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Liver Transplantation Overview - June 28 2013
1. UPDATE AND INNOVATIONS IN
LIVER TRANSPLANTATION
Lewis Teperman, M.D.
Director of Transplantation
Vice Chairman of Surgery
NYU School of Medicine
Annual Presentation to Nurses
June 28, 2013
1
3. Sources: (1) 2007 OPTN/SRTR Annual Report Tables 1.3 and 1.7; and (2) http://optn.transplant.hrsa.gov/ar2009/
Number of Patients on UNOS Liver Waiting List
(as of
3/14/2011 = 16,853)
Transplant
s
3
4. Causes of Death in 262 DonorsCauses of Death in 262 Donors
41
27
74
51
15
10
8
5
6
4
4
4
4
3
2
2
2
1
0 10 20 30 40 50 60 70 80
MOTOR VEHICLE ACCIDENT
GUN SHOT WOUND
SUBARACHNOID BLEED/CVA
HEAD INJURY
FALLING
INTRACRANIAL ANEURYSM
ASPIRATION
MENINGITIS
BRAIN TUMOR
IATROGENIC
CHILD ABUSE
DROWNING
DRUG INTOXICATION
SUDDEN INFANT DEATH
SEIZURE
DIABETES
CHOKING
SPORTS ACCIDENT
5. New York Organ Donor NetworkNew York Organ Donor Network
New York is saferNew York is safer
Crime is downCrime is down
Vehicular accidents are downVehicular accidents are down
Organ Donation
Living Donation 20%
Deceased Donation 10%
Import Organ Offers 75%
5
6. Doctors Confirm West Nile in a 4thDoctors Confirm West Nile in a 4th
Transplant PatientTransplant Patient
Doctors have confirmed that a woman in Florida is the fourth personDoctors have confirmed that a woman in Florida is the fourth person
to have contracted West Nile virus after receiving an organto have contracted West Nile virus after receiving an organ
transplanted from a single donor who had the virus, a federal healthtransplanted from a single donor who had the virus, a federal health
official said last night.official said last night.
Finding the virus in all four organ recipients "very strongly suggestsFinding the virus in all four organ recipients "very strongly suggests””
that the disease was transmitted by the organs rather than bythat the disease was transmitted by the organs rather than by
mosquito bites, said the official, Dr. Lyle Petersen, a West Nile expertmosquito bites, said the official, Dr. Lyle Petersen, a West Nile expert
at the Centers for Disease Control and Prevention.at the Centers for Disease Control and Prevention.
------ The New York TimesThe New York Times
6
7. WEST NILE VIRUS
• West Nile, a flavivirus, is a relatively
new pathogen to the U.S.
• Other flaviviruses include:
- Yellow fever
- Dengue
- Saint Louis Encephalitis
LW Teperman, MD, T Diflo, MD, A Fahmy, MB, GR Morgan, MD, et al. “West Nile Virus Infections in Organ Transplant Recipients---
New York and Pennsylvania, August---September, 2005.” MMWR Disptach of CDC October 5, 2005: 54 (Dispatch); 1-3.
7
8. West Nile VirusWest Nile Virus
Approximate Geographic Range in 1998Approximate Geographic Range in 1998
8
12. Tumor ConveyanceTumor Conveyance
““Teen Organ Donor's Gift Turns Tragic”Teen Organ Donor's Gift Turns Tragic”11
““Transmission of Anaplastic Large CellTransmission of Anaplastic Large Cell
Lymphoma via Organ Donation AfterLymphoma via Organ Donation After
Cardiac Death”Cardiac Death”22
1. SAG HARBOR, N.Y., April 1, 2008, Nancy Cordes, CBS News Correspondent
2. JW Harbell, TB Dunn, M Faudia, DG John, AS Goldenberg and LW Teperman.. American Journal of Transplantation,
January 2008; Vol. 1; Issue I; 238-244.
