Liver transplantation with severe steaotic graft and postoperative organ dysfonction

Eric Vibert, MD, PhDHopital Paul Brousse (AP/HP)

Villejuif

The recipient

• Male, 54 year-old, 72 kg, 1.70 m, Groupe A+

• Diabete mellitus

• Chronic Lymphoid Leukemia treated in 2007 with recent recurrence treated withchemotherapy (Fludarabine / Endoxan / MABthera)

• No history of liver disease

• Hospitalized for gastroenteritis 3 weeks afterthe last cycle of chemotherapy…

Hospitalized for Gastroenteritis…

• Abdominal pain, diarrhea, nausea

• No encephalopathy

• Liver Echography : No bile duct dilatation

Leuco Hb Plat. PT Uree Creat Lact

2550 16 73000 46% 12 91 1.57

Bili(µmol/L)

ASAT ALAT GGT

90 1450 1528 151

Then for HVB Acute Hepatitis…

• Viral serology were negative except HVB

– High positive viral load +++ (9 UI/ML)

• HVB Reactivation due to Chemotherapy for Leukemia administrated without HVB serology

• Treatment by Viread and NAC during 2 weeks

• No clinical and/or biological improvement

Transfert in our tertiary care center

From Acute Hepatits to Fulminant

• Day 0 : Jaundice / No encephalopathy / No Drugs

• Day 1 : Transjugular liver biopsy : 30% of livernecrosis – Sign of HVB replication – No cirrhosis

• Day 5 : Encephalopathy and Heart Rythme Trb…

1300

1128 1110

854

320

149

1200 1174 1200

911800

291

D0 D1 D2 D3 D4 D5

Cytolysis on five days

ASAT ALAT

307

347

211

312

350378

35 30 28 30 20 17

D0 D1 D2 D3 D4 D5

Bilirubin rate and PT on five days

Bil TP

No liver morphological abnormalities

Pancreas oedema…

Listing for LT in « Super Urgence »

• First proposal was refused (at H1 after listing)

– Male, 86 year-old with GGT 800 UI/ml

• Second proposal (at H12… after listing)

– Male, 45 yea-old, 82 kg for 1.80 m, Gr 0-

– 48 hours of ICU for Cerebral Stroke and Anoxia

Bili ASAT ALAT GGT

At Admiss. 30 µmol/L 1280 450 1330

At Proposal 6 µmol/L 316 151 492

The graft… from France South West..

Evaluation by the surgeon who make the retrieval : Big graft, probably steaotic but transplantable… Frozen section not feasible in situ, we need to come back to Paris We increased Cold Ischemia of 8 hours…..

We accepted these graft because the recipient is more and more severe….

Liver Transplantation under veno-venous bypass with VC replacement

VC Replacement and CEC : Big graft (Risk of VC compression) + Acute Pancreatitis

Cold Ischemia : 10h0025 Red Pack Cell…

Diffuse hemorrhage…

Levesque et al, Vibert. Clin Tranpl 2012

At the end of liver transplantation

Volume of the graft, Acute pancreatis, Hemorrhage… and probable re LT

Evolution at Day 1 from LT

Biopsy of the graft : More than 50% ofmacrosteatosis and 10% of microsteatosis…

/ LT Bili ASAT ALAT PT / Fact V

At H4 117 6607 1482 34 / 23

At H12 130 5900 1200 23 / 15

Under Noradrenaline, no bleeding

Re Listing for LT in « Super Urgence »

• First proposal was accepted… (at H1 after listing)

– Male, 45 year-old, 69 kg for 1.60 m, Gr 0-

– 24 hours of ICU for Cerebral Stroke and Anoxia

Bili ASAT ALAT GGT

At Admiss. 30 µmol/L 203 470 91

Re LT / Cold Ischemia 4h / 7 RPC

8 reinterventions with abdominal exploration and pancreatic necrosectomy

Very long post operative course…

12 weeks of ICU and 8 weeks in Hospitalization

Actual status at 3 years of FU

• Asymptomatic, he works in a bank

• ASAT 29, ALAT 100, GGT 83, TP 87%

• Under viread…

Thanks for your attention

eric.vibert.pbr@gmail.com These slides will be on slideshare