Selecting Patients for Liver Transplantation: Who, When and Unusual Cases

Ahmet Gurakar, MD Johns Hopkins School of Medicine Medical Director, Liver Transplant Program Nov 26 , 20112 Florence Nightingale Liver Transplant Program Istanbul

LIVER TRANSPLANT TEAM

Transplant Hepatology-Patient Selection

-Maintenance on the list -New Policy Develop.

MICU-SICU-NCCUAnesthesia

Consultative ServicesCardio-Pulmonary-Nephro-Neuro-Psychology-Soc.W

Liver Transplant Surgery-Donor selection

-New Policy Develop.

Referral for Liver Transplantation Evaluation

Acute Liver failure ( ALF ) Complications of cirrhosis; i.e.

Encephalopathy, Ascites, Hepatorenal Syndrome, Bleeding from Portal Hypertension, all indicating a change in the Natural History of the Disease

Detection of HCC Consider referral at the first

appearance of the above complications, even in the presence of low MELD score

JG O’Leary, R Lepe. GL Davis. Gastro 2008:134:1764-1776

Expanding Indications for Liver Transplantation (OLT)

Metabolic Disorders: 1) Primary defect in the liver; a) Hepatic Complications: Wilson’s Disease,

A1AntiTrypsin Deficiency, Hereditary tyrosinemia I, Glycogen storage I/IV, PFIC(Byler Dis.), Arteriohepatic dysplasia(Alagille synd.), neonatal hemochromatosis

b)Extrahepatic Complications: FAP(Familiar Amyloidotic Polyneuropathy), Primary hyperoxaluria I, Crigler-Najjar I, Familiar hypercholesterolemia, Urea Cycle Defects, Hemophilia

2)Primary defect extra hepatic; a) May Recur: Hereditary Hemochromatosis, Gaucher,

Erytopoietic protoporphyria, NASH b) Curative for Hepatic component: Cystic Fibrosis Zhang KY Clin Liver

Dis 11(2007) 265-281

Expanding Indications for OLT

ALF ( Acute Liver Failure ): Hep A,B, DILI ( drug induced liver failure )

ESLD ( End Stage Liver Disease ):Hep B/C, ETOH, Autoimmune, PBC, PSC, Crytogenic/NASH, Secondary Biliary Cirrhosis)

Malignancy: a) Primary: HCC. uncommon forms; Fibrolamellar cancer, epitheliod hemangioendothelioma, hepatoblastoma

b) Metastatic: Carcinoid, Islet Cell

Misc: Polycystic Liver Disease, Budd-Chiari Syndrome ( with cirrhotic changes ).

Relative Contraindications to OLT

Advanced age Cholangiocarcinoma (undergoing study

with strict protocols to include chemotherapy, radiation and staging surgery)

HIV without AIDS ( under NIH protocol study ) HIV+HCV with less survival compared to HIV alone.

Portal Vein Thrombosis Psychological Instability BMI > 40 Ahmed A: Clin Liver Dis

11(2007):227-247

MELD in US

2007 UNOS

MELD Exceptions

Primary oxaluria: MELD: 16 Familial Amyloidosis (FAP): MELD: 16 Polycytic Liver /Kidney Disease:

MELD: 16 Hepatopulmonary Syndrome: MELD:

20 Post TIPS, persistant ascites and/or

pleural effusion: MELD: 16 Post TIPS Portal Hypertensive

Bleeding: MELD: 20 ( >4 Unit PRBC/month)

External drainage of a biliary stricture for more than 30 days: MELD: 20

3 episodes of Biliary Sepsis in 6 months: MELD: 20

Urea cycle defect : PELD: 20

MELD Exceptions (2)

JHH Adult Liver Transplant Cardiac Evaluation Protocol

• Low Risk Candidates:• Intermediate and High Risk Candidates: - High Risk: - Intermediate Risk: . Porto Pulmonary Hypertension (PPHTN ) . Hepato Pulmonary syndrome ( HPS ) . Annual Cardiovascular Assessment

Low Risk Candidates:

• 18-45 without risk factors will have a standard resting 2D ECHO

• >45 without risk factors will undergo resting 2D ECHO and dobutamine stress echocardiography to evaluate for obstructive coronary disease.

• (RVSP) as an estimate of pulmonary artery pressure

• (TAPSE) as an index of right ventricular function• ECHO Bubble Study if RA O2 SAT <93% or signs

of platypnea or orthodeoxia.

Intermediate Risk:

• History of coronary artery disease• History of compensated or prior heart failure• Diabetes• Renal Insufficiency• Peripheral arterial disease• Family history of premature coronary artery

disease or sudden death• Dyslipidemia• NASH• Heavy prior tobacco use

Cardiovascular issues post LTx

• Pre Tx Troponin 1 > 0.07, DM, CV Disease associated, with post LTX Cardiac events.

