Liver Transplantation Philip Goodney, MD June 22, 2005.
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Transcript of Liver Transplantation Philip Goodney, MD June 22, 2005.
![Page 1: Liver Transplantation Philip Goodney, MD June 22, 2005.](https://reader034.fdocuments.us/reader034/viewer/2022051315/56649e035503460f94aee0e6/html5/thumbnails/1.jpg)
Liver Transplantation
Philip Goodney, MD
June 22, 2005
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Format
• Question and Answer (multiple choice)
• Review of reading in Sabiston Chapter
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List ‘em
• Name the most common indications for liver transplantation, in order, for adults and children.
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List ‘emTABLE 27-1 -- Indications for Liver Transplantation
Adults Children
Noncholestatic cirrhosis 65 Biliary atresia 58
Viral hepatitis B and C Inborn errors 11
Alcoholic Cholestatic 9
Cryptogenic PSC
Cholestatic 14 Alagille’s sy
Primary biliary cirrhosis
4
PSC Viral hepatitis 2
Autoimmune 5 Miscellaneous 16
Malignant neoplasm 2
Miscellaneous 14
Autoimmune
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True or False
• The number of cadaveric donors has changed dramatically over the last 13 years
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True or False
• The number of cadaveric donors has changed dramatically over the last 13 years
• False
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Question
• What two kinds of information are used in the Child-Turcote-Pugh Score of Severity of Liver Disease ?
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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)
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Question
• What three variables does the MELD score take into account?
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Question
• What three variables does the MELD score take into account?
– Bilirubin– INR– Creatinine
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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?
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Question:
• Mr. MELD, baby
• (MELD = model of end-stage liver disease)
TABLE 27-3 -- Concordance with 3-Month Mortality: MELD and CTP
Score Concordance95% 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
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Question
• Which of the following are absolute contraindications to liver transplantation?
– Active sepsis– Extrahepatic malignancy– HIV– Portal vein thrombosis– HCC
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Question
• What type of virus is hepatitis B?
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Question
• What type of virus is hepatitis B?
• hepandnavirus
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Question
• Which of the following are absolute contraindications to liver transplantation?
– Active sepsis– Extrahepatic malignancy– HIV– Portal vein thrombosis– HCC
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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?
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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
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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?
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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
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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?
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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
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Question
• What infection can accelerrate the cirrhosis that accompanies ETOH abuse?
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Question
• What infection can accelerrate the cirrhosis that accompanies ETOH abuse?
• HCV
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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
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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)
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Question
• What 3 factors make it likely that a patient with HCC will benefit from liver transplantation?
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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)
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Question
• What are the characteristics of a marginal / expanded criteria donor?
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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
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Question
• What variables are considered when matching donor and recipient?
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Question
• What variables are considered when matching donor and recipient?
• ABO (can be crossed if urgent)
• Size
• Age (for pedi patients)
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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.
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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
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Road Map
• Describe the purpose and path of circulation of veno-venous bypass
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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
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Question
• How long does it take for a recipient of a split liver Right lobe to achieve a “standard” liver mass equivalent?
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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!!
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Question
• Name the possible operative complications that can occur in liver transplantation.
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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
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Question
• How common is primary non-function?
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Question
• How common is primary non-function?– 2-3%
– Hemodynamic instability– MSOF– Encephalopaty
– Rx: retransplantation
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Question
• How is a definitive diagnosis of acute rejection made? How is it treated?
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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
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Question
• What is “vanishing bile duct” syndrome?
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Question
• What is “vanishing bile duct” syndrome?
• Manifestation of chronic rejection
• Poorly understood
• Candidates for re-transplantation
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Statistics
• What is the 10 year survival of patients with liver transplantation, based on 30,000 UNOS patients? Adults vs. Kids?
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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
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Survival
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Thanks for listening! Have a great day!
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