Liver and Heart Transplantation

Chapter 70 Liver and Heart Transplantation




Liver transplantation




2 What are the reasons for liver transplantation?


The list of diseases treatable by liver transplantation has expanded steadily over the last decade. Most commonly, the disease process leading to liver transplantation is chronic. Less frequent is acute-on-chronic disease and acute liver failure. Chronic viral hepatitis B or C and alcoholic liver remain the most common reasons for transplantation. Increasingly, nonalcoholic fatty liver disease is an indication for liver transplantation.


Overall, the etiology of chronic liver disease can be classified as follows:



The severity of liver disease is calculated on a numeric scale that ranges from 6 (less ill) to 40 (gravely ill). The scoring system, model for end-stage liver disease (MELD), was introduced almost a decade ago and is also used for allocation of organs. The MELD risk score is a mathematical formula that includes creatinine, bilirubin, and international normalized ratio. It does not include the cause of liver disease. Exception points can be earned with hepatocellular carcinoma and comorbidities such as hepatopulmonary syndrome.


Priority exception to MELD is category status 1, which defines acute severe onset of liver failure (fulminant hepatic failure).



3 Why is a patient rejected for liver transplantation?


Reasons to deny transplantation may be due to medical conditions and psychosocial reasons and may vary from center to center. Liver transplantation is considered a medium- to high-risk procedure. Significant coronary artery disease, compromised cardiac function (reduced ejection fraction), and uncontrolled pulmonary hypertension are considered contraindications for liver transplantation. Nevertheless, patients may be eligible once cardiopulmonary disease is adequately treated (i.e., percutaneous transluminal coronary angioplasty). Significant vasopressor support and intubation (other than airway protection) immediately before transplantation may exclude eligibility for transplantation. Uncontrolled infection or sepsis is also considered a contraindication. A positive HIV test, without evidence of AIDS, is not a contraindication, and reasonable survival has been reported. Advanced hepatocellular carcinoma (outside Milan or UCSF criteria) or metastatic disease is generally considered to be a contraindication because of high risk of recurrence and poor 5-year survival. In fulminant hepatic failure, uncontrolled and markedly elevated intracerebral pressure (ICP) is the most common reason for exclusion.


Psychosocial factors such as active drug or alcohol abuse or the lack of a good social support system may lead to the exclusion of the patient from transplantation. Thorough preoperative evaluation and periodic review of the patient’s medical and psychosocial condition are crucial for successful transplantation and long-term survival.


Older age per se is not a reason to deny liver transplantation. Increasingly, patients older than 65 years of age receive liver transplants.



4 What is the patient pathophysiology before liver transplantation?


Every organ system can be affected by end-stage liver disease. Frequently, patients with end-stage liver disease have considerable comorbidities:




image Central nervous system: Hepatic encephalopathy (grade I-IV in chronic and acute-on-chronic disease) and elevated ICP in acute hepatic failure.


image Cardiac system: Hyperdynamic circulation with high cardiac output and low systemic vascular resistance. This may be blunted in patients receiving nonselective β-blockade for secondary prevention of upper gastrointestinal bleeding; cirrhotic cardiomyopathy.


image Respiratory system:





image Gastrointestinal system: Portal hypertension with possible upper gastrointestinal bleeding, (refractory) ascites.


image Hematologic system: Anemia, thrombocytopenia (mainly sequestration into the spleen), prolonged prothrombin time–partial thromboplastin time, and decreased fibrinogen. Hypercoagulability (especially in patients with malignant disease).


image Renal system: Hepatorenal syndrome type I or II, acute kidney injury.


image Miscellaneous: Significant electrolyte disturbances (sodium, potassium, glucose), immunosuppression with increased risk for infection, malnutrition.




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Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Liver and Heart Transplantation

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