Liver Transplant: What s Different? Brian Lin, MD, FACEP Emergency Medicine, Kaiser Permanente, San Francisco UCSF Clinical Assistant Professor

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1 Liver Transplant: What s Different? Brian Lin, MD, FACEP Emergency Medicine, Kaiser Permanente, San Francisco UCSF Clinical Assistant Professor

2 No Disclosures.

3 Background 45 years : 90,830 transplants 127 centers

4 Living Transplant Recipients Text Gelb B, Feng S. Expert Reviews 200

5

6 Goals & Objectives Liver Transplantation Nuts & Bolts History, Exam, and Workup Complications

7 Case History 50 yo F with hx of liver transplant 4 weeks ago p/w abdominal pain & fever

8 Physical Exam BP 150/90 HR 105 RR 20 sat 99% T 99.8 No jaundice Abdomen: Staples intact JP drain, scant serous output Tender over graft

9 The transplant history

10 The transplant history: Indication for transplant PBC = Primary biliary cirrhosis PSC = Primary sclerosing cholangit HCC = Hepatocellular carcinoma

11 Indication for Transplant Viral Hepatitis Hep B Hep C Why it Matters Recurrence Risk: Low High Alcohol relapse & Alcoholic cirrhosis related complications Immune Dysfunction Autoimmune, PBC, PSC Autoimmune tendencies = more suppressed = Opportunistic infections

12 The Transplant History Indication for transplant? Surgery/Type of transplant?

13 Cadaveric Liver Transplant (Whole liver)

14 How the other half lives Cadaveric Split Liver Transplant

15 The Transplant History Indication for transplant? Surgery/Type of transplant? Med Regimen, & compliance?

16 Medication Regimen & Compliance Rejection Infection Ulcer Other

17 The Transplant History Indication for transplant? Surgery/Type of transplant? Med Regimen, & compliance?

18 Case Progression Cadaveric transplant for Budd-Chiari sydrome Compliant with meds: Tacrolimus (Prograf) Mycophenolate mofetil (Cellcept) Prednisone Testing? DDx? Initial Tx?

19 Testing & Treatment CBC Chemistry LFTs, Lipase Blood Cxs UA, Cx Drug levels (as available) CMV PCR Upright CXR Ultrasound

20 DDx? Abscess? Nosocomial? Biloma? Surgical complication? Infection? CMV? Fungal? Vascular problem? Anastomotic leak? Thrombosis? Rejection? Acute? Chronic?

21 Early (1 mo) Mid (1-6 months) Late (>6 months) The Chronology of Complications

22 Early (1 mo) Mid (1-6 months) Late (>6 months) Surgical Long-term medical Malignancy Infection Rejection Disease Recurrence

23 Early (1 mo) Mid (1-6 months) Late (>6 months) Surgical Bile Leak HAT Strictures Infection Nosocomial Fungal Rejection Acute Opportunistic Chronic Long-term medical HTN, DM, CKD Malignancy HCC, PTLD Lymphoma, Skin cancer Disease Recurrence Hep C Autoimmune

24 Early (1 mo) Mid (1-6 months) Late (>6 months) Surgical Bile Leak HAT Strictures

25 Biliary Complications: Dx: Leaks Inspect surgical drains Ultrasound or CT Treatment: Endoscopic, percutaneous, surgery Abx as appropriate

26 Biliary Complications: Strictures Stricture Dilation Re-opened

27 Hepatic Artery Thrombosis (HAT) Hepatic artery Patent Thrombosed

28 Early (1 mo) Mid (1-6 months) Late (>6 months) Technical Bile Leak HAT Strictures Long-term medical Malignancy Infection Nosocomial Fungal Opportunistic Rejection Disease Recurrence Acute Chronic

29 Early (1 mo) Mid (1-6 months) Late (>6 months) Rejection Acute Chronic

30 We all handle it differently.

31 Rejection Humoral Acute cellular Chronic (ductopenic)

32 Rejection Symptoms & Signs Fever Pruritis Graft tenderness Labs elevated LFTs leukocytosis w/ eosinophilia

33 Rejection Rate: 15-20% Gelb B, Feng S. Expert Reviews

34 Immunosuppression Highlights Typical 2-3 agents to start Weaning over initial weeks to months Typically, with: Prophylaxis against OIs Ulcers/Gastritis

