Liver Transplantation Liver Transplantation and Hepatitis C and Hepatitis C

A Clinical UpdateA Clinical Update

Joseph S. Galati, M.DJoseph S. Galati, M.DMedical DirectorMedical Director

St. Luke’s Texas Liver InstituteSt. Luke’s Texas Liver Institute

Liver Transplant EvaluationLiver Transplant EvaluationGoalsGoals

• Systematic team approachSystematic team approach• Fairness among patientsFairness among patients• Protect a scarce resourceProtect a scarce resource• Establish a relationship Establish a relationship • Assure patient understanding Assure patient understanding • Meet the patient’s support systemMeet the patient’s support system• Improve outcome of liver Improve outcome of liver

transplantation!transplantation!

Liver Transplant EvaluationLiver Transplant Evaluation

RISK BENEFIT

Components of the EvaluationComponents of the Evaluation

Liver TransplantLiver Transplant SurgerySurgery

Medical evaluationMedical evaluation

Psycho-socialPsycho-social EvaluationEvaluation

FinancialFinancialEvaluationEvaluation

NutritionalNutritionalEvaluationEvaluation

RadiologyPharmacy

Transplant Nurse CoordinatorTransplant Nurse Coordinator

Liver Transplant EvaluationLiver Transplant Evaluation

MedicalMedicalEvaluationEvaluation

FinancialFinancialevaluationevaluation

PsychosocialPsychosocialevaluationevaluation

Evaluation for Liver Evaluation for Liver TransplantationTransplantation

• What is the cause of the patient’s liver What is the cause of the patient’s liver disease?disease?

• Does the patient need a liver transplant Does the patient need a liver transplant evaluation at this time?evaluation at this time?

• Is the patient a good candidate for liver Is the patient a good candidate for liver transplantation?transplantation?

Medical Evaluation for Liver Medical Evaluation for Liver TransplantationTransplantation

Severity of Liver DiseaseSeverity of Liver DiseaseAbsolute indications:Absolute indications:• Hepatic synthetic Hepatic synthetic

dysfunctiondysfunction• PeritonitisPeritonitis• Hepatorenal Hepatorenal

syndromesyndrome• Fulminant hepatic Fulminant hepatic

failurefailure

Relative indicationsRelative indications::• Refractory Refractory

encephalopathyencephalopathy• Refractory variceal Refractory variceal

bleedingbleeding• Refractory ascitesRefractory ascites• Refractory pruritusRefractory pruritus• Disabling fatigueDisabling fatigue• HCCHCC

Medical Evaluation Assessment Medical Evaluation Assessment of Extrahepatic Diseasesof Extrahepatic Diseases

• Cardiac evaluation: age, risk factors, symptomsCardiac evaluation: age, risk factors, symptoms• Pulmonary evaluation: risk factors, symptomsPulmonary evaluation: risk factors, symptoms• Gastrointestinal evaluation: age, risk factors, Gastrointestinal evaluation: age, risk factors,

symptomssymptoms• Renal evaluation: abnormal renal functionRenal evaluation: abnormal renal function• Neuro-psychiatric evaluation: ? encephalopathyNeuro-psychiatric evaluation: ? encephalopathy• Cancer assessment: extent of current disease, Cancer assessment: extent of current disease,

screeningscreening

Evaluation for Liver TransplantationEvaluation for Liver TransplantationSurgical AssessmentSurgical Assessment

• Portal vein thrombosisPortal vein thrombosis• Prior surgeriesPrior surgeries• ObesityObesity• Surgical riskSurgical risk• Assess suitable size of donor liverAssess suitable size of donor liver

Psycho-Social EvaluationPsycho-Social Evaluation

Social WorkerSocial Worker

• Social supportSocial support • Medical complianceMedical compliance• Sobriety Sobriety

PsychiatristPsychiatrist

• Psychiatric disorders Psychiatric disorders

• Personality disordersPersonality disorders

Evaluation for Liver Evaluation for Liver TransplantationTransplantation

Assessment of ComplianceAssessment of Compliance• Clinic visitsClinic visits• InstructionsInstructions• MedicationsMedications• Sobriety contractSobriety contract• DietDiet

Patients with History of Substance AbusePatients with History of Substance Abuse

• Abstinence for at least 6 monthsAbstinence for at least 6 months• Assess need for sobriety contractAssess need for sobriety contract• Random alcohol and drug screensRandom alcohol and drug screens• Watch for narcotics abuse potentialWatch for narcotics abuse potential• Appropriate medical work up based on Appropriate medical work up based on

nature of substance abuse historynature of substance abuse history

Psychosocial AssessmentPsychosocial Assessment

Sobriety contract:Sobriety contract:• AA attendance x 6 moAA attendance x 6 mo

• Random blood alcohol levelsRandom blood alcohol levels

• Random urine drug screens Random urine drug screens

• Continued sobrietyContinued sobriety

I will not drinkI will not smoke potI will take my pills

X___________

50

60

70

80

90

100

0 yrs 1 yr 2 yrs 3 yrs 4 yrs

Non ALD

ALD > 6 moabstinence

ALD 0-6 moabstinence

Survival After Liver Transplantation By Pre-Survival After Liver Transplantation By Pre-Transplant Length of AbstinenceTransplant Length of Abstinence

Evaluation for Liver Transplantation Evaluation for Liver Transplantation Financial AssessmentFinancial Assessment

• Pre-approval by patients’ health insurance company Pre-approval by patients’ health insurance company for the evaluation and the transplant.for the evaluation and the transplant.

