Liver transplantation (LT) has become the treatment of choice for patients with life-threatening liver disorders refractory to other treatments. Depending on the patient’s condition and organ availability, options include whole organ or split liver deceased donor, and living donor (partial liver) transplantation. The risks of surgery, recurrent disease, and long-term immunosuppression must be weighed against the potential benefits. Survival rates after LT currently exceed 85% at 1 year and 70% at 5 years.

1. Chronic liver disease/cirrhosis.

a. Most common indications: cirrhosis from hepatitis C virus (HCV), hepatitis B virus (HBV), nonalcoholic steatohepatitis (NASH), alcoholic cirrhosis, primary sclerosing cholangitis (PSC), and primary biliary cirrhosis (PBC).

b. Signs of advanced and decompensated chronic liver disease include hepatic encephalopathy, refractory ascites and hepatohydrothorax, hepatorenal syndrome, hepatopulmonary syndrome, recurrent and refractory variceal bleeding, recurrent infections (e.g., spontaneous bacterial peritonitis), intractable pruritus, and significant malnutrition (weight loss, muscle wasting).

2. Acute liver failure (ALF)/necrosis.

a. Classification.

i. Hyperacute: onset of jaundice to onset of encephalopathy period <7 days.

ii. Acute: onset of jaundice to onset of encephalopathy period 8 to 28 days.

iii. Subacute: onset of jaundice to onset of encephalopathy period 5 to 12 weeks; accounts for approximately 5% of all LT in the United States.

b. Etiologies.

i. Most common etiology: acetaminophen toxicity.

ii. Other etiologies: infections (hepatitis A, B, E, HSV), metabolic disorders (e.g., Wilson disease), vascular disorders (Budd-Chiari syndrome), autoimmune hepatitis, drug toxicity, and exposure to exogenous toxins.

c. ALF patients may decompensate rapidly; refer early to a transplant center.

i. Initial presentation: severe hepatic dysfunction, marked coagulopathy, rapid deterioration of mental status, serious metabolic derangements (acidosis), acute renal and respiratory failure.

ii. Poor prognostic indicators for spontaneous recovery from ALF: factor V level <30%, pH <7.3, international normalized ratio (INR) >6.5, stage 3 or 4 encephalopathy, lack of response to medical therapy within 24 to 48 hours.

2. Other indications.

a. Hepatocellular carcinoma or other tumor confined to the liver.

b. Metabolic liver disease (Ornithine transcarbamylase deficiency, Crigler-Najjar disease, etc.).

c. Congenital (biliary atresia, polycystic liver disease).

1. Extrahepatic tumor.

2. Uncontrolled infection/sepsis.

3. Irreversible neurologic injury.

4. Active alcohol or drug abuse.

5. Contraindication to surgery (usually severe cardiopulmonary disease).

A. Venous and arterial monitoring catheters and large-volume infusion lines placed in the operating room can be a source of immediate morbidity (pneumo- or hemothorax, pericardial tamponade, arterial pseudoaneurysm, air embolism).

B. The transplant operation is divided into three phases.

1. Preanhepatic: mobilization of the diseased liver in preparation for its removal.

2. Anhepatic.

a. Characterized by progressive coagulopathy and decreased venous return to the heart secondary to clamping of the inferior vena cava and portal vein.

b. Venovenous and/or portal-venous bypass may be used during this phase to avoid significant hemodynamic changes and decrease bleeding.

c. After the native liver is removed, the donor liver is placed in an orthotopic position, and the vascular (IVC, portal vein, hepatic artery) anastomoses are sewn.

3. Postanhepatic: begins at time of reperfusion.

a. Reperfusion can lead to hypotension, pulmonary hypertension, and arrhythmias.

b. Hemodynamic changes may result from acidosis, electrolyte abnormalities (mainly hyperkalemia), air embolus, or volume overload.

c. Close monitoring, appropriate volume resuscitation, and electrolyte management are critical.

d. Hemostasis and completion of the biliary anastomosis are done.

A. Postoperative course depends largely on the patient’s preoperative status and the development of any complications. Basic care of all patients involves the following.

1. Stabilization and recovery of the major organ systems.

2. Monitoring for evidence of improving graft function: improving mental status and coagulation profile, resolution of hypoglycemia, clearance of serum lactate, and decreasing transaminases and bilirubin (48 to 72 hours).

3. Provision of adequate immunosuppression.

4.

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