1. Caroline O’Brien

2.  Comprises two main lobes, each made of thousands of lobules.  Sheets of hepatocytes embedded in capillary network.  Dual blood supply; portal vein and hepatic artery.  Capacity for regeneration.  Bile transported to duodenum and gallbladder.

3.  Figure 1: Anatomy of the liver

4.  Production of bile  Converting food to energy  Cleaning the blood  Blood clotting  Synthesis  Storage

5.  End stage liver disease  Chronic and acute liver failure  Hepatitis  Alcoholic liver disease  Cancer  Primary biliary cirrhosis  Toxins  Hereditary conditions  Obesity

6.  Figure 2: Primary liver disease leading to liver transplantation Europe, 1988 to 2009

7.  Symptoms often vague  Risk factors  Jaundice  Swollen abdomen  Tenderness  Portal hypertension  Altered drug metabolism

8.  Blood tests  Liver function tests  Imaging methods  Liver biopsy

9.  Implemented February 27 2002.  Aim is to prioritise patients on waiting list.  Numerical scale ranging from 6 to 40.  Four levels in the MELD scale.  Incorporates bilirubin, INR and creatinine levels.  Study found MELD score an excellent predictor of patient survival.

10.  Damage must be substantial to affect liver function.  Disease can be treated for a limited time using medication.  Only cure available currently is a liver transplant.

11.  Removal, preparation and implantation of organs.  After incision, abdomen examined for abnormalities.  Isolation.  Transection  Implantation of new liver.  Control of bleeding.

12.  Ireland, 2011 – 61 liver transplants  Britain, 2002 – 2007 – 3333 liver transplants  US centres for Disease Control and Prevention – 2004 – cirrhosis is 12 th leading cause of death of adults in US.

13.  Figure 3: Growth in annual number of liver transplants carried out in Europe

14.  Exploratory use of cardiovascular magnetic resonance imaging in a CMR suite.  Robot assistance in liver surgery as an advantage over a laparoscopic approach.  Effect of active airway warming on body core temperature during adult liver transplantation.

15.  Study into in vivo suppression of HIV by antigen specific T cells derived from engineered hematopoietic stem cells.  Study carried out into an umbilical cord- derived mesenchymal stem cell transfusion in primary biliary cirrhosis.

16.  Functions of the liver  Causes of end stage liver disease  Diagnosis  Treatments  Clinical trials  Stem cells

17.  (1) Stanford Children’s Health, Anatomy and Function of the Liver. http://www.stanfordchildrens.org/en/topic/default?id=anatomy-and-function-of-the-liver-90- P03069 http://www.stanfordchildrens.org/en/topic/default?id=anatomy-and-function-of-the-liver-90- P03069  (2) http://open.jorum.ac.uk/xmlui/handle/10949/2518http://open.jorum.ac.uk/xmlui/handle/10949/2518  (3) John Hopkins Medicine, Liver Transplantation Procedure. http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/liver_transplantation _procedure_92,P07698/ http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/liver_transplantation _procedure_92,P07698/  (4) NHS choices, Liver Transplant – Why is it needed. http://www.nhs.uk/Conditions/Liver-transplant/Pages/Why-it-is-necessary.aspx http://www.nhs.uk/Conditions/Liver-transplant/Pages/Why-it-is-necessary.aspx  (5) Health Communities, Liver Disease Causes and Risk Factors. http://www.healthcommunities.com/liver-disease/causes.shtml http://www.healthcommunities.com/liver-disease/causes.shtml  (6) Blanchier M, Leleu H, Peck-Radosavljevic M et al. The Burden of Liver Disease. European Association for the Study of the Liver. 2013. http://www.easl.eu/assets/application/files/54ae845caec619f_file.pdf http://www.easl.eu/assets/application/files/54ae845caec619f_file.pdf  (7) Sutter Health, CPMC, MELD and the waiting list for liver transplantation. http://www.cpmc.org/advanced/liver/patients/topics/MELD.html http://www.cpmc.org/advanced/liver/patients/topics/MELD.html  (8) Botta F, Giannini E, Romagnoli P et al. MELD scoring system is useful for predicting prognosis in patients with liver cirrhosis and is correlated with residual liver function: a European study. GUT, An International Journal of Gastroenterology and Hepatology. 2013; 52(1): 134-139. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1773509/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1773509/  (9) Division of Transplant Surgery, Liver Transplantation. http://transplant.surgery.ucsf.edu/conditions--procedures/liver-transplantation.aspx http://transplant.surgery.ucsf.edu/conditions--procedures/liver-transplantation.aspx

18. (10) Cunningham P, Counihan A, Fitzmaurice A et al. National Organ Procurement Service Annual Report 2011. 2011. http://www.beaumont.ie/media/NationalOrganProcurementAnnualReport20111.pdf http://www.beaumont.ie/media/NationalOrganProcurementAnnualReport20111.pdf (11) British Liver Trust, Facts about liver disease. http://www.britishlivertrust.org.uk/media-centre/facts-about-liver-disease/ http://www.britishlivertrust.org.uk/media-centre/facts-about-liver-disease/ (12) Reddy ST, Thai NL, Fakhri AA et al. Exploratory use of cardiovascular magnetic resonance imaging in liver transplantation as a one-stop shop for preoperative cardiohepatic evaluation. 2013 Nov 15; 96(9):827- 33. http://www.ncbi.nlm.nih.gov/pubmed/23982342 http://www.ncbi.nlm.nih.gov/pubmed/23982342 (13) Troisi RI, Patriti A, Montalti R et al. Robot assistance in liver surgery: a real advantage over a fully laparoscopic approach? Results of a comparative bi-institutional analysis. 2013 Jun; 9(2):160-6. http://www.ncbi.nlm.nih.gov/pubmed/23526589 (14) Han SB, Gwak MS, Choi SJ et al. Effect of active airway warming on body core temperature during adult liver transplantation. 2013 Jan-Feb; 45(1):251-4. http://www.ncbi.nlm.nih.gov/pubmed/23375310 http://www.ncbi.nlm.nih.gov/pubmed/23375310 (15) Kitchen SG, Levin BR, Bristol G et al. In vivo suppression of HIV by antigen specific T-cells derived from engineered hematopoietic stem cells. 2012;8(4). http://www.ncbi.nlm.nih.gov/pubmed/22511873 http://www.ncbi.nlm.nih.gov/pubmed/22511873 (16) Wang L, Li J, Liu H et al. Pilot study of umbilical cord derived mesenchymal stem cell transfusion in patients with primary biliary cirrhosis. 2013 Aug; 28 Suppl1:85-92. http://www.ncbi.nlm.nih.gov/pubmed/?term=mesenchymal+stem+cell+transfusion+in+patients+with+pri mary+biliary http://www.ncbi.nlm.nih.gov/pubmed/?term=mesenchymal+stem+cell+transfusion+in+patients+with+pri mary+biliary