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Liver transplantation 

Liver transplantation

Chapter:
Liver transplantation
Author(s):

Gideon M. Hirschfield

, Michael E.D. Allison

, and Graeme J.M. Alexander

DOI:
10.1093/med/9780199204854.003.152205_update_001

August 28, 2014: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.

Update:

Source of livers for transplantation—non-heart-beating donors are increasingly used, albeit with increased complication rates; living related liver donation is now widespread and routine in many centres.

Updated on 28 Nov 2012. The previous version of this content can be found here.
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date: 24 March 2017

Liver transplantation is considered for patients with liver disease that is predicted to shorten life or causes symptoms that preclude an acceptable quality of life and for individuals with life-shortening genetic disease that can be cured by transplantation. One-year survival exceeds 90%, 5-year survival approaches 80%, and individual median survivals exceed 20 years.

The selection of patients and timing of transplantation is difficult, since both premature transplantation and delayed grafting can shorten life. Manifestations of chronic liver disease that should prompt referral to a transplant centre include hepatic encephalopathy, ascites, spontaneous bacterial peritonitis, jaundice, malnutrition, hepatic osteodystrophy, hepatorenal syndrome, reversed portal vein blood flow, portal vein thrombosis, and hepatocellular carcinoma. Super-urgent liver transplantation is often life saving for those with acute liver failure (encephalopathy, coagulopathy, liver disease of <6 months duration).

Liver transplantation usually involves a whole liver graft from a deceased donor, but innovations include the use of split livers, auxiliary grafts, living related transplantation, and more recently the use of non-heart-beating donors. Size matching between donor and recipient is important, but transplantation across the ABO barrier is performed in exceptional circumstances. HLA matching and pre-existing donor sensitization are not considered important. Therapeutic immunosuppression is most commonly with triple therapy: calcineurin inhibitor (tacrolimus, ciclosporin), azathioprine, and prednisolone.

In the immediate postoperative period most complications relate to the anastamoses, bleeding or poor graft function. Early postoperative complications include infection (bacterial, viral (cytomegalovirus), fungal), problems with vascular and biliary anastomoses, and acute rejection. In the longer term the consequences of immune suppression (impaired renal function, increased cardiovascular risk, infection and malignancy) remain important, alongside chronic vascular rejection and disease recurrence.

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