Difference between revisions of "Liver transplantation"

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* Assesment of ability of the [[patient]] to withstand [[immunosuppression]]   
 
* Assesment of ability of the [[patient]] to withstand [[immunosuppression]]   
 
* Assessment of [[Patient|patients]] demands of post-transplantation care  
 
* Assessment of [[Patient|patients]] demands of post-transplantation care  
The following evaluations are required:  
+
Pre-transplant evaluation is particularly aggressive in patients prior to [[Organ transplant|transplantation]] to minimize post operative morbidity and mortality due to effects of surgery and [[Immunosuppression|immunosuppressive therapy]].The following evaluations are required:  
 
* Cardiopulmonary   
 
* Cardiopulmonary   
 
* Screening for [[Cancer of unknown primary origin|occult cancer]]  
 
* Screening for [[Cancer of unknown primary origin|occult cancer]]  
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==== Laboratory investigations ====
 
==== Laboratory investigations ====
 
Laboratory investigations essential for patient evaluation prior to liver transplantation are as follows:   
 
Laboratory investigations essential for patient evaluation prior to liver transplantation are as follows:   
 +
 +
==== General investigations ====
 
* [[Liver function tests]]:  
 
* [[Liver function tests]]:  
 
** [[Bilirubin]] levels  
 
** [[Bilirubin]] levels  
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* [[Complete blood count]]   
 
* [[Complete blood count]]   
 
* [[Creatinine clearance]]   
 
* [[Creatinine clearance]]   
 +
 +
==== Cause specific investigations ====
 
* Serum [[Sodium|Na]] levels  
 
* Serum [[Sodium|Na]] levels  
 
* Serum [[alpha-fetoprotein]]   
 
* Serum [[alpha-fetoprotein]]   
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* Urine [[:Category:Drugs|drug]] screen  
 
* Urine [[:Category:Drugs|drug]] screen  
 
==== Cardiopulmonary evaluation ====
 
==== Cardiopulmonary evaluation ====
Cardiopulmonary evaluation helps in the evaluation of the [[patient]] for:<ref name="pmid24716201">{{cite journal |vauthors=Martin P, DiMartini A, Feng S, Brown R, Fallon M |title=Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation |journal=Hepatology |volume=59 |issue=3 |pages=1144–65 |year=2014 |pmid=24716201 |doi= |url=}}</ref><ref name="pmid14583357">{{cite journal |vauthors=Zoghbi GJ, Patel AD, Ershadi RE, Heo J, Bynon JS, Iskandrian AE |title=Usefulness of preoperative stress perfusion imaging in predicting prognosis after liver transplantation |journal=Am. J. Cardiol. |volume=92 |issue=9 |pages=1066–71 |year=2003 |pmid=14583357 |doi= |url=}}</ref>  
+
Cardiopulmonary evaluation helps in the evaluation of the [[patient]] for pathologies that need to be ruled out prior to transplantation:<ref name="pmid24716201">{{cite journal |vauthors=Martin P, DiMartini A, Feng S, Brown R, Fallon M |title=Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation |journal=Hepatology |volume=59 |issue=3 |pages=1144–65 |year=2014 |pmid=24716201 |doi= |url=}}</ref><ref name="pmid14583357">{{cite journal |vauthors=Zoghbi GJ, Patel AD, Ershadi RE, Heo J, Bynon JS, Iskandrian AE |title=Usefulness of preoperative stress perfusion imaging in predicting prognosis after liver transplantation |journal=Am. J. Cardiol. |volume=92 |issue=9 |pages=1066–71 |year=2003 |pmid=14583357 |doi= |url=}}</ref>  
 
* [[Heart|Cardiac]] pathologies:<ref name="pmid16498651">{{cite journal |vauthors=Guckelberger O, Mutzke F, Glanemann M, Neumann UP, Jonas S, Neuhaus R, Neuhaus P, Langrehr JM |title=Validation of cardiovascular risk scores in a liver transplant population |journal=Liver Transpl. |volume=12 |issue=3 |pages=394–401 |year=2006 |pmid=16498651 |doi=10.1002/lt.20722 |url=}}</ref><ref name="pmid9346688">{{cite journal |vauthors=Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y |title=Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation |journal=Liver Transpl Surg |volume=2 |issue=6 |pages=426–30 |year=1996 |pmid=9346688 |doi= |url=}}</ref>  
 