12
13. Transmission of Anaplastic
Large Cell Lymphoma via
Organ Donation After
Cardiac Death
J.W. Harbell, T.B. Dunn, M. Fauda, D.G.John, A.S. Goldenberg, L.W. Teperman;
AJT:2008; 8, pps 238-244.
15. Donor-Derived Disease Transmission EventsDonor-Derived Disease Transmission Events
in the United States: Data Reviewedin the United States: Data Reviewed
by the OPTN/UNOS Disease Transmissionby the OPTN/UNOS Disease Transmission
Advisory CommitteeAdvisory Committee
M. G. Ison,*, J. Hager, E. Blumberg,M. G. Ison,*, J. Hager, E. Blumberg,
J. Burdick, K. Carney, J. Cutler, J. M. DiMaio,J. Burdick, K. Carney, J. Cutler, J. M. DiMaio,
R. Hasz, M. J. Kuehnert, E. Ortiz-Rios,R. Hasz, M. J. Kuehnert, E. Ortiz-Rios,
L. Teperman and M. NalesnikL. Teperman and M. Nalesnik
American Journal of Transplantation 2009; 9: 1–7American Journal of Transplantation 2009; 9: 1–7
15
16. Table 5: Reports made to DTAC regarding a potential donor-
derived malignancy transmission
2005-2007
Malignancies Donor
Reports1
Confirmed
Recipients2
Recipient
Deaths3
Renal Cell Carcinoma 25 3 0
Lung adenocarcinoma 5 2 2
Glioblastoma
multiforme
4 1 1
Lymphoma 3 4 2
Metastatic Melanoma 3 2 1
Prostate
adenocarcinoma
2 0 0
OTHERS X X X
TOTALS 55 15 6
1. Number of donors reported possible donor-derived disease transmission. 2. Number of recipients with confirmed (proven, probable or possible) donor-derived
disease. 3. Number of recipients who died as the result of a donor-derived disease transmission.
17. ““The liver does notThe liver does not
undergo senescence.”undergo senescence.”
-Hans Popper, MD-Hans Popper, MD
18. The Successful Use of OlderThe Successful Use of Older
Donors for LiverDonors for Liver
TransplantationTransplantation
L. Teperman, L. Podesta, L. Mieles, T. StarzlL. Teperman, L. Podesta, L. Mieles, T. Starzl
JAMA 1989; 262:2837JAMA 1989; 262:2837
19. Donor FactorsDonor Factors
Age BarrierAge Barrier > 80 Years> 80 Years
Fat Content:Fat Content: macro vs. micromacro vs. micro
Length of stayLength of stay > 10 days> 10 days
HypernatremiaHypernatremia
19
20. Expanded Criteria DonorExpanded Criteria Donor
Define Relative Risk(RR) of FailureDefine Relative Risk(RR) of Failure
RR 1.7: 70% greater risk of failureRR 1.7: 70% greater risk of failure
FactorFactor RRRR P-ValueP-Value
Donor Age 40 to 49Donor Age 40 to 49 1.161.16 0.00060.0006
Donor Race BlackDonor Race Black 1.191.19 0.00010.0001
DCD LiverDCD Liver 1.521.52 0.00060.0006
Partial / Split LiverPartial / Split Liver 1.531.53 0.00010.0001
Donor Age 70 or AboveDonor Age 70 or Above 1.631.63 0.00010.0001
20
21. 19961991
Obesity Trends* Among U.S. Adults
BRFSS, 1991, 1996, 2004
(*BMI ≥30, or about 30 lbs overweight for 5’4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
2004
Source Mokdad A.H., et all JAMA 2003,289-1 21
22. Obesity Trends* Among U.S. Adults
BRFSS, 2011
http://feww.files.wordpress.com/2011/07/obesity-2011-feww1.png
22
24. Retransplant Rates in RegionRetransplant Rates in Region
vs. the USvs. the US
13.4
10.3
6.7
4.9
8.4
5.6
0
2
4
6
8
10
12
14
ECD Non ECD Overall
Region 9 Rest of Country
RetransplantRates(%)
NYU
5%
24
26. Old Allocation SystemOld Allocation System
Child-Turcotte-Pugh Scoring System to Assess
the Severity of Liver Disease
* For cholestatic liver diseases, these values for bilirubin are to be submitted for the values above.
