Liver Transplantation: Update of Concepts and Practice, An Issue of Clinics in Liver Disease, 1e

264 Pages·2014·5.356 MB·English

by  Kalyan Ram Bhamidimarri MD MPH

Liver Transplantation:
Update of Concepts
and Practice
Editors
KALYAN RAM BHAMIDIMARRI
PAUL MARTIN
CLINICS IN
LIVER DISEASE
www.liver.theclinics.com
Consulting Editor
NORMAN GITLIN
August 2014 • Volume 18 • Number 3
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LiverTransplantation:UpdateofConceptsandPractice
Contributors
CONSULTING EDITOR
NORMANGITLIN,MD,FRCP(LONDON),FRCPE(EDINBURGH),FACG,FACP
Formerly,ProfessorofMedicine,ChiefofHepatology,EmoryUniversity;Currently,
Consultant,AtlantaGastroenterologyAssociates,Atlanta,Georgia
EDITORS
KALYANRAMBHAMIDIMARRI,MD,MPH
AssistantProfessorofClinicalMedicine,DivisionofHepatology,MiamiTransplant
Institute,UniversityofMiami,Miami,Florida
PAULMARTIN,MD,FRCP,FRCPI
Chief,DivisionofHepatology,MillerSchoolofMedicine,UniversityofMiami,Miami,
Florida
AUTHORS
SUMEETK.ASRANI,MD,MSc
DivisionofHepatology,BaylorUniversityMedicalCenter,Dallas,Texas
THIAGOBEDUSCHI,MD
MiamiTransplantInstitute,UniversityofMiami,Miami,Florida
KALYANRAMBHAMIDIMARRI,MD,MPH
AssistantProfessorofClinicalMedicine,DivisionofHepatology,MiamiTransplant
Institute,UniversityofMiami,Miami,Florida
SUPHAMAIBUNNAPRADIST,MD
DivisionofNephrology,DepartmentofMedicine,KidneyandPancreasTransplant
Program,DavidGeffenSchoolofMedicineatUCLA,LosAngeles,California
MICHAELR.CHARLTON,MBBS,FRCP
ProfessorofMedicine,DirectorofHepatologyandMedicalDirectorofLiver
Transplantation,IntermountainMedicalCenter,Murray,Utah
SANDYFENG,MD,PhD
Professor,DivisionofAbdominalTransplantation,DepartmentofSurgery,Universityof
California,SanFrancisco,SanFrancisco,California
IVOW.GRAZIADEI,MD
DepartmentofInternalMedicineII(GastroenterologyandHepatology),MedicalUniversity
ofInnsbruck,Innsbruck;DepartmentofInternalMedicine,DistrictHospitalHall,Hallin
Tirol,Austria
iv Contributors
SOHAIBK.HASHMI,BS
HarrisonSurgicalScholar,DepartmentofSurgery,TheUniversityofPennsylvania,
Philadelphia,Pennsylvania
PETERC.HAYES,MBChB,PhD
DepartmentofHepatology,RoyalInfirmaryofEdinburgh,Edinburgh,UnitedKingdom
DEIRDREKELLY,FRCPCH,FRCP,FRCPI,MD
ProfessorofPaediatricHepatology,TheLiverUnit,BirminghamChildren’sHospital,
UniversityofBirmingham,Birmingham,UnitedKingdom
WILLIAMH.KITCHENS,MD,PhD
DepartmentofSurgery,MassachusettsGeneralHospital,Boston,Massachusetts
JENNIFERC.LAI,MD,MBA
AssistantProfessor,DivisionofGastroenterology/Hepatology,DepartmentofMedicine,
UniversityofCalifornia,SanFrancisco,SanFrancisco,California
JAMESF.MARKMANN,MD,PhD
ChiefoftheDivisionofTransplantation,DepartmentofSurgery,MassachusettsGeneral
Hospital;ClaudeE.WelchProfessorofSurgeryatHarvardMedicalSchool,Boston,
Massachusetts
PAULMARTIN,MD,FRCP,FRCPI
Chief,DivisionofHepatology,MillerSchoolofMedicine,UniversityofMiami,Miami,
Florida
NORMAC.McAVOY,MBChB,MRCP
ConsultantGastroenterologistandHonorarySeniorLecturer,DepartmentofHepatology,
RoyalInfirmaryofEdinburgh,Edinburgh,UnitedKingdom
JACQUELINEG.O’LEARY,MD,MPH
MedicalDirector,HepatologyResearch;MedicalDirector,LiverandTransplantUnit,
DivisionofHepatology,BaylorUniversityMedicalCenter,Dallas,Texas
PAIGEM.PORRETT,MD,PhD
DivisionofLiverTransplantation,AssistantProfessorofSurgery,DepartmentofSurgery,
TheUniversityofPennsylvania,Philadelphia,Pennsylvania
KAYVANROAYAIE,MD,PhD
DivisionofAbdominalOrganTransplantation,DepartmentofSurgery,OregonHealthand
SciencesUniversity,Portland,Oregon
SASANROAYAIE,MD
LiverCancerProgram,Hofstra-NorthShoreLIJSchoolofMedicine,LenoxHillHospital,
NewYork,NewYork
MARCELOS.SAMPAIO,MD,PhD
DivisionofNephrology,DepartmentofMedicine,KidneyandPancreasTransplant
Program,DavidGeffenSchoolofMedicineatUCLA,LosAngeles,California
ABRAHAMSHAKED,MD,PhD
DivisionofLiverTransplantation,EldrigeL.EliasonProfessorofSurgery,Departmentof
Surgery;Director,PennTransplantInstitute,TheUniversityofPennsylvania,Philadelphia,
Pennsylvania
Contributors v
JAMESF.TROTTER,MD
