Liver transplant Flashcards
Liver transplant - PRIC MCP?
P: primary disease, decompensation, complications MELD score, indication, deceased/living/orthotopic vs. split,/ABO/CMV.
Type of operation: duct to duct vs. Roux-en-Y
Note - Liver are not HLA matched.
R: RF for complications - prolonged ischaemic time, early rejection, compliance, return to ETOH
I: any recent biopsy, imaging (US/CT/MRCP/ERCP/stenting - biliary strictures)
Complications:
- Transplant: peri/post-op complications, acute/chronic rejection/graft failure, hepatic artery thrombosis, portal/hepatc vein stenosis/obstruction, biliary stricture
- Disease:* recurrence
- Drugs: Metabolic, Infection (CMV, PCP, Fungal), Malignancy, Bone, Rejection + Hirsuitism/gingival hypeplasia, poor wound healing
M: current ImmSx regime, previous regime, infection prophylaxis, any recent changes in regime/dose and why. Steroid history.
How are drug metabolic complications Mx?
C: current problem, hospital admissions, how often is te F/U? How is patient/family coping? How is work affected?
P: insight
What is the prognosis of Liver transplant (1-y)
75%
What are the indications for liver transplant? (4)
End-stage Liver disease who had life-threatening episode of decompensation or QOL had become unbearably reduced.
- Child-Pugh >6
- MELD >10
- Episode of Variceal bleeding, SBP or grade II encephalopathy
What are contraindications of Liver transplant?
Think top down:
General: active infection (including HIV, biliary infection), or incurable/advanced malignancy, continuing ETOH consumption.
Head: Significan psychiatric issues, non-adherence history, lack of social support.
Chest: Severe Cardio-respiratory disease that cannot be corected and is a risk for surgery, intra-pulmonary shunting, severe porto-pulmonary HTN
Abdo: Cholangiocarcinoma, Anatomic abnormaliies (e.g. prior complex HPB surgery), Vessel problems (PVT, previous porto-caval shunt (TIPSS is ok))
Renal: severe renal disease
What are immediate (post-op) complications of liver transplant? (5)
Primary graft non-function/failure
Technical problems (bleeding, thrombosis [HA,HV,PV], bile leak)
Acute CELLULAR rejection
Sepsis
Renal failure
What are medium-long term complications of liver transplantation?
Specific to Liver
Biliary Stricture
Hepatic artery stenosis/thrombosis
General complicaitons of any transplant
Rejection (acute or chronic)
Recurrence of primary disease
Infection: CMV, PCP, fungal
Metabolic: DM, HTN, Lipid, OP, weight gain
Malignancy: PTLD, skin, solid
Renal failure
Medication specific: CNI (neuropathy, CsA - hirsuitism, GH), Pancreatitis (AZA), Sirolimus (BM suppression, Hepatic artery thrombosis, impaired wound healing)
Pre-transplant work-up for Liver transplantation?
Assess disease severity & complications
- LFTs and synthetic function
- Decompensation: HE, SBP, varices
- Symptoms: pruritis++ severely affecting QOL
- MELD >10
- Milan criteria (if HCC)
Assess for Cardio-pulmonary fitness
- Cardiac: ECG, TTE with bubble study [assess for shun ?HPS], dobutamine ECHO or MIBI
- Resp: ABG, Spirometry, PFT, 6MWT
Assess for vascular anatomy and HCC
- Triple phase CT for above
- Rule out HCC mets - bone scan, CT chest, CTB
Fitness for post-transplant care
- Infection risk: HIV, Hep B/C, CMV
- Assess for malignancy
- Psychosocial evaluation: support/carer, coping skills, substance use, motivation, insight.
What is your regime of prophylaxis post transplant depending on CMV status?
R +ve/ D +ve
R –ve/ D +ve
R-ve/ D -ve
Oral valganciclovir daily for 3/12
Oral valganciclovir daily for 6/12
Monitoring only
How would you manage CMV disease?
Antiviral: IV Ganciclovir for 1-2 weeks followed by 3 months of PO Valganciclovir.
When is the anti-fungal prophylaxis is indicated in liver transplant? (3)
Most common infection is Candida. Prophylaxis is with Fluconazole.
Patients with long-term ABx use before transplant
Acute Liver failure
Complicated surgery
What is the dose regime of Bactrim in PCP prophylaxis?
Double strength 1/2 tablet 3 times/week
Liver transplant examination? (5)
Clubbing & Hypertension
Stigmata of chronic prednisolone use: candida, echymoses, cushingoid
No features of decompensation: flap & ascites
No Jaundice & Graft tenderness to suggest possible rejection or biliary stricture.
There was no signs of cyclosporin associated CNS toxicity with unremarkable Neurological examine
What are DDx of fever in Liver transplant patient? (5)
Biliary tract stricture/cholangitis
CNS infection (especially fungal)
Hepatitis
Viral infection (CMV, HSV, VZV)
Pneumonia and UTI
What are the long-term complications of Liver transplant and how would you manage them? (general + specific to liver transplant)
Goals: mainain graft function, prevent rejection and complications of immunosuppression - namely, infection, OP, malignancy, metabolic side effects and opimisation of vascular risk factors.
Rejection & Renal impairment
- Monitor: graft tenderness, CNI levels, LFTs and EUCs
- Biopsy if evidence of graft dysfunction
- If confirmed pulse of methylpred + increase background ImmSx
Infection (including PCP, CMV, fungal)
- Monitor: CNI levels to ensure not over-immunosuppressed, inflamatory markers, FBC for leukopaenia/atypical lymphocytes (CMV), consider CXR, urine and CMV PCR depending on presentation.
- Non-pharm: educate, hygiene, vaccinate, low index of suspicion for infection & promp antimicrobials
- Pharm: Bactrim, consider Valganciclovir (if serodiscordant or recipient +ve) and anti-fungal prophylaxis
Metabolic
- Monitor: weight, BP, fasting lipids, glucose & HBA1C
- Non-pharm: educate on CV risk, promote healthy life-style - diet, exercise, smoking cessation, moderation of ETOH
- Pharm: diabetes control, statins, manage obesity and HTN.
Osteoporosis
- Monitor: 1-2 yearly DEXA, Calcium, vitamin D (25) - aim >75
- Non-pharm: Calcium and Vit D replacement
- Pharm: denosumab or bisphosphonate when T-score <-1.5
Malignancy
- Monitor: Low index of suspicion for solid tumour
- Refer to dermatologist for regular skin checks
Biliary stricture
- Monioring: LFT for cholestasis, if so investigate with USS/MRCP/ERCP
