Transcript When Is It Time For Transplant: S. Williams

When is it Time for a Transplant?
CAHN Conference
February 25, 2011
Sandy Williams RN(EC), MScN, NP
Nurse Practitioner / Transplant Coordinator
London Health Sciences Centre
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Objectives
• Review the indications for liver
transplantation
• Understand
– Optimal Timing
– Information needed to facilitate the assessment
– Transplant Process
Consider
Long-term outcomes & concerns
Who Needs a Liver Transplant?
• End-stage organ failure
• Tumour
• No other surgical or medical
option
• Limited life span
• “Sick enough to warrant the
risks & healthy enough to
survive the surgery”
Patient’s Fears about Assessment
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Purpose of the Transplant Assessment
• To allow patient to get to know the transplant team,
have their questions answered, understand the
process & expected outcome
• To establish rapport with the patient & family so that
they have confidence in the team & see them as
their advocates
• To assess the need for a transplant
• To reveal any contraindications or additional risk
factors for surgery
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Helpful Referral Information
• Comprehensive health history – current
symptoms, past surgery, medications etc.
• Recent blood work, U/S, endoscopies,
echocardiogram, CT scans, O.R. notes
investigations related to diagnosis of liver
disease
• Psycho-social situation, family supports,
finances/insurance coverage
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Transplant Assessment Protocol
• Consults – surgery, medicine, social work, dietician,
recipient coordinator
• Labs – comprehensive chemistry, serology, tumour
markers
• Echocardiogram/MIBI
• Doppler U/S +/-CT scan
• Endoscopy/Colonoscopy
• Other consults & investigations as indicated
by medical history & test results
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Possible Outcomes of Assessment
• Too well – transplant not necessary at this
time or other treatment is sufficient
• Appropriate for listing
• Unsuitable – because they have sepsis or require
heart surgery, ETOH rehab before transplant
• Too ill & will never be appropriate for transplantation
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Transplant Patient Selection Criteria
• Accepted indications for Liver Transplantation
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Fulminant Failure (acute illness)
Hepatic malignancy (HCC) within criteria
Decompensated chronic liver diseases
Alcohol-related disease (abstinence, insight & rehab)
HCV, HBV, Autoimmune Hepatitis
Extra-hepatic conditions (hepatopulmonary )
Inherited metabolic liver disease (FAP, Wilson, etc.)
Contraindications to Transplant
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Inability to withstand or benefit from transplant
Extrahepatic or extensive tumour
Other life-threatening illness or Sepsis
Less than 50% chance of surviving 5 years
Unwilling to follow healthcare advice
Too well to warrant the risks
Lack of social support
Patient does not wish to have a transplant
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Adult Recipients : Etiology
Primary Diagnosis
Hepatitis C
35%
Autoimmune (AIH, PBC, PSC)
NASH/cryptogenic
21%
17%
Alcohol-related
Fulminant failure
11%
5%
Hepatitis B
Metabolic disease
5%
3%
HCC (tumour)
15%
Re-transplant
8%
Symptoms of Liver Disease
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Hyperbilirubinemia
Renal dysfunction
Coagulopathy
Ascites/Edema/Effusions
Hypoalbuminemia
Bleeding
FatigueDecreased LOC->Coma
Muscle wasting
Hypoglycemia
Itch
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Optimizing Pre-Op Condition
• Maintain nutrition/conditioning -supplements, low salt diet &
exercise (rarely necessary to restrict protein)
• Manage ascites/effusions – diuretics, diet, TIPS
• Monitor for renal failure, electrolyte imbalance & tumours
• Prevent Bleeding – beta blockers & banding
• Prevent encephalopathy – lactulose, antibiotics
• Treat itch – cholestyramine, rifampin, sertraline
• Prevent peritonitis – ciprofloxin
• Ensure realistic expectations of wait time, recovery & post-op
quality of life
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Viral Hepatitis – Pre-op Care
• Decrease viral load as much as possible as this
impacts long-term survival
• Monitor for usual liver failure symptoms
(particularly prone to tumours)
• Reinforce the fact that a liver transplant
doesn’t clear the virus & that post-transplant
viral treatment will be required
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Surveillance for Pre-op Patients
• Blood work as indicated by condition – including
alphafetoprotein & viral loads
• U/S every 6 months (may require CT scans)
• Echocardiogram yearly
• Routine investigations for age,
gender & specific disease
“another important part of pre-transplant
care is providing understanding &
compassion for their situation”
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Life threatening Pre-op Complications
• Patients with liver disease often don’t die from liver failure,
but from complications related to poor liver function
• Hepatorenal syndrome & electrolyte/glucose & fluid
imbalance
• Sepsis (pneumonia, peritonitis)
• Malnutrition & Weakness that makes them prone to sepsis
Bleeding can often be controlled – banding/TIPS
Coma can usually be reversed with lactulose, fluids &
antibiotics (depending on the cause)
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Alcohol, Methadone & Narcotic Use
• Significant ETOH history requires at least 6 months abstinence
+insight +relapse prevention program
• Stable methadone use is not a contraindication to
transplantation in many programs
• Narcotic use may be necessary for chronic pain, however
should be weaned if possible to prevent encephalopathy
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Transplant for people living with HIV
• People who have liver disease & are HIV+ may be candidates
for liver transplant if their HIV viral load is undetectable
• Stable CD4 counts
• They meet the standard criteria for transplant
• No significant HIV related illness (such as Kaposi’s sarcoma)
“ the difficulty with HIV+ patients is that by the time their liver
disease has progressed to the point of needing a transplant, the HIV
has also progressed such that they may not be appropriate”
*The interaction of the transplant anti-rejection medications & HAART
drugs makes it difficult to manage these patients after the transplant
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Hepatocellular Carcinoma - Milan Criteria
• The accepted listing criteria for transplant candidates
with HCC
• Single lesion, ≤ 5 cm in size, or
• No more then 3 lesions, all ≤ 3cm
• No extrahepatic disease, vascular invasion or nodes
• Canadian Liver Transplant Study Group
• There are other tumour criteria & each program
decides what is acceptable for their group
People who decline transfusions
• Patients who don’t accept blood transfusions may be
eligible for liver transplant if;
• Low INR , adequate hemoglobin & platelets
• Vascular anatomy is straightforward
• Limited prior abdominal surgery
Patient is made aware that if their blood work deteriorates they
may be removed from the list
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Quantifying Severity of Illness
• Not everyone with cirrhosis needs a transplant
& we don’t rush into it because of the
potential toxicity of the immunosuppression
• For those who do have life-threatening illness,
it is necessary to rank the severity of illness in
order to prevent pre-transplant deaths
• The aim is for everyone to have equitable
access to the limited resource
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Model End Stage Liver Disease: MELD score
• MELD (or NaMELD)
– Based on objective indices
• Albumin, INR, Bilirubin and creatinine
– Meant to bring fairness to patient selection &
ensure that transplantation is needed
– Doesn’t always reflect degree of illness for those
with hepatopulmonary syndrome, urea cycle
defects
– Several variations of this formula
– Criticized for favouring patients with tumours
MELD Calculator
Who Gets the Organ?
