Liver transplantation pre-surgical management: Difference between revisions
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=== '''Laboratory testing''' === | === '''Laboratory testing''' === | ||
ABO-Rh blood typing | * ABO-Rh blood typing | ||
* Liver biochemical and function tests (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, bilirubin, international normalized ratio [INR]) | |||
Liver biochemical and function tests (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, bilirubin, international normalized ratio [INR]) | * Complete blood count with differential | ||
* Creatinine clearance | |||
Complete blood count with differential | * Serum sodium | ||
* Serum alpha-fetoprotein | |||
Creatinine clearance | * Calcium and vitamin D levels | ||
* Serologies for cytomegalovirus, Epstein-Barr virus, varicella, human immunodeficiency virus, hepatitis A, hepatitis B, hepatitis C, rapid plasma reagin | |||
Serum sodium | * Urinalysis | ||
* Urine drug screen | |||
=== '''Cardiopulmonary evaluation''' === | === '''Cardiopulmonary evaluation''' === | ||
* Morbidity and mortality from liver transplantation are increased in patients with coronary artery disease | * Morbidity and mortality from liver transplantation are increased in patients with coronary artery disease or those with severe hypoxemia and elevated mean pulmonary artery pressure measurements.<ref name="pmid14762853">{{cite journal| author=Krowka MJ, Mandell MS, Ramsay MA, Kawut SM, Fallon MB, Manzarbeitia C et al.| title=Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database. | journal=Liver Transpl | year= 2004 | volume= 10 | issue= 2 | pages= 174-82 | pmid=14762853 | doi=10.1002/lt.20016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14762853 }}</ref> | ||
* 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).<ref name="pmid9346688">{{cite journal| author=Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y| title=Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation. | journal=Liver Transpl Surg | year= 1996 | volume= 2 | issue= 6 | pages= 426-30 | pmid=9346688 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9346688 }}</ref> | |||
* Electrocardiogram | * Electrocardiogram | ||
* '''Cardiac stress testing''' | * '''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 | * 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.<ref name="pmid22763103">{{cite journal| author=Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL et al.| title=Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. | journal=J Am Coll Cardiol | year= 2012 | volume= 60 | issue= 5 | pages= 434-80 | pmid=22763103 | doi=10.1016/j.jacc.2012.05.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22763103 }}</ref> | ||
* If initial noninvasive testing is abnormal, cardiac catheterization is indicated. | * 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. | * If clinically significant coronary artery stenoses are present, patients should be evaluated for revascularization prior to transplantation. | ||
| Line 41: | Line 33: | ||
* Patients should undergo pulse oximetry to screen for hepatopulmonary syndrome. | * 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. | * 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 | * Testing to rule out other causes includes a chest radiograph, pulmonary function tests, and chest computed tomography. | ||
=== '''Cancer screening''' === | === '''Cancer screening''' === | ||
* | * Abdominal CT scanning or magnetic resonance imaging | ||
* Screening for cervical cancer, breast cancer, and prostate cancer should be obtained when indicated | * Screening for cervical cancer, breast cancer, and prostate cancer should be obtained when indicated | ||
* skin testing or interferon-gamma release assay for tuberculosis | * 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 | * 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. | * Similarly, any required dental extractions should be carried out prior to transplantation. | ||
* Patients from endemic areas should be screened for coccidiomycosis or strongyloides. | * Patients from endemic areas should be screened for coccidiomycosis or strongyloides. | ||
| Line 53: | Line 45: | ||
==== '''Hepatic imaging and HCC staging''' ==== | ==== '''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 | * 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 | |||
==== '''Upper endoscopy''' ==== | ==== '''Upper endoscopy''' ==== | ||
Upper endoscopy should be performed in patients with cirrhosis or portal hypertension to evaluate for varices. | * Upper endoscopy should be performed in patients with cirrhosis or portal hypertension to evaluate for varices. | ||
==== '''Bone density testing''' ==== | ==== '''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 | * 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 | |||
Revision as of 01:55, 17 December 2017
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
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Liver trasnsplantation Microchapters |
Overview
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 or those with severe hypoxemia and elevated mean pulmonary artery pressure measurements.[1]
- 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).[2]
- 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.[3]
- 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.
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.
- 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
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
- ↑ Krowka MJ, Mandell MS, Ramsay MA, Kawut SM, Fallon MB, Manzarbeitia C; et al. (2004). "Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database". Liver Transpl. 10 (2): 174–82. doi:10.1002/lt.20016. PMID 14762853.
- ↑ Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y (1996). "Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation". Liver Transpl Surg. 2 (6): 426–30. PMID 9346688.
- ↑ Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL; et al. (2012). "Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation". J Am Coll Cardiol. 60 (5): 434–80. doi:10.1016/j.jacc.2012.05.008. PMID 22763103.