4/26/2017. Liver Transplant and Palliative Care: Teaming up to improve care

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1 Liver Transplant and Palliative Care: Teaming up to improve care Jody C. Olson, M.D., FACP Assistant Professor of Medicine and Surgery Hepatology and Critical Care Medicine All patients with end-stage liver disease may benefit from palliative care, and being active on the transplant list does not preclude this addition. In fact patient s overall quality of life may be improved by such consultation. 1

2 Objectives: Review epidemiology of cirrhosis Review disease states commonly encountered in LTx Describe the process of liver transplant candidate selection Describe when de-listing is appropriate Discuss palliative care partnerships Prevalence of Cirrhosis in the US 0.27% corresponding to 633,323 adults 69% were unaware of having the disease 30,000 diagnoses per year at tertiary referral centers Scaglione et al., J Clin Gastroenterol 2015 Sep;49(8): leading causes of death worldwide 2012 Rank Cause Deaths (000s) % deaths Deaths per 100,000 population 0 All Causes 1 Ischaemic heart disease 2 Stroke 3 Chronic obstructive pulmonary disease 4 Lower respiratory infections 5 Trachea, bronchus, lung cancers 6 HIV/AIDS 7 Diarrhoeal diseases 8 Diabetes mellitus 9 Road injury 10 Hypertensive heart disease 11 Preterm birth complications 12 Cirrhosis of the liver 13 Tuberculosis 14 Kidney diseases 15 Self-harm 16 Birth asphyxia and birth trauma 17 Liver cancer 18 Stomach cancer 19 Colon and rectum cancers 20 Alzheimer's disease and other dementias Source: WHO Estimates for Cause Specific Mortality accessed at 2

3 Worldwide burden of liver disease Ischemic Heart Disease Stroke COPD Lower Resp Infections Liver Disease Other Source: WHO Estimates for Cause Specific Mortality accessed at Asrani et al., Gastroenterology (2013);145: Total number of cirrhosis hospitalizations Allen and Kim, Seminars in Liver Dis 2016; 36(02):

4 Total hospital charges associated with cirrhosis hospitalizations in billions of dollars Allen and Kim, Semin Liver Dis 2016; 36(02): Costs associated with critical care of advanced liver disease in billions of dollars Data from Dr. W. Ray Kim Common causes of liver disease in the US: Hepatitis C virus infection Alcohol overuse Non-alcoholic fatty liver disease Autoimmune hepatitis Primary sclerosing cholangitis Primary biliary cirrhosis Hemochromatosis Unknown 4

5 NON-Alcoholic Fatty Liver Disease: Also called NAFLD or NASH Becoming the most common cause of liver disease in the US Steatohepatitis Difficult to treat Non-alcoholic steatohepatitis: Fatty liver vs. fatty liver DISEASE: A fatty liver is a common finding on routine imaging studies Fatty liver does not necessarily = fatty liver disease Fatty liver + abnormal liver tests = fatty liver disease 5

6 Other genetic liver disease: PSC PBC Autoimmune hepatitis Alpha 1 antitrypsin disease No specific testing recommendations. Normal liver: Normal liver microscopic view: 6

7 Liver blood flow and portal circulation: Progression of scarring: 7

8 Cirrhotic liver: Grading Liver Disease: The MELD score Model for End Stage Liver Disease Adapted by UNOS for liver allocation Useful for predicting overall mortality related to liver disease Hepatology 2001;33:

9 Hepatology 2001;33: MELD Score Calculation: MELD Score: x Log e (creatinine mg/dl) x Log e (bilirubin mg/dl) x Log e (INR) Multiply by 10 and round to the nearest whole number. Range Kamath et al. Cirrhosis Prevention ACLF Natural History Deranged inflammatory response Decompensation Recovery Multi organ dysfunction/failure Transplant Liver support? Early Transplantation? Death Death Olson and Kamath (2011) Current Opinion in Critical Care 17:

