Selection and work-up for liver transplantation

Abstract

The primary goal of evaluating patients for liver transplantation (LT) is to identify appropriate candidates and establish a pre-transplantation plan. Prospective patients must first be referred to a transplantation centre for evaluation and, if deemed suitable, for work-up, with a view to being listed for transplantation. South Africa has centres offering LT in Johannesburg and Cape Town. Typically, referred patients are evaluated by a clinician, and further evaluations and tests are performed before the patient is discussed at a multidisciplinary transplantation meeting. Initiating the referral early in the course of disease facilitates improved outcomes, by allowing earlier LT before the establishment of end-stage disease. It is also well described that patients awaiting transplantation (and their families) demonstrate better psychological adaptation when the entire spectrum of issues is approached by a multidisciplinary clinical team.1 It is not uncommon for children to exhibit behavioural problems, depression, poor social adaptation and non-compliance after transplantation, which can be moderated by early counselling after referral. 2 Purpose and policyOrgan availability is the rate-limiting step regarding successful transplantation and a reduction in waiting-list mortality. This is particularly applicable in centres that do not have related living donor programmes, but rely solely on deceased donor organs. Consequently, the decision-making and selection process must be transparent, and a consistent set of evidence-based criteria must be applied to determine whether selection for transplantation is appropriate. IndicationsBorne out by our experience, approximately 50% of paediatric patients requiring LT have biliary atresia.2 However, the indications for LT fall into 5 major categories of liver disease: (i) cholestatic diseases; (ii) metabolic disorders; (iii) fulminant liver failure; (iv) auto-immune hepatitis; and (v) liver tumours. General listing criteriaInfants and children should be listed for LT when there is evidence that hepatic decompensation has occurred, is imminent, or is inevitable based on the natural history of the disease. Clinical endpoints that determine suitability for transplantation may include one or more of the following: severe cholestasis; portal hypertension with/without variceal bleeding; multiple episodes of ascending cholangitis; failure of hepatic synthetic function; malnutrition and failure to thrive; intractable ascites; encephalopathy; unacceptably poor quality of life due to liver disease; and life-threatening complications of stable liver disease, such as hepatopulmonary syndrome. Pre-LT assessment and work-upThe first step in evaluating a potential candidate for LT is to determine the severity and prognosis of the liver disease. A subjective clinical assessment is undertaken together with an objective assessment including comprehensive laboratory and radiological evaluations. The aim of this is to: (i) identify contra-indications that would either exclude LT, require dis...

Association between anesthesiologist experience and mortality after orthotopic liver transplantation

“…Although anesthesiologists are recognized as integral members of the transplant team, there is a paucity of data regarding the effects of intraoperative anesthetic interventions on orthotopic liver transplantation (OLT) outcomes. Furthermore, the potential effect of anesthesia practitioner experience is often not considered; most publications concentrate on the optimization of OLT recipient outcomes by appropriate risk stratification and sound surgical technique …”

Outcomes of paediatric liver transplant for biliary atresia

“…23 Nutritional rehabilitation is of utmost importance, as the nutritional status has a recognised effect on pre-and post-transplant mortality. 29,30 The relationship between MUAC and risk of death is currently being studied and unpublished results have prompted the implementation of a policy at the WDGMC transplant unit to delay liver transplant until the MUAC z score is above -2. Eleven of the fifteen patients who died had a pre-transplant z-score for MUAC of -2 or worse.…”

“…34,36 The selected patients would be those with proven risk factors for an unsuccessful KPE, would include patients beyond 100 days as an indication on its own, and those older than seventy days, who fall into other risk groups such as those with BASM, Ohi Type II or III, those with ductal plate abnormalities, and those with established cirrhosis. 14,29…”

Liver transplantation from living donors with Gilbert's syndrome is a safe procedure for both donors and recipients

“…Generally, most LTs undertaken in Western countries have been supplied by cadaveric‐donor pools; however, living donors constitute a large proportion of the donor pool in Turkey and many Asian countries . In many countries with insufficient cadaveric‐donor pools, living donors are the provisional of LTs . The steadily rising number of LT candidates has led transplantation centers to reassess their donor selection criteria.…”

“…Living‐donor hepatectomy procedures associated with notable levels of morbidity and mortality may cause serious ethical and legal problems for surgeons and operation centers. Hence, selection criteria for living‐donor candidates are very critical . After a complete health history assessment and detailed physical examination, various serological and biochemical parameters including serum bilirubin levels are tested for living donors .…”