LDLT Amany Saleh Elyamany Assistant professor of Hepatology Faculty of Medicine Alexandria University

Natural history studies of cirrhosis find that the development of decompansation is associated with a decreased median survival from greater than 12 years to 2 years.

Each transplant program has its own program specific guidelines.  AASLD has created recommendations for candidate evaluation and selection for transplantation when a patient develops a decompensation, reaches a CTP score of ≥ 7, or reaches a MELD score of ≥ 10 

MELD scoring system was adopted February 2002 to prioritize patients with ESLD for organ allocation.  The MELD score deteremines "sickness of the liver" and is a mathematically derived number based upon a score calculated using serum bilirubin, INR, and creatinine.  It was originally developed by a team at the Mayo Clinic in Rochester, Minnesota to predict survival after the placement of a TIPS in patients with cirrhosis. Ideally, the timing of liver transplantation occurs when the risk of dying from the liver disease is greater than the risk of dying from the surgical procedure.

Indications for Living Donor Liver Transplantation

Contraindications for Living Donor Liver Transplantation (Exclusion criteria)

Pre-transplant Evaluation (LDLT)

Update to MELD is done: monthly for those with MELD< 18, every 2 weeks for MELD18-25, weekly for MELD>25.

Evaluating a potential donor Donor safety is paramount.

Donor Criteria for Living Donor Transplantation include:

Phases of the Donor’s Evaluation

Phase I: (A)- Full history and physical examination (B)- Lab investigations

(C)- Imaging studies:

Phase II: (A)- Viral Markers: (B)- Tumor Markers: (C)- Consultations:

Phase III: (A) Imaging studies: (B) Consultations: (C) Liver biopsy: 1

Recipient Criteria for Living Donor Transplantation

NUTRITION Pretransplantation: Malnutrition is one of the most unrecognized problems of patients with end-stage liver disease awaiting LT. The prevalence of malnutrition in liver disease is difficult to assess because of the lack of a standardized diagnosis and classification of malnutrition in this population. Fluid retention and the fact that the plasma levels of most visceral proteins reflect both poor liver function and nutritional reserve complicate nutritional assessment in cirrhosis. Some physicians consider protein calorie mal­nutrition (PCM) to be the most common complication in patients with cirrhosis. The prevalence of PCM differs according to the cause. It has been described in 20% of the patients with compensated cirrhosis, and the incidence rises to 60% in patients with liver insuffi­ciency

The amount of protein (in grams) Three ounces of meat, poultry (chicken), or fish (=21 grams). One cup of milk or yogurt (=eight grams). One large egg (=seven grams). One ounce of cheese (=seven grams). One-half of a cup of cooked, dried, pinto, kidney or navy beans (=three grams).

Post transplantation nutrition: I. Short Term Goals A high protein diet is recommended for the first six to eight weeks post transplant to help in the healing and recovery process. II. Long Term Goals Achieve and maintain a healthy weight. In other words, try to avoid becoming overweight. Prednisone can continue to stimulate appetite.

Treatment of Underlying Liver Diseases

Hepatitis B Virus In HBV-related cirrhosis, antiviral therapy should be considered if HBV replication is present(HBVDNA +ve).

Hemochromatosis The practice guidelines from AASLD state that all patients with HHC and evidence of iron overload should be strongly encouraged to undergo regular phlebotomies until iron stores are depleted. Phlebotomies should be continued for life with the frequency of maintenance therapy dependent on serum ferritin level.

Primary Biliary Cirrhosis All patients with PBC with abnormal liver enzyme levels should be considered for specific therapy. UDCA treatment is associated with a marked improvement in serum biochemical markers of cholestasis, UDCA slows the progression of PBC in treated patients, Unfortunately, this therapy does not lead to the resolution of the disease. The recommended dosage for UDCA is 13 to 15 mg/kg in a divided or single dose

Primary Sclerosing Cholangitis PSC, with or without ulcerative colitis, is the most common known predisposing factor for cholangiocarcinoma. Patients with PSC should therefore be regularly screened for this malignancy.

Autoimmune Hepatitis Treatment of autoimmune hepatitis with immunosuppression may not be indicated in patients with inactive cirrhosis, preexisting comorbid conditions, or drug intolerance. AASLD practice guidelines state that treatment regimens should include prednisone (10 mg/day) in combination with azathioprine or higher dose prednisone (20 mg/day) alone. Cyclosporine, G-mercaptopurine, cyclophosphamide and mycophenolate mofetil have been also used successfully in isolated cases with drug toxicity to prednisone or azathioprine.

POST-TRANSPLANT CARE

A- Immuno- suppressive medications Corticosteroids: Calcineurin inhibitors

Anti metabolites:

Rapamune (Sirolimus):

Acute cellular rejection Diagnosis is made histopathologically when suspected biochemically.

CHRONIC REJECTION Triple therapy is usually used. Plasmapharesis may be used in case of severe hyperbilirubinemia with antibody mediated rejection.

Infections CMV infection HSV Fungal infection Bacterial infection

Management of recurrent HCV AFTER LIVER TRANSPLANT