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

1. Critical Care
Hepatology
Dr.
Jon
Gatward
Staff
Specialist
Royal
Prince
Alfred
Hospital
Sydney

9. 0
10
20
30
40
50
60
70
England
N.Ireland
Scotland
Wales

11. Critical Care
Hepatology
Dr.
Jon
Gatward
Staff
Specialist
Royal
Prince
Alfred
Hospital
Sydney

13. Case Study!
45M
Primary
Sclerosing
CholangiLs
/
Crohn’s
Recurrent
cholangiLs
OLT

15. 171
to
end
Aug
13

16. 4.5L
ascites
and
free
pus
in
abdomen
Massive
transfusion
Liver
looked
grey

17. Vasodilatory shock
Rising lactate
Rising K
Hypoglycaemia
DIC……

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

29. Liver
congested,
non-­‐homogenous
perfusion
Duplex:
arterial
flow,
no
portal
or
hepaLc
venous
flow
Liver
removed

30. the
anhepatic
phase

31. 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

32. 84ml.kg.h-­‐1
Vs.
Na
150
(12.5ml
23.4%
Saline
per
5L
Hemasol
B0)

33. re-transplantation
Extended
criteria
BD
donor
(fapy
liver)

34. 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

36. F R O M D E M I – G O D S TO G o d s . . .!

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

39. Single Pass Albumin Dialysis!

40. Sauer.
Hepatology
2004;
39:
1408

41. re-transplantation

42. (=7.5% of all
grafts)

43. 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

44. 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

45. !"
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(/("
Total
DBD
DCD
dbd and dcd

46. slow uptake of dcd livers
W.I.T.

47. !
!
!
!
!
!
!
!
!
!
!
!
!
"#!$%&%$$'()!
*+!',,%-.,%/!
$%,$0%1'()!
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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

49. ECMO circuit
2nd roller pump for HA
PN
Insulin

50. conclusions