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You Need a Liver Transplant , Now What to Expect?

   

Liver transplantation is a physically and emotionally challenging endeavour that is stressful to patients and their families. A thorough and detailed evaluation is necessary. The goal of the workup is four fold:

• It must establish a diagnosis of chronic liver disease, the severity of the disease and the    possible cause
• It must exclude any absolute or relative contraindication to the liver transplant surgery
• The patient is in a relatively stable physical and mental health to undergo a long and complex surgery
• Finally, it must assess the suitability of each patient to better allocate a cadaveric organ and optimize survival ( irrespective of a living or cadaveric donor)

The pre-transplant medical work up includes a detailed history, clinical examination along with a variety of laboratory and radiological tests.

History:

• Current symptoms and medical problems
• Detailed past history of any cardiac ( heart), pulmonary ( Chest) issues or any cancers
• Full evaluation of the candidate’s past, present, and future risk of exposure to infection    including tuberculosis
• A complete vaccination history
• Current medications and allergies.
• Drug and alcohol abuse
• Social history (especially for transplant co-ordinators as it is an excellent opportunity to engage household members and other close contacts in the education and protection of the future recipient).

Clinical Examination:

 

    A thorough general and systemic examination is performed to specifically look for the following:

• Signs of Chronic liver disease
• Any potential Cardiac /respiratory or neurological issue
• Nutritional status including malnutrition or Obesity
• Focus of infection

 
Blood Tests
1 ABO Blood Grouping + RH Typing
2 Complete blood count with Peripheral smear
3 Liver Function Test
4 Renal Function Test
5 Magnesium
6 Glucose Fasting /Post Prandial
7 Glycosalated Haemoglobin (HBA1c)
8 Prothrombin Time/ International Normalised Ratio ( PT/INR)
9 Activated Partial Thromboplastin Time (APTT)
10 Fibrinogen
11 Lipid Profile
12 Thyroid Profile
13 Ferritin
Tumour Markers
14 AFP (Alpha Feto Protein)
15 CEA (Carcinoembryonic Antigen)
16 CA19.9 (Cancer Antigen 19-9)
Viral Markers
17 CMV IgG/ IgM ( Cytomegalovirus)
18 HBsAg ( Hepatits B surface antigen)  
19 HBc- Total ( Hepatitis B core antibody)
20 Anti HBs Antibodies
21 Anti HCV ( Hepatitis C virus)
22 HIV I-II ( human Immunodeficiency Virus)
22 HIV I-II ( human Immunodeficiency Virus)
23 VDRL (Venereal Disease Research Laboratory Test)
Culture
24 Urine
25 Blood
26 Ascitic Fluid Culture
27 Sputum
28 Urine RE/ME (Routine Examination/ Microscopic Examination)
29 24 hours Urine protein Creatinine ratio
30 24 hours Urine Creatinine Clearance
Pulmonary Evaluation
31 HRCT Chest (High Resolution Computed Tomography)  
32 Pulmonary Function Test (PFT)
33 Arterial Blood Gas (ABG)
34 Arterial Lactate
35 Pleural Fluid Culture
Cardiac Evaluation
36 ECG(Electrocardiography)
37 2D Echo
38 Dobutamine Stress echo
Radiology
39 Ultrasonography Abdomen
40 Contrast Enhanced Computed Tomography CECT Triple Phase of abdomen
Additional Test For Females(If required)
41 UPT (Urine Pregnancy Test)
42 Ultrasonography Pelvis
43 Pap Smear
44 Mammography/Sonomammography

Besides the above, an upper gastro-intestinal endoscopy is performed on all potential recipients

Once, all the reports are available, mandatory consultations and clearances from the following specialities are needed:

• Hepatologist ( Liver Physician)
• Transplant Surgeon
• Cardiologist
• Pulmonary physician
• Dietician
• Psychiatrist
• Dentist
• Anaesthetist
• Physiotherapist
• Gynaecologist ( for female recipients)
• Dentist
• Financial clearance

Once the workup is complete, all workup results and consultations are presented at the Liver Transplant Clinical meeting. This meeting is generally attended by :

• Transplant surgeons,
• Hepatologists,
• Anaesthetist
• Intensivist.
• Pathologist
• Radiologist
• Transplant Co-ordinator
• Primary Care Physician ( if Possible)

The work-up and structure of the committee may vary slightly with different centres; however, the process is uniform and primarily involves answering the following questions.

• Does the patient need Liver Transplant as therapy for his or her disease?
• Have the indications and contraindications been properly assessed?
• What is the surgical risk and prognosis?
• Is the patient's medical condition such that he or she will be able to tolerate the procedure and postoperative course?
• What are the chances of recurrent disease affecting graft and patient survival?

Patients are excluded if they were too well, too sick, too old or had other comorbid conditions (e.g. - Severe heart disease), substance abuse problems (e.g. - Not abstinent from alcohol intake), or any other psychosocial barriers that may not augur well for the survival of the graft.

Once candidates have undergone routine screening, an individualized approach is warranted to identify particular predisposing factors that may predict infection/risk factors and outcome. Assessment may need to be periodically repeated in patients who remain on the cadaveric waiting list, with 6 monthly investigations and viral screening as the preferred standard in most centres, and more frequent testing if indicated.

The key to successful pre-transplant evaluation is the recognition of risk , the acquisition of information, a multi-disciplinary team decision that would result in an organized and thoughtful approach to perioperative and post-transplant management; thus ensuring best outcomes.

   Aug 19th, 2016


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