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