Assessment of Graft Assessment of Graft Liver Function Liver Function During Liver During Liver

TransplantationTransplantation

SC SC 梁祥光梁祥光

What are we concerned aboutWhat are we concerned about

during liver transplantation?during liver transplantation?

Are the conditions of the patient Are the conditions of the patient stable?stable?

Does the transplanted liver work?Does the transplanted liver work?

What kinds of monitors orWhat kinds of monitors or

predictors are available? predictors are available?

For monitoring of vital signs:For monitoring of vital signs:

ECG, Swan-Ganz, CVP, A-line, ECG, Swan-Ganz, CVP, A-line, oximeter, oximeter,

electrolyte, acid-base, urine output, electrolyte, acid-base, urine output,

body temperature body temperature

With regard to liver function, With regard to liver function, whichwhich

predictors can be useful?predictors can be useful?

What are these ideas based on?What are these ideas based on?

The functions of the liverThe functions of the liver catabolic & anabolic functions catabolic & anabolic functions

(carbohydrate, (carbohydrate, fat & protein metabolism)fat & protein metabolism) production of bileproduction of bile production & execretion of bilirubinproduction & execretion of bilirubin immunological functions(cytokines & immunological functions(cytokines &

interferons)interferons) scavenging & filtration of endotoxins & scavenging & filtration of endotoxins &

bacteriabacteria storage of vitamin B12 & glycogenstorage of vitamin B12 & glycogen biotransformation & elimination of drugs biotransformation & elimination of drugs

& xenobiotics& xenobiotics

Ideal agentsIdeal agents nontoxic & lack pharmacological effectsnontoxic & lack pharmacological effects administrationadministration rate-determining steps of eliminationrate-determining steps of elimination route of eliminationroute of elimination measurementmeasurement protein-bindingprotein-binding costcost reliable assayreliable assay generally availablegenerally available Gao L et al, Anaesth Intens Care 2000; 28: 375-Gao L et al, Anaesth Intens Care 2000; 28: 375-

8585

Predictors or markers of liver Predictors or markers of liver functions(1)functions(1)

HepatologistHepatologist prothrombin ratioprothrombin ratio plasma enzymes(GOT, GPT)plasma enzymes(GOT, GPT) bilirubinbilirubin albuminalbumin

Predictors or markers of liver functions(2)Predictors or markers of liver functions(2)AnaesthetistAnaesthetist capacity-limited, binding-insensitive capacity-limited, binding-insensitive

hepatic eliminationhepatic elimination neuromuscular blocking agent, neuromuscular blocking agent,

aminopyrine, aminopyrine, caffeinecaffeine capacity-limited, binding-sensitive capacity-limited, binding-sensitive

hepatic eliminationhepatic elimination erythromycinerythromycin flow-limited eliminationflow-limited elimination ICG, galactoseICG, galactose

J. W. Sear, Br. J. Anaesth. 2002 88: 757-760.J. W. Sear, Br. J. Anaesth. 2002 88: 757-760.

ICGICG 95% albumin-binding 95% albumin-binding liver function & blood flowliver function & blood flow IV injection(0.5mg/kg), blood sample(2ml IV injection(0.5mg/kg), blood sample(2ml

at at 5min intervals for 15-30min)5min intervals for 15-30min) ICG elimination rate & graft liver functionICG elimination rate & graft liver function ICG clearance>200mi/minICG clearance>200mi/min good liver functiongood liver function ICG clearance<200mi/minICG clearance<200mi/min death, prolonged intensive care, death, prolonged intensive care, retransplantationretransplantation

Gao L et al, Anaesth Intens Care 2000; 28: 375-85Gao L et al, Anaesth Intens Care 2000; 28: 375-85

Rocuronium(1)Rocuronium(1)Aminosteroidal muscle relaxantAminosteroidal muscle relaxant

EliminationElimination

Major(80%): liverMajor(80%): liver

Minor: kidneyMinor: kidney

Metabolite: 17-desacetylrocuroniumMetabolite: 17-desacetylrocuronium

AssayAssay

train-of-fourtrain-of-four

gas chromatographic-mass gas chromatographic-mass spectrometryspectrometry

L Gao, Br. J. Anaesth. 2002 88: 764-770L Gao, Br. J. Anaesth. 2002 88: 764-770

Rocuronium(2)Rocuronium(2)

What is observed in the administration of What is observed in the administration of rocuronium?rocuronium? pleohepatic phasepleohepatic phase rocuronium’s clearance is slightly less rocuronium’s clearance is slightly less

than that of patient with liver disease than that of patient with liver disease undergoing nontransplantation surgery undergoing nontransplantation surgery and healthy control subjectsand healthy control subjects

anhepatic phaseanhepatic phase rocuronium’s clearance is similar to that rocuronium’s clearance is similar to that

in the pleohepatic phasein the pleohepatic phase Dennis M Fisher et al, anesthesiology 1997; 86:1306-16Dennis M Fisher et al, anesthesiology 1997; 86:1306-16

Rocuronium(3)Rocuronium(3) neohepatic phaseneohepatic phase

decreased plasma rocuronium decreased plasma rocuronium concentration compared with that concentration compared with that during the anhepatic phaseduring the anhepatic phase

L Gao, Br. J. Anaesth. 2002 88: 764-770L Gao, Br. J. Anaesth. 2002 88: 764-770

Rocuronium(4)Rocuronium(4) postoperative outcomepostoperative outcome

Fig 1Fig 1 Percentage change in plasma recuronium concentration Percentage change in plasma recuronium concentration between between

neohepatic and anhepatic phases in patients who died neohepatic and anhepatic phases in patients who died after after

surgery and those who survived. surgery and those who survived.

L Gao, Br. J. Anaesth. 2002 88: 764-770L Gao, Br. J. Anaesth. 2002 88: 764-770

What can we do in the future?What can we do in the future?

Prediction of prognosis?Prediction of prognosis?↓↓

Sensitivity and specificity?Sensitivity and specificity?↓↓

D/D(surgical procedure, rejection)?D/D(surgical procedure, rejection)?↓↓

Management?Management?↓↓

Outcome?Outcome?

Thanks for your attention!Thanks for your attention!