Transplantation

With the increasing waiting times, maintaining the patient in an acceptable medical condition in order to undergo a successful liver transplant is a challenge for the managing team. Both prophylactic measures and therapeutic interventions are needed to deal with the numerous complications that can arise.

Timing of Liver Transplantation

A sound knowledge of the natural history of disease is essential in the decision making process vis-à-vis the timing of transplantation. The development of complications typically results in an upgrade of the priority status for transplantation in exchange for a higher surgical mortality and a large increase in cost. This apparent paradox cannot be resolved given the current organ shortage. In acute liver failure, prognostic criteria have been developed to assess the necessity for urgent liver transplantation. In patients with chronic liver disease, the prevention and management of potential complications requires an inordinate amount of attention and comprehensive care on the part of the clinician.

Prophylaxis of Complications

Patients in the waiting list are at risk for developing HCC. Screening with ultrasound and alpha-fetoprotein level determination every 6 months is performed by most transplant centers. Screening upper endoscopy to rule out the presence of medium/large varices with red wheals is also recommended, as these patients may benefit from prophylaxis of variceal hemorrhage with beta-blockers. Hepatitis B vaccination is seldom useful in advanced stages of liver disease, but is recommended by some centers. Hepatitis A vaccination has become recently available and its utility in patients with liver disease is currently being evaluated.

Therapy of Complications

The rationale for each therapy is beyond the scope of this handbook and the reader is referred to standard references.16,17 Each of the four major complications has a management protocol.(Table 9.12) However, the development of one complication can trigger additional problems. GI hemorrhage and infection have the potential of aggravating liver and renal function, while intractable ascites impairs respiratory function and aggravates malnutrition. Overt hepatic encephalopathy can result in aspiration pneumonia and may require prophylactic tracheal intubation. Fluid overload in the setting of renal failure and severe hypoalbuminemia requires extracorporeal measures for correction, such as CVVH (continuous venovenous hemofiltration). These patients require extensive and intensive support to overcome these problems.

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