* [[Heart|Cardiac]] pathologies:<ref name="pmid16498651">{{cite journal |vauthors=Guckelberger O, Mutzke F, Glanemann M, Neumann UP, Jonas S, Neuhaus R, Neuhaus P, Langrehr JM |title=Validation of cardiovascular risk scores in a liver transplant population |journal=Liver Transpl. |volume=12 |issue=3 |pages=394–401 |year=2006 |pmid=16498651 |doi=10.1002/lt.20722 |url=}}</ref><ref name="pmid9346688">{{cite journal |vauthors=Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y |title=Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation |journal=Liver Transpl Surg |volume=2 |issue=6 |pages=426–30 |year=1996 |pmid=9346688 |doi= |url=}}</ref>  
 
** [[Coronary heart disease|Coronary artery disease]]   
 
** [[Coronary heart disease|Coronary artery disease]]   

Latest revision as of 20:49, 25 January 2018


WikiDoc Resources for Liver transplantation

Articles

Most recent articles on Liver transplantation

Most cited articles on Liver transplantation

Review articles on Liver transplantation

Articles on Liver transplantation in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Liver transplantation

Images of Liver transplantation

Photos of Liver transplantation

Podcasts & MP3s on Liver transplantation

Videos on Liver transplantation

Evidence Based Medicine

Cochrane Collaboration on Liver transplantation

Bandolier on Liver transplantation

TRIP on Liver transplantation

Clinical Trials

Ongoing Trials on Liver transplantation at Clinical Trials.gov

Trial results on Liver transplantation

Clinical Trials on Liver transplantation at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Liver transplantation

NICE Guidance on Liver transplantation

NHS PRODIGY Guidance

FDA on Liver transplantation

CDC on Liver transplantation

Books

Books on Liver transplantation

News

Liver transplantation in the news

Be alerted to news on Liver transplantation

News trends on Liver transplantation

Commentary

Blogs on Liver transplantation

Definitions

Definitions of Liver transplantation

Patient Resources / Community

Patient resources on Liver transplantation

Discussion groups on Liver transplantation

Patient Handouts on Liver transplantation

Directions to Hospitals Treating Liver transplantation

Risk calculators and risk factors for Liver transplantation

Healthcare Provider Resources

Symptoms of Liver transplantation

Causes & Risk Factors for Liver transplantation

Diagnostic studies for Liver transplantation

Treatment of Liver transplantation

Continuing Medical Education (CME)

CME Programs on Liver transplantation

International

Liver transplantation en Espanol

Liver transplantation en Francais

Business

Liver transplantation in the Marketplace

Patents on Liver transplantation

Experimental / Informatics

List of terms related to Liver transplantation

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]


Overview

When a healthy liver allograft is used in place of damaged liver tissue, it is termed as liver transplantation. Thomas Starzl used dogs as the first animals for research on liver transplantation in the 1960s. In 1963, the first liver transplant in humans was attempted by Dr. Thomas Starzl of Colorado, United States. The most common indications for liver transplantation in the United States are hepatitis C virus, alcoholic liver disease, autoimmune liver disease, primary biliary cirrhosis, primary sclerosing cholangitis, hepatitis B virus, liver disease due to inborn errors of metabolism, cancer, biliary atresia and acute liver failure. On the other hand, absolute contraindications to liver transplantation include hepatocellular carcinoma with metastasis, acute liver failure with persistently elevated intracranial pressure ICP >50mmHg, hemangiosarcoma, hilar cholangiocarcinoma, sepsis, and active alcohol or drug abuse. Pretransplant measures such as cardiopulmonary evaluation, screening for occult cancer, infection, and psychosocial evaluation must be performed prior to surgery. The most commonly used technique employed in patients is orthotopic transplantation. This involves removal of the native liver and placement of the donor organ in the same anatomic location as the original liver. Immunosuppressive agents used after transplantation include cyclosporine, everolimus, mycophenolate, corticosteroids, azathioprine, and tacrolimus in different combinations. The most common causes of death in liver transplant patients are infection, malignancy, and rejection. It is necessary to monitor patients for signs of complications and treat them effectively.

