LIVER TRANSPLANTATION

PRESENTED BY BELBIMOL E II YEAR MSC NURSING

LIVER TRANSPLANTATION
Starzl performed the first human liver transplant in 1963. Paediatric patients account for about 12.5% of liver transplant recipients. The most frequent indication for liver transplantation is extrahepatic biliary atresia The decision to perform transplantation in patients with metabolic liver disease includes: the origin of the disease, possibility of success of medical treatment, and reversibility of extra hepatic manifestations

URGENCY FOR LIVER TRANSPLANTATION IS INDICATED BY

Age :<1 yr growth failure :height or weight 2 standard deviations below normal Hyperbilirubinemia Hypoalbuminemia coagulopathy :prolonged international normalized ratio (INR)

DEFINITION
It is a replacement of diseased liver with healthy liver either by allograft or homograft

INCIDENCE
Paediatric patients account for about 12.5% of liver transplant recipients. Most of them are below one year. In children(1 to 5 years), the 6 month survival rate is 87-77%.(US)

INDICATIONS
1)Fulminant liver failure Viral Drug induced Auto-immune Toxin induced Perinatal hemochromatosis Wilsons disease Tyrosinemia Idiopathic

CONTINUED 2)End stage liver failure: Obstructive biliary tract disease Intrahepatic cholestasis Idiopathic metabolic disorders Miscellaneous: cryptogenic cirrhosis, Congenital hepatic fibrosis, TPN- associated cirrhosis

CONTINUED 3)Metabolic disorders: Crigler-Najjar (type-1) Primary leading to hepatic disease, oxalosis Familial cholesterolemia Urea cycle defects Organic acidemias

CONTINUED 4) Unresectable liver tumours Hepatoblastoma Hepatocellular carcinoma Hemangioendothelioma Hemangiomas

CONTRAINDICATIONS
Advanced cardio pulmonary or CNS disorder that cannot be reversed by OLT (orthotopic liver transplantation) HIV positivity Irresectable hepatic malignancy Progressive non-hepatic illness Irreversible neurologic disorder

LIVER DONATION

Cadaveric liver donation

Living liver donation

Candidate evaluation Waiting period Surgery Postsurgical care

CANDIDATE EVALUATION
Hepatologists (medical liver specialists) Transplant surgeons Social workers Psychologists, psychiatrists, or both

Nurses
Transplant coordinators

Candidate evaluation Waiting period Surgery Postsurgical care

 patient's name is placed on a waiting list for an organ Decision by a multidisciplinary committee Candidates are stratified according to the severity of their illness and blood type based on medical urgency based on a 3-month pre-transplant assessment risk profile to assign priority and organ allocation to the most severely ill patients.

WAITING PERIOD

CONTINUED Candidates with fulminant hepatic failure (status 1) are allocated organs ahead of all other waiting patients Patients who qualify for liver transplantation are assigned a score based on a nationwide ranking system. This system is called the Model for End-Stage Liver Disease (MELD) for adults and the Pediatric End-Stage Liver Disease (PELD) for patients younger than 12 years.

CONTINUED MELD
creatinine level international normalized ratio (INR) for prothrombin time bilirubin.

PELD
albumin level growth failure patient's age does not include the creatinine level.

PRE TRANSPLANTATION CARE

Alternatives to liver transplantation Liver support devices

Bio artificial liver Extracorporeal liver-assist device The molecular Absorbent Recirculating System (MARS)

Hepatocyte transplantation

PRE-OPERATIVE MANAGEMENT
Referral to a transplant centre Medical and psychological issues are assessed Counselling families Early evaluation Portoenterostomies should be performed in children with biliary atresia Formula containing medium-chain triglycerides to patients with liver disease have malabsorption as well as anorexia

CONTINUED Diet Caloric requirements may be as high as 150 kcal/kg/day. Nocturnal nasogastric tube feedings and intravenous nutrition, especially lipids, may be required because of the anorexia and malabsorption. Fat-soluble vitamin deficiencies must be prevented by providing vitamin supplements.

CONTINUED Vitamin E deficiency (ataxia, peripheral neuropathy, gross motor delay) is best avoided by using a wellabsorbed water-soluble preparation containing d-tocopherol polyethylene glycol succinate. Vitamin D deficiencyassociated bone disease is prevented with oral preparations of 25hydroxyvitamin D3.

CONTINUED

Early changes of vitamin A deficiency appear in the conjunctiva and cornea; they are prevented by using an oral, water-soluble preparation of vitamin A. Vitamin K deficiency is commonly encountered as a prolonged prothrombin time, which may respond to oral supplementation but often requires parenteral vitamin K.

CONTINUED Vitamin and fat absorption may be enhanced with oral ursodeoxycholic acid as a choleretic (increases bile flow into the intestine) and an intraluminal bile acid. Prothrombin time and serum levels of vitamins E, D, and A should be monitored. Iron deficiency due to occult blood loss and zinc deficiency associated with chronic diarrhoea may occur.

CONTINUED Immunizations should be given for hepatitis A and B to avoid additional hepatic injury caused by these infections; immunizations containing live viruses (measles-mumps-rubella, varicella) should be given on schedule because immunosuppression after transplantation may prevent administration.

CONTINUED

control of variceal bleeding, ascites, encephalopathy, coagulopathy, and sepsis. better preservation of the organ (up to 18 hr ex vivo with <2% primary non-function) using a lobe or segment of the liver from a cadaver or living donor and by using ABO blood type mismatches

Candidate evaluation Waiting period Surgery Postsurgical care

SURGERY
Living donors - general anaesthesia patient prepared for surgery within the same time frame as the donor. A liver from a deceased donor must be transplanted into the recipient within 12-18 hours. A team of surgeons and anaesthesiologists performs an operation to remove the liver from the donor. The liver is then preserved and packed for transport.

 These procedures are performed using standard surgical practices and sterile techniques. Upon completion of the operation, the incisions are closed, and the donor's body is prepared for funeral or cremation.

Technique Orthotopic whole liver: the intrahepatic portion of the inferior vena cava can be removed /left in the recipient and the new liver "piggybacked" onto the cava. Split liver: inferior vena cava left in place and the new liver will be anastomosed to the native vena cava

 reestablishment of blood flow to the liver via the portal vein and hepatic artery and the reestablishment of blood flow away from the liver via the hepatic veins. the bile duct's continuity with the GI tract established via a hepaticojejunostomy.

Technical challenges in split-liver grafts

vascular anatomy sufficient volume for metabolic demands of the patient biliary drainage.

Candidate evaluation Waiting period Surgery Postsurgical care

POST-OPERATIVE MANAGEMENT
To prevent rejection: fat-soluble form Steroids Cyclosporine water-soluble or tacrolimus Hirsutism and gingival hyperplasia are specific side effects of cyclosporine. Triple immune suppression with prednisolone, azathioprine and cyclosporine

COMPLICATIONS
Septicaemia Vascular thrombosis Biliary complications Poor graft function Chronic rejection Renal failure Hypertension Intestinal perforation Hematemesis Bleeding and side effects of drugs Post-transplant lymphoproliferative disease (PTLD)