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CONTENTS
1. Case study: liver transplantation
Learning objective – To evaluate the criteria for Liver Transplantation.
2. Journal Watch
CASE STUDY:
Liver Transplantation
HPI: 70 year old Hispanic male with decompensated cirrhosis secondary to chronic alcohol abuse (abstained from alcohol for 2 years), admitted multiple times over the past few weeks for weakness, dizziness, recurrent high fever (BCx and UCx negative), ARF with hyperkalemia and hypoglycemia, chest pain, leg and abdominal swelling presented with progressive abdominal distention with SOB at rest, chest pain for 2 months.
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PMH: DM Type II, HTN, CAD, diastolic CHF, decompensated cirrhosis secondary to alcohol abuse, Cervical spondylosis with myelopathy ex-smoker.
PE: VS – BP 182/77 mmHg, P- 65, T-98.2, RR- 20/min, O2 sat – 96 %
AAO X3, HEENT: mild icterus; Chest: few bibasilar crackles Heart: regular rhythm, normal S1 and S2, no gallop or murmurs; Abdomen: distended abdomen, nontender, no organomegaly appreciated, BS+, shifting dullness present, no fluid thrill Pulses: peripheral pulses present Ext: pitting edema present Neuro: no focal deficits, no asterexis.
Pertinent labs: LFT: AST: 65, ALT: 36 Alk. Phos.: 157, Total Bili: 3.8, Direct Bili: 1.6, Total Protein: 8.2, Albumin: 2.2 (low A:G ratio), INR: 1.55, Ammonia: 140 BUN: 116, Creatinine: 2.7, B-Natriuretic Peptide: 998
Ascitic Fluid: Albumin: 0.8, LDH: 74, Cell count: RBC: 1262, WBC: 125 Culture: no growth
SAAG gradient: 1.4 (serum albumin ascites gradient, suggests it is a transudate and possibly secondary to portal hypertension
Diagnostic studies:
Chest X-ray: Congestion- Congestive heart failure
Abdominal CT
Echo: LVEF low normal, with mild pulmonary HTN and mitral annular
calcification. Trace tricuspid regurgitation.
Is this patient a candidate for liver transplantation?
Topics covered:
1. Liver transplantation overview
2. Indications
3. Determining the need
4. Alternatives
5. Argument- does this patient qualify?
Liver transplantation has evolved rapidly from an experimental procedure to standard therapy for patients with end-stage liver disease. One- and five-year patient survival for deceased donor liver transplants has reached 83 and 67 percent respectively, due to advances in surgical techniques, immunosuppression, and organ preservation. There are approximately 17,000 patients listed for liver transplantation in the United States, while the number of liver transplants performed in the US is only 6000 per year due to limited supply of donor organs. As a result, more than 2000 patients succumb to the complications of end-stage liver disease while awaiting organ transplant.
Liver transplantation has had a profound impact on the care of patients with end-stage liver disease and is the most effective treatment (also cost effective) for many patients with acute or chronic liver failure resulting from a variety of causes. Before transplantation, patients with advanced liver disease usually died within months to years. These patients now have the opportunity for extended survival with excellent quality of life after liver transplantation. Furthermore, the costs of liver transplants have steadily declined in recent years.
Most liver transplants are performed using a whole liver from a deceased donor and is termed orthotopic liver transplantation. However, because of the unique anatomical organization of the liver, donor organs can be divided and the separate parts transplanted into two recipients. Using this technique, a portion of the left lobe of an adult donor organ can be transplanted into a child and the remaining portion used to transplant the liver into an adult. Under ideal circumstances, a deceased donor organ also can be split and transplanted into two adult recipients. The same surgical techniques can be used to facilitate transplantation using living donors, where only a portion of the donor liver is removed for transplantation. Living donor transplantation for children, using a portion of the left lobe, is a well-established procedure. Living donor transplantation for adults, in which the donor right lobe typically is transplanted, also is performed at many transplant centers, although donor safety remains a concern.
Hepatocyte transplantation and stem cell transplantation are new exciting methodologies aimed at reducing the wait time for donor organs by harvesting liver cells from the recipient itself, thus also reducing the chance for immunosuppression; but these are still experimental.
