Perioperative Management of Liver Tranplant Patients

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Unformatted text preview: Perioperative Management of Liver Transplant Patients of January 22, 2007 Geoffrey Schultz, MD Topic Objectives Topic 1. Overview of indications & selection for liver transplantation. 2. Identification & treatment of complications associated with liver disease in the preoperative period. 3. Identification & treatment of complications following orthotopic liver transplantation. 4. Induction of immunosuppressive pharmacotherapy following transplantation. 5. Diagnosis & treatment of graft rejection. Orthotopic Liver Transplantation Orthotopic 1st orthotopic liver transplantation 1963. Approximately 5,000 orthotopic liver transplantations annually for 17,000 in need. Indications for Liver Transplantation in Adults: Indications Etiologies of End-Stage Liver Disease 1. Fulminant Hepatic Failure 2. Alcoholic Liver Disease 3. Chronic Hepatitis C 4. Chronic Hepatitis B 5. Non­alcoholic steatohepatitis 6. Autoimmune Hepatitis 7. Primary Biliary Cirrhosis 8. Primary Sclerosing Cholangitis 9. Hepatic tumors 10. Metabolic and genetic disorders Indications for Liver Transplantation in Adults Indications Presence of irreversible liver disease and a life expectancy of less than 12 months with no effective medical or surgical alternatives to transplantation Chronic liver disease that has progressed to the point of significant interference with the patient's ability to work or with his/her quality of life Progression of liver disease that will predictably result in mortality exceeding that of transplantation (85% one­ year patient survival and 70% five­year survival) Manifestations of End-Stage Liver Disease Manifestations Progressive jaundice Intractable ascites Spontaneous bacterial peritonitis Hepatorenal Syndrome Encephalopathy Variceal bleeding Intractable pruritus Chronic fatigue (such as resulting in loss of gainful employment) Bleeding diathesis or coagulopathy Selection Criteria for Organ Allocation Selection United Network for Organ Sharing (UNOS) governing body for organ allocation utilizes MELD score. Model for End Stage Liver Disease (MELD) Score • 0.957 x loge (creatinine) + 0.378 x loge (bilirubin mg/dL) + 1.12 x loge (INR) + 0.643 x 10 • Range from 10 to 40 • Special considerations, amendments for HCC, renal failure. Preoperative management of complications associated with hepatic failure & decompensated cirrhosis decompensated Hepatic Encephalopathy Cerebral Edema Acute Renal Failure Infection & Sepsis Metabolic Derangements Malnutrition Coagulopathy Portal Hypertension Hepatic Encephalopathy Hepatic Etiology: Attributed to increased serum ammonia levels secondary to metabolism of nitrogenous substances in the gut. Symptoms: Range from euphoria to coma. Treatment: lactulose, decreased intake of nitrogen containing compounds, oral neomycin. Cerebral Edema Cerebral Etiology: Unknown Swelling of brain results in increased ICP & herniation. Invasive monitoring with goal of ICP < 20 mmHg & CPP > 50 mmHg. Treatment: Anxiolysis, HOB elevation, hyperventilation, avoidance of overhydration, mannitol diuresis, HD if compromised renal function. Acute Renal Failure Acute Etiology: Toxin induced, Derangements in systemic & intrarenal hemodynamics. Treatment: Prevention of hypotension, treatment of infection, avoidance of nephrotoxic agents. Once established, renal failure in this setting is often irreversible. Early utilization of renal replacement therapy is indicated. Infection & Sepsis Infection Etiology: Immunologic derangements including complement deficiency, reduced opsonins, WBC dysfunction. Treatment: Frequent cultures, including ascites. Broad spectrum antibiotics, including anti­fungals. Metabolic Derangements Metabolic 1. Hypokalemia • Increased sympathetic tone promotes cellular uptake of K. Decreased serum K promotes production of ammonia by the kidney. 