Liver Transplantation

Clinical Assessment and Management

James Neuberger, James Ferguson, Philip N. Newsome, Michael R. Lucey, James Neuberger, James Ferguson, Philip N. Newsome, Michael R. Lucey

• Publisher: Wiley-Blackwell
• Year: 2021
• ISBN:
  9781119633990
• Edition: 2
• Topic: Medicina
• Subtopic: Gastroenterologia ed epatologia

Explore this practicaland step-by-step guide to managing liver transplant patients from leading internationalcliniciansin Hepatology

The newly revised Second Edition of Liver Transplantation: Clinical Assessment and Management deliversexpert clinical guidance on best practices in managing the care of liver transplant patients.Authors are all experts in theirfield and cover a world-wide perspective.Organizedin an accessible, stepwise fashion and packed with text featuressuch askey points, the book covers all critical areasof each stage oftheliver transplantjourney, from assessment, to management on the list, to long term care.

Readers will learn when to refer a patient for liver transplantation, how to assess a potential liver transplant recipient, learn the principles of the procedure and thelong termmanagement of the transplant recipient. Liver Transplantation providesthe entire hepatology and surgical team the information required for a sound understanding of the entire procedure, from pre- to post-operative care and management.

Clinically oriented and management-focused, the book is far more accessible than the liver transplant sections in traditional hepatology textbooks. Readers will also enjoy:

• A thorough discussion of when to refer a patient for liver transplantation, including general considerations and the use and abuse of prognostic models
• An exploration of the selection, assessment, and managementof patients on the transplant list, including how to manage a patient with chronic liver disease while on the waiting list
• A treatment of liver transplantation for acute liver failure(ALF), including assessmentandmanagement of ALF patients on the transplant waiting list
• A discussion of care of the liver transplant recipient after the procedurein theshort and long term

Perfect forgastroenterologists, hepatologists, andsurgeonsand other health care professionalsmanagingpatients with liver disease who are awaiting, undergoingand followingliver transplantation, Liver Transplantation: Clinical Assessment and Management will also earn a place in the libraries ofmedical students, residents, internal medicine physicians, and GI/Hepatology traineesand all health care professionals providing clinical care to people with liver disease, before, during and after transplantation.

Part 1
When to Refer a Patient for Liver Transplantation

1
Overview on Organ Donation and Liver Transplantation

Michael Ronan Lucey

Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

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Key points

• Liver disease and its consequences are a major cause of death globally.
• Many patients with cirrhosis die from non‐hepatic causes.
• The causes of liver failure vary between countries, but alcohol and NAFLD are the major causes of cirrhosis and liver failure in the developed world.
• ALD and non‐specific cirrhosis have the worst prognosis, with the outcome of the former being dependent on whether the patient continues to drink alcohol.
• Only a small proportion of those dying from liver failure are suitable for consideration for liver transplantation.
• Rates of deceased and living organ donation vary between countries.

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The global burden of liver disease

Liver disease is a major cause of illness and death throughout the world. Recent estimates indicate that cirrhosis, with or without hepatocellular carcinoma (HCC), is the cause of around 2 million deaths annually (Asrani et al. 2019). As shown in Table 1.1, the relative contribution of liver disease to total annual mortality varies geographically. These variances reflect the causes of liver injury that predominate in different parts of the world. For example, alcohol‐related liver disease (ALD) and non‐alcoholic fatty liver disease (NAFLD) are the predominant causes of chronic liver disease in North America and Europe, whereas chronic viral hepatitis plays a greater role in Africa and Asia. The data are limited by concerns about the accuracy of information in some countries of South America, Asia and Africa. The picture is also in flux because of social changes in the use of alcohol in different countries (for example, declining alcohol consumption in France and Spain, and rising consumption in the US) and changing dietary habits leading to an increase in mean body mass in parts of the world that are adopting a Western lifestyle. In turn, the relative impact of these forces is apt to be influenced by public health efforts to reduce the risk of liver disease.

Table 1.1 Global mortality related to liver disease and liver cancer, 2015.

Source: Asrani et al. (2019).

	Cirrhosis and the liver				HCC
	Global rank	Deaths (000s)	% of total deaths	CDR (per 100,000 population)	Deaths (000s)
World	11	1162	2.1	15.8	788
East Asia and Pacific	13	328	2.0	14.4	547
Europe and Central Asia	17	115	1.2	12.7	78
Latin America and Caribbean	9	98	2.7	15.6	33
Middle East and North Africa	8	77	3.5	18.2	24
North America	12	50	1.7	14.0	27
South Asia	10	314	2.5	18.0	38
Sub‐Saharan Africa	16	179	1.9	17.9	42

Note: This is likely to be an underestimate and does not account for deaths due to acute hepatitis. Data available from Global Health Estimates 2015: Deaths by Cause, Age, Sex, by Country and by Region, 2000–2015. Geneva: World Health Organization, 2016. CDR, crude death rate; HCC, hepatocellular carcinoma.

What causes death in patients with liver disease?

In a recent study of national statistics from Great Britain, in which the causes of death in more than 5000 patients with cirrhosis were contrasted with a contemporaneous cohort of more than 150,000 persons who died without cirrhosis, and a similar nationwide cohort study from Denmark, 50% of deaths in the liver cohorts were attributed to causes related to cirrhosis (Ratib et al. 2017). In the British study, patients with alcohol‐related cirrhosis, chronic viral hepatitis, or autoimmune/metabolic disease were at a higher risk of liver‐related death than of any other cause of death, and this risk was greatest for patients with ALD, whereas patients with compensated cirrhosis of unspecified etiology were at a higher risk of non‐liver or neoplastic death, when compared with the general population, up to 5 years post diagnosis. This distinction is most likely a consequence of the co‐morbid cardiovascular mortal risks associated with NAFLD arising in the setting of metabolic syndrome.

In a separate study, Orntoft et al. (2014) analyzed a cohort of 1951 Danish patients with a first‐time hospital discharge diagnosis of alcoholic hepatitis (AH) between 1999 and 2008, of whom 1001 patients (364 women, 637 men) died. The authors stratified this subgroup according to interval from admission to death: 401 before and 600 after the first 85 days In the early death group; the causes of death were liver failure (40%), infection (20%), or hepato‐renal failure (11%). In the patients dying later in their clinical course, 326 did not have features of cirrhosis and their causes of death were mostly related to resumption of alcohol use, whereas among the 675 with cirrhosis, 34% died of liver failure, 16% of infection, and 11% of variceal bleeding.

The onset of a decompensating event is often recognized as the turning point in the clinical course of patients with cirrhosis. Jepsen et al. (2010) described the clinical course from the moment of decompensation in a cohort of 466 with a hospital‐based diagnosis of alcohol‐related cirrhosis (see also Orntoft et al. 2014). At diagnosis 24% were compensated, 55% had ascites, 6% had variceal bleeding, 4% had bleeding plus ascites, and 11% had hepatic encephalopathy. During the follow‐up interval of 1611 patient years, 36% remained abstinent, 43% were intermittent drinkers, and 21% drank alcohol persistently. Figure 1.1 shows mortality according to the patient’s initial presentation. The study demonstrates that the majority of subjects already had decompensated at the point of recruitment. Second, there was no characteristic pattern of decompensating events at presentation. Third, mortality was high after decompensation. Moreover, even patients who had well‐compensated liver function at recruitment had a poor prognosis, with > 50% dead at 5 years. Unfortunately, the authors did not analyze the outcome comparing abstinence with continued drinking. Recent studies ...