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
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Critical Care Hepatology Dr. Jon Gatward Staff Specialist Royal Prince Alfred Hospital Sydney
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England N.Ireland Scotland Wales
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Critical Care Hepatology Dr. Jon Gatward Staff Specialist Royal Prince Alfred Hospital Sydney
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Case Study!45M Primary Sclerosing CholangiLs / Crohn’s Recurrent cholangiLs OLT
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171 to end Aug 13
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4.5L ascites and free pus in abdomen Massive transfusion Liver looked grey
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Vasodilatory shock Rising lactate Rising K Hypoglycaemia DIC……
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• 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
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• 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
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• 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
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• 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
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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
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• 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
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acute rejection • 5-‐7 days • Fever • DeterioraLon in graY funcLon • AST/ALT • Biopsy (percutaneous or trans-‐jugular) • Pulsed methylprednisolone • Re-‐transplantaion
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• 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
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Liver congested, non-‐homogenous perfusion Duplex: arterial flow, no portal or hepaLc venous flow Liver removed
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the anhepatic phase
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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
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84ml.kg.h-‐1 Vs. Na 150 (12.5ml 23.4% Saline per 5L Hemasol B0)
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re-transplantation
Extended criteria BD donor (fapy liver)
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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
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F R O M D E M I – G O D S TO G o d s . . .!
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• 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
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• 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
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Single Pass Albumin Dialysis!
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Sauer. Hepatology 2004; 39: 1408
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re-transplantation
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(=7.5% of all grafts)
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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
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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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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
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ECMO circuit 2nd roller pump for HA PN Insulin
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conclusions