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Monitoring and Care

The worsening organ availability crisis continues to affect liver transplantation (LT) candidates. According to the United Network for Organ Sharing (UNOS), there were 16,092 patients awaiting LT as of March 31, 2012. The number of deceased liver transplants in the year 2011 was 6,094. The lower number of transplants coupled with longer waiting times increases the likelihood that candidates will have complications of their liver disease.…

Radiological Evaluation in Transplantation

Diagnostic and interventional radiological procedures have an important role in liver transplantation. They are used before operation in the selection and presurgical management of candidates and posttransplantation in the follow-up, diagnosis, and treatment of complications. Pretransplantation Evaluation Radiological evaluation of the liver transplant patient is usually performed on an outpatient basis. The goal is to determine abnormalities that preclude transplantation along with abnormalities that will affect…

Role of the Clinical Nurse Coordinator

Less than 25 years ago, a major nursing medical-surgical textbook stated: “The successful transplantation of organs and tissues as a means of preserving life, correcting deformities, and repairing organic damage has been an age old dream of physicians. In recent years, as a result of scientific advances in both surgery and physiology, that dream seems to be coming true.” The “dream” of successful transplantation and the…

Pretransplantation Evaluation: Infectious Disease

Despite great progress in liver transplantation, infections remain a major cause of morbidity and mortality. Although not every infection can be anticipated, many types can be predicted, and some can even be prevented. The sources of pathogenic organisms can be from the recipient’s endogenous flora, the environment, or the donor. Accordingly, infectious disease evaluation and screening of both the candidate and the donor are important to…

Pretransplantation Evaluation: Renal

Kidney-related complications are common sequelae of hepatic failure. These complications include electrolyte and acid-base abnormalities in addition to alterations in renal function from hemodynamic changes and parenchymal disease. Since the introduction of the Model for End-Stage Liver Disease (MELD) score in 2002, there has been a rise in the average serum creatinine level, percentage of renal replacement therapy (RRT), and use of combination liver-kidney transplant in…

Pretransplantation Evaluation: Cardiac

Liver transplantation is now offered to a larger population of patients because of the growth and experience of transplant centers and the improvements in technology and technique. For example, coronary artery disease (CAD), left ventricular dysfunction, and arrhythmias were once considered absolute contraindications to liver transplantation. However, currently patients with these cardiac issues may be considered for liver transplantation. This chapter examines the incidence, risk factors,…

Psychiatric Assessment of Liver Transplant Candidates

The psychiatric assessment of the transplant candidate is a critical component of the transplant evaluation process. There is a relatively high degree of psychiatric morbidity in patients being considered for organ transplantation. However, active psychiatric illness is a modifiable risk factor. The first goal of the psychiatric assessment is to determine the risk for psychiatric complications that may compromise a patient’s ability to successfully navigate the…

Ethical Decisions in Transplantation

Donation and Procurement of Organs As a complex, high-technology, lifesaving procedure associated with considerable risks, liver transplantation often poses numerous ethical dilemmas that require difficult decisions. These quandaries pertain to patients, their potential donors, and society at large. The underlying ethical principles that guide treatment decision making about ethical dilemmas include the following: Respecting the self-determination of patients with decision-making capacity ( autonomy ) Protecting the…

Transplantation for Hepatic Malignancy in Children

Liver transplantation has become an important component of treatment algorithms in children diagnosed with primary hepatic malignancy. Interestingly, liver transplantation for malignancy in the pediatric population has historic significance. A 3-year old child with biliary atresia and an incidentally discovered hepatocellular carcinoma (HCC) underwent transplantation on January 2, 1970, and that individual is the oldest surviving liver transplant recipient. Hepatoblastoma and HCC are the two most…

Transplantation for Metabolic Disease in Children

Liver transplantation has made possible the functional cure of several metabolic diseases characterized by inherited genetic defects. In many pediatric transplantation centers, metabolic diseases, most notably α 1 -antitrypsin deficiency, are the second or third most common indication for liver transplantation after biliary atresia and fulminant hepatic failure. The Studies of Pediatric Liver Transplantation (SPLIT) database shows that of the more than 4000 U.S. and Canadian…

