1. Liver Transplantation & its Anaesthetic Management Dr. Swadheen kumar Rout 2nd year P.G Dept. of Anaesthesiology M.K.C.G College & hospital

2. Introduction:- Liver transplantation is the only life saving procedure in pts. with end stage liver disease & some cases of acute liver failure. Orthotopic Heterotopic First orthotopic liver transplant was performed by Dr Thomas Starzl in 1963. Patient was a 3 year old child with biliary atresia, who died in the operating room from massive haemorrhage caused by venous collaterals & uncontrollable coagulopathy. However with continued improvements in Organ preservation technique, Surgical technique, Immunosuppressive agents, Management of Has become highly successful in prolonging survival & improving coagulopathy,in affected patients. quality of life Treatment of

3. Data from the United Network for Organ Sharing (UNOS) on 24,900 ad patients undergoing liver transplantation in a 10 year study showed tha yr, 4-yr, and 10-yr patient survival rates were 85%, 76%, and 61%, respectively, Survival (%) after adult liver transplantation by thus confirming that liver transplantation results in prolongation of life. diagnosis* Diagnosis 1-yr 4-yr 10-yr Primary sclerosing cholangitis 91 84 78 Primary biliary cirrhosis 89 84 79 Autoimmune hepatitis 86 81 78 Chronic hepatitis C 86 75 67 Alcoholic liver disease 85 76 63 Cryptogenic cirrhosis 84 76 67 Chronic hepatitis B 83 71 63 Malignancy 72 43 34 Liver transplantation can be performed in patients of all ages. Paediatric liver transplantation has a better survival rate (10-yr = 80

4. Indications for liver transplantation: Acute liver failure Acute hepatitis A,B,C infection Drug/toxin hepato-toxicity Cirrhosis from chronic liver diseases Chronic hepatitis B virus and chronic hepatitis C virus infection Alcoholic liver disease Autoimmune hepatitis Cryptogenic liver disease Primary biliary cirrhosis and primary sclerosing cholangitis Metabolic Disorders Alpha-1 antitrypsin deficiency Hereditary haemochromatosis Wilsons disease Glycogen-storage disorders Type 1 hyperoxaluria Familial homozygous hypercholesterolemia Malignancy Primary hepatic cancer: hepatocellular carcinoma and cholangiocarcinoma Metastatic: carcinoid tumors and islet cell tumours Miscellaneous Polycystic liver disease Budd-Chiari syndrome

5. The decision to list a patient for transplantation is based more on the severity of hepatic dysfunction than the underlying aetiology. Determining the need for liver transplantation must take into account the natural history of the patients disease and carefully compare it to the anticipated survival after liver transplantation. Priority is based on specific prognostic criteria using a number of scoring systems devised by United Network for Organ Sharing (UNOS) for optimal use of the limited number of available organs. In the past Childs-Turcotte-Pugh (CTP) score plus the amount of time on the waiting list. For listing purposes, a patient must have at least 7 points (i.e, be at least a Childs class B),

6. However this did not always ensure that organs were allocated to the sickest patients with the greatest risk of mortality. In 2002, model for end-stage liver disease (MELD) , based on the patients risk of dying while awaiting transplantation. The MELD risk score is a mathematical formula based on the following factors: 1) Creatinine 2) Bilirubin (mg/dL) 3) International normalized ratio Most patients on the liver transplant waiting list have a MELD score between 11 & 20.

7. Pediatric End-Stage Liver Disease (PELD) scoring system incorporates the following criteria(