Points 1 2 3
Encephalopathy None 1-2 3-4
Ascites Absent Slight or At least
controlled moderate
by diuretics despite diuretics
Bilirubin(mg/dL) <2 2-3 >3
Albumin >3.5 2.8-3.5 <2.8
Prothrombin time <1.7 1.7-2.3 >2.3
(seconds prolonged)
or INR
For PBC, PSC or other <4 4-10 >10
cholestatic liver diseases:
Bilirubin (mg/dL)*
26
27. Problems with CTP ScoreProblems with CTP Score
Limited numberLimited number ofof categoriescategories
LimitedLimited discriminating abilitydiscriminating ability
UsesUses subjective parameterssubjective parameters -- gaminggaming
LaboratoryLaboratory variabilityvariability (protime, albumin)(protime, albumin)
Never validatedNever validated
CreatinineCreatinine not includednot included
27
28. Q: What is MELD?Q: What is MELD?
A: Disease Severity ScoreA: Disease Severity Score
29. 90% Survival Probability on the waitlist90% Survival Probability on the waitlist
VariablesVariables
BilirubinBilirubin
CreatinineCreatinine
INRINR
““ CHANGE REAGENT”CHANGE REAGENT”
Liver disease etiology (deleted)Liver disease etiology (deleted)
MELD MODEL:MELD MODEL:
Predicts Survival in TIPS Patient
?
29
30. Creatinine Bilirubin INR Dialysis? HCC? MELD
Person #1 0.8 0.3 1.04 N N 6
Person #2 1.1 1.4 1.14 N N 10
Person #3 3.2 1.0 1.03 N N 18
Person #6 8.9 0.6 1.01 Y N 20
Person #4 1.8 1.6 2.00 N N 22
Person #5 0.9 1.7 1.26 N 2 – 5 cm* 22
Person #7 3.5 12.0 1.56 N N 33
MELD EquationMELD Equation
MELD = (0.957 x LN (creatinine) + 0.378 xMELD = (0.957 x LN (creatinine) + 0.378 x
LN (bilirubin) + 1.12x LN(INR) + 0.643) x 10LN (bilirubin) + 1.12x LN(INR) + 0.643) x 10
Capped at 40Capped at 40
30
31. HCC: Extra CreditHCC: Extra Credit
Patients meeting criteria receivePatients meeting criteria receive 2222 points.points.
After a three-month reevaluation patientsAfter a three-month reevaluation patients
receive additional points.receive additional points.
Thereafter they receive additional pointsThereafter they receive additional points
every three months.every three months.
31
33. Hepatitis C Tumor BurdenHepatitis C Tumor Burden
4 million US Patients4 million US Patients
1 million Cirrhotics (10 years)1 million Cirrhotics (10 years)
1/4 million HCC1/4 million HCC (10 years)(10 years)
33
35. Abdominal Organ ClusterAbdominal Organ Cluster
Transplantation for the Treatment ofTransplantation for the Treatment of
Upper Abdominal MalignanciesUpper Abdominal Malignancies
Thomas E Starzl MD, PHD; Satoro Todo MD; Andreas Tzakis MD; Luis Podesta MD;
Luis Mieles MD, Anthony Demetris MD, Lewis Teperman MD; Rick Selby MD; William
Stevensen MD; Andre Steiber MD; Robert Gordon MD; Shunzaburo Iwatzuki MD
35
37. OLT Survival Milan CriteriaOLT Survival Milan Criteria
60 1812 3024 4236 48
20
0
40
60
100
80
Months
Probability(%)
Mazzaferro, V. N Engl J Med 199637
38. HCCHCC
While we wait, the tumor grows!While we wait, the tumor grows!
Treatment is appropriateTreatment is appropriate
Are 6 cm lesions really more deadly thanAre 6 cm lesions really more deadly than
5 ?5 ?
