Liver Transplant

Aka: Liver Transplant, Hepatic Transplant, Liver Transplant Center Referral Indications

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II. Epidemiology

  1. Availability in Chronic Liver Failure
    1. Candidates: 18,000 per year for 4000 available livers
    2. Wait time for Liver Transplantation: 2-3 years

III. Indications: Chronic Liver Failure (Cirrhosis) - Transplant Center Referral

  1. MELD Score >15 (or significant complications)
  2. Fulminant Liver Failure
  3. Decompensated Cirrhosis
    1. Hepatorenal Syndrome
    2. Cirrhotic Ascites
    3. Child-Pugh Stage B
  4. Hepatocellular Carcinoma
    1. No single lesion >5 cm
    2. No more than 3 lesions (largest 3 cm or less)

IV. Indications: Acute Liver Failure - Acetaminophen - Transplant Center Referral (King's College Criteria)

  1. Option 1: Lab findings after initial Resuscitation (either present)
    1. Arterial pH <7.3 (after Resuscitation)
    2. Serum Lactic Acid >3.0 mmol/L
  2. Option 2: Findings in first 24 hours (all 3 present)
    1. Hepatic Encephalopathy (Grade 3 or 4)
    2. INR >6.5
    3. Serum Creatinine >3.4 mg/dl
  3. MDCalc
    1. https://www.mdcalc.com/calc/532/kings-college-criteria-acetaminophen-toxicity

V. Diagnosis: Acute Liver Failure - Non-Acetaminophen - Transplant Center Referral (King's College Criteria)

  1. Option 1
    1. Any encephalopathy grade AND INR >6.5
  2. Option 2
    1. Any encephalopathy grade AND
    2. Three of the following criteria
      1. Age <10 years or >40 years
      2. Jaundice >7 days before onset of encephalopathy
      3. INR >3.5
      4. Serum Bilirubin >=17 mg/dl
  3. Option 3
    1. Wilson Disease
    2. Idiosyncratic Drug Reaction
    3. Seronegative hepatitis

VI. Contraindications

  1. Hepatocellular Carcinoma >5 cm
  2. Other active malignancy
  3. Active Alcohol Abuse or other Substance Abuse
  4. Chronic infection
  5. Advanced cardiopulmonary disease

VII. Efficacy

  1. One year survival: 85%
  2. Five year survival: 75%

VIII. Management: Post-transplant care

  1. Expect on average up to 2 emergency department visits post-transplant (with 70% admission rate)
  2. Typical post-transplant ED presentations are related to gastrointestinal or infectious symptoms
  3. Have a low threshold for imaging (CT, Ultrasound) in post-operative transplant symptoms (esp. first year)

IX. Complications

  1. Transplant Rejection
  2. Hepatic Ischemia
  3. Biliary Obstruction
  4. Drug Reaction or Hypersensitivity
  5. Immunocompromised State
    1. Most intense Immunosuppression in first year after transplant
    2. High risk for opportunistic infectious complications (e.g. Pneumocystis jiroveci)

X. References

  1. Swencki (2023) Crit Dec Emerg Med 37(8):4-12

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