Indications for Liver Transplantation
a. Liver cirrhosis due to chronic hepatitis B/C and alcoholic liver disease- most common cause
b. Fulminant hepatic failure (most commonly due to viral hepatitis and drug induced hepatotoxicity
c. Cholestatic liver disease: Primary biliary cirrhosis, primary sclerosing cholangitis, cystic fibrosis, biliary atresia
d. Metabolic disorders causing cirrhosis: alpha-1 antitrypsin, Wilson disease, NASH (Non-alcoholic steatohepatitis), Cryptogenic cirrhosis, hemochromatosis, glycogen storage disorders
e. Malignancies: Hepatocellular carcinoma, hepatoblastoma.
f. Miscellaneous: Budd-Chiari syndrome, polycystic disease.
Contraindications
Cardiopulmonary disease that cannot be corrected and is a prohibitive risk for surgery; malignancy outside of the liver within five years of evaluation or not meeting oncologic criteria for cure; active alcohol and drug use.
Determining the Potential for Successful Liver Transplantation
As soon as it has been determined that a patient is sick enough to require consideration for transplantation and that no other alternative treatments are available, a careful evaluation should be performed to address the following fundamental questions:
A. Can the patient survive the operation and the immediate postoperative period?
B. Can the patient be expected to comply with the complex medical regimen required after liver transplantation?
C. Does the patient have other comorbid conditions that could so severely compromise graft or patient survival that transplantation would be futile and an inappropriate use of a scarce donor organ?
The typical evaluation of potential transplant recipients performed at most transplant centers includes:
A. A careful history and physical examination;
B. Cardiopulmonary assessment, including cardiac echocardiography, pulmonary function tests, dobutamine stress testing, and cardiac catheterization in selected patients;
C. Laboratory studies to confirm the etiology and severity of liver disease;
D. Creatinine clearance;
E. Laboratory studies to determine the status of current or previous hepatitis B virus (HBV), hepatitis C virus (HCV), Epstein-Barr virus, cytomegalovirus, and human immunodeficiency virus (HIV) infections; and
F. Abdominal imaging to determine hepatic artery and portal vein anatomy and the presence of hepatocellular carcinoma.
Potential alternatives
Examples include immunosuppressive therapy for patients with severe autoimmune hepatitis, chelation therapy for patients with severe chronic Wilson disease, and antiviral therapy for patients with decompensated cirrhosis secondary to chronic hepatitis B.
Does this patient qualify?
The patient described in this case study had the following Prognostic score and Liver transplantation score:
APACHE II score: 26
APACHE II score is not per se a model for liver transplantation but is an indicator for mortality and is also taken into account for overall evaluation of a patient for transplantation. Acute Physiologic and Chronic Health Evaluation (APACHE) score is a prediction model utilizing point score calculated from 12 routine physiological measurements (such as blood pressure, body temperature, heart rate etc.) during the first 24 hours after admission in the ICU and is useful in predicting mortality rates. Scores range from 0-71 with higher scores having higher mortality rates.
MELD score on Apr 1st, ‘08: 26
MELD score on Mar 19th , ’08: 21 (admit)
MELD score (Model for end-stage liver disease; comprising of INR, serum bilirubin and serum creatinine from the same day) is used by the United Network for Organ Sharing (UNOS) and Eurotransplant for prioritizing allocation of liver transplants based on the score, besides other criteria. A higher score would place a patient earlier on the list as that predicts a worse prognosis. A score of 26 would represent an in-hospital mortality of 76% over a 3-month period.
The question that arises is that should this patient be on the transplant list and what are the chances of been considered for a liver transplant. Based on the MELD score and that the patient is in hepatorenal syndrome he is a suitable candidate to be on the Liver transplant list. The reasons that will preclude his possibility of receiving a transplant are his age (70 years) and heart failure which although not significant by Echo could lead to acute exacerbation following transplant leading to cardio-respiratory distress, besides increasing the risk of CAD. Age per se is not an excluding criteria for liver transplant except on one occasion, have not been found to fair as well in terms of mortality post-transplantation as those below 60 years. Thus, although this patient meets certain criteria for liver transplantation, he is not a candidate given his comorbid conditions and his chances of being accepted on the transplant list after rigorous testing is extremely low and will be rejected for transplant. An alternative for him would be TIPS that would reduce the portal pressure and would be of symptomatic benefit but will not change the mortality risk.
Written by:
Residents:
Souvik Sarkar, M.D.
Amito Chandiwal, M.D.
Supervising Attending:
Moiz Kasubhai, M.D.
Please give your comments at the online blog
References:
Parts of this article has been adapted from: Murray, K.F. and Carithers R.L., AASLD Practice Guidelines: Evaluation of the Patient for Liver Transplantation, Hepatology, June 2005.