MedicalDirectorofLiverTransplantation,BaylorUniversityMedicalCenter,Dallas,Texas
ELIZABETHC.VERNA,MD,MS
AssistantProfessorofMedicine,DivisionofDigestiveandLiverDiseases,Centerfor
LiverDiseaseandTransplantation,ColumbiaUniversityCollegeofPhysiciansand
Surgeons,NewYork,NewYork
RODRIGOVIANNA,MD
DirectorofTransplantServices;ProfessorofClinicalSurgery,MiamiTransplantInstitute,
UniversityofMiami,Miami,Florida
RUSSELLH.WIESNER,MD
ProfessorofMedicine,MayoCollegeofMedicine,Rochester,Minnesota
JOWRAY,PhD,CPSYCHOL
HealthPsychologist,CriticalCareandCardiorespiratoryDivision,GreatOrmondStreet
HospitalforChildrenNHSFoundationTrust,London,UnitedKingdom
HEIDIYEH,MD
DivisionofTransplantation,DepartmentofSurgery,MassachusettsGeneralHospital,
Boston,Massachusetts
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LiverTransplantation:UpdateofConceptsandPractice
Contents
Preface:LiverTransplantation:UpdateofConceptsandPractice xiii
KalyanRamBhamidimarriandPaulMartin
EvolvingTrendsinLiverTransplantation:ListingandLiverDonorAllocation 519
RussellH.Wiesner
The success of liver transplantation in the past three decades as a life-
savingprocedureforpatientswithend-stageliverdiseasehasledtothe
ever-increasing disparity between the demands for liver transplantation
andthesupplyofdonorliverorgans.Donorallocationanddistributionre-
mainsachallengeandamoralissueastohowtheseorganscanbeequi-
tably distributed. This article reviews the evolution of the liver allocation
policyanddiscussesindetailthechallengescliniciansfacetodayinthis
areaofmedicine.
CardiacandPulmonaryIssuesinLTAssessmentCandidates 529
NormaC.McAvoyandPeterC.Hayes
Withtheincidenceofliverdiseaseincreasingworldwide,agrowingnumber
ofpatientsarebeingreferredforassessmentforlivertransplant(LT).Unfor-
tunately,thedonorpoolisnotexpandingatthesamerate,whichconse-
quentiallyresultsinincreasingdemandonafiniteresource.Itistherefore
imperativethatthecandidatewhoundergoesanLTgetsmaximalbenefit
witharesultantmaximalincreaseinlifeexpectancy.Thisarticleaddresses
some of the main cardiac and pulmonary issues that may occur in LT
assessmentcandidates.
RenalDysfunctioninEnd-StageLiverDiseaseandPost–LiverTransplant 543
MarceloS.Sampaio,PaulMartin,andSuphamaiBunnapradist
Renal dysfunction is a frequent complication in patients with end-stage
liver disease awaiting orthotopic liver transplantation and in the post
liver-transplantpatient.Althoughthestereotypicalformofrenaldysfunc-
tion is the hepatorenal syndrome, other causes of acute kidney injury in
this population include prerenal azotemia and acute tubular necrosis.
Renalinjuryinapatientwithcirrhosisisassociatedwithapoorprognosis.
Acute-On-ChronicLiverFailure 561
SumeetK.AsraniandJacquelineG.O’Leary
TheModelforEnd-StageLiverDisease(MELD)hasbeenthesinglebest
predictor of outcome of the progression of cirrhosis. Acute-on-chronic
liverfailure(ACLF)hasbeenproposedasanalternativepathinthenatural
historyofcirrhosis.ACLFoccursinpatientswithchronicliverdiseaseand
ischaracterizedbyaprecipitatingevent,resultinginacutedeteriorationin
liverfunction,multiorgansystemfailure,andhighshort-termmortality.In
thisreview,thenaturalcourseofpatientswithACLF,especiallyasitrelates
viii Contents
tomanagementofcirrhoticpatientsonthetransplantwaitinglist,andits
impactonlivertransplantationoutcomesaredefined.
HepatitisVirusesandLiverTransplantation:EvolvingTrendsinAntiviral
Management 575
ElizabethC.Verna
Viral hepatitis is both a leading indication for liver transplant (LT) and an
important causeof posttransplant graft loss and mortality.Treatment and
prevention of hepatitis B virus in LT recipients, with the observed corre-
sponding improvement in post-LToutcomes,isamong thegreatsuccess
stories in transplantation. By comparison, treatment of hepatitis C virus
withsafeandeffectiveregimensisonlyjustbecomingareality.Chronichep-
atitisEvirusinfectioninLTrecipientsrepresentsanewlydescribedphenom-
enonthatcanalsoleadtograftloss;earlydiagnosisandtreatmentmaybe
keyinthemanagementofthesepatients.