Exceptional case review (RRB)Exceptional case review (RRB)
John Roberts, UCSF, AJT 2006;
Yao, et al. Am J Transplant. 2007;7:2587-2596. 38
39. HCC Recurrence after OLTHCC Recurrence after OLT
5040 6010 3020
.2
0
.4
.6
1.
.8
Months
Recurrence
.3
.5
.7
.9
.1
No Vascular Invasion
Vascular Invasion
Hemming, A. Ann Surg 2001
0
39
40. HepatomasHepatomas
Initial MELD ExceptionInitial MELD Exception
29 points29 points
~ 20% of transplants~ 20% of transplants
20-24 points20-24 points
Excellent SurvivalExcellent Survival
MELD is Evolving!MELD is Evolving!
Consider living donationConsider living donation
40
41. Strategies for Long WaitingStrategies for Long Waiting
TimeTime
TACETACE
Living Donor TransplantLiving Donor Transplant
41
46. Patient Survival after liverPatient Survival after liver
transplantation:transplantation:
Benign vs. Malignant diseaseBenign vs. Malignant disease
Months after 46
48. There is NO consensus on optimalThere is NO consensus on optimal
duration of HBIG, dose, or mode ofduration of HBIG, dose, or mode of
administration.administration.
-- Lewis TepermanLewis Teperman
10/15/200610/15/2006
48
50. A Randomized Trial of HBIGA Randomized Trial of HBIG
Withdrawal UsingWithdrawal Using
Emtricitabine/Tenofovir DF inEmtricitabine/Tenofovir DF in
Post-Liver Transplant RecipientsPost-Liver Transplant Recipients
L TepermanL Teperman11
, J Spivey, J Spivey22
, F Poordad, F Poordad33
, T Schiano, T Schiano44
, N Bzowej, N Bzowej55
,,
S PungpapongS Pungpapong66
, P Martin, P Martin77
, D Coombs, D Coombs88
, K Hirsch, K Hirsch88
, J Anderson, J Anderson88
and F Rousseauand F Rousseau88
11
The Mary Lea Johnson Richards Organ Transplantation Center,The Mary Lea Johnson Richards Organ Transplantation Center,
New York University Medical Center, New York, NY;New York University Medical Center, New York, NY; 22
Emory Healthcare, Atlanta, GA;Emory Healthcare, Atlanta, GA;
33
Cedars-Sinai Medical Center, Los Angeles, CA;Cedars-Sinai Medical Center, Los Angeles, CA; 44
Recanati/Miller Transplantation Institute,Recanati/Miller Transplantation Institute,
Mount Sinai Hospital, New York, NY;Mount Sinai Hospital, New York, NY; 55
California Pacific Medical Center, San Francisco, CA;California Pacific Medical Center, San Francisco, CA;
66
Mayo Clinic Jacksonville, Jacksonville, FL;Mayo Clinic Jacksonville, Jacksonville, FL; 77
Schiff Liver Institute,Schiff Liver Institute, University of Miami,University of Miami,
Miller School of Medicine, Miami, FL;Miller School of Medicine, Miami, FL; 88
Gilead Sciences Inc., Durham, NCGilead Sciences Inc., Durham, NC
51. BackgroundBackground
HBIG prophylaxis is routinely prescribed toHBIG prophylaxis is routinely prescribed to
prevent HBV recurrence post-orthotopic liverprevent HBV recurrence post-orthotopic liver
transplantation (OLT)transplantation (OLT)
HBIG prevents recurrence byHBIG prevents recurrence by neutralizingneutralizing HBsAgHBsAg
Long-term prophylaxis with HBIG is inconvenientLong-term prophylaxis with HBIG is inconvenient
and expensive, but is the mainstay of post-and expensive, but is the mainstay of post-
transplant therapy.transplant therapy.
