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

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 [INR])

Complete blood count with differential

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 

• Morbidity and mortality from liver transplantation are increased in patients with coronary artery disease [31] or those with severe hypoxemia and elevated mean pulmonary artery pressure measurements [32,33]. However, the risk of poor outcomes does not appear to be increased in patients with mild to moderate pulmonary hypertension (pulmonary artery systolic pressure between 40 and 59 mmHg) [34].
• Electrocardiogram
• Cardiac stress testing 
• American College of Cardiology Foundation suggested noninvasive stress testing in liver transplantation candidates with no active cardiac conditions if there are multiple risk factors for coronary artery disease present [35].
• If initial noninvasive testing is abnormal, cardiac catheterization is indicated.
• If clinically significant coronary artery stenoses 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 (CT).

Cancer screening

• abdominal CT scanning or magnetic resonance imaging (MRI)
• 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 (
• Similarly, any required dental extractions should be carried out prior to transplantation.
• 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 (to ensure there are no anatomic barriers to transplantation) and, in the case of HCC, 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 (where available)

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