Perioperative Management of Liver Transplant Patients

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Perioperative Management of Liver Transplant
Patients

• January 22, 2007
• Geoffrey Schultz, MD

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Topic Objectives

• 1. Overview of indications selection for liver
  transplantation.
• 2. Identification treatment of complications
  associated with liver disease in the preoperative
  period.
• 3. Identification treatment of complications
  following orthotopic liver transplantation.
• 4. Induction of immunosuppressive pharmacotherapy
  following transplantation.
• 5. Diagnosis treatment of graft rejection.

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Orthotopic Liver Transplantation

• 1st orthotopic liver transplantation 1963.
• Approximately 5,000 orthotopic liver
  transplantations annually for 17,000 in need.

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Indications for Liver Transplantation in
AdultsEtiologies of End-Stage Liver Disease

• 1. Fulminant Hepatic Failure
• 2. Alcoholic Liver Disease
• 3. Chronic Hepatitis C
• 4. Chronic Hepatitis B
• 5. Non-alcoholic steatohepatitis
• 6. Autoimmune Hepatitis
• 7. Primary Biliary Cirrhosis
• 8. Primary Sclerosing Cholangitis
• 9. Hepatic tumors
• 10. Metabolic and genetic disorders

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Indications for Liver Transplantation in Adults

• Presence of irreversible liver disease and a life
  expectancy of less than 12 months with no
  effective medical or surgical alternatives to
  transplantation
• Chronic liver disease that has progressed to the
  point of significant interference with the
  patient's ability to work or with his/her quality
  of life
• Progression of liver disease that will
  predictably result in mortality exceeding that of
  transplantation (85 one-year patient survival
  and 70 five-year survival)

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Manifestations of End-Stage Liver Disease

• Progressive jaundice
• Intractable ascites
• Spontaneous bacterial peritonitis
• Hepatorenal Syndrome
• Encephalopathy
• Variceal bleeding
• Intractable pruritus
• Chronic fatigue (such as resulting in loss of
  gainful employment)
• Bleeding diathesis or coagulopathy

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Selection Criteria for Organ Allocation

• United Network for Organ Sharing (UNOS) governing
  body for organ allocation utilizes MELD score.
• Model for End Stage Liver Disease (MELD) Score
• 0.957 x loge (creatinine) 0.378 x loge
  (bilirubin mg/dL) 1.12 x loge (INR) 0.643 x
  10
• Range from 10 to 40
• Special considerations, amendments for HCC, renal
  failure.

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Preoperative management of complications
associated with hepatic failure decompensated
cirrhosis

• Hepatic Encephalopathy
• Cerebral Edema
• Acute Renal Failure
• Infection Sepsis
• Metabolic Derangements
• Malnutrition
• Coagulopathy
• Portal Hypertension

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Hepatic Encephalopathy

• Etiology Attributed to increased serum ammonia
  levels secondary to metabolism of nitrogenous
  substances in the gut.
• Symptoms Range from euphoria to coma.
• Treatment lactulose, decreased intake of
  nitrogen containing compounds, oral neomycin.

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Cerebral Edema

• Etiology Unknown
• Swelling of brain results in increased ICP
  herniation.
• Invasive monitoring with goal of ICP lt 20 mmHg
  CPP gt 50 mmHg.
• Treatment Anxiolysis, HOB elevation,
  hyperventilation, avoidance of overhydration,
  mannitol diuresis, HD if compromised renal
  function.

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Acute Renal Failure

• Etiology Toxin induced, Derangements in systemic
  intrarenal hemodynamics.
• Treatment Prevention of hypotension, treatment
  of infection, avoidance of nephrotoxic agents.
• Once established, renal failure in this setting
  is often irreversible. Early utilization of renal
  replacement therapy is indicated.

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Infection Sepsis

• Etiology Immunologic derangements including
  complement deficiency, reduced opsonins, WBC
  dysfunction.
• Treatment Frequent cultures, including ascites.
  Broad spectrum antibiotics, including
  anti-fungals.

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Metabolic Derangements

• 1. Hypokalemia
• Increased sympathetic tone promotes cellular
  uptake of K. Decreased serum K promotes
  production of ammonia by the kidney.
• 2. Hyponatremia
• 3. Hypoglycemia
• Secondary to decreased hepatic glycogen stores
  decreased gluconeogenesis.

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Coagulopathy

• Etiology Compromised synthetic function,
  deficiency of coagulation factors, platelet
  dysfunction.
• Contribute to GI bleeding in conjunction with
  portal hypertension.
• Treatment Prevention with H2 blockers, PPI.
  Judicious use of Factor VIIa FFP.

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Post-operative complications management of
liver transplant patients

• Right pleural effusion
• May affect ventilation, necessitating drainage.
• Hepatic edema secondary to aggressive
  resuscitation increased intravascular volume.
• Goal CVP 6-10. Minimize increased hepatic vein
  pressures, sinusoidal congestion that impair
  graft perfusion exacerbate reperfusion injury.

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Post-operative complications management of
liver transplant patients

• Renal failure
• Elevation of creatinine BUN observed in nearly
  all transplant patients secondary to ATN,
  hepatorenal syndrome. Usually self-limiting. May
  necessitate therapy with loop diuretics, renal
  replacement therapy.

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Post-operative complications management of
liver transplant patients

• Electrolyte Derangements
• Recovering graft increases demand for magnesium
  phosphorous.
• Transfusion of citrate rich blood products
  results in decreased serum magnesium calcium.
• Rapid correction of chronic hyponatremia with
  isotonic solution can have severe neurological
  consequence. Judicious use of hypotonic solutions
  with goal of serum Na 125-130 advised.

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Post-operative complications management of
liver transplant patients

• Thrombocytopenia
• Preoperative portal hypertension results in
  splenomegaly platelet sequestration. Generally
  improves as graft recovers. May necessitate
  replacement if bleeding is encountered or
  invasive procedures are planned. Splenectomy is
  rarely indicated.
• Platelet dysfunction secondary to renal hepatic
  failure may be improved acutely with DDAVP.

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Post-operative complications management of
liver transplant patients

• Biliary leak
• RUQ pain, fever, persistent elevation of
  bilirubin, liver enzymes. Biloma on CT. Treated
  with endoscopic stent, percutaneous drainage.
  Possible surgical revision if duct is ischemic.
• Hepatic artery thrombosis
• Persistent elevation or increasing liver enzymes,
  poor graft function. Diagnosed with U/S, CT
  angiography, MRA. Treated with immediate
  revascularization.

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Induction of Immunosuppression

• Triple therapy
• Calcineurin inhibitor (tacrolimus, cyclosporine),
  anti-proliferative agent (mycophenolate),
  corticosteroid taper.
• Initiated immediately following transplantation.
• Levels followed daily in immediate post-operative
  period with decreasing frequency once
  stabilized in desired range.
• Agents vary according to etiology of liver
  disease.
• Thymoglobulin Hb Ig utilized in hepatitis
  patients along with entecavir prograf to limit
  viral replication to avoid coritocsteroid
  usage.

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Allograft rejection

• Hyperacute rejection
• Secondary to preformed Ab to graft antigen.
  Extremely rare. Necessitates retransplantation.
• Acute Cellular Rejection
• 70 of patients 5 to 14 days following
  transplant.
• Heralded by fever, jaundice, elevation of liver
  enzymes.
• Diagnosed by liver biopsy. Demonstrates
  endothelialitis non-suppurative cholangitis.

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• http//med.stanford.edu/shs/txp/livertxp