Liver transplantation

Liver transplantation

Indication liver transplantation
- Acute liver disease; patients with fulminant hepatic failure.
- Chronic liver disease; cirrhosis (Child's pugs grade C), also complication of cirrhosis (even with perserved liver function) such as hepatopulmonary syndrome (shunting in the lung leading to hypoxia) and porto-pulmonary hypertension.
- Primary biliary cirrhosis; if serum bilirubin is >100 umol/L or symptoms (itching) intolerable.
- Chronic hepatitis B; if HBV DNA negative or levels falling under therapy.
- Chronic hep C
- Autoimmune hep; if failed to respond to medication or major side effects to corticosteroid therapy.
- Alcoholic liver disease; well-motivated patients who have stopped drinking without improvement of the liver.
- Primary metabolic disorder; Wilson's, hereditary haemochromatosis, alpha-antitrypsin.
- Other conditions; primary sclerosing cholangitis, polycystic liver NASH and matabolic diseases such as primary oxaluria.

Contradiction liver transplantation
- Active sepsis outside hepatobiliary tree
- Malignancy outside liver
- Liver metastase (except neuroendocrine)
- Relative contradiction; anatomical consideration that would make surgery more difficult (e.g. extensive splanchic venous thrombosis)
- Age 70+ (some exceptions possible)

Rejection
- Acute and cellular rejection (5-10 days after tranplantation); it can be asymptomatic or there may be a fever. Histologically, there is a pleomorphic portal infiltrate with prominent easoinophils, bile ducts damage and endothelialitis of the blood vessels. Responds to immunisuppressive therapy.
- Chronic ductopenic rejection (6-9 months post-transplant); presents with disappearing bile ducts and an arteriopathy with narrowing and occulusion of the arteries. Rarely reversed with immnosuppression, often requires retransplantation
- Graft vs Host; extremly rare.

Prognosis
Low-risk patients have 90% 1-year survival, 5- year survival => 70-85%. Life long immunosuppression is required.
! Transplantion for HCV cirrhosis, PSC and HCC are the major diseases in which long term survvalis compromised by disease recurrence.