51
52. Cost of HBIG in Relation with HBIG Dosing and Strategy of
Administration in Patients Receiving HBIG + Lamivudine
Yearly cost of different schedules of HBIg administration in Euros. The “on demand” schedule using
2,000 IU of HBIg allows a savings of over 50% compared with fixed monthly doses of 5,000 IU.
Di Paolo et al. Transplantation 2004; 77: 1203-
1208.
52
53. AimAim
This ongoing randomized study (Study 107)This ongoing randomized study (Study 107)
evaluates the safety andevaluates the safety and efficacy of TVDefficacy of TVD
with/without HBIGwith/without HBIG in preventing recurrence ofin preventing recurrence of
CHB post OLTCHB post OLT
The aim of thisThe aim of this interim analysisinterim analysis is to evaluate theis to evaluate the
efficacy, safety and tolerability of TVD in thisefficacy, safety and tolerability of TVD in this
populationpopulation
53
55. Virologic OutcomesVirologic Outcomes
No detectable HBV DNA (169No detectable HBV DNA (169
copies/mL; lower limit of quantitation)copies/mL; lower limit of quantitation)
in either groupin either group
No HBsAg positivityNo HBsAg positivity
55
56. Hepatitis CHepatitis C
Most common indication forMost common indication for
transplantation 25 - 45%transplantation 25 - 45%
95% of recipients persist with antibody to C95% of recipients persist with antibody to C
At least 50% develop active hepatitis onAt least 50% develop active hepatitis on
biopsybiopsy
It is unknown how many progress to aIt is unknown how many progress to a
chronic statechronic state
56
57. Treatment for Hepatitis CTreatment for Hepatitis C
InterferonInterferon
RibavirinRibavirin
Pegylated - InterferonPegylated - Interferon
PegasysPegasys
PEG-IntronPEG-Intron
Protease Inhibitors 2011Protease Inhibitors 2011
NYU post tx pilot 7/15 negNYU post tx pilot 7/15 neg
-TIMING--TIMING-
57
58. Baylor Zenapax Trial
Steroid Sparing
I L 2 Receptor Antagonist Induction
Randomized Controlled Trial
Results:
No Difference in Hepatitis C Recurrence,
Diabetes, or Rejection
November 2005
Fasola, C G., Heffron, T. G., Sher, L., Douglas, D. D., Brown, R., Ham, J,. Teperman, L.,…et al. “Multicenter Randomized Hepatitis C
(HCV) Three Trial Post Liver Transplantation (OLT): A Preliminary Report.” Transplantation. 78(2) Supplement 1: 146, July 27, 2004.58
59. A Randomized Multicenter Study
Comparing Efficacy and Safety of
Steroid-Free and Standard
Immunosuppression for Liver
Transplantation Recipients with
Chronic Hepatitis C
(submitted)
Goran B. Klintmalm1
, Gary L. Davis1
, Lewis Teperman2
, George J. Netto3
, Ken Washburn4
, Steven Rudich5
, Elizabeth Pomfret6
, Hugo
E. Vargas7
, Robert Brown8
, Devin Eckhoff9
, Timothy Pruett10
, John Roberts11
, David C. Mulligan7
,Michael Charlton12
, Thomas G.