• Happens 25-70%• 7% mortality during early and

medium term • 3rd cause of Death • Detailed pre-LTx

Cardiovascular evaluation is warranted.

• CAC (Coronary Artery Calcium) Score has been anecdotal.

Pulmonary Hypertension:

• Confirmatory right heart catheterization will be performed in patients with a RVSP >50mmHg on resting echocardiogram.

Patients not needed to be seen by cardiologypreviously, a resting ECHO

Annual Cardiovascular Assessment

Patients seen by cardiology for preoperative consultation , after 12 months , will have a repeat resting ECHO and follow-up with the cardiology

Prevelance 5-32%

Post Transplant Metabolic Syndrome

Definition of Metabolic Syndrome (MT)

• BMI >30 or waist >102 cm in men and 88 cm among women.

• Fasting Plasma Glucose >100 mg/dl• BP > 130/85 mmHg• Triglycerides > 150 mg/dl• HDL < 40 mg/dl in men and < 50 mg/dl in

women

Waiting list candidates as of today 8:15pm

All 111,022

Kidney 88,585

Pancreas 1,361

Kidney/Pancreas 2,202

Liver 16,152

Intestine 264

Heart 3,133

Lung 1,772

Heart/Lung 67

Based on OPTN data as of 05/06/2011

The Organ Procurement and Transplantation Network (OPTN)

Organ Bağış Oranları (milyon nüfus başına)

http://optn.transplant.hrsa.gov/latestdata/rptData.asp

2010-USCadaveric Donor 6009 20

300.000.000 1.000.000Living Donor 282 0.94

300.000.000 1.000.000

2010 -TRCadaveric Donor 209 3

70.000.000 1.000.000Living Donor 486 7

70.000.000 1.000.000

Organ Procurement and Transplantation Network Liver Kaplan-Meier Patient Survival Rates For Transplants Performed : 1997 - 2004

Based on OPTN data as of May 6, 2011

Region DonorType

YearsPost

Transplant

Number Functioning /

AliveSurvival

Rate95%

ConfidenceInterval

U.S. Cadaveric 1 Year 13067 86.3 (85.7, 86.8)

U.S. Living 1 Year 823 90.1 (88.1, 92.1)

U.S. Cadaveric 3 Year 12836 78.0 (77.4, 78.6)

U.S. Living 3 Year 1070 82.5 (80.5, 84.6)

U.S. Cadaveric 5 Year 10424 72.0 (71.3, 72.7)

U.S. Living 5 Year 510 77.7 (74.6, 80.8)

KARACİĞER

Donör   Toplam

Canlı Kad. Sayı

77 82 159

33 53 86

133 112 245

200 124 324

205 114 319

264 209 473

390 212 602

364 229 593

486 209 695

2,152 1,344 3,496

2002

2003

2004

2005

2006

2007

2008

2009

2010

TOPLAM

NEGATIVE

Cardiopulmonary Exercise Testing

Stuart D. Russell, MD

Associate Professor of Medicine

Chief, Heart failure and Transplantation

Johns Hopkins Hospital

No disclosures related to this talk

Peak Exercise Tolerance as Measured by Peak Oxygen Consumption

VO2=Q x a-vO2 diff

10 25 40 55 70

Peak VO2 (mL/ kg/ min)

Masters-level Marathoner

Competitive Inline Skater

NFL (23 yo, All-Pro) Running Back

Healthy (20 yo)- untrained

Cardiac Transplant- untrained

Heart Failure- untrained

• •

CPX and liver transplant

Used AT > 9.1 ml/kg/min based on optimal ROCPrentis et al Liver Transpl 2012;18:152

Β coefficient Odds ratio (95% CI) P value

AT ml/kg/min 1.200 3.35 (1.37-8.19) < 0.001

Blood -0.095 0.91 (0.85-0.97) 0.002

FFP -0.006 0.94 (0.89-1.0) 0.02

Donor age -0.060 0.94 (0.88-1.0) 0.06

Univariate analysis

Multivariate analysis

AT ml/kg/min 1.344 3.84 (1.17-12.58) 0.02

Summary

Cardiac complications are common post liver transplant and are one of the most common causes of mortality and morbidity

Cardiopulmonary stress testing is a non invasive way of assessing risk of both morbidity and mortality post liver transplant

Small studies have demonstrated that rehab can increase peak VO2 in patients with liver disease

Unclear if exercise training pre transplant will alter outcomes

HEH

Hepatic epithelioid

hemangioendothelioma