Liver Transplantation

INDICATIONS:
Children
  • Biliary atresia
  • Neonatal hepatitis
  • Congenital hepatic fibrosis
  • Alagille's disease"
  • Byler's disease
  • a 1 -Antitrypsin deficiency
  • Inherited disorders of metabolism
  • Wilson's disease
  • Tyrosinemia
  • Glycogen storage diseases
  • Lysosomal storage diseases
  • Protoporphyria
  • Crigler-Najjar disease type I
  • Familial hypercholesterolemia
  • Primary hyperoxaluria type I
  • Hemophilia
Aduts
  • Primary biliary cirrhosis(Hepatitis C)
  • Secondary biliary cirrhosis
  • Primary sclerosing cholangitis(PSC)
  • Autoimmune hepatitis
  • Carob's disease'
  • Cryptogenic cirrhosis
  • Chronic hepatitis with cirrhosis
  • Hepatic vein thrombosis
  • Fulminant hepatitis
  • Alcoholic cirrhosis
  • Chronic viral hepatitis
  • Primary hepatocellular malignancies
  • Hepatic adenomas
  • Portal hypertensive gastropathy
  • Nonalcoholic steatohepatitis
  • Familial amyloid polyneuropathy
  • Arteriohepatic dysplasia, with paucity of bile ducts, and congenital malformations, including pulmonary stenosis.
  • Intrahepatic cholestasis, progressive liver failure, mental and growth retardation
  • Multiple cystic dilatations of the intrahepatic biliary tree.
  • Unresectable disease
  • Hematochromatosis is also an indication for Liver Transplantation
  • 'Among genetic and metabolic conditions, Hematachroatosis is the most common reason for Liver Transplantation
  • Split liver transplantation: liver of deceased donor split into two (right lobe for an adult and left lobe is usually used for a child)
  • In adult-to-adult living donor liver transplantation, the right lobe of the liver is usually transplanted
  • Child-Pugh's classification is used to assess the status of pt. of liver cirrhosis.
  • A liver cirrhotic pt. having variceal bleeding or ascites can be controlled by shunt surgery only if he falls in Child­Pugh's 'A' class (or some pts. of B class). Moderate to severe grade liver insufficiency can only be managed by liver transplantation.
CONTRAINDICATIONS:
  • Cholangiocarcinoma has a high recurrence rate and is not an indication for transplantation
  • Other important contraindications: liver metastases, AIDS
Outcome after liver transplantation
  • Best results following chronic liver disease Following acute liver failure
  • High mortality in the early post-transplant period because of multi-organ failure
  • Those who recover have a very good long term allograft survival
  • Chronic rejection of any solid organ entails cellular injury to endothelial cells, resulting in intimal proliferation, fibrosis, and eventually, ischemic injury to the graft. Immunosuppressive therapy is directed at controlling lymphocyte activity and minimizing cellular rejection.
  • King's college criteria for orthotopic liver transplantation in acute liver failure

Paracetamol induced Non-paracetamol induced

  • pH < 7.30 irrespective of grade of encephalopathy OR
  • Prothrombin time(PT) > 100 s
  • +
  • Serum creatinine > 300μmol/L

  • PT > 100 s OR any three of the following
  • PT > 50 s
  • Age < 10 years or > 40 years
  • Etiology: non-A, non-B, halothane or idiosyncratic drug reaction
  • More than 7 days jaundice before encephalopathy
  • Bilirubin > 300μmol/L
  • Donor bile duct with recipient bile duct or Roux en Y choledochojejunostomy is the best way to get bile drainage in donor liver In orthotropic liver transplantation
 Exam Question
  • Hepatitis C is the Most common indication for Liver transplantation
  • Patient of hepatitis C treated with orthotopic liver transplantation which shows rising transaminase and bilirubin levels after an year should be given immunosuppresent to prevent T-lymphocyte mediated rejection injury to hepatic endothelial cells
  • Liver transplantation offers the only chance of cure in those with unresectable hepatocellular carcinoma
  • Donor bile duct with recipient bile duct or Roux en Y choledochojejunostomy is the best way to get bile drainage in donor liver In orthotropic liver transplantation The best available treatment for portal hypertensive gastropathy is Liver transplantation
  • Indications of Liver transplantation are Biliary atresia,Sclerosing cholangitis & Cirrhosis
  • According to Pugh's classification moderate to severe hepatic insufficiency is managed by liver transplantation
  • Liver transplantation was first done by Starzl
  • In late stage of PSC treatment is liver transplantation
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