Indications for Liver Transplantation in Adults:Etiologies of End-Stage Liver Disease

1. Fulminant Hepatic Failure
2. Alcoholic Liver Disease
3. Chronic Hepatitis C
4. Chronic Hepatitis B
5. Non-alcoholic steatohepatitis
6. Autoimmune Hepatitis
7. Primary Biliary Cirrhosis
8. Primary Sclerosing Cholangitis
9. Hepatic tumors
10. Metabolic and genetic disorders

Indications for Liver Transplantation in Adults
Presence of irreversible liver disease and a life expectancy of less than 12 months with no effective medical or surgical alternatives to transplantation
Chronic liver disease that has progressed to the point of significant interference with the patient's ability to work or with his/her quality of life
Progression of liver disease that will predictably result in mortality exceeding that of transplantation (85% one-year patient survival and 70% five-year survival)

Manifestations of End-Stage Liver Disease
Progressive jaundice
Intractable ascites
Spontaneous bacterial peritonitis
Hepatorenal Syndrome
Variceal bleeding
Intractable pruritus
Chronic fatigue (such as resulting in loss of gainful employment)
Bleeding diathesis or coagulopathy

Post-operative complications & management of liver transplant patients
Right pleural effusion
 May affect ventilation, necessitating drainage.
Hepatic edema secondary to aggressive resuscitation & increased intravascular volume.
 Goal CVP 6-10. Minimize increased hepatic vein pressures, sinusoidal congestion that impair graft perfusion & exacerbate reperfusion injury.
Renal failure
 Elevation of creatinine & BUN observed in nearly all transplant patients secondary to ATN, hepatorenal syndrome. Usually self-limiting. May necessitate therapy with loop diuretics, renal replacement therapy.
Electrolyte Derangements
 Recovering graft increases demand for magnesium & phosphorous.
Transfusion of citrate rich blood products results in decreased serum magnesium & calcium.
Rapid correction of chronic hyponatremia with isotonic solution can have severe neurological consequence. Judicious use of hypotonic solutions with goal of serum Na 125-130 advised.
 Preoperative portal hypertension results in splenomegaly & platelet sequestration. Generally improves as graft recovers. May necessitate replacement if bleeding is encountered or invasive procedures are planned. Splenectomy is rarely indicated.
Platelet dysfunction secondary to renal & hepatic failure may be improved acutely with DDAVP.
Biliary leak
 RUQ pain, fever, persistent elevation of bilirubin, liver enzymes. Biloma on CT. Treated with endoscopic stent, percutaneous drainage. Possible surgical revision if duct is ischemic.
Hepatic artery thrombosis
 Persistent elevation or increasing liver enzymes, poor graft function. Diagnosed with U/S, CT angiography, MRA. Treated with immediate revascularization.

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