• Assess patients’ support system resources for the Assess patients’ support system resources for the expenses of travel and stay during the peri-expenses of travel and stay during the peri-operative periodoperative period

• Assess patients’ financial responsibility towards all Assess patients’ financial responsibility towards all hospital bills and post transplant medicationshospital bills and post transplant medications

Primary Biliary CirrhosisPrimary Biliary CirrhosisWhen to refer to OLT ?When to refer to OLT ?

• Bilirubin rising or approaching 6 mg/dlBilirubin rising or approaching 6 mg/dl• Child-Pugh class B or C cirrhosisChild-Pugh class B or C cirrhosis• First variceal bleedFirst variceal bleed• Refractory pruritus Refractory pruritus (with good function)(with good function)• Disabling fatigueDisabling fatigue

Primary Sclerosing Cholangitis:Primary Sclerosing Cholangitis:When to refer to transplant ?When to refer to transplant ?

• Predictor models not as reliablePredictor models not as reliable• Child-Pugh class B or C cirrhosisChild-Pugh class B or C cirrhosis• Recurrent cholangitisRecurrent cholangitis• Refractory pruritusRefractory pruritus• Cholangiocarcinoma?Cholangiocarcinoma?

Viral Hepatitis and Liver Viral Hepatitis and Liver TransplantTransplant

Hepatitis C:Hepatitis C: 100% serologic 100% serologic

recurrencerecurrence 60-70% histologic 60-70% histologic

recurrencerecurrence 10-15% severe 10-15% severe

recurrencerecurrence

Hepatitis B:Hepatitis B: With no HBIG = 90 % With no HBIG = 90 %

histologic recurrencehistologic recurrence With HBIG 30 % With HBIG 30 %

histologic recurrencehistologic recurrence With lamivudine + With lamivudine +

HBIG = ?HBIG = ?

Liver Transplant EvaluationLiver Transplant Evaluation

Acceptable Acceptable candidatecandidate

PPlace on waiting list

Unacceptable candidateUnacceptable candidate

Able to modify negativefactors

Unable toUnable tomodify modify negative negative factorsfactors

Reject for liver Reject for liver transplanttransplant

On the “List”On the “List”• Status 3: minimum 7 C-P pointsStatus 3: minimum 7 C-P points• Status 2b: minimum 10 C-P pointsStatus 2b: minimum 10 C-P points• Status 1: FHF, children, non-function, HA-TStatus 1: FHF, children, non-function, HA-T• Status 2a: 10 C-P points, Status 2a: 10 C-P points, plus plus be in the ICU with be in the ICU with

the followingthe following• Variceal hemorrhage (after TIPSS/shunt)Variceal hemorrhage (after TIPSS/shunt)• HepatorenalHepatorenal• Encephalopathy (despite therapy)Encephalopathy (despite therapy)• Refractory ascitesRefractory ascites

• Status 1: FHF, children, non-function, HA-TStatus 1: FHF, children, non-function, HA-T

Deaths on the Waiting ListDeaths on the Waiting List1990/1995/20001990/1995/2000

This accounts for a 25% death rate on the liver list

Kidney 956 1,543 3,073Liver 382 834 1,756Pancreas 22 5 18Kidney-Pancreas* - 86 169Heart 654 782 712Lung 57 348 591Heart-Lung 67 28 53Intestine* - 19 44

Cadaveric Donors, Cadaveric Transplants,Cadaveric Donors, Cadaveric Transplants,and Number on Waiting Listand Number on Waiting List

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Source: Donors from OPTN data as of 9/5/00; transplants from Scientific Registry data as of 9/5/00; snapshot of OPTN waiting list on the last day of each year.

Donors

Transplants

Waiting List at Year’s End

Waiting Lis t Characteris ticsLiver Registrants in 1999

•35% Ages 35-49, 44% Ages 50-6435% Ages 35-49, 44% Ages 50-64•78% White, 7% Black, 10% Hispanic78% White, 7% Black, 10% Hispanic•51% Blood type O51% Blood type O•95% Waiting for first transplant95% Waiting for first transplant•56% On waiting list for 1 year or more56% On waiting list for 1 year or more•66% Medical urgency status 366% Medical urgency status 3

Liver Graft Survival Rates by Liver Graft Survival Rates by Waiting List Status at TransplantWaiting List Status at Transplant

57

68 6677 71

8473

87

0

20

40

60

80

100

Percent

Status 1 Status 2A/2 Status 2B/3 Status 3/4

Note: Waiting list status for 1-year survival reported for codes 1, 2A, 2B, and 3; 5-year survival reported for codes 1, 2, 3, and 4.

Source: Scientific Registry data as of 9/5/00.

1 Year (1998 Cohort) 5 Years (1992-97 Cohort)

So…when is the proper time to So…when is the proper time to refer for transplant?refer for transplant?

N e v e r t o o e a r l y