance imaging.
• Screening for cervical cancer, breast cancer, and prostate cancer should be obtained when indicated.
• Skin testing or interferon-gamma release assay for tuberculosis
• Treatment may be initiated prior to transplantation or deferred until after transplantation, depending on the clinical assessment of the patient.
• Patients from endemic areas should be screened for coccidiomycosis or strongyloides.
• Several vaccinations are recommended prior to liver transplantation including hepatitis A, hepatitis B, pneumococcus, influenza, diphtheria, pertussis, and tetanus.

Hepatic imaging and HCC staging 

• Hepatic imaging should be obtained to assess the vasculature and for tumor staging.
• This is typically done with multiphase contrast-enhanced CT scanning or contrast-enhanced MRI.
• If cross-sectional imaging cannot be obtained, the hepatic vasculature can be assessed with transabdominal ultrasonography with Doppler imaging or contrast-enhanced ultrasonography.

Upper endoscopy 

• Upper endoscopy should be performed in patients with cirrhosis or portal hypertension to evaluate for varices.

Bone density testing 

• Patients should be screened for osteoporosis with bone density testing.
• If osteoporosis is present, treatment should be initiated prior to transplantation.
• Oral bisphosphonates should be used with caution in patients with esophageal varices.