bcc4: jon gatward on liver transplantation
DESCRIPTION
Intensivist Jon Gatward speaks at BCC4 about Liver Transplantation. His informative talk covers complications including post-reperfusion syndrome, biliary complications, hepatic artery thrombosis and 'other badness'. It also explores DCD livers and issues for retransplantation. Keep up to date with slides and posts on the intensivecarenetwork.comTRANSCRIPT
Critical Care Hepatology Dr. Jon Gatward Staff Specialist Royal Prince Alfred Hospital Sydney
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Critical Care Hepatology Dr. Jon Gatward Staff Specialist Royal Prince Alfred Hospital Sydney
Case Study!45M Primary Sclerosing CholangiLs / Crohn’s Recurrent cholangiLs OLT
171 to end Aug 13
4.5L ascites and free pus in abdomen Massive transfusion Liver looked grey
Vasodilatory shock Rising lactate Rising K Hypoglycaemia DIC……
• Occurs in 7% • Clinical:
• Vasodilatory shock oYen with bradycardia
• Pulmonary hypertension • Hyperkalaemia
• Cause? • Sudden ↑ venous return • vasoacLve substances • K rich preservaLon fluids
• Usually resolves within 5 minutes
• 30% of paLents need inotropes and/or vasopressors.
• Risk Factors: Long WIT and CIT
post-reperfusion syndrome
Agopian. Annals of Surgery 2013; 258: 409
• Approximately 1% in Australia • Unrecoverable hepato-‐cellular dysfuncLon à death or re-‐transplantaLon within 1 week NOT caused by
• vascular thrombosis • biliary complicaLons • rejecLon • recurrent disease
• Major risk factor: DCD (WIT and CIT à ischemia-‐reperfusion injury)
• Controlled DCD 0-‐10% • Uncontrolled DCD (Spain – 10-‐25%)
Le Dinh World J Gastroenterol 2012; 18: 4491
primary non-function
• Common: 5% within 30days, 15% overall • Bile leakage • Bile duct strictures
• AnastomoLc • Ischaemic Type Biliary Lesions (ITBL)
• Risk Factors • Donor age >60 à 67% have biliary complicaLons • Donor obesity • Autoimmune disease in recipient
Le Dinh World J Gastroenterol 2012; 18: 4491 De Vera Am J Transplant 2009; 9: 773
biliary complications
Suarez Transplanta7on 2008; 85: 9 Jay Ann Surg 2011; 253: 259
Agopian. Annals of Surgery 2013; 258: 409
• DCD à 10 x rate of ITBL • 3 x more likely to lose graY
• Prognosis • 50% à death or re-‐transplantaLon
• Treatment • ERCP
• PrevenLon • ECMO, machine perfusion, different preservaLves, anLcoagulants, early portocaval shunt
Le Dinh World J Gastroenterol 2012; 18: 4491 De Vera Am J Transplant 2009; 9: 773
itbl & dcd
Suarez Transplanta7on 2008; 85: 9 Jay Ann Surg 2011; 253: 259
Agopian. Annals of Surgery 2013; 258: 409
HAT (3.1% paLents) • Early (30 days)
• FHF, duct necrosis and leaks, sepsis, graY loss • Risk factors
• Children, low recipient weight • ProthromboLc states • Re-‐transplantaLon, arterial variants • PSC, CMV+ graY into CMV-‐ recipient • NOT DCD
• DUS screening +/-‐ CT angio • Treatment
• Observe • Re-‐vascularize • Re-‐transplant
HAS • Assoc with biliary strictures, esp aYer DCD
• Risk factors • Surgical trauma • RejecLon • Recurrent disease
DCD is not a risk factor!
Le Dinh World J Gastroenterol 2012; 18: 4491 Agopian. Annals of Surgery 2013; 258: 409
hepatic artery thrombosis and stenosis
• Rare (1.1% paLents) • Portal hypertension….graY failure • Risks:
• Difficult surgery • Recurrence of disease • Thrombophilia
• Treatment • Diuresis • Angioplasty / re-‐vascularisaLon • Re-‐transplantaLon
portal vein thrombosis
DCD is not a risk factor!
Agopian. Annals of Surgery 2013; 258: 409 Le Dinh World J Gastroenterol 2012; 18: 4491
acute rejection • 5-‐7 days • Fever • DeterioraLon in graY funcLon • AST/ALT • Biopsy (percutaneous or trans-‐jugular) • Pulsed methylprednisolone • Re-‐transplantaion
• Cardiovascular failure • Underlying cardiomyopathy, periop stress
• Respiratory failure • Effusions, right diaphragm palsy, muscle weakness • HPS, PPS • InfecLon • TRALI
• CNS failure • Encephalopathy, oedema, raised ICP • Seizures (note Tacrolimus) • ICH
• Renal failure • Common and mulL-‐factoral. • HRS usually improves with liver. • Consider IACS
• Sepsis
other badness
Liver congested, non-‐homogenous perfusion Duplex: arterial flow, no portal or hepaLc venous flow Liver removed
the anhepatic phase
1 2
0 8 16 24 32 40 48 56 64 72 7.4
7.3
Time (hrs)
5
10
pH
7.1
7.2
Lactate (mmol.l-‐1) Anhepatic
Phase
84ml.kg.h-‐1 Vs. Na 150 (12.5ml 23.4% Saline per 5L Hemasol B0)
re-transplantation
Extended criteria BD donor (fapy liver)
1 2
0 8 16 24 32 40 48 56 64 72 7.4
7.3
Time (hrs)
5
10
pH
7.1
7.2
Lactate (mmol.l-‐1) Anhepatic
Phase
F R O M D E M I – G O D S TO G o d s . . .!
• RELIEF Trial • 189 pts vs standard care • Decreased Cr, bilirubin • Decreased encephalopathy • No effect on mortality
Bañares et al. Extracorporeal liver support with the molecular adsorbent recirculaLng system (MARS) in paLents with acute-‐on-‐chronic liver failure. The RELIEF Trial
Blood circuit
Albumin circuit
Dialysis circuit
• HELIOS Study • 145 pts vs standard care • Only subgroup HRS Type 1 plus MELD >30 had survival benefit
Rifai et al. Extracorporeal liver support by fracLonated plasma separaLon and absorpLon (Prometheus®) in paLents with acute-‐on-‐chronic liver failure (HELIOS study): a prospecLve randomized controlled mulLcenter study
Single Pass Albumin Dialysis!
Sauer. Hepatology 2004; 39: 1408
re-transplantation
(=7.5% of all grafts)
risk factors for things going wrong
Factor RR Recipient age >55 1.5 MELD score ≥34 1.4
AeLology: malignancy AeLology: HCV
1.8 1.5
Prior transplant 2.2 HospitalisaLon 1.3 Donor age >55 1.5 WIT > 48min 1.3 CIT >8.9h 1.3 Agopian. Annals of Surgery 2013; 258: 409
dcd and risk of death??
U.S. registry data 96-07 42,254 DBD recipients 1,113 DCD recipients RR of death after DCD1.29
Jay. J Hepatol 2011; 55: 808
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dbd and dcd
slow uptake of dcd livers
W.I.T.
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Conclusions Good outcomes with strict ANLTU criteria Donor age increased to 50yrs
Verran MJA 2013; 199: 104
high numbers declined or not retrieved
ECMO circuit 2nd roller pump for HA PN Insulin
conclusions