Transplantation for Biliary Atresia in Children

Biliary atresia (BA) is the result of an idiopathic, progressive, fibroinflammatory process that affects intra hepatic and extrahepatic bile ducts. It typically presents in the first few weeks of life and without early recognition and surgical treatment progresses rapidly to biliary cirrhosis, leading to either liver transplantation or death by 2 years of age. This chapter provides clinicians and surgeons with a detailed overview of the…

Transplantation for Cholestatic Liver Disease in Children

Cholestasis, a potentially serious condition that indicates hepatobiliary dysfunction, is defined as a serum conjugated bilirubin fraction greater than 1.0 mg/dL if the total serum bilirubin level is less than 5 mg/dL, or a value of conjugated bilirubin more than 20% of the total bilirubin if the total bilirubin level is 5 mg/dL or higher, or elevated total serum bile acid level. Cholestasis is a relatively…

General Criteria for Transplantation in Children

Liver transplantation provides lifesaving treatment for children with liver disease. Current challenges include identifying those ready for a liver transplantation and the optimal timing for listing a patient for transplantation. Condition at the time of transplantation affects survival, and consequently time spent on the waiting list can be paramount to overall prognosis. Within a span of 3 decades, pediatric liver transplantation has matured as a clinical…

Unusual Indications for Transplantation

Liver transplantation is a widely available and accepted procedure for the treatment of advanced-stage liver disease. The leading indications for liver transplantation in adults are chronic hepatitis C, nonalcoholic steatohepatitis, chronic hepatitis B, alcoholic liver disease, and the cholestatic liver diseases primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC). In children the leading indication for liver transplantation is biliary atresia. Liver transplantation is also used…

Transplantation for Nonalcoholic Steatohepatitis

Nonalcoholic Steatohepatitis as a Cause of Advanced Liver Disease and as an Indication for Liver Transplantation A recent cross-sectional study of patients in a large outpatient general medical clinic setting observed the prevalence of nonalcoholic fatty liver disease (NAFLD) to be 46%, with nonalcoholic steatohepatitis (NASH) observed in 12.2% of the total cohort, making NASH the most common liver disease in North America. The prevalence of…

Transplantation for Alcoholic Liver Disease

Alcoholic liver disease (ALD) is the second most common diagnosis among patients undergoing liver transplantation (LT) in the United States and Europe. ALD, either alone or in combination with hepatitis C virus (HCV) infection, accounts for 20% of all the primary transplants that took place in the United States from 1988 to 2009, comprising more than 19,000 recipients. Moreover, the outcome for patients transplanted for ALD…

Transplantation for Budd-Chiari Syndrome

In 1845 George Budd, a British internist, described a patient with hepatic venous thrombosis who developed abdominal pain, hepatomegaly, and ascites. William Osler reported the first case of a membranous web causing vena caval and hepatic vein obstruction in 1879. The Austrian pathologist, Hans Chiari, specified the clinicopathological features of the syndrome, emphasizing occlusion of the intrahepatic veins in 1899. Budd-Chiari syndrome (BCS) results from obstruction…

Transplantation for Hematological Disorders

Liver transplantation (LT) often affords a last-ditch treatment option for a disparate group of disorders that may be managed by the hematologist. In some cases LT cures the patient by correcting the cause of the problem, whereas in other cases patients may benefit only transiently because induced organ damage is irreversible. Atypically LT may bring a new illness to the patient, as when an affected liver…

Transplantation for Metastases

Transplant Indications for Secondary Malignancies in the Past Liver transplantation for secondary malignancies has a long history; many programs included this indication in their pioneer phase in cases where the primary tumor was successfully removed and metastatic disease was confined to the liver. Metastases from cancers of the colon, tail of the pancreas, hypernephroma, meningioma, and duodenal leiomyosarcoma have been reported by Calne. The Denver-Cincinnati Registry…

Transplantation for Cholangiocarcinoma

Background Cholangiocarcinoma (CCA), first described by Durand-Fardel in 1840, is a malignant neoplasm arising from epithelial cells of the extrahepatic and intrahepatic bile ducts, excluding the papilla of Vater and the gallbladder. CCA is the second most common primary hepatobiliary malignancy in the United States. The incidence of CCA is increasing, and its prognosis remains grim without surgical treatment. Early diagnosis has been a constant challenge…