Category: Liver

Liver Transplant Assessment in patients with Chronic Liver Disease with the Royal Free – For Doctors

Matt Stammers1 Comment

Disclaimer: This article is not intended as advice for patients but is intended as information for medical professionals only.

Firstly you have to establish the indication for transplant:

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All the indications are listed here in this policy document but broadly they are broken down into:

  1. Chronic liver disease
  2. Hepatocellular Carcinoma
  3. Variant Syndrome
  4. National Appeals Panel
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National appeals panels arbitrate on decisions regarding transplantation which fall outside of standard criteria

The UKELD score can be used to assess suitability for transplant. As the score reaches 49 this indicates a 9% one-year mortality rate and is the minimum criterion to be listed for transplantation. A score of 60 suggests 50% one-year mortality. Remember that these statistics were developed by looking at patients on the transplant list already so may not be applicable to new presentations.

HCC’s must be small

There are also a few pilot studies, including one for downstaging HCC’s which appeared to have a more indolent course. If patients are staged as ‘low risk’ for recurrence then they do benefit from transplantation but this is still in a pilot stage. There is also one for alcohol related liver disease but the criteria are so stringent that so far nobody has been transplanted on that pilot.

Assess the risk for that individual patient

In order to do this we need to look at survival. Every year in the UK about 2/3rds of patients are listed for transplant but around a third are deemed too unwell or needing other conservative treatment options first.

Biological factors are key and they will look at co-morbidities as well as several other factors. They will generally perform an echocardiogram, pulmonary function tests, blood gases, exercise capacity tests and some additional investigations for high risk patients. Nutrition will be assessed.

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Outcomes are worse in those with BMI 40.  Recent/current extrahepatic malignancy is an absolute contraindication. Tobacco smoking is a relative contraindication as it affects prognosis post-transplant.

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In the UK, if people have gone back to drinking alcohol despite medical interventions within a medium-term time interval they are not transplantable. The point of stopping the alcohol is so that the liver can recover. The commonly held myth of the ‘6-month rule’ actually doesn’t exist in reality. Most of the guidelines instead talk about 2 years as an appropriate time interval, and the definition of absitinence is usually total. This advice needs to be clearly documented in the notes. Even a glass of wine at Christmas is not strictly allowed. Alcohol-free lager is also not allowed (as above)

This is because drinking even alcohol-free lager is a risk factor for relapse. Selective engagement in treatment is another risk factos for relapse; as is previous history, access to alcohol, underemployment, relationship factors, children, social support structures and personal motivation to engage in new habits.

There are also tests that can be used to detect whether or not people have been drinking alcohol. Increasingly cigarette smoking is being strongly discouraged as well because it is associated with poorer outcomes post-transplant.

Acute Liver Failure for doctors – How it’s managed at King’s Liver ITU

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Disclaimer: This article is not advice for patients and is intended as information for medical professionals only.

Acute liver failure with encephalopathy (toxic cognitive impairment) has a much worse outcome. Particularly if it comes on insidiously.

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Acute encephalopathy secondary to paracetamol for instance has a better outcome than that secondary to hepatitis or more chronic causes.

Paracetamol overdose is still by far the biggest cause of acute liver failure in the UK.

paracetamol

Resuscitation, early treatment with N-Acetylcysteine is key and involve ITU early.

Think about hypoglycaemia & hypovoleamia. Crystalloids with glucose and NAC are the mainstay of early management. Give antibiotics if you suspect at risk of infection and call the liver unit early if: history, consciousness, coagulopathy or any other adverse signs.

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There has been a dramatic improvement in outcomes as a result of the above. Survival is now over 75% of those going to King’s liver unit for acute liver failure.

Transplantation has led to massive improvements in the survival of those with previously a poor prognosis, but the medical management has also improved significantly even for those who cannot be transplanted.

This is in part due to earlier recognition. The average INR of those arriving at King’s has fallen from 6 to 3.5 over the past 15 years and rates of encephalopathy on arrival have improved greatly.

Cerebral oedema is an issue but it is becoming rarer due to early administration of NAC and resuscitation.

Some treatments such as cooling don’t seem to work. Plasma exchange might have a role in the future.

Transplantation particularly has a role in those where the cause is not clear / seronegative disease. Transplantation is not as effective in paracetamol overdose.

