Who and When to Refer for Liver Transplantation

Transcription

1 Who and When to Refer for Liver Transplantation Jorge L. Herrera, M.D. University of South Alabama Mobile, AL Gastroenterology Get to Know your Transplant Center(s) How far is the transplant center from you? How early do they want to meet patients? When cirrhosis is diagnosed When any decompensation occurs When the MELD score is > 10 * MELD scores over 15 How involved do you want to be? Follow your patients until transplant? Have the transplant center manage the advanced cirrhotic? *Murray KF, Carithers RL. AASLD Guidelines. Hepatology 2005;41:1-25 Gastroenterology Timing the Referral - MELD INR Bilirubin Serum Creatinine Predicts 3-month mortality Does not include Ascites Encephalopathy Variceal Bleeding Freeman RB. Hepatology 2008;47:

2 Risk of Dying from Transplantation vs. Waiting Merion RM, et al. Am J Transplant 2005;5: Timing of Transplant Differ Among Regions in the U.S. 58 Organ Procurement Organizations (OPO) Smaller OPO s ~ 1.2 million people Larger OPO s ~ up to 18 million people Waiting time differs depending on OPO size Smaller OPO s 19% have MELD >24 at transplant Larger OPO s 50% have MELD >24 at transplant Brown RS, et al. Gastroenterology 2007;132: Reality Check Mayo Clinic Experience Mayo Clinic Jacksonville, FL patients referred for transplant evaluation 295/555 (53%) denied placement 150/295 (51%) disease stage was too early Of the 150, only 9% were subsequently listed during the study period Average MELD of those listed was 21 Advocate listing patients with MELD > 15 Aranda-Michel J, et al. Mayo Clin Proc 2008;83:

3 Address Patient s Expectations Getting a liver will fix all my problems Patients gain a new set of health problems after receiving the liver transplant! If I get in the waiting list now, I will get a liver faster Weed Out Unsuitable Candidates Explore your referral center s attitudes about: Active alcohol and/or substance abuse Recent extra-hepatic malignancy (<5 years, except non-melanoma skin cancer) Cigarette smoking Morbid obesity Significant co-morbidities CAD, diabetes Ehtisham J, et al. Liver Transpl 2010;16: Thuluvath PJ. Liver Transpl 2005;11:S25-S29 One-Year Survival of Younger vs. Older Transplant Recipients Older: >60, except UC Davis (>70) Keswani RN, et al. Liver Transpl 2004;10:

4 Age and Liver Transplantation Co-morbidities are more important than age Seniors >65 years have a worse prognosis compared to years Survive the operation full or minimally limited functional capacity Screen for heart disease, bone disease, malignancy Keswani RN, et al. Liver Transpl 2004;10: Predictors of Mortality in age >60y 1. Mechanical ventilation 2. Diabetes mellitus 3. Positive HCV serology 4. Serum creatinine >1.6 mg/dl 5. Combined recipient + donor age > 120 years Factors 1y Survival 5y Survival 0 88% 75% 1 85% 69% % n 8, Aloia TA, et al. Liv Transpl 2010;16: Living Donor Liver Transplantation Controls the timing of transplant Limited availability Controversial, but increasing in popularity Jan to August ,634 transplants, of which 124 were living donors Particularly well suited for HCC cases Typically recipients transplanted at lower MELD scores UNOS database: (accessed August 25, 2010) Florman S, Miller CM. Liver Transpl 2006;12:

5 MELD Exceptions Hepatocellular carcinoma Single lesion <5cm or < 3 lesions, each <3cm Hepatopulmonary syndrome Screen with O 2 saturation testing Diagnose with bubble echocardiogram Refer before resting PaO 2 <50 mmhg Portopulmonary hypertesion Screen with echocardiogram Confirm with right heart catheterization Refer before pulmonary pressure > mm Hg Ioannou GN, et al. Gastroenterology 2008;134: Rodriguez-Rosin R, et al. NEJM 2008;358: Kawut SM. Clin Liv Dis 2006;20: Getting the Patient Ready For Transplant Starts when cirrhosis is first diagnosed! Immunizations Hepatitis A & B Pneumococcal pneumonia Influenza Worse prognosis in cirrhosis Lower efficacy of vaccine as liver disease advances Minimal response after transplant Reiss G, et al. Aliment Pharmacol Ther 2004;19:

6 Esophageal Varices Screening indicated for all patients with cirrhosis No varices repeat in 3 years or if decompensation Small varices High risk stigmanta prophylaxis No stigmata surveillance in 1 year Medium/Large varices institute prophylaxis Garcia-Tsao G, et al. Hepatology 2007;46: Hepatocellular Carcinoma Screening Every 6 months Liver imaging + alpha fetoprotein level Ultrasound Triple-phase contrast CT scan Triple-phase contrast MRI Diagnostic findings Arterial phase hyperdense lesion hypodense on venous phase ( wash-out ) Bruix J, Sherman M. Management of HCC AASLD Guidelines. Hepatology 2010 Cancer Screening Colon Breast Gynecologic Prostate ENT smokers and previous alcoholics 6

7 Bone Health Increased incidence of osteoporosis in cirrhosis Even in non-cholestatic liver disease Pre-transplant T score of 68 HCV patients % osteoporosis 35% normal bone mass Bone loss accelerated after transplant 16% per year Hay JE, et al. Clin Liver Dis 2005;9: Gulchelaar MM, et al. Liver Transpl 2006;12: Prevalence of Osteoporosis and Fractures in Liver Disease Collier J. Hepatology 2007;46: Increased Bone Loss After Transplant Collier J. Hepatology 2007;46:

8 Posttransplant Osteoporosis and Fractures Collier J. Hepatology 2007;46: Recommendations for Bone Density Testing Collier J. Hepatology 2007;46: Dental Health Oral infection potential source of sepsis 300 liver transplant candidates Severe dental disease in 32% Type of liver disease did not affect dental health Edentulous patients less likely to have seen a dentist in the recent past Last dental exam >12 months prior was highest risk factor for severe dental disease Guggenheimer J, et al. Liver Transpl 2007;13:

9 Psychosocial Issues Adherence Social support Alcohol use Methadone maintenance programs Psychiatric disorders Krahn LE, DiMartini A. Liver Transpl 2005;10: Conclusions Who to refer? Decompensated liver disease (CP >7, MELD >10) No contraindications When to refer? Distance to transplant center Transplant center philosophy Referring physician s desire to be involved in the treatment of advanced liver disease 9