Treating patients with end-stage liver disease: Are we ready? Dr. Mino R. Mitri, M.D., C.M., M.Ed., FRCPC
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1 Treating patients with end-stage liver disease: Are we ready? Dr. Mino R. Mitri, M.D., C.M., M.Ed., FRCPC
2
3 No Conflict of Interest
4
5 157 patients
6 157 patients 6 transplanted
7 Criteria Liver Transplant Palliative Care Approach
8 Criteria Liver Transplant = Palliative Care Approach
9
10
11 advanced chronic liver disease when the limits of medical therapy have been reached. AASLD 2013
12 Patients should be selected if expected survival in the absence of transplantation is one year or less, or if the patient had an unacceptable quality of life because of liver disease. EASL 2015
13 Patients should be selected if expected survival in the absence of transplantation is one year or less, or if the patient had an unacceptable quality of life because of liver disease. EASL 2015
14
15 An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual.
16 Liver Transplant Palliative Care Patient with ESLD
17 Hawley, 2014
18 Hawley, 2014
19 Compensated Cirrhosis
20 Compensated Cirrhosis 6-12 years
21 Compensated Cirrhosis Decompensated Cirrhosis 6-12 years
22 Compensated Cirrhosis Decompensated Cirrhosis 6-12 years 2 years
23
24
25
26
27
28 Class A Class B Class C
29 100% 1 year survival 80% 45% Class A Class B Class C
30 Model for End-Stage Liver Disease (MELD) Score
31
32 15
33
34 20-25% Death
35 5-10% Clinical Deterioration
36 < 2 months
37 10%
38 well enough to undergo evaluation and listing, but sick enough to have developed signs of progression to a terminal state. Fox, 2014
39 Liver Transplant Palliative Care Patient with ESLD
40 Liver Transplant + Palliative Care Patient with ESLD
41 Hawley, 2014
42 Treating patients with end-stage liver disease: Are we ready?
43
44 Treating patients with end-stage liver disease: Are we ready?
45 Patient Care
46 ESLD Patient Care
47 Patient Care ESLD Cancer
48 Ascites Cirrhotic Cardiomyopathy Gastroesophageal Varices Hepatic Encephalopathy Hepatic Hydrothorax Hepatocellular Carcinoma Hepatopulmonary Syndrome Hepatorenal Syndrome Portal Vein Thrombosis Portopulmonary hypertension Spontaneous Bacterial Peritonitis
49 Ascites Cirrhotic Cardiomyopathy Gastroesophageal Varices Hepatic Encephalopathy Hepatic Hydrothorax Hepatocellular Carcinoma Hepatopulmonary Syndrome Hepatorenal Syndrome Portal Vein Thrombosis Portopulmonary hypertension Spontaneous Bacterial Peritonitis
50
51 Portal Hypertension vs Non-Portal Hypertension
52
53
54
55 Portal Hypertension vs Non-Portal Hypertension
56
57 Spirinolactone 5:2 ratio Furosemide
58 Furosemide
59 Furosemide X
60 Spirinolactone 100mg : 40mg Furosemide
61 < 2gm / day
62
63 Large Volume Paracentesis (>5L)
64 6-8gm of Albumin per extra liter Large Volume Paracentesis (>5L)
65 Malignancy Cirrhosis
66 Malignancy Cirrhosis Peritoneovenous Shunting
67 Malignancy Cirrhosis Peritoneovenous Shunting Transjugular Intrahepatic Portosystemic Shunt (TIPS)
68
69 Portal Vein
70 Hepatic Vein Portal Vein
71 Ascites Cirrhotic Cardiomyopathy Gastroesophageal Varices Hepatic Encephalopathy Hepatic Hydrothorax Hepatocellular Carcinoma Hepatopulmonary Syndrome Hepatorenal Syndrome Portal Vein Thrombosis Portopulmonary hypertension Spontaneous Bacterial Peritonitis
72
73 Ammonia (NH3)
74
75
76
77
78
79
80 Bloodstream
81 Bloodstream Ammonia (NH3)
82 Bloodstream Ammonia (NH3)
83 Bloodstream Ammonia (NH3) Ammonium (NH4+)
84 Bloodstream Ammonia (NH3) Ammonium (NH4+)
85 Bloodstream Lactulose 30-45mL PO TID-QID Ammonia (NH3) Ammonium (NH4+)
86 Bloodstream Ammonia (NH3) Ammonium (NH4+)
87 Bloodstream Rifaximin 550mg PO BID or 400mg TID Ammonia (NH3) Ammonium (NH4+)
88
89
90 (Peng et al., 2018)
91 (Peng et al., 2018)
92 (Peng et al., 2018)
93 (Peng et al., 2018)
94
95 Always prescribe lactulose
96
97 Go REALLY low and REALLY slow
98
99
100 Opioids Codeine Tramadol Morphine Hydromorphone Oxycodone Fentanyl Methadone
101 Opioids Codeine Tramadol Morphine Hydromorphone Oxycodone Fentanyl Methadone
102
103 NSAIDs Acetaminophen Gabapentin Pregabalin Nortriptyline Carbamazepine Non-Opioids
104 NSAIDs Acetaminophen Gabapentin Pregabalin Nortriptyline Carbamazepine Non-Opioids
105 Patient Care ESLD Cancer
106 Ascites Cirrhotic Cardiomyopathy Gastroesophageal Varices Hepatic Encephalopathy Hepatic Hydrothorax Hepatocellular Carcinoma Hepatopulmonary Syndrome Hepatorenal Syndrome Portal Vein Thrombosis Portopulmonary hypertension Spontaneous Bacterial Peritonitis
107
108
109
110
111 Treating patients with end-stage liver disease: Are we ready?
112 Treating patients with end-stage liver disease: Are YOU ready?
113 Dr. Mino R. Mitri, M.D., C.M., M.Ed., FRCPC
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