Heffron13
, John Ham14
,David Douglas7
,Linda Sher15
,Prabhakar Baliga16
, Milan Kinkhabwala8
, Baburao Koneru17
,Michael Abecassis18
,
Michael Millis19
, Linda W. Jennings1
, Carlos G. Fasola13
1
Baylor University Medical Center, Dallas, TX; 2
New York University Medical Center, NY; 3
Johns Hopkins Medical Institutions,
Baltimore, MD; 4
University of Texas Health Science Center at San Antonio; 5
University of Cincinnati, Cincinnati, OH; 6
Lahey Clinic,
Burlington, MA; 7
Mayo Clinic, Scottsdale, AZ; 8
New York Presbyterian Hospital, New York, NY; 9
University of Alabama – Birmingham, AL; 10
University of Virginia, Charlottesville, VA; 11
University of California, San Francisco, CA; 12
Mayo Clinic, Rochester, MN; 13
Emory University
School of Medicine, Atlanta, GA (current address: Scott and White Clinic, Temple, TX); 14
Oregon Health Sciences University, Portland, OR; 15
University of Southern California, Los Angeles, CA; 16
Medical College of South Carolina, Charleston, SC; 17
University of Medicine and
Dentistry of New Jersey, Newark NJ; 18
Northwestern Memorial Hospital, Chicago, IL; 19
University of Chicago, Chicago, IL
59
60. ““The challenge ofThe challenge of
transplant surgery is NOTtransplant surgery is NOT
the surgery”the surgery”
60
63. Risk of Chronic Renal FailureRisk of Chronic Renal Failure
A 15-year experience at Baylor MedicalA 15-year experience at Baylor Medical
Center found that at 13 years after liverCenter found that at 13 years after liver
transplantationtransplantation
Incidence of severe renal dysfunction ofIncidence of severe renal dysfunction of
18.1%18.1%
Chronic renal failure in 8.6% of patientsChronic renal failure in 8.6% of patients
ESRD in 9.5% of patientsESRD in 9.5% of patients
Gonwa TA et al. Transplantation 2001;72:1934-1939.
63
65. Calcineurin inhibitor-freeCalcineurin inhibitor-free
maintenance withmaintenance with
mycophenolatemycophenolate
mofetil/sirolimus in livermofetil/sirolimus in liver
transplant recipients: Save-transplant recipients: Save-
the-Nephron Trialthe-Nephron Trial
(submitted)(submitted)
L .Teperman,L .Teperman,11
D. Moonka,D. Moonka,22
A.Sebastian,A.Sebastian,33
L. Sher,L. Sher,44
P. Marotta,P. Marotta,55
C. Marsh,C. Marsh,66
B. Koneru,B. Koneru,77
J. Goss,J. Goss,88
D. Preston,D. Preston,99
and J. Robertsand J. Roberts1010
11
New York University School of Medicine, New York, New York;New York University School of Medicine, New York, New York; 22
Henry Ford Health Systems, Detroit, Michigan;Henry Ford Health Systems, Detroit, Michigan; 33
Integris Baptist MedicalIntegris Baptist Medical
Center, Oklahoma City, Oklahoma;Center, Oklahoma City, Oklahoma; 44
University of Southern California, Los Angeles, California;University of Southern California, Los Angeles, California; 55
London Health Sciences Hospital,London Health Sciences Hospital,
London, Ontario, Canada;London, Ontario, Canada; 66
Scripps Green Hospital, La Jolla, California;Scripps Green Hospital, La Jolla, California; 77
University of Medicine and Dentistry of New Jersey, Newark,University of Medicine and Dentistry of New Jersey, Newark,
New Jersey;New Jersey; 88
Saint LukeSaint Luke’s Episcopal Hospital, Houston, Texas;’s Episcopal Hospital, Houston, Texas; 99
Genentech, South San Francisco, California;Genentech, South San Francisco, California; 1010
University of California, SanUniversity of California, San
Francisco, CaliforniaFrancisco, California
Lew, This version contains comments from LS, JR, and DM. PM provided feedback of no comments. Lew, This version contains comments from LS, JR, and DM. PM provided feedback of no comments. 65
66. STN Trial DesignSTN Trial Design
MMF +MMF + tacrolimustacrolimus
±± corticosteroidscorticosteroids
MMF + cyclosporine
± corticosteroids
MMF + tacrolimusMMF + tacrolimus
MMF + cyclosporine
