Treating patients with end-stage liver disease: Are we ready? Dr. Mino R. Mitri, M.D., C.M., M.Ed., FRCPC mino.mitri@ubc.ca
No Conflict of Interest
157 patients
157 patients 6 transplanted
Criteria Liver Transplant Palliative Care Approach
Criteria Liver Transplant = Palliative Care Approach
advanced chronic liver disease when the limits of medical therapy have been reached. AASLD 2013
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
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
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.
Liver Transplant Palliative Care Patient with ESLD
Hawley, 2014
Hawley, 2014
Compensated Cirrhosis
Compensated Cirrhosis 6-12 years
Compensated Cirrhosis Decompensated Cirrhosis 6-12 years
Compensated Cirrhosis Decompensated Cirrhosis 6-12 years 2 years
Class A Class B Class C
100% 1 year survival 80% 45% Class A Class B Class C
Model for End-Stage Liver Disease (MELD) Score
15
20-25% Death
5-10% Clinical Deterioration
< 2 months
10%
well enough to undergo evaluation and listing, but sick enough to have developed signs of progression to a terminal state. Fox, 2014
Liver Transplant Palliative Care Patient with ESLD
Liver Transplant + Palliative Care Patient with ESLD
Hawley, 2014
Treating patients with end-stage liver disease: Are we ready?
Treating patients with end-stage liver disease: Are we ready?
Patient Care
ESLD Patient Care
Patient Care ESLD Cancer
Ascites Cirrhotic Cardiomyopathy Gastroesophageal Varices Hepatic Encephalopathy Hepatic Hydrothorax Hepatocellular Carcinoma Hepatopulmonary Syndrome Hepatorenal Syndrome Portal Vein Thrombosis Portopulmonary hypertension Spontaneous Bacterial Peritonitis
Ascites Cirrhotic Cardiomyopathy Gastroesophageal Varices Hepatic Encephalopathy Hepatic Hydrothorax Hepatocellular Carcinoma Hepatopulmonary Syndrome Hepatorenal Syndrome Portal Vein Thrombosis Portopulmonary hypertension Spontaneous Bacterial Peritonitis
Portal Hypertension vs Non-Portal Hypertension
Portal Hypertension vs Non-Portal Hypertension
Spirinolactone 5:2 ratio Furosemide
Furosemide
Furosemide X
Spirinolactone 100mg : 40mg Furosemide
< 2gm / day
Large Volume Paracentesis (>5L)
6-8gm of Albumin per extra liter Large Volume Paracentesis (>5L)
Malignancy Cirrhosis
Malignancy Cirrhosis Peritoneovenous Shunting
Malignancy Cirrhosis Peritoneovenous Shunting Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Portal Vein
Hepatic Vein Portal Vein
Ascites Cirrhotic Cardiomyopathy Gastroesophageal Varices Hepatic Encephalopathy Hepatic Hydrothorax Hepatocellular Carcinoma Hepatopulmonary Syndrome Hepatorenal Syndrome Portal Vein Thrombosis Portopulmonary hypertension Spontaneous Bacterial Peritonitis
Ammonia (NH3)
Bloodstream
Bloodstream Ammonia (NH3)
Bloodstream Ammonia (NH3)
Bloodstream Ammonia (NH3) Ammonium (NH4+)
Bloodstream Ammonia (NH3) Ammonium (NH4+)
Bloodstream Lactulose 30-45mL PO TID-QID Ammonia (NH3) Ammonium (NH4+)
Bloodstream Ammonia (NH3) Ammonium (NH4+)
Bloodstream Rifaximin 550mg PO BID or 400mg TID Ammonia (NH3) Ammonium (NH4+)
(Peng et al., 2018)
(Peng et al., 2018)
(Peng et al., 2018)
(Peng et al., 2018)
Always prescribe lactulose
Go REALLY low and REALLY slow
Opioids Codeine Tramadol Morphine Hydromorphone Oxycodone Fentanyl Methadone
Opioids Codeine Tramadol Morphine Hydromorphone Oxycodone Fentanyl Methadone
NSAIDs Acetaminophen Gabapentin Pregabalin Nortriptyline Carbamazepine Non-Opioids
NSAIDs Acetaminophen Gabapentin Pregabalin Nortriptyline Carbamazepine Non-Opioids
Patient Care ESLD Cancer
Ascites Cirrhotic Cardiomyopathy Gastroesophageal Varices Hepatic Encephalopathy Hepatic Hydrothorax Hepatocellular Carcinoma Hepatopulmonary Syndrome Hepatorenal Syndrome Portal Vein Thrombosis Portopulmonary hypertension Spontaneous Bacterial Peritonitis
Treating patients with end-stage liver disease: Are we ready?
Treating patients with end-stage liver disease: Are YOU ready?
Dr. Mino R. Mitri, M.D., C.M., M.Ed., FRCPC mino.mitri@ubc.ca