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.com
19. • 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
20. • 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
21. • 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
22. • 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
23. 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
24. • 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
25. acute rejection
• 5-‐7
days
• Fever
• DeterioraLon
in
graY
funcLon
• AST/ALT
• Biopsy
(percutaneous
or
trans-‐jugular)
• Pulsed
methylprednisolone
• Re-‐transplantaion
26. • 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
37. • 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
38. • 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