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Sickest patient
Compatible blood type
Size compatible
Longest Waiting Time
Liver Transplantation in Canada:
Current Status
• Patient survival:
1yr = 92%, 3yr = 80%, 10yr = 60%
• Approximately 420 Liver transplants in
Canada/year
– 7 adult centers
– 800 patients on liver transplant waiting lists
– 150 deaths/year on waiting list
Expanding the Donor Pool
• Living Donor Liver Transplantation
– Adult to Child, Adult to Adult
– (relative, friend, or anonymous)
• Split Liver Transplantation
• Donation After Cardiac Death (DCD)
• Web-based ‘Matching’ service (not in Canada)
• Domino (amyloid liver given to another patient)
Living Donor Liver Transplantation
Left Hepatic Vein
Left Lateral Segment
Right Portal
Vein with
Common
Portal Vein
Left Portal
Vein
Right Hepatic Duct
Left Hepatic
Artery
Left Hepatic
Duct
Right Hepatic Artery
with Celiac Axis
Split Liver Transplantation
Advantages of Living Donation
• Decreased waiting time
• Reduced cold ischemic time
• Elective procedure
• Increased number of cadaver organs for
others waiting for transplant
Donation After Cardiac Death
• Occurs in hopeless cases in the hospital where the
decision to withdraw life support is made (decision is
independent of the decision to donate organs). These
patients don’t meet the conventional “brain death”
criteria
• Organ donation occurs immediately once the heart has
stopped and the patient is declared dead
• This type of donation was initiated in response to families
who were disappointed when their loved ones weren’t
able to donate due to strict criteria
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When a donor becomes available
• Patient is called in to hospital from home or local
hospital
• Standard pre-op tests are performed
• The transplant team travels to wherever the donor is
to inspect the organ & perform the hepatectomy
• The liver is flushed with a preservation solution
& delivered to the transplant hospital
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Transplant Surgery
• Takes 5-8 hours
• Starts with careful removal of
patient’s liver (which is sent to
pathology)
• Requires connecting veins,
arteries & bile ducts
• Immunosuppression starts in the
operating room
• Bile flow starts immediately &
coagulation improves
• Patients then go directly to ICU
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Expected Peri-Operative Course
• Brief ICU stay
• Up walking within a few
days
• Able to walk a flight of
stairs before discharge
from hospital
• Incision heals within 2
weeks
• Leave hospital in 1-3
weeks & stay in town
for another week
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Follow-Up Care & Advice
• Lifelong Immunosuppression
• Regular blood tests & check-ups
• Encouraged to be active - live a normal &
healthy lifestyle
• Transplant team available for transplantrelated concerns & family doctor can manage
routine medical care
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Post-Op Issues In Liver Transplantation
• Long Term Issues
– Immunosuppression – side effects
– Comorbidities – diabetes, heart disease
– Renal dysfunction
– Obesity
– Recurrent disease & return to alcohol misuse
– Malignancies – lymphoma, skin cancer
– Failed expectations
Post-transplant Disease Recurrence
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HCV
HBV
AIH/PBC/PSC
NASH
HCC
100% (5yr -30%cirrhosis)
100% without prophylaxis
20%
Up to 80%
Depends on criteria
Patients may have some recurrence of their disease but
usually not severe enough to require a second transplant
Re-transplant for Hepatitis C
• Very poor outcomes if the patient has liver
failure within 5 years of the transplant
• Patients with severe recurrent Hep C are
prone to diabetes & renal failure & this
combination makes getting to a second
transplant difficult & surviving a second
transplant unlikely
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Quality of Life after Transplant
• Return to work & school
within 2-6 months
• Able to travel, play
sports & have children
• Most recipients rate
their quality of life as
good or excellent
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So…… What if I have questions???
If you have questions
about referring a patient
for transplant, please
contact your local
transplant coordinator or
other transplant team
members – we’re happy
to take your call!!
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May your liver be smooth & you mind always clear,
May you know only laughter throughout the year