Transplantation



Transplantation





(Hepatology. 2005;41:1-26)


REFERRAL:



  • Decision ultimately rests with the transplant center



    • Transplant when the natural history of liver disease suggest a better survival with transplant


  • United Network for Organ Sharing (www.UNOS.org): develops minimum criteria for listing


  • Evaluate for listing when Child-Pugh ≥7 (B) or MELD ≥10, or evidence of decompensation (i.e. GI bleed, PSE, Ascites)


INDICATIONS:



  • Acute liver failure/Fulminant hepatic failure (7%): These patients are assigned the highest priority (called Status 1)



    • Cryptogenic, HAV, HBV, Drug induced (acetaminophen), Metabolic (Wilson’s), Vascular (ischemia), Toxin (Amanita)


  • ESLD: Cirrhosis with liver failure (80%); Those with Child-Pugh ≥7 (B) or MELD ≥10-15 should be considered for transplant



    • HCV (50% of the 80%), ETOH, HBV, Autoimmune, PBC, PSC, NASH, Budd-Chiari, Sarcoid, Polycystic liver disease, Cryptogenic


  • Congenital:



    • Hemochromatosis, Wilson’s, α1-AT, Cystic fibrosis, Congenital hepatic fibrosis, Oxylosis, Hereditary/Familial amyloidosis


  • Hepatic Tumor (10%):



    • Hepatocellular carcinoma (HCC): can be associated with: HBV, HCV, Heriditary Hemochromatosis, NASH with Cirrhosis



      • Milian Criteria (represent those acceptable to transplant): 1 tumor <5 cm, 2 or 3 tumors <3 cm; No metastasis


    • Hepatic adenoma, Carcinoid tumor


  • Other: Recurrent or severe encephalopathy, Refractory ascites, SBP, Recurrent variceal bleeding

    Hepatorenal syndrome

    Bilirubin >10 mg/dl, Albumin <3 g/dl, PT >3 sec above control


CONTRAINDICATIONS:



  • Absolute:



    • Uncontrolled sepsis/infection, Active ETOH/Substance abuse, Extrahepatic malignancy, Inadequate social support


    • Hepatocellular carcinoma (see Milian criteria, above); Extensive portal and/or mesenteric vein thrombosis


    • Severe comorbidities: advanced cardiac disease (CAD, CHF, Cor pulmonale), Advanced HIV/AIDS


  • Relative (depends on severity of conditions and experience of center)



    • Cholangiocarcinoma, Pulmonary hypertension (uncontrolled), Previous extensive abdominal surgery, Advance age (?)


    • Thrombosis: Portal vein, Hepatic artery; HIV/AIDS infection


EVALUATION/SCORING: The sickest first …

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Aug 24, 2016 | Posted by in GASTROENTEROLOGY | Comments Off on Transplantation

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