10 Key concept: Reversibility Insult Liver function (%) Weeks Olson and Kamath (2011) Current Opinion in Critical Care 17: Goals of Care: ACLF vs Natural History Jalan, R., Gines, P., Olson JC., et al., J of Hepatology (2012) 57: The Harsh Truth: Liver disease is progressive in a vast majority of cases In absence of transplant it is not curable High morbidity and mortality Dramatic impact in quality of life Has to get worse before it can get better 10

11 Transplant evaluation process: Do you need a transplant? Severity of disease and MELD Conditions in which liver transplant cures a disease, e.g. familial amyloid, primary hyperoxaluria Are you sick enough? Decision driven by risk benefit analysis and ultimately by UNOS organ allocation policies MELD score MELD score > 15 Disease cured by transplant, MELD exception given, e.g. HCC, FAP, PH Can you survive a transplant? Are you too sick? Underlying comorbid states Malignancy, heart failure Severity of illness beyond the window of opportunity On multiple pressors Multi-organ failure Severe malnutrition with debility 11

12 The grey areas of transplant evaluation: Social support Substance abuse Financial/insurance Ability to cope with the post transplant care Age A few words about substance abuse: In general most centers (including KUMC) require 6 months of documented sobriety in cases in which liver disease is directly related Six months of counseling is generally required Exception pathways in some centers (Mayo) Impact on the center: SRTR and UNOS Graft and Patient Survival Waitlist death** 12

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14 Mayo Clinic Rochester University of Nebraska Doing what is right Best for the patient Best for the center Allows us to do what we do By extension allows us to do the most good for the most people 14

15 Current partners in transplant evaluation: Social work Financial counselors Cardiology Surgery Psychiatry Dietician Palliative care?? Some real life case examples: A 57 year old male presents to an outside hospital. On presentation he is found to be markedly confused but can protect his airway. His sister presents to the hospital with him and provides history as follows: Case 1 continued: Long standing of alcohol abuse Has known complications of alcohol misuse Lives alone Unemployed Sister is caring and willing to help but unable to assume total care 15

16 Case 1: Labs CBC notable for mild macrocytic anemia CMP Creatinine 3.5 BUN 120 Total Bilirubin 4.5 INR: 2.6 MELD 35 What do you do?? What really happened: Accepted the patient in transfer Shortly after arrival transitioned to comfort care only Family unable to travel to KC Pt died alone 16

17 Case 2 59 year old male with known alcohol misuse but no prior diagnosis of cirrhosis found by his daughter to be weakened and deeply jaundiced. He is transported to a local hospital and admitted to the ICU. Case 2 Continued: He is treated for alcohol withdrawal Ativan gtt Requires mechanical ventilation Renal failure on dialysis The family is told that he is not (and will not) be a transplant candidate and they are urged to withdraw support. Case 2 continued: At the families urging, sedatives are withheld He eventually awakes and is successfully extubated He remained on dialysis The family is continually urged to withdraw support 17

18 Case 2 continued: After ten days, he remains on IHD He is awake but confused (HE Grade 2-3) The family removes him from the hospital against medical advice and transport him on commercial airline to a transplant center in Wisconsin Case 2 conclusion: Two years later Off dialysis with normal renal function Returned to work Completed alcohol treatment MELD score 8-9 without evidence of hepatic decompensation. All patients admitted to the ICU with complications of cirrhosis deserve a consultation with a transplant center to determine candidacy for liver transplantation. Perceived contraindication to transplant should never preclude this consultation because patients with cirrhosis admitted to the ICU have a mortality rate of 50%. Olson, Wendon, et al., Hepatology 2011;54:

19 Too sick to transplant? A question that is difficult to answer Some general rules: In ICU on multiple pressors Progressive debility Prolonged ventilatory failure Infection unlikely to be resolved Palliative Care Partnerships When is the right time for consultation? At time of diagnosis? At time of listing? When patient is starting to fail? QUESTIONS? 19