Liver Transplantation

History

  • In the 1960s, Thomas Starzl used dogs as the first animals for research on liver transplantation in Boston and Chicago.
  • In 1963, the first liver transplant in humans was attempted by a surgical team led by Dr. Thomas Starzl of Denver, Colorado, United States.[1]
  • Dr. Starzl performed many additional transplants until he was successful in 1967 with the first one-year survival post-transplantation.
  • In 1970, the regimen for immunosuppressive therapy following transplant was introduced, but azathioprine and steroids did not improve survival rates of patients.
  • In the 1980s, with the introduction of cyclosporine by Sir Roy Calne, there was an improvement in rejection rates.
  • In 1983, liver transplantation was no longer an experimental modality, but a clinically acceptable form of therapy for both adult and pediatric patients with appropriate indications.
  • In 1986, the introduction of monoclonal antibodies such as muromonab-CD3 [OKT3] further contributed to improvement of quality of immunosuppressive therapy used in patients, with significant decline in rejection rates.
  • In 1988, University of Wisconsin (UW) solution was developed, which ensured a smooth surgery and longer preservation period.
  • In 1992, the concept of xenotransplantation and cloning techniques were introduced by Starzl.
  • In 1999, approximately 5000 procedures were carried out, in contrast to 100 which had been performed a decade earlier.
  • Recently, the introduction of newer immunosuppressive agents such as IL-2 receptor blockers and tacrolimus, have drastically increased patient survival rates to 1 and 5-year rates of approximately 85 and 70 percent respectively.[2]
  • In December 2016, 147,128 liver transplants were performed in the US as compared to 7217 in 1998 based on data from the United Organ Sharing (UNOS) network.

Indications

Liver transplantation is applicable to any acute or chronic condition resulting in irreversible liver dysfunction, provided that the recipient does not have other conditions that will preclude a successful transplant. Most liver transplants are performed for chronic liver diseases that lead to irreversible scarring of the liver, or cirrhosis.

Contraindications

Absolute contraindications for liver transplantation include:[3]

Relative contraindications for liver transplantation include:[3][4][5][6][7][8][9][10][11][12][13]

Patient evaluation prior to transplantation

Pre-transplant patient evaluation has the following objectives:

Pre-transplant evaluation is particularly aggressive in patients prior to transplantation to minimize post operative morbidity and mortality due to effects of surgery and immunosuppressive therapy.The following evaluations are required:

Laboratory investigations

Laboratory investigations essential for patient evaluation prior to liver transplantation are as follows:

General investigations

Cause specific investigations

Cardiopulmonary evaluation

Cardiopulmonary evaluation helps in the evaluation of the patient for pathologies that need to be ruled out prior to transplantation:[3][14]

Cancer screening

Prior to transplantation, screening for the following carcinomas is recommended:

Upper GI endoscopy

Bone densitometry

Vaccinations and evaluation for infection

Psychosocial evaluation and education

Techniques

Orthotopic Liver Transplantation

Immunosuppressive management

Results

Living donor transplantation

  • Living donor liver transplantation (LDLT) has emerged in recent decades as a critical surgical option for patients with end stage liver disease, such as cirrhosis and/or hepatocellular carcinoma often attributable to one or more of the following:[29][42][43]
  • The concept of LDLT is based on:
    • Remarkable regenerative capacities of the human liver
    • Widespread shortage of cadaveric livers for patients awaiting transplant
  • In LDLT, a piece of healthy liver is surgically removed from a living person and transplanted into a recipient, immediately after the diseased liver of the recipient has been entirely removed
  • Historically, LDLT was used as a means for parents of children with severe liver disease to donate a portion of their healthy liver to replace the damaged liver of their children
  • In 1986, the first successful LDLT was performed at the Universidade de São Paulo (USP) Medical School, by Dr. Silvano Raia.
  • More technically demanding than standard, cadaveric donor liver transplantation
  • Has faced several ethical problems[44]

Complications of Liver Transplantation

    • Laboratory investigations

Imaging studies

Acute and chronic graft rejection

Acute graft rejection:[45]

Chronic graft rejection:

Infection

Infections may be classified based on the duration post transplantation.

  • After the first 6 months, risk of infection in transplant patients is equal to that of the population

Cytomegalovirus (CMV)

  • Most common viral infection (affects 25-85% patients)
  • Occurrence: Between posttransplant months 1 and 3
  • Infection may be:
    • Primary
    • Reactivated

Pneumocystis carinii pneumonia (PCP)

Other less common organisms causing infection include:

