1. Liver Transplantation Philip Goodney, MD June 22, 2005

2. Format Question and Answer (multiple choice) Review of reading in Sabiston Chapter

3. List ‘em Name the most common indications for liver transplantation, in order, for adults and children.

4. List ‘em TABLE 27-1 -- Indications for Liver Transplantation AdultsChildren Noncholestatic cirrhosis65Biliary atresia58 Viral hepatitis B and C Inborn errors11 Alcoholic ** Cholestatic9 Cryptogenic PSC Cholestatic14Alagille’s sy Primary biliary cirrhosis 4 PSCViral hepatitis2 Autoimmune5Miscellaneous16 Malignant neoplasm2 Miscellaneous14 Autoimmune

5. True or False The number of cadaveric donors has changed dramatically over the last 13 years

6. True or False The number of cadaveric donors has changed dramatically over the last 13 years False

7. Question What two kinds of information are used in the Child-Turcote-Pugh Score of Severity of Liver Disease ?

8. Question What two kinds of information are used in the Child-Turcote-Pugh Score of Severity of Liver Disease ? –Clinical symptoms (encepholopathy, ascites, PSC/PBC) –Lab data (albumin, PT)

9. Question What three variables does the MELD score take into account?

10. Question What three variables does the MELD score take into account? –Bilirubin –INR –Creatinine

11. Question: If you were going to Foxwoods, and you had to bet on a patient’s survival with end-stage liver disease, who would you rather rode shotgun: Mr. MELD or Mr. CTP? Why?

12. Question: Mr. MELD, baby (MELD = model of end-stage liver disease) TABLE 27-3 -- Concordance with 3-Month Mortality: MELD and CTP ScoreConcordance 95% Confidence Interval Model for End-Stage Liver Disease (MELD) 0.880.85, 0.90 Child-Turcote-Pugh (CTP)0.790.75, 0.83

13. Question Which of the following are absolute contraindications to liver transplantation? –Active sepsis –Extrahepatic malignancy –HIV –Portal vein thrombosis –HCC

14. Question What type of virus is hepatitis B?

15. Question What type of virus is hepatitis B? hepandnavirus

16. Question Which of the following are absolute contraindications to liver transplantation? –Active sepsis –Extrahepatic malignancy –HIV –Portal vein thrombosis –HCC

17. Question You’ve had chronic hepatitis B for 25-30 years and you have now begun to show clinical symptoms of cirrhosis. Imaging demonstrates a nodular liver with a mass. What is the likely diagnosis?

18. Question You’ve had chronic hepatitis B for 25-30 years and you have now begun to show clinical symptoms of cirrhosis. Imaging demonstrates a nodular liver with a mass. What is the likely diagnosis? Hepatocellular carcinoma

19. Question: You go back in time 25 years. You wish to be treated for your HBV. What is the treatment, and what is the chance that it may lead to remission?

20. Question: You go back in time 25 years. You wish to be treated for your HBV. What is the treatment, and what is the chance that it may lead to remission? Interferon alpha 2b. 40% remission rate

21. Question: Because you are a big baseball star, you get a liver transplant even though you have chronic HBV. What are the treatments to keep you from infecting your graft?

22. Question: Because you are a big baseball star, you get a liver transplant even though you have chronic HBV. What are the treatments to keep you from infecting your graft? High titer G +/- lamivudine

23. Question What infection can accelerrate the cirrhosis that accompanies ETOH abuse?

24. Question What infection can accelerrate the cirrhosis that accompanies ETOH abuse? HCV

25. Match ‘em PSC PBC Pruritis Jaundice Elevated Alk phos Damage to large bile ducts Damage to small intrahepatic ducts Associated with IBD Associated with cholangiocarcinoma Liver failure Does well with transplantation

26. Match ‘em Pruritis (both) Jaundice (both) Elevated Alk phos (both) Damage to large bile ducts (PSC) Damage to small intrahepatic ducts (PBC) Associated with IBD (PSC) Associated with cholangiocarcinoma (PSC) Liver failure (both) Does well with transplantation (both)

27. Question What 3 factors make it likely that a patient with HCC will benefit from liver transplantation?

28. Question What 3 factors make it likely that a patient with HCC will benefit from liver transplantation? Low grade tumor Tumor <5cm Limited multifocality of tumor (No macrovascular invasion too)

29. Question What are the characteristics of a marginal / expanded criteria donor?

30. Question What are the characteristics of a marginal / expanded criteria donor? –Older donors (age up to 75!!) –Hep c +, hep B core + –Steatosis of liver graft

31. Question What variables are considered when matching donor and recipient?

32. Question What variables are considered when matching donor and recipient? ABO (can be crossed if urgent) Size Age (for pedi patients)

33. True or False Dr. Dow will think it is really cool if you take the hepatic veins off the donor’s cava when recovering your first liver in our new transplant program.

34. True or False Dr. Dow will think it is really cool if you take the hepatic veins off the donor’s cava when recovering your first liver in our new transplant program. False

35. Road Map Describe the purpose and path of circulation of veno-venous bypass

36. Road Map Describe the purpose and path of circulation of veno-venous bypass –Inflow: portal and femoral veins –Outflow : IJ 2.5 L/min Control of body temperature (Rewarming) Cvvh during the case ? If it matters

37. Question How long does it take for a recipient of a split liver Right lobe to achieve a “standard” liver mass equivalent?

38. Question How long does it take for a recipient of a split liver Right lobe to achieve a “standard” liver mass equivalent? Only 1 month!!

39. Question Name the possible operative complications that can occur in liver transplantation.

40. Question Name the possible operative complications that can occur in liver transplantation. –Bleeding (page me) –Portal vein thrmobosis (may use collaterals) –Hepatic artery reconstruction –Primary nonfunction

41. Question How common is primary non-function?

42. Question How common is primary non-function? –2-3% –Hemodynamic instability –MSOF –Encephalopaty –Rx: retransplantation

43. Question How is a definitive diagnosis of acute rejection made? How is it treated?

44. Question How is a definitive diagnosis of acute rejection made? How is it treated? Liver bx -- demonstrate the presence of periportal lymphocytic infiltrate that extends into the liver parenchyma, as well as the invasion of inflammatory cells into the vascular endothelium. --corticosteroids. More potent monoclonal or polyclonal anti–T-cell antibodies are effective against corticosteroid-resistant rejection, leading to the reversal of the acute episode in more than 90% of the recipients

45. Question What is “vanishing bile duct” syndrome?

46. Question What is “vanishing bile duct” syndrome? Manifestation of chronic rejection Poorly understood Candidates for re-transplantation

47. Statistics What is the 10 year survival of patients with liver transplantation, based on 30,000 UNOS patients? Adults vs. Kids?

48. Statistics What is the 10 year survival of patients with liver transplantation, based on 30,000 UNOS patients? Adults vs. Kids? Adults: 59% px survival, 51% graft survival Pedi: 78% px survival, 63% graft

49. Survival

50. Thanks for listening! Have a great day!