Liver Transplantation

Indications & Scoring - Liver Lifeline Logic

Common Indications:

• Decompensated Cirrhosis (Viral, Alc, NASH)
• Acute Liver Failure (ALF)
• Hepatocellular Carcinoma (HCC) (within Milan Criteria)
• Metabolic/Cholestatic diseases (e.g., Wilson's, PSC)

Scoring Systems:

• MELD/PELD: Predicts 3-month mortality. MELD >15 common threshold.
  • 📌 Mnemonic (MELD): I Crush Beer Daily (INR, Cr, Bili, Dialysis).
  • MELD Components:

    Comp.	Detail
    Bilirubin	Serum total
    INR	Prothrombin
    Creatinine	Serum
    Dialysis	≥2x/wk/CRRT

• King's College Criteria: For ALF prognosis/transplant need.
• Milan Criteria (HCC): 1 tumor ≤5cm OR ≤3 tumors ≤3cm each; no major vascular invasion or extrahepatic spread.

Key Contraindications:

• Absolute: Active sepsis, extrahepatic malignancy, severe cardiopulmonary disease, active substance abuse.
• Relative: Advanced age (>70), morbid obesity.

⭐ MELD score (Bilirubin, INR, Creatinine, Dialysis) is pivotal for liver allocation, predicting 3-month mortality; score >15 often triggers listing for transplant eligibility assessment.

Donor & Recipient Prep - The Perfect Match Mission

• Donors: Deceased (DBD/DCD) or Living (LDLT).
• ABO Compatibility: Crucial. Identical > Compatible.

Donor Evaluation Criteria:

• Deceased Donor (Ideal):
  • Age <50 yrs (acceptable up to 60-65).
  • BMI <30 kg/m².
  • Steatosis (macrovesicular) <30%.
  • Negative viral markers (HBsAg, Anti-HCV, HIV).
• Living Donor (LDLT):
  • Age 18-55 yrs, voluntary, psychosocially stable.
  • BMI <30 kg/m², Steatosis <10-15%.
  • Adequate remnant liver volume (>30%), GRWR >0.8%.

Recipient Workup Essentials:

• Comprehensive cardiac, pulmonary, and renal function assessment.
• Infection screen: Viral (CMV, EBV, HIV, HBV, HCV), bacterial, fungal.
• Psychosocial evaluation and nutritional assessment.

⭐ For living donor liver transplantation (LDLT), a Graft-to-Recipient Weight Ratio (GRWR) of at least 0.8% is vital for adequate graft function and donor safety.

Surgical Highlights - Operation Liver Swap

• OLT: Standard. Piggyback (preserves recipient IVC, donor IVC to hepatic veins/side-clamped IVC) vs. conventional (IVC resection). Piggyback: better hemodynamics.
• Vascular Anastomoses (Order): 1. Suprahepatic IVC/Hepatic Veins 2. Portal Vein 3. Hepatic Artery.
• Biliary Reconstruction: Choledochocholedochostomy (duct-to-duct) or Roux-en-Y hepaticojejunostomy.
• Anhepatic Phase: Native liver out, before graft reperfusion. Veno-venous bypass (VVB) can maintain hemodynamic stability.

⭐ Hepatic artery thrombosis (HAT) is a dreaded early vascular complication, potentially leading to graft loss or biliary strictures.

Post-Op & Hurdles - Immunity & Issues

Immunosuppression:

*   Hyperacute: Mins-hrs, pre-formed Abs.
*   Acute Cellular (ACR): **1-12 wks**, T-cell; Rx: Steroids.
*   Chronic: >**6 mo**, ductopenia, arteriopathy.

• Complications:
  • Infections: CMV, Fungal (Candida, Aspergillus).
  • Vascular: Hepatic Artery Thrombosis (HAT), Portal Vein Thrombosis (PVT).
  • Biliary: Leaks, Strictures.
  • Disease Recurrence: HCV, HCC.

⭐ Acute cellular rejection is the most common type of rejection, typically occurring within the first few weeks to months post-transplant, and is usually responsive to steroid therapy.

High‑Yield Points - ⚡ Biggest Takeaways

• MELD score (bilirubin, INR, creatinine) dictates allocation priority.
• Milan criteria (1 tumor ≤5cm or ≤3 tumors each ≤3cm) for HCC transplant eligibility.
• Commonest indications: cirrhosis (adults), biliary atresia (children).
• Lifelong immunosuppression (e.g., tacrolimus, MMF) is crucial post-transplant.
• Key complications: rejection, infection (CMV), hepatic artery thrombosis, biliary strictures.
• Living donor liver transplantation (LDLT) offers an alternative to deceased donor organs.
• Orthotopic technique (OLT) is the standard surgical approach.