2. Hyponatremia 3. Hypoglycemia • Secondary to decreased hepatic glycogen stores & decreased gluconeogenesis. Coagulopathy Coagulopathy Etiology: Compromised synthetic function, deficiency of coagulation factors, platelet dysfunction. Contribute to GI bleeding in conjunction with portal hypertension. Treatment: Prevention with H2 blockers, PPI. Judicious use of Factor VIIa & FFP. Post-operative complications & management of liver transplant patients management Right pleural effusion • May affect ventilation, necessitating drainage. Hepatic edema secondary to aggressive resuscitation & increased intravascular volume. • Goal CVP 6­10. Minimize increased hepatic vein pressures, sinusoidal congestion that impair graft perfusion & exacerbate reperfusion injury. Post-operative complications & management of liver transplant patients management Renal failure • Elevation of creatinine & BUN observed in nearly all transplant patients secondary to ATN, hepatorenal syndrome. Usually self­ limiting. May necessitate therapy with loop diuretics, renal replacement therapy. Post-operative complications & management of liver transplant patients management Electrolyte Derangements • Recovering graft increases demand for magnesium & phosphorous. • Transfusion of citrate rich blood products results in decreased serum magnesium & calcium. • Rapid correction of chronic hyponatremia with isotonic solution can have severe neurological consequence. Judicious use of hypotonic solutions with goal of serum Na 125­130 advised. Post-operative complications & management of liver transplant patients management Thrombocytopenia • Preoperative portal hypertension results in splenomegaly & platelet sequestration. Generally improves as graft recovers. May necessitate replacement if bleeding is encountered or invasive procedures are planned. Splenectomy is rarely indicated. • Platelet dysfunction secondary to renal & hepatic failure may be improved acutely with DDAVP. Post-operative complications & management of liver transplant patients management Biliary leak • RUQ pain, fever, persistent elevation of bilirubin, liver enzymes. Biloma on CT. Treated with endoscopic stent, percutaneous drainage. Possible surgical revision if duct is ischemic. Hepatic artery thrombosis • Persistent elevation or increasing liver enzymes, poor graft function. Diagnosed with U/S, CT angiography, MRA. Treated with immediate revascularization. Induction of Immunosuppression Induction Triple therapy • Calcineurin inhibitor (tacrolimus, cyclosporine), anti­proliferative agent (mycophenolate), corticosteroid taper. • Initiated immediately following transplantation. • Levels followed daily in immediate post­operative period & with decreasing frequency once stabilized in desired range. Agents vary according to etiology of liver disease. • Thymoglobulin & Hb Ig utilized in hepatitis patients along with entecavir & prograf to limit viral replication & to avoid coritocsteroid usage. Allograft rejection Allograft Hyperacute rejection • Secondary to preformed Ab to graft antigen. Extremely rare. Necessitates retransplantation. Acute Cellular Rejection • 70% of patients 5 to 14 days following transplant. • Heralded by fever, jaundice, elevation of liver enzymes. • Diagnosed by liver biopsy. Demonstrates endothelialitis & non­suppurative cholangitis. Althaus SJ, Perkins JD, Soltes G, Glickerman D. Use of a Wallstent in successful treatment of IVC obstruction following liver transplantation. Transplantation. 1996 Feb 27;61(4):669­72. Kim BW, Won JH, Lee BM, Ko BH, Wang HJ, Kim MW. Intraarterial thrombolytic treatment for hepatic artery thrombosis immediately after living donor liver transplantation. Transplant Proc. 2006 Nov;38(9):3128­31. Cotler, Scott J, MD UptoDate Treatment of acute cellular rejection in liver transplantation Brown, Robert S., MD, MPH, Dove, Lorna M, MD, MPH UptoDate Patient selection for liver transplantation Eric Goldberg, MD, Sanjiv Chopra, MD UptoDate Overview of the treatment of fulminant hepatic failure Bussutil RW, Klintmalm GB, Transplantation of the Liver, WB Saunders Company, Philadelphia. 1996 Peter J. Friend; Charles J. Imber Transplantation Immunology. Current Status of Liver Transplantation pp. 29 – 46, MAR 2006 http://med.stanford.edu/shs/txp/livertxp ...
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