Lecture 42: Liver Transplant and Hepatocellular carcinoma Flashcards
What are the indications for transplant?
- HCV
- HBC
- Alcohol
- Cholestatic
- Cryptogenic/NASH
- Variceal bleed
- ascites
- hepatorenal syndrome
- Hepatic encephalopathy/dysfunction
What is Status 1A?
People who would die in 7 days if they don’t get a liver transplant
Acute Wilson’s disease or fulminant liver failure (from acetaminophen overdose)
Why is MELD better than CTP prediction of mortality?
More objective (3 lab tests) Also 35 different scores for MELD vs. 3 for CTP
What are mechanisms for cases that are exceptions to MELD?
Regional Review Boards review these cases to determine if an exception should be made
What is a liver transplant?
4 hook ups (aka 4 anastomoses)
Donor recipient hook up of bile duct, portal vein, hepatic artery, hepatic vein
What are the two most common types of cholestatic disease?
- PBC
2. PSC
What helps determine survival after transplant?
The MELD score
MELD score can also help predict net benefit of transplant
What are the 3 most common indications for liver transplant?
- HCV
- Alcohol
- Cholestatic liver disease
What are the mechanisms that allow one to bypass the MELD score?
. MELD exception points are used to account for situations when the MELD does not adequately predict likelihood of death on the waiting list
Is there a survival difference between living donor and deceased donor liver transplant?
Living Donor transplant is associated with similar survival as deceased donor liver transplant
What are exceptions for MELD?
- HCC
- Hepatopulmonary syndrome
- Hilar cholangiocarcinoma
- CF
- FAP
- Primary hyperoxaluria
- Portopulmonary Syndrome
These diseases are causing shit outside of liver
What % of patients will die awaiting liver transplant?
10-20%
What is a liver donor liver transplant?
Transplanting only a PART of the liver from a living donor
Complications are minor, but much higher than kidney so they need to make sure the person is not being paid…
What are the characteristics of HCC?
Most common type of primary liver cancer
80-90% occur in cirrhosis (from HBV and HCV)
What are risk factors for HCC?
- cirrhosis (use ultrasound to screen)
- HBV
- Aflatoxin B1 (mycotoxin of aspergillus species)
What is the significance of Aflatoxin B1?
A mycotoxin of aspergillus species
Causes mutation in p53 tumor suppressor gene
Risk factor for HCC
Aflatoxin + HBV is dramatically increased risk for HCC
How do you make diagnosis of HCC?
Usualy asymptomatic until too late
Need to screen with Ultrasound
Also can make a diagnosis based on BLOOD FLOW
How can you use blood flow to diagnose HCC?
Normal liver will get blood from portal vein AND hepatic artery
Tumors, however, will get 100% of their blood flow from hepatic artery
Seeing “delayed wash out” in MRI will be diagnostic of HCC
What is death caused by in HCC?
Death is caused by liver failure and NOT metastasis
What are the nonsurgical therapies for HCC?
Transarterial chemoembolization (TACE)…shooting chemo through hepatic artery Radiofrequency ablation (RFA)…cooking the tumor
What chemotherapy is used for HCC?
Sorafenib
Blocks VEGF to halt the tumor growth
What is the MoA of Sorafenib?
Targets VEGF and prevents HCC growth
What is the significance of hemodynamic difference between HCC and surrounding liver?
Differences in hemodynamics (blood flow) between HCC and surrounding liver allow for
1. Diagnosis WITHOUT biopsy (CT or MRI) 2. Selective treatment (TACE)
What is best shot of long term cure for HCC?
Best shot at a long term cure for HCC is with liver transplant