MMF + sirolimusMMF + sirolimus
MMF + sirolimusMMF + sirolimus
Post-randomizationPost-randomization
1 year1 year
Pre-randomizationPre-randomization StableStable
4 – 124 – 12
WW
EE
EE
KK
SS
PP
OO
SS
TT
--
TT
XX
2 years2 years
ScreeningScreening Enrollment
66
67. Mean %Mean % Increase in CalculatedIncrease in Calculated
GFRGFR
Baseline to Month 6Baseline to Month 6
N = 84
55.8±±1.91.9
N = 86
50.6±±1.91.9
0
5
10
15
20
25
30
35
MeanPercentIncrease
(±SEM)
MMF/SRL
MMF/CNI
3.2
40
Baseline GFR ± SEM (mL/min)
29.2
67
68. ConclusionsConclusions
At leastAt least 62%62% of individuals are able toof individuals are able to toleratetolerate aa
maintenance regimen of MMF/SRL and willmaintenance regimen of MMF/SRL and will
benefitbenefit
In the short term,In the short term, MMF/SRL improvesMMF/SRL improves renalrenal
functionfunction when compared to CNI-containingwhen compared to CNI-containing
regimensregimens
The addition ofThe addition of lipid-lowering agentslipid-lowering agents may bemay be
necessary in patients receiving MMF/SRLnecessary in patients receiving MMF/SRL
Complete follow-up of the 294Complete follow-up of the 294 patients willpatients will
provide a moreprovide a more statisticallystatistically robust conclusionrobust conclusion
about the long-term effect of this regimenabout the long-term effect of this regimen
68
69. Donor and NYU TimelineDonor and NYU Timeline
1999 Living Donation (Right Lobe Adult)
1997 Split Livers (peds) (Adult)
1990 Living Donation
Lateral Segment (peds)
1988 Reduced Sized Grafts (peds)
1963 University Hospital Built
1965 1st Successful
Liver Transplant
New Transplant Regulations
69
71. Transplant Chief at Mt. Sinai Quits Post inTransplant Chief at Mt. Sinai Quits Post in
Wake of InquiryWake of Inquiry
A week after Mount Sinai Medical Center was cited byA week after Mount Sinai Medical Center was cited by
the state for dozens of serious violations, the chief of itsthe state for dozens of serious violations, the chief of its
liver transplant center has stepped down and the entireliver transplant center has stepped down and the entire
program will be restructured, hospital officialsprogram will be restructured, hospital officials
announced yesterday.announced yesterday.
------ The New York TimesThe New York Times
71
72. Summer of 2010Summer of 2010
2 Recent U.S. Deaths2 Recent U.S. Deaths
ColoradoColorado
MassachusettsMassachusetts
72
73. New York StateNew York State
Report of the Subcommittee on DonorReport of the Subcommittee on Donor
Perioperative Care and Facility ReportPerioperative Care and Facility Report
Lewis Teperman M.D., Chair
73
74. New Preoperative Care RegsNew Preoperative Care Regs
1.1. Psychiatric EvaluationPsychiatric Evaluation
2.2. Bank BloodBank Blood
3.3. StaffStaff
1.1. 2 donor surgeons*2 donor surgeons*
2.2. A third transplant surgeon*A third transplant surgeon*
3.3. Anesthesia (2 attendings)Anesthesia (2 attendings)
4.4. Post operative carePost operative care
1.1. ICU (days 0 - 1)ICU (days 0 - 1) 1 Nurse / 2 Patients1 Nurse / 2 Patients
2.2. FloorFloor 1 Nurse / 4 patients1 Nurse / 4 patients
3.3. ResidentsResidents (pgy2) / NP(pgy2) / NP 24/724/7
5.5. RegistryRegistry
1.1. OutcomeOutcome
* Qualified
74
75. Living Donor RecipientsLiving Donor Recipients
InclusionInclusion
Listed with UNOS and must have a significantListed with UNOS and must have a significant
complication of liver diseasecomplication of liver disease
Relative ExclusionsRelative Exclusions
MELD > 25MELD > 25
Cholangio CarcinomaCholangio Carcinoma
ExclusionsExclusions
AFHFAFHF
Retransplant for CRetransplant for C
Acute Alcoholic HepatitisAcute Alcoholic Hepatitis
75
76. HCC: Extra CreditHCC: Extra Credit
Is Living Donation justified?Is Living Donation justified?
Patients meeting criteria receivePatients meeting criteria receive 2222
points.points.