External Links


References

  1. STARZL T, MARCHIORO T, VONKAULLA K, HERMANN G, BRITTAIN R, WADDELL W. "HOMOTRANSPLANTATION OF THE LIVER IN HUMANS". Surg Gynecol Obstet. 117: 659–76. PMID 14100514. 
  2. Kanwal F, Dulai GS, Spiegel BM, Yee HF, Gralnek IM (2005). "A comparison of liver transplantation outcomes in the pre- vs. post-MELD eras". Aliment. Pharmacol. Ther. 21 (2): 169–77. PMID 15679767. doi:10.1111/j.1365-2036.2005.02321.x. 
  3. 3.0 3.1 3.2 3.3 3.4 Martin P, DiMartini A, Feng S, Brown R, Fallon M (2014). "Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation". Hepatology. 59 (3): 1144–65. PMID 24716201. 
  4. Mathurin P, Moreno C, Samuel D, Dumortier J, Salleron J, Durand F, Castel H, Duhamel A, Pageaux GP, Leroy V, Dharancy S, Louvet A, Boleslawski E, Lucidi V, Gustot T, Francoz C, Letoublon C, Castaing D, Belghiti J, Donckier V, Pruvot FR, Duclos-Vallée JC (2011). "Early liver transplantation for severe alcoholic hepatitis". N. Engl. J. Med. 365 (19): 1790–800. PMID 22070476. doi:10.1056/NEJMoa1105703. 
  5. Cooper C, Kanters S, Klein M, Chaudhury P, Marotta P, Wong P, Kneteman N, Mills EJ (2011). "Liver transplant outcomes in HIV-infected patients: a systematic review and meta-analysis with synthetic cohort". AIDS. 25 (6): 777–86. PMID 21412058. doi:10.1097/QAD.0b013e328344febb. 
  6. Mindikoglu AL, Regev A, Magder LS (2008). "Impact of human immunodeficiency virus on survival after liver transplantation: analysis of United Network for Organ Sharing database". Transplantation. 85 (3): 359–68. PMID 18301332. doi:10.1097/TP.0b013e3181605fda. 
  7. Terrault NA, Roland ME, Schiano T, Dove L, Wong MT, Poordad F, Ragni MV, Barin B, Simon D, Olthoff KM, Johnson L, Stosor V, Jayaweera D, Fung J, Sherman KE, Subramanian A, Millis JM, Slakey D, Berg CL, Carlson L, Ferrell L, Stablein DM, Odim J, Fox L, Stock PG (2012). "Outcomes of liver transplant recipients with hepatitis C and human immunodeficiency virus coinfection". Liver Transpl. 18 (6): 716–26. PMC 3358510Freely accessible. PMID 22328294. doi:10.1002/lt.23411. 
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  10. Wreghitt T (2001). "Liver Transplantation in Adults Coinfected With HIV. Transplantation 2001; 72: 1684". Transplantation. 72 (10): 1594–5. PMID 11726816. 
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  12. Stock PG, Roland ME, Carlson L, Freise CE, Roberts JP, Hirose R, Terrault NA, Frassetto LA, Palefsky JM, Tomlanovich SJ, Ascher NL (2003). "Kidney and liver transplantation in human immunodeficiency virus-infected patients: a pilot safety and efficacy study". Transplantation. 76 (2): 370–5. PMID 12883195. doi:10.1097/01.TP.0000075973.73064.A6. 
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  14. Zoghbi GJ, Patel AD, Ershadi RE, Heo J, Bynon JS, Iskandrian AE (2003). "Usefulness of preoperative stress perfusion imaging in predicting prognosis after liver transplantation". Am. J. Cardiol. 92 (9): 1066–71. PMID 14583357. 
  15. Guckelberger O, Mutzke F, Glanemann M, Neumann UP, Jonas S, Neuhaus R, Neuhaus P, Langrehr JM (2006). "Validation of cardiovascular risk scores in a liver transplant population". Liver Transpl. 12 (3): 394–401. PMID 16498651. doi:10.1002/lt.20722. 
  16. Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y (1996). "Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation". Liver Transpl Surg. 2 (6): 426–30. PMID 9346688. 
  17. Colle IO, Moreau R, Godinho E, Belghiti J, Ettori F, Cohen-Solal A, Mal H, Bernuau J, Marty J, Lebrec D, Valla D, Durand F (2003). "Diagnosis of portopulmonary hypertension in candidates for liver transplantation: a prospective study". Hepatology. 37 (2): 401–9. PMID 12540791. doi:10.1053/jhep.2003.50060. 
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bg:Чернодробна трансплантация de:Lebertransplantation it:Trapianto di fegato he:השתלת כבד nl:Levertransplantatie fi:Maksansiirto



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