LiverTransplantforHepatocellularCancer:VerySmallTumors,VeryLarge
Tumors,andWaitingTime 603
KayvanRoayaieandSasanRoayaie
The role of liver transplant for treatment of early hepatocellular cancer
(HCC)isnolongercontested.However,itsbenefitrelativetootherthera-
pies for patients with very early (<2 cm) HCC is still a matter of debate.
TwentyyearsaftertheestablishmentoftheMilancriteria,wearebeginning
torealizethatthenumberandsizeoftumorsmaynotbethebestmetricby
which to prognosticate outcomes and allocate organs. A better assess-
mentoftumoraggressivenessisclearlyneeded.
TheAdolescentLiverTransplantPatient 613
DeirdreKellyandJoWray
The rapid development of new diagnostic tests and improved therapy,
especiallythesuccessoflivertransplantation,haschangedtheoutcome
for children with liver disease, many of whom survive into adolescence
withoutlivertransplantation.Theindicationsfortransplantationinadoles-
cencearesimilartopediatricindicationsandreflectthemedicaladvances
madeinthisspecialtythatallowlatertransplantation.Theseyoungpeople
need a different approach to management that involves consideration
of their physical and psychological stage of development. A focused
approach to their eventual transition to adult care is essential for long-
termsurvivalandqualityoflife.
ExpandedCriteriaDonors 633
SandyFengandJenniferC.Lai
Thegreatestchallengefacinglivertransplantationtodayistheshortageof
donor livers. Demand far exceeds supply, and this deficit has driven ex-
pansionofwhatisconsideredanacceptableorgan.Theevolvingstandard
hasnotcomewithoutcosts,however,aseachnewfrontierofexpanded
donor quality (i.e., advancing donor age, donation after cardiac death,
and split liver) has possibly traded wait-list for post-transplant morbidity
and mortality. This article delineates the nature and severity of risk
Contents ix
associatedwithspecificdeceaseddonorlivercharacteristicsandrecom-
mendsstrategiestomaximallymitigatetheserisks.
ChallengesinLivingDonorLiverTransplantation 651
JamesF.Trotter
Livingdonorlivertransplantationisaprocedurethathaswanedinitsap-
plication over the past decade but remains a beneficial procedure for
properlyselectedcandidates.Thisreviewdiscussessomeofthenewer,
relevantstudiesinthefield,focusingonoutcomeswithhepatocellularcar-
cinoma,ABO-incompatibletransplant,andissuesindonorcomplications
andsafety.
MultivisceralTransplantation:WhereDoWeStand? 661
KalyanRamBhamidimarri,ThiagoBeduschi,andRodrigoVianna
Intestinaltransplantationisthedefinitivetherapyforpatientswithirrevers-
ible intestinal failure and can be combined with transplantation of other
abdominalorgans,suchasstomach,spleen,andpancreaswithorwithout
liver.Thereisanincreasingtrendinthevolumeofintestinalandmultivisc-
eraltransplantationinthepastfewdecadesandthereisalsoincreasing
trendinpatientandgraftsurvivalprimarilyduetoimprovedpatientselec-
tion,advancesinimmunosuppression,andimprovedperioperativeman-
agement. This review summarizes the various key elements in patient
selection,typesofgrafts,andupdatesintheperioperativemanagement
involvedinmultivisceraltransplantation.
RecurrenceofNonviralLiverDiseasesAfterLiverTransplantation 675
IvoW.Graziadei
Manynonviraldiseasesthatcauseliverfailuremayrecurafterlivertrans-
plantation. Although most studies have shown that a recurrent disease
does not negatively affect patient and graft survival in the intermediate
postoperativecourse,thereisgrowingevidencethat,especiallyinpatients
withprimarysclerosingcholangitisandinpatientswithrecurrentabusive
alcohol drinking, disease recurrence is a significant risk factor for graft
dysfunctionandgraftloss.Therefore,therecurrenceofnonviraldiseases
hasbecomeaclinicallyimportantandprognosticallyrelevantissueinthe
long-termmanagementofrecipientsoflivertransplantation.
Immunosuppression:TrendsandTolerance? 687
PaigeM.Porrett,SohaibK.Hashmi,andAbrahamShaked
Advances in pharmacologic immunosuppression are responsible for the
excellent outcomes experienced by recipients of liver transplants. How-
ever,long-termfollow upofthesepatientsrevealsanincreasingburden
ofmorbidityandmortalitythatisattributabletothesedrugs.Theauthors
summarizetheagentsusedincontemporarylivertransplantationimmuno-
suppressionprotocolsanddiscusstheemergingtrendwithinthecommu-
nitytominimizeoreliminatetheseagentsfromuse.Theauthorspresent
recentlypublisheddatathatmayprovidethefoundationforimmunosup-
pression minimization or tolerance induction in the future and review