After a three-month reevaluationAfter a three-month reevaluation
patients receive additional points.patients receive additional points.
Thereafter they receive additionalThereafter they receive additional
points every three months.points every three months.
76
77. Hepatoma PredictorHepatoma Predictor
LDLT and Waiting List TimeLDLT and Waiting List Time
20 64 108 1412 1816
2
0
4
8
12
10
Waiting list time (months)
Recipientlifeexpectancy(years)
2220 24
6
14
5 yr survival after DLT 70%
DLT drop out 2%/month
DLT drop out 4%/month
Immediate LDLT
Sarasin, F. Hepatology 200177
79. Donor CandidacyDonor Candidacy
Requirements (1)Requirements (1)
Emotionally relatedEmotionally related
Age 18 - 60Age 18 - 60
Blood Type CompatibleBlood Type Compatible
A AA A
O O, B, A, ABO O, B, A, AB
79
80. MELD Score Comparison of CadavericMELD Score Comparison of Cadaveric
vs. Living Related Donorsvs. Living Related Donors
Average Living Donor MELD Score:Average Living Donor MELD Score:
17.417.4
Average Cadaveric MELD Score:Average Cadaveric MELD Score:
3232
80
82. 1% Rule1% Rule
70kg recipient needs a 700cc liver graft70kg recipient needs a 700cc liver graft
(1% GRWR)(1% GRWR)
1% mortality1% mortality
(Actually ~0.05% but over emphasize to(Actually ~0.05% but over emphasize to
define risk)define risk)
82
83. Living DonorLiving Donor
Right Hepatic resectionRight Hepatic resection
50% - 65% of the hepatic mass50% - 65% of the hepatic mass
Right is RightRight is Right
Left hepatic resections will haveLeft hepatic resections will have
more complicationsmore complications
83
84. Living DonorsLiving Donors
What the Surgeon Needs to Know:What the Surgeon Needs to Know:
Liver ParenchymaLiver Parenchyma
Right lobe volumeRight lobe volume
Exclude fattyExclude fatty
infiltrationinfiltration
Characterize lesionsCharacterize lesions
Hepatic arteriesHepatic arteries
Arterial variantsArterial variants
RHA originRHA origin
Portal veinsPortal veins
PV variants, RPVPV variants, RPV
originorigin
Hepatic veinsHepatic veins
RHV lengthRHV length
MHV branches to rightMHV branches to right
lobelobe
Inferior accessory HVInferior accessory HV
Biliary ductsBiliary ducts
Biliary variantsBiliary variants
Rt lateral duct originRt lateral duct origin
84
86. CT CholangiographyCT Cholangiography
Higher SpatialHigher Spatial
Resolution than MRResolution than MR
Shorter Exam TimeShorter Exam Time
Radiation DoseRadiation Dose
Contrast AgentContrast Agent
86
87. Donor Rule #2Donor Rule #2
Know the donorKnow the donor’s anatomy prior to the’s anatomy prior to the
procedureprocedure
Donor Rule #1Donor Rule #1
Do not hurt the donorDo not hurt the donor
See Rule #2See Rule #2
SafetySafety
87
88. Living Donor BiliaryLiving Donor Biliary
TechniqueTechnique
1.1. Demonstrate anatomy prior to ORDemonstrate anatomy prior to OR
2.2. Confirm anatomy with an on tableConfirm anatomy with an on table
cholangiogramcholangiogram
3.3. Exclude right to left cross overExclude right to left cross over
4.4. Perform a duct to duct anastomosisPerform a duct to duct anastomosis
5.5. Utilize a t-tube for post operative studies andUtilize a t-tube for post operative studies and
drainagedrainage
88
89. Picture of on table cholangiogram priorPicture of on table cholangiogram prior
to splittingto splitting
89
In 2005, there were 2949 human cases in 42 states, and ecologic WNV activity was seen in all 48 contiguous states.
Human activity was scattered throughout the US, but most human cases were seen in CA, the southwest, and the central mountain states.