living donor liver transplantation for fulminant hepatic failure · 2013-05-13 · living donor...
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![Page 1: Living Donor Liver Transplantation for Fulminant Hepatic Failure · 2013-05-13 · Living Donor Liver Transplantation for Fulminant Hepatic Failure Hiroto Egawa M.D. Organ Transplant](https://reader033.vdocument.in/reader033/viewer/2022042015/5e742b71f0cc7f49ad30956c/html5/thumbnails/1.jpg)
Living Donor Liver Transplantation for Fulminant Hepatic Failure
Hiroto Egawa M.D.Organ Transplant DivisionKyoto University HospitalKyoto Japan
Expandidng the pool: Impact of Living Donor and Split Liver TransplantationKyoto Japan June 9 2004
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Liver Transplantation for FHF
• FHF is rapidly progressive and irreversible• Need for liver transplantation is urgent• It is difficult to obtain grafts in a timely
manner from cadaveric donors• The death rate of patient awaiting for liver
transplantation is as high as 40% or 62%.
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Rare cadaveric donors in Asia
>80% mortality in the absence of liver trasnplantation
Almost hopeless wait Living Donor Liver Transplantation
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Living–related Liver Transplantation in FHFMatsunami et al. Lancet 1992;340:1411
•15-year-old boy of 48 kg•Acute liver failure by drug reaction•Left lobe graft from his father•51% of SLV
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LDLT for FHF
Advantage– Availability of graft
• short waiting time • timely transplantation
– Good quality of a graftfrom a healthy donor
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LDLT for FHF
Disadvantage– Short time to decide the donation– Short time to evaluate donor candidates– Donor complications– Complex surgery – Recipient complications– Possible small for size graft
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Offer 1st interview and inform Family of a recipientFamily of donor candidates
Medically acceptable recipient &Definite voluntary willingness of a donor
Recipient transfer& further evaluation
Medical and psychological donor evaluation
Separate donor interview
2nd interview of recipient family & donor
Transplantation
Secure & quick
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Urgent Living-Donor EvaluationMedical
Physical ex. &laboratory data
Blood type (30min)CBC, coagulation, chemistry (30min) Infection (2hr) HLA (2hr)Occult blood of stool, Urine analysis (5min)
RadiologyAbdominal & chest X-p (5min)US scleening (20 min) CT scan (15min) Check steatosis &
Anatomy &Volumetry
Cardio-pulmonaryfunction check ECG, UCG, spirometry
PsychologicalInterview by psychiatrist
1hr
Decision
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Non-alcoholic Steato-hepatitisNo alcoholic historyNo other etiology
Risk factorsdiabetes, hyperlipidemia, obesity, hypertension
Symptoms no specific symptoms and liver failure with chirrosis
Physical signshepatomegaly
Pathologysteatosis and fibrosis
Incidenceunknown in Japan, increasing
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Preoperative Assesment of Steatosiswith CT Scan
Liver / Spleen ratio ofCT value #1/ #3: 53.9 / 58.9 = 0.91#2/ #3 : 58.3 / 58.9 = 0.98
Safety value > 1.2Marginal value 1.0-1.2Risky value <1.0
Steatosis >> excise, diet >> re-assessment
But, how should we do in an urgent case ?
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Strategy for Possible Steatosis in an Urgent Case
• High risk donor: alchohol, BMI >28 • Suspected by radiology: US, CT
BMI (Rinella. Liver Transplantation 2001;5:409)
Evaluation by CT density: liver / spleen ratio (LSR)
LSR<1.0 LSR >1.0
Abnormal LFT Normal LFT
accept
Liver biopsy
reject
HbA1C, HOMA-IRNo OK
No OK
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metabolic
PSC
PBC
BA
reTx
tumor
LC
FHFcholestatic
tumorLC
metabolic
FHF
othersothers82 cases
Pediatric Adult
Indication for Living Donor Liver Transplantation in Kyoto
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100
50
0 5 10
metabolic
cholestatic
Indication and Patient Survival in Children
(years)
tumor
fulminantLiver cirrhosis
%
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100
50
0 5
metabolic
cholestatic
Indication and Patient Survival in Adults
(%)
(years)
tumor
fulminant
Liver cirrhosis
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Etiology of FHF
<1 y.o. 1~18 y.o.
Unknown (15)
HBV (1) HSV (1)
≥18 y.o.
Unknown (15)
HBV (3)Heat stroke(1)
Unknown (22)
HBV (16)
AIH (2)HAV (2)
Drug induced (3)
Chrome poison (1)
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Donor
<1 y.o. 1~18 y.o. ≥18 y.o.
Father (8)
Mother (8)
Father (8)Mother (8)
Father (9)
Mother (3)Sibling (16)
Child (9)
Spouse (8)Uncle (1)
Ground mother (1)
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Blood Type Combination
<1 y.o. 1~18 y.o.
Identical (10)
Compatible (3)
Incompatible (4)
≥18 y.o.
Identical (13)
Compatible (6)
Identical (35)
Compatible (9)Incompatible (2)
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Graft TypeReduced-mono (2)
Mono (3)
Lateral (12)
<1 y.o.
Left (4)
Mono (1)
Lateral (9)
Right (3)
APOLT (2)
1~18 y.o. ≥18 y.o.
