Transcript Cardiothoracic Surgery Morbidity and Mortality - Dartmouth

Liver Transplantation
Philip Goodney, MD
June 22, 2005
Format
• Question and Answer (multiple choice)
• Review of reading in Sabiston Chapter
List ‘em
• Name the most common indications for liver
transplantation, in order, for adults and
children.
List ‘em
TABLE 27-1 -- Indications for Liver Transplantation
Adults
Noncholestatic cirrhosis
Children
Biliary atresia
58
Viral hepatitis B and C
Inborn errors
11
Alcoholic *
Cholestatic
9
Cryptogenic
PSC
Cholestatic
65
14
Primary biliary
cirrhosis
PSC
Autoimmune
5
Malignant neoplasm
2
Miscellaneous
14
Alagille’s sy
Autoimmune
Viral hepatitis
4
Miscellaneous
16
2
True or False
• The number of cadaveric donors has changed
dramatically over the last 13 years
True or False
• The number of cadaveric donors has changed
dramatically over the last 13 years
• False
Question
• What two kinds of information are used in the
Child-Turcote-Pugh Score of Severity of
Liver Disease ?
Question
• What two kinds of information are used in the
Child-Turcote-Pugh Score of Severity of
Liver Disease ?
– Clinical symptoms (encepholopathy, ascites,
PSC/PBC)
– Lab data (albumin, PT)
Question
• What three variables does the MELD score
take into account?
Question
• What three variables does the MELD score
take into account?
– Bilirubin
– INR
– Creatinine
Question:
• If you were going to Foxwoods, and you had
to bet on a patient’s survival with end-stage
liver disease, who would you rather rode
shotgun: Mr. MELD or Mr. CTP? Why?
Question:
• Mr. MELD, baby 
• (MELD = model of end-stage liver disease)
TABLE 27-3 -- Concordance with 3-Month Mortality: MELD and CTP
Concordance
95% Confidence
Interval
Model for End-Stage Liver Disease
(MELD)
0.88
0.85, 0.90
Child-Turcote-Pugh (CTP)
0.79
0.75, 0.83
Score
Question
• Which of the following are absolute
contraindications to liver transplantation?
–
–
–
–
–
Active sepsis
Extrahepatic malignancy
HIV
Portal vein thrombosis
HCC
Question
• What type of virus is hepatitis B?
Question
• What type of virus is hepatitis B?
• hepandnavirus
Question
• Which of the following are absolute
contraindications to liver transplantation?
–
–
–
–
–
Active sepsis
Extrahepatic malignancy
HIV
Portal vein thrombosis
HCC
Question
• You’ve had chronic hepatitis B for 25-30 years
and you have now begun to show clinical
symptoms of cirrhosis. Imaging demonstrates
a nodular liver with a mass. What is the likely
diagnosis?
Question
• You’ve had chronic hepatitis B for 25-30 years
and you have now begun to show clinical
symptoms of cirrhosis. Imaging demonstrates
a nodular liver with a mass. What is the likely
diagnosis?
• Hepatocellular carcinoma
Question:
• You go back in time 25 years. You wish to be
treated for your HBV. What is the treatment,
and what is the chance that it may lead to
remission?
Question:
• You go back in time 25 years. You wish to be
treated for your HBV. What is the treatment,
and what is the chance that it may lead to
remission?
• Interferon alpha 2b. 40% remission rate
Question:
• Because you are a big baseball star, you get a
liver transplant even though you have chronic
HBV. What are the treatments to keep you
from infecting your graft?
Question:
• Because you are a big baseball star, you get a
liver transplant even though you have chronic
HBV. What are the treatments to keep you
from infecting your graft?
• High titer G +/- lamivudine
Question
• What infection can accelerrate the cirrhosis
that accompanies ETOH abuse?
Question
• What infection can accelerrate the cirrhosis
that accompanies ETOH abuse?
