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Liver Transplantation: Diseases Suitable For Transplantation

Liver transplantation is performed for approximately 700 patients per year in the UK. The liver can be split and transplanted into an adult and child simultaneously. Diseases suitable for transplantation include hepatitis C cirrhosis, alcoholic liver disease, and hepatocellular carcinoma meeting certain criteria. Clinical indications for transplantation include acute liver failure, expected 1-year mortality over 9% without transplant, and HCC meeting the Milan criteria. The transplant procedure involves removing the native liver and implanting the donor liver, restoring normal anatomy. Post-operative management focuses on immunosuppression and monitoring for complications like hepatic artery thrombosis.

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63 views2 pages

Liver Transplantation: Diseases Suitable For Transplantation

Liver transplantation is performed for approximately 700 patients per year in the UK. The liver can be split and transplanted into an adult and child simultaneously. Diseases suitable for transplantation include hepatitis C cirrhosis, alcoholic liver disease, and hepatocellular carcinoma meeting certain criteria. Clinical indications for transplantation include acute liver failure, expected 1-year mortality over 9% without transplant, and HCC meeting the Milan criteria. The transplant procedure involves removing the native liver and implanting the donor liver, restoring normal anatomy. Post-operative management focuses on immunosuppression and monitoring for complications like hepatic artery thrombosis.

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georgedejeu
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© © All Rights Reserved
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Asist Univ Dr George Dejeu

Liver transplantation
Approximately 700 liver transplants are performed each year in the UK, but around 14% of patients listed
die before being transplanted. The liver can be split into right and left lobes for transplantation into an
adult and child simultaneously or to allow living donor liver transplants.

Diseases suitable for transplantation


• Hepatitis C cirrhosis.
• Alcoholic liver disease (6 months abstinence before consideration).
• Primary biliary cirrhosis.
• Primary sclerosing cholangitis (excluding cholangiocarcinoma).
• Hepatocellular carcinoma (HCC) in a cirrhotic liver (selected cases).
• Fulminant hepatic failure (e.g. acute viral hepatitis, drug reactions, or paracetamol overdose).

Clinical indications
• Acute fulminant liver failure.
• Category 1. Expected 1y mortality >9% without liver transplant.
• Category 2. HCC within ‘Milan criteria’ (see Box 19.3).
• Category 3. Variant syndromes affecting quality of life.

o Persistent and intractable pruritus.


o Diuretic-resistant ascites.
o Hepatorenal syndrome.
o Hepatopulmonary syndrome.
o Chronic hepatic encephalopathy.

The transplant procedure


The liver is transplanted on an urgent basis, ideally within 12h of retrieval. The recipient undergoes
removal of the native liver, may be placed on veno-venous bypass, and then the new liver is implanted in
an orthotopic position, restoring the normal vascular anatomy with the biliary drainage via an end-to-end
choledocho-choledochostomy or a Roux-en-Y hepa- tico-jejunostomy if the recipient bile duct is diseased.

If the recipient has accessory hepatic arteries, the common hepatic artery may be insufficient to perfuse
the liver and so arterial conduits can be fashioned from the donor iliac arteries retrieved with the liver.

Post-operative management
Most commonly, immunosuppression is achieved using combination of tacrolimus, azathioprine, and
steroids. The liver is less prone to acute rejection than other organs, so immunosuppression can be fairly
rapidly tapered after the immediate post-operative phase.

Hepatic artery thrombosis (HAT) is a common complication, usually requiring immediate


retransplantation, and usually presents as metabolic acidosis with rising serum lactate levels. Doppler
ultrasound scanning is done as soon as possible after the operation to detect HAT at an early stage.
Administration of platelet transfusions increases the risk of HAT. Graft survival is 80% at 1y and 60% at
5y.
Asist Univ Dr George Dejeu

Monitoring disease progression using a Child–Pugh score. Patients in class C should be referred
for transplantation
• Child–Pugh class B, 5–6 points.
• Child–Pugh class B, 7–9 points.
• Child–Pugh class C, 10–15 points.
1 point 2 points 3 points
Bilirubin (μmol/L) <34 34–51 >51
Albumin (g/L) >35 28–35 <28
Prothrombin time (seconds prolungued) 1–3 4–6 >6
Ascites None Slight Moderate
Encephalopathy grade None 1–2 3–4

King’s College criteria for transplantation for acute liver failure


Paracetamol overdose Other causes
Arterial pH <7.3; OR PT >100s; OR
All three of: Any three of:
PT >100s; Bilirubin >300μmol/L;
Creatinine >300μmol/L; Encephalopathy within 7 days;
Grade III/IV encephalopathy. PT >50s;
Age <10 or >40;
Drug toxicity.

The Milan criteria for transplantation for hepatocellular carcinoma


(HCC)
• Child’s class B or C cirrhosis; and
• Single tumour <5cm or up to three tumours <3cm; and
• Absence of macrovascular portal vein invasion.

The Child–Pugh classification of portal hypertension


1 point 2 points 3 points
Bilirubin (μmol/L) <34 34–51 >51
Albumin (g/L) >35 28–35 <28
PT (s) <3 3–10 >10
Ascites None Moderate Moderate–severe
Encephalopathy None Moderate Moderate–severe
Grade A: 5–6 points; Grade B: 7–9 points; Grade C: 10–15 points.

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