Left (6)Ext.Lat. (1)
Right (34)
APOLT (4)
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Recipient Age and Patient Survival100
50
05 10
%
years
<1years
1-18 years
>18 years
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Impact of Recipient Age• Inferior outcomes of the less-than-1-year-old children
– Farmer DG, et al. Ann Surg 2003;237:666– Bonatti H, et al. Transplant Proc 1997;29:434– Noujaim HM, et al. J Pediatr Surg 2002;37:159
Technical difficulty
Rash deterioration Donor scarcity
Vascular thrombosis
SepsisHaemorrhageMOF
Low incidence of ACRbut
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LDLT for FHF in Children
• 8patients(Age:3 mo-11years)• Etiology: drug induced (2), idiopathic (6)• Outcomes
– 3 death in patients with idiopathic etiology– Causes of death
• Recurrence of acute hepatitis in the 3 months old child• Refractory rejection in the 8 months old child
Lie CL et al. Liver Transplantation 2003;9:1185
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Result of LDLT for FHF in Children <1y.o.-Kyoto Experience-
Etiology outcome Causes of death
HBV(1) aliveHSV(1) alive
unknown(15) alive (4) (normal LFT [1] and waiting for re-Tx [2])dead (11) recurrent hepatitis (5)
refractory ACR (1)chronic rejection (1)EBV hepatitis (1)MOF after Rota-virus infection (2)HAT (1)
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Result of LDLT for FHF in Children <1y.o.-Kyoto Experience-
Etiology Biopsy findings
HBV (1) no biopsyHSV (1) no biopsy
unknown (15) moderate ACR (4)severe ACR (7)chronic rejection (1)hepatitis (7)massive necrosis (4)
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A Case of FHF 5 months old girl, 7.8 kg, unknown etiologyDonor: mother, identical blood type
severe ACR with hepatocyte dropout, simulating “recurrent fulminant hepatitis
moderate ACR with lobulainflammation
Day 12 Day 24
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LDLT for FHF with unknown etiologyin Children <1y.o.
• Poor outcomes• Strong immunosuppression is required• No strategy for recurrent hepatitis
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LDLT for FHF in KyotoComa grade
II (12)
III (19)
IV (13) Hyperacute(9)
Acute (21)
Subacute(12)
Type
Hoofnalge 1991
hyper acute subacute
jaundice encephalopathy7d 28d
Adult cases
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Neurological Death after LDLT
• Reported incidence: 4 ~ 11%• Kyoto Experience
– Incidence: 5%– All adult patients– GBWR: 0.73 ~ 1.24%– Preoperative coma grade: III (1), IV (3)
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How much volume do we needfor adult patients with FHF?• Left lobe :
– 23%-54% SLV• Nishizaki et al. Surgery 2002;131:182
– >35% • Miwa et al. Hepatology 1999;30:1521
• Right Lobe – 40% and more is favorable
• Liu et al. British J Surgery 2002;89:317
• Right or left or APOLT ?
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100
50
0
%
Years
Left Lobe
Right Lobe
51 2 3 4 6 7
APOLT
Graft Type and Patient Survival
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GBWR and Graft Type
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Right Lobe Left Lobe APOLT
GBWR = graft weight/recipient weight x100 (%)
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GBWR and Patient Survival100
50
0 51
%
Years
GBWR < 0.8%
GBWR >1.0%
GBWR 0.8-1.0%
2 3 4 6 7
P<0.05
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How much volume do we needfor adult patients with FHF?
• There is no difference between left lobe and right lobe when the graft volume is enough.
• The safe limit is GBWR of 0.8.• Grafts with GBWR of 0.8 should be used
even in APOLT .
Answer
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Risk Factors in Adults-Kyoto Experience-
• Preoperative factors– Other organ dysfunction
• Renal dysfunction: Cre>2.0, with dialysis• Respiratory dysfunction: on ventilator• Pancreatitis
– Preoperative steroid administration > 20 days– MELD > 25 (p=0.054)
• Operative factors– Small for size: GBWR < 0.8
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Small-for-size Syndrome
• Prolonged cholestasis
• Coagulopathy
• Massive ascites
• Gastrointestinal bleeding
• Renal dysfunction
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Strategy for Small for Size Graft
• Monitoring PV pressure < 20cmH2O
• Surgery– Outflow wide anastomosis
reconstruction of HVs draining to MHVright lobe graft with MHV
– Inflow splenic artery ligationporto-caval shunt
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Small-for-size partial liver graft in an adult recipient; a new transplant technique
O.Boillot, et.al., The LANCET; vol.359 (2002)
banding
PC shunt
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A Case of Heat Stroke• Recipient
– 16y.o. boy– Heat stroke with liver &
kidney failure– Come grade IV– 79kg in body weight
• Donor– Patient's mother– 51kg in body weight
• GBWR: 0.62 (496g)
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Effect of Inflow Modurationfor Small for Size
0
500
1000
1500
2000
2500
3000
3500
4000
4500
-5 0 5 10 15 20 25 30 35 40 45 50 55 60 65
0
5
10
15
20
25
POD
PT
ALT
T-Bil
ALT T-Bil, PT(sec)
r-PVRecipient left PV
Partial porto-caval shunt
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Musts in LDLT for FHF• Aim 1: Timely LDLT
– Offer to LDLT center ASAP– Inform family about an option of LDLT ASAP– Evaluate donor candidate quickly
• Aim 2: Donor safety & ethics– Inform donor risks as well as recipient benefits– Do not rush donor candidates to decide organ donation – Evaluate donor candidate without omission – Secure residual liver volume >30%
• Aim 3: Enough graft & residual liver volume– Choose graft type with GBWR > 0.8– Choose appropriate procedures in case of small for size graft
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Save recipient
Donor safety
Donor Evaluation in LDLT for FHF