• HCV
Match ‘em
• PSC
• PBC
•
•
•
•
•
•
•
•
•
Pruritis
Jaundice
Elevated Alk phos
Damage to large bile ducts
Damage to small
intrahepatic ducts
Associated with IBD
Associated with
cholangiocarcinoma
Liver failure
Does well with
transplantation
Match ‘em
•
•
•
•
•
•
•
•
•
Pruritis (both)
Jaundice (both)
Elevated Alk phos (both)
Damage to large bile ducts (PSC)
Damage to small intrahepatic ducts (PBC)
Associated with IBD (PSC)
Associated with cholangiocarcinoma (PSC)
Liver failure (both)
Does well with transplantation (both)
Question
• What 3 factors make it likely that a patient
with HCC will benefit from liver
transplantation?
Question
• What 3 factors make it likely that a patient
with HCC will benefit from liver
transplantation?
•
•
•
•
Low grade tumor
Tumor <5cm
Limited multifocality of tumor
(No macrovascular invasion too)
Question
• What are the characteristics of a marginal /
expanded criteria donor?
Question
• What are the characteristics of a marginal /
expanded criteria donor?
– Older donors (age up to 75!!)
– Hep c +, hep B core +
– Steatosis of liver graft
Question
• What variables are considered when matching
donor and recipient?
Question
• What variables are considered when matching
donor and recipient?
• ABO (can be crossed if urgent)
• Size
• Age (for pedi patients)
True or False
• Dr. Dow will think it is really cool if you take
the hepatic veins off the donor’s cava when
recovering your first liver in our new
transplant program.
True or False
• Dr. Dow will think it is really cool if you take
the hepatic veins off the donor’s cava when
recovering your first liver in our new
transplant program.
• False
Road Map
• Describe the purpose and path of circulation of
veno-venous bypass
Road Map
• Describe the purpose and path of circulation of
veno-venous bypass
– Inflow: portal and femoral veins
– Outflow : IJ
•
•
•
•
2.5 L/min
Control of body temperature (Rewarming)
Cvvh during the case
? If it matters
Question
• How long does it take for a recipient of a split
liver Right lobe to achieve a “standard” liver
mass equivalent?
Question
• How long does it take for a recipient of a split
liver Right lobe to achieve a “standard” liver
mass equivalent?
• Only 1 month!!
Question
• Name the possible operative complications
that can occur in liver transplantation.
Question
• Name the possible operative complications
that can occur in liver transplantation.
–
–
–
–
Bleeding (page me)
Portal vein thrmobosis (may use collaterals)
Hepatic artery reconstruction
Primary nonfunction
Question
• How common is primary non-function?
Question
• How common is primary non-function?
– 2-3%
– Hemodynamic instability
– MSOF
– Encephalopaty
– Rx: retransplantation
Question
• How is a definitive diagnosis of acute rejection
made? How is it treated?
Question
• How is a definitive diagnosis of acute rejection
made? How is it treated?
• Liver bx -- demonstrate the presence of periportal
lymphocytic infiltrate that extends into the liver
parenchyma, as well as the invasion of inflammatory
cells into the vascular endothelium.
• --corticosteroids. More potent monoclonal or
polyclonal anti–T-cell antibodies are effective against
corticosteroid-resistant rejection, leading to the
reversal of the acute episode in more than 90% of the
recipients
Question
• What is “vanishing bile duct” syndrome?
Question
• What is “vanishing bile duct” syndrome?
• Manifestation of chronic rejection
• Poorly understood
• Candidates for re-transplantation
Statistics
• What is the 10 year survival of patients with
liver transplantation, based on 30,000 UNOS
patients? Adults vs. Kids?
Statistics
• What is the 10 year survival of patients with
liver transplantation, based on 30,000 UNOS
patients? Adults vs. Kids?
• Adults: 59% px survival, 51% graft survival
• Pedi: 78% px survival, 63% graft
Survival
Thanks for listening! Have a great
day!