Summary Listen
- Liver transplantation involves the partial or complete replacement of a diseased liver with a healthy one, sourced from either a deceased (cadaveric) or living donor. Heterotopic transplantation leaves the native liver in place, while orthotropic transplantation replaces it entirely. Auxiliary transplants add a portion of healthy liver alongside a portion of the native liver, often in cases of acute liver failure. Domino liver transplants involve using a liver with a specific metabolic defect from one patient to treat another patient with a different type of liver disease. Swap transplants involve matching donor-recipient pairs from two families to overcome blood group incompatibility.
- Indications for liver transplantation in adults include acute liver failure (caused by toxins, viral hepatitis, or drug-induced injury), chronic liver disease (cirrhosis from hepatitis B or C, alcohol, or autoimmune diseases), acute-on-chronic liver failure, metabolic liver diseases, and certain liver cancers (hepatocellular carcinoma) or metastases. Pediatric indications include biliary atresia, progressive familial intrahepatic cholestasis (PFIC), metabolic liver diseases, hepatoblastoma, and acute liver failure.
- Timing of liver transplant depends on the severity and type of liver disease (acute vs. chronic). Acute liver failure requires urgent assessment. The King's College criteria help predict which patients with acute liver failure will not recover spontaneously and require transplant. Absolute contraindications for transplant include brain herniation, severe hypotension despite vasopressors, documented systemic infection, and irreversible multi-organ failure.
- Acute-on-chronic liver failure (ACLF) involves an acute insult on pre-existing liver disease. ACLF grading helps determine the urgency of transplant. Early assessment is crucial, particularly for severe ACLF (grade 2 and 3). Factors indicating futility in ACLF grade 3 include severe frailty, systemic infection, respiratory failure, and severe circulatory failure.
- In chronic liver disease, the MELD score is often used to prioritize patients on the transplant list. Liver transplantation for malignancy is generally reserved for unresectable cases of hepatocellular carcinoma, with selection based on criteria like the Milan criteria. When a second malignancy is detected, timing depends on whether the underlying liver disease is acute or chronic.
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About the Speakers
Dr. M. Rajgopal Acharya
Senior Consultant Liver Transplant and HPB Surgeon, Star Hospital, Hyderabad
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