35 Steroids: Start high, rapid taper heavy immunosuppressant Antimetabolite: GI side effects myelosuppression Calcineurin inhibitors (CNIs): Nephrotoxicity mtor inhibitor: HAT risk factor? nephrotic syndrome Hyperkalemia

36 Early (1 mo) Mid (1-6 months) Late (>6 months) Technical Bile Leak HAT Strictures Long-term medical Malignancy Infection Nosocomial Fungal Opportunistic Rejection Disease Recurrence Acute Chronic

37 Early (1 mo) Mid (1-6 months) Late (>6 months) Infection Nosocomial Fungal Opportunistic

38 Infection Nosocomial (<1 month) Wound infxns, PNA, UTI MRSA, VRE Fungal (0-2 months) Candida, Aspergillus Opportunistic (1-6 months) CMV, EBV, HSV Nocardia, Listeria, Pneumocystis, Toxoplasma

39 Cytolomegalovirus Sxs: fevers, (CMV) malaise, arthralgias, GI sxs Atypical lymphocytes, thrombocytopenia, high LFTs Dx: CMV PCR

40 Early (1 mo) Mid (1-6 months) Late (>6 months) Technical Bile Leak HAT Strictures Long-term medical Malignancy Infection Nosocomial Fungal Opportunistic Rejection Disease Recurrence Acute Chronic

41 Early (1 mo) Mid (1-6 months) Late (>6 months) Long-term medical HTN, DM, CKD

42 Early (1 mo) Mid (1-6 months) Late (>6 months) Malignancy HCC, PTLD Lymphoma, Skin cancer

43 Early (1 mo) Mid (1-6 months) Late (>6 months) Disease Recurrence Hep C Autoimmune

44 Early (1 mo) Mid (1-6 months) Late (>6 months) Technical Bile Leak HAT Strictures Infection Nosocomial Fungal Rejection Acute Opportunistic Chronic Long-term medical HTN, DM, CKD Malignancy HCC, PTLD Lymphoma, Skin cancer Disease Recurrence Hep C Autoimmune

45 The Consult Fill in the blanks Decision-making/Data interpretation Help Dispo (Transfer, Follow up)

46 Case Resolution POD 7 POD 14 POD Today Transplant team called, provides add l labs

47 Case Resolution U/S: suspicious for HAT Transferred & Treated Weeks later: Recovering well, staples and drains out

48 Summary Get the transplant history Chronology of complications Call the liver team!

49

50 Thanks! Special thanks to: AAEM Education Committee Dr. Francis Yao, UCSF Hepatology Dr. John Roberts, UCSF Transplant Surgery UCSF Liver Transplant Surgery Team References: See handout

51 Bonus Material Other important points about liver transplant patients that didn t make the cut for the 25 minute talk, but that you should know...

52 Medication interactions There are long lists of medications that have the potential to interact with immunosuppressant drugs. Giving anything to these patients can seem pretty scary. I went through a list of drugs that are specifically contraindicated in the liver tx pt; though there are a lot of meds, the good news is, there were just a few that jumped out at me as things I would commonly prescribe. I ll ask you to remember four:

53 Emergency Department No Nos Drug plus equals Erythromycin CNI Nephrotoxicity Diltiazem CNI Nephrotoxicity Phenytoin CNI immunosuppression Maalox/Mylanta Mycophenylate immunosuppression CNI = calcineurin inhibitor (cyclosporin, tacrolimus)

54 Tylenol, aspirin, and motrin, oh my! These patients will often tell you they are not allowed to have these drugs. Is this true? Tylenol: permissible, but limit to 2 grams/24 hrs rather than 4 grams. NSAIDs: not preferred, as most pts are on prograf, which is renal toxic. Those who aren t, probably have underlying renal disease! ASA: actually, most pts are on this already as a standard for months post-tx to prevent

55 CMV: Fun facts What constitutes disease, rather than asymptomatic infection? CMV PCR <1000: probably not disease, rather, carrier state How is CMV prophylaxis determined at tx? If pt is (-) but donor is (+), patient gets 6 months valocyclovir prophylaxis If patient is (+), donor is (+), or both

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