1. Liver Transplantation for Alcoholic Liver Disease
David Orr
Hepatologist
NZLTU

2. Milestones in Transplantation
1948 ACTH and Corticosteroids
mercaptopurine
1957 Kidney Transplantation (Murray)
1963 Liver Transplantation (Starzl)
1967 Successful Liver Transplanatation (Starzl)
1979 Cyclosporine (Calne)
% 1 year survival (Calne)
1988 Living Related Liver transplant (Raia)
1994 Living donor R lobe (Yamaoka)
1997 Monosegmental Liver transplants (Rela) 2

3. Indications For LT Acute hepatic failure
Early graft failure (PGNF, HAT)
Late graft failure (CR, biliary cirrhosis, HAT, recurrent disease)
Chronic Liver disease
CPS> Severe bone disease (esp PBC/PSC)
Uncontrolled variceal bleeding Hepatopulmonary syndrome
Diuretic resistant ascites Portopulmonary hypertension
Chronic hepatic encephalopathy Hepatorenal syndrome
SBP HCC
Severe malnutrition Intractable pruritis
Metabolic liver disease

4. Acute Liver Failure Paracetamol Listing Criteria
(Poor prognosis criteria: survival <5%)
pH < 7.3 (after fluid resus) Or
Grade III – IV HE
INR > 8
Serum Cr > 300

5. Acute Liver Failure Non Paracetamol
INR > 8 (irrespective of HE grade) Or
3 of 5 Criteria
1. INR > 4
2. Age < 10 or >40
3. Aetiology: Drug induced or Non-A, Non-B
4. Bilirubin > 300
5. Jaundice to encephalopathy > 7 days

6. Acute Liver Failure Aetiology Viral: Hep A, B, E (Rare: HSV, EBV, CMV)
Drug: Paracetamol, Isoniazid/rifampicin,
NSAIDs, Valproate, carbamazepine,
Ecstasy, anaesthetic, phenytoin,
MAOIs

7. Acute Liver Failure Aetiology -AFLP, HELLP
-Wilson’s: Coombes neg hemolytic
anaemia, KF rings
-Amanita phalloides: severe diarrhoea
5 hr post ingestion, ALF 4-5/7
-AIH
-BCS
-Lymphoma
-Ischaemic hepatitis

8. Contraindications to LT
Relative Contraindications
Absolute Contraindications
Extrahepatic sepsis
Mod Pulm-HT (MPAP 35-
50mmHg)
No psychosocial support
Advanced cardiopulmonary
disease
PSMVT
HIV
Age > 75 years
Severe Pulm-HT (MPAP>
Substance abuse
AIDS
Extrahepatic malignancy

9. CADAVERIC ORGAN DONOR SHORTAGE
Waiting List Registrants
Donors
UNOS July 2001 3

10. Median Waiting Times: Liver Transplant by Blood Type

11. Current Allocation Schema
Severity of Illness (Status)
Allocation determined by:
Blood Type
Waiting time
Size

12. Live Donor Liver Transplant2

13. Living related liver transplant : Donor requirements
Unsolicited volunteer
Family member (not necessarily blood relative)
No clear medical contra-indications
Size appropriate
ABO matched
Age <50
Normal liver, HIV negative

14. Donor problems Biliary complications 6% Re-operation 5% Death <0.3%
Mean ICU Stay days
Hospital Stay days
Brown et al. AASLD 2001

15. Recipient Issues Retransplant rate 2.5% Acute liver Failure 2%
Biliary complications 23%
Arterial complications 8%
Brown et al. AASLD 2001

16. Common Problems after LT
Diabetes NODM 15%
Osteoporosis Increased risk in cholestatic liver diseases, long term steroids
Obesity
Hypertension CNI
Hyperlipidemia Sirolimus
Neurological Headache- CNI
Hematological Anaemia. HCV related
Viruses CMV, EBV, Herpes viruses
Malignancy Skin, all solid tumours, PTLD
Renal Failure CNI

17. What to watch for within the first week
Hepatic Artery thrombosis
Portal Vein thrombosis
Infections Bacterial/Viral/Fungal
Drug toxicity
Renal Impairment
Acute cellular rejection

18. Acute cellular Rejection
40-50% of recipients within 1st year post transplant
Mainly in first month
High AST/ALT/Alk phos
Peripheral eosinophilia
Diagnose on liver biopsy

19. Histology ACR

20. Infection post Transplant
Month 1
Nosocomial infection
Bacteria and fungi
19-28% of patients have bacteremia
Staph, Enterococcus (50-60%)
Month 2-6
CMV

21. CMV
Herpesvirus
Highest risk are recipients from CMV mismatch or Recipients of OKT-3/Thymoglobulin
Without prophyllaxis (oral Valganciclovir), risk of symptomatic disease 64%
Fever, leukopenia, hepatitis in up to 25%
Pneumonitis, GI infection
Predisposes: chronic rejection, worse HCV recurrence and fungal superinfection
Treat with iv Ganciclovir/oral Valganciclovir for 3 months

22. Biliary Complications “The Achilles heel of liver transplantation”
Late (> 30 days)
Anastomotic stricture
Nonanastomotic strictures
Bile leak on T tube removal
Sphincter of Oddi dysfunction
Early (< 30 days)
Anastomotic bile leak
Anastomotic stricture
Bile leak at T tube exit
Obstruction of T tube
Sphincter of Oddi dysfunction

23. Post LT Cholangiopathy

24. Disease Recurrence post transplant
HCV %
30% cirrhotic at 5 years
HBV % without prophylaxis
AIH/PBC/PSC %
NASH Up to 80%
Cholangiocarcinoma
HCC dependant on tumor size
Hemochromatosis

25. Primary Diseases of Recipients

26. Patient Survival
Survival (%)
Years post transplant

27. Causes of Death
ANZLT registry 2006.

28. Q & A Orthotopic liver transplantation:
a. better prognosis in adults than children
b. contraindicated in cholangiocarcinoma
c. liver not viable >12 hr after harvesting
d. external biliary drainage influences cyclosporin
dosage
e. outcome of Tx is independent of stage of liver
disease

29. Q & A A patient presents with hepatitis. ALT 3500
The least likely diagnosis
a. panadol od
b. alcohol
c. Budd Chiari
d. viral hepatitis
e. ischaemic hepatitis

30. Q & A
What is the best predictor for oesophageal variceal bleeding?   A. portal venous pressure B. Child Pugh Score C. Variceal size D. INR

31. Q & A
Female diacharged home after hemicolectomy. Husband brings her back 48 hours later with abdominal pain, jaundice, and anemia. What is the strongest predictor of increased mortality without liver transplant?   A. raised bilirubin B. raised creatinine c. Raised AST d. Raised ALT e. PT 160

32. Q & A
50 year old man with chronic liver disease with heaptitis B infection. Recent gastroscopy shows large oesophageal varicies. Alb 32 platelets 70 AFP 300 INR 1.4 CT shows localised mass in liver What is the best treatment/management?   A. Chemoembolisation B. Liver transplant C. RFA D. Cryotherapy E. local rescetion