Liver Transplant

Question 1

Indications (8)

Answer 1

• Ascites
• Spont bacterial peritonitis
• Variceal hemorrhage
• Portosystemic encephalopathy
• Severe metabolic bone disease
• Severe pruritus
• Malnutrition
• Malignancy

Question 2

Contraindications (5)

Answer 2

• Extra-hepatic malignancy
• Active alcohol or substance abuse
• Active infection
• Severe co-morbid disease
• AIDS (not HIV)

Question 3

How does UNOS work?

Answer 3

• Allocate w/in region of liver by urgency (level 1 highest)
• If no candidates in given region then offer to other regions
• MELD score (meas of 3 month mortality)
  
  • Must be at least 7 to list
  • Max is 40
• If hepatocellular carcinoma … those that meet certain size and tumor number criteria start at 20
• Acute liver failure w/o pre-existing disease = status 1

Question 4

Alternatives

Answer 4

• Reduced size
• Split-liver
• Extended- use
  
  • HCV + donor to HCV + recipient
  • Hep B core ab + donors
  • Accept more fat than usual
  • Older donors > 65
• Living donor liver transplant
  
  • L lobe to children; R lobe to adults
  • Risk of biliary leak in donors

Question 5

3 Phases of Rejection

Answer 5

Hyper-Acute (hrs to days)

• RARE
• see ischemic injury, hepatocyte loss, vascular thrombosis
• HUGE inc in all (ALT/AST, bilirubin, ALP)
• *Treat w/ re-transplant

Acute (5-7 days)

• Bile duct infiltrate and injury
• Portal and hepatic vein endophlebitis
• Moderate inc in ALP and bilirubin; mild inc ALT/AST
• *Treat w/ steroids and OKT3

Chronic (wks - yrs)

• Early lymphocytic then bile duct paucity –> vanishing bile duct syndrome
• HUGE inc ALP and Bilirubin; mild inc ALT/AST
• *Treat w/ tacrolimus or re-transplant

Question 6

4 Types of Drugs to Prevent Liver Rejection

Answer 6

• Steroids - block IL-1 stimulation of T cells
• Cyclosporine and Tacrolimus - interfere w/ IL-2 production and CD4+ self-amp
• Aza and mycophenolate - inhibit T cell proliferation and differentiation
• Anti-thymocyte globulin & muromonob (OKT3) - antibodies against activated T cells

Question 7

Rejection Med Side Effects

Answer 7

• Tacrolimus, cyclosporine, steroids - hyperlipidemia, DM, obesity, HTN, bone disease
• Malignancy - from squamous cell carcinoma or colon cancer