Prognostic criteria include: age, coagulopathy and encephalopathy. King’s have produced a new calculator to help distinguish between those who will/won’t benefit from transplant: New King’s Calculator.

Nutritional Aspects in Chronic Liver Disease

Matt StammersLeave a comment

Disclaimer: This article is not intended as medical advice for patients and is for general information only.

This is an important but often overlooked area.

A lot of the guidelines on this are over 20 years old.

Malnutrition leads to multiple problems: piis1542356511011694_gr1_lrg

It is a vicious cycle. Particularly with the empty calories of alcohol.

There are often co-existant other medical problems such as: bile salt malabsorption, pancreatic exocrine insufficiency, SBBO, Neomycin.

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The goal of treatment is to improve nutritional status and correct micro-nutrient deficiencies. Major options include oral/enteral supplementation or oral nasogastric/jejunal feeding.

PEG tube
Supplement
Supplement
NG/PEG

All of the above are relatively simple measures to improve nutrition and they can have a dramatic influence on outcomes. In one study 1.Cabre et al patients with acute alcohol related hepatitis were randomised to steroids and nutrition or steroids alone. Only 8% of those who had nutrition plus steroids died, compared to 38% of those who only had steroids (p <0.05). The authors felt that the steroid only group had more infections, explaining the difference in mortality.

Other guidelines by 2. Plauth et al support this conclusion as well as the need for a low salt-diet in liver disease.

References:

  1. Cabré E, Rodríguez-Iglesias P, Caballería J, Quer JC, Sánchez-Lombraña JL, Parés A, Papo M, Planas R, Gassull MA. Short- and long-term outcome of severe alcohol-induced hepatitis treated with steroids or enteral nutrition: a multicenter randomized trial. Hepatology. 2000;32:36–42.
  2. Plauth M, Cabré E, Riggio O, Assis-Camilo M, Pirlich M, Kondrup J, Ferenci P, Holm E, Vom Dahl S, Müller MJ, et al. ESPEN Guidelines on Enteral Nutrition: Liver disease. Clin Nutr. 2006;25:285–294.

Cirrhosis and Pregnancy

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Disclaimer: This article is not intended as medical advice for patients but is for informational purposes only.

liver-disease-in-pregnancy

Cirrhosis is when parts of the liver become hardened by damage done over time. Cirrhotic sections of liver unlike normal liver segments cannot repair itself.

Fortunately this is a relatively rare scenario as most patients develop cirrhosis later in life. However, cirrhosis is becoming more common due to rising rates of obesity. Pregnant women with cirrhosis  (which may be undiagnosed) can run into difficulty.

The biggest risk is bleeding, because pregnancy leads to an increased circulating volume of blood and the foetus compresses the inferior vena cava.

ivc-compression

Most of this bleeding occurs in the oesophagus and normally has to be prevented surgically either by banding of these vessels – called varices or inserting a shunt called a TIPS or transhepatic-portosystemicshunt. Pregnant women should ideally have foetal monitoring while undergoing any procedures.

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Large liver-specialist centres need to be involved, especially if other problems subsequently develop. Early delivery may sometimes be necessary.

As long as the mother’s health is optimised then the same is normally true for the baby as in normal pregnancy.

Hepatitis

Hepatitis of any kind can be more serious in pregnancy. It needs to be managed with specialist input. Certainly chronic hepatitis B warrants some form of management at some point prior to birth in order to minimise the risk of transmission to the foetus.

Liver Imaging for Gastroenterologists

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Disclaimer: This article is not intended as medical advice for patients but is for informational purposes only, primarily aimed at clinicians.

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The liver is supplied by multiple vessels and divided into 8 segments.

In the normal liver most of the blood supply comes from the portal vein.

Tumours however tend to be supplied by the arterial supply (more on this later).

Regarding imaging. Ultrasound is great but unfortunately results are not reproducible between different operators.

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Common benign findings include: Cysts

liver_cyst_ultrasound

but sometimes they are not so simple

hyadtidThis one above turned out to be a hyatid cyst (Echinococcosis).

haemangioma

Haemangiomas can be even more difficult to distinguish.

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Focal nodular hyperplasia (above) can be distinguished from hepatomas by using Primavist (came out 2004). This contrast is taken up avidly by healthy hepatocytes and not by cancers.

Diffusion weighed MRI can help to distinguish between small metastases and other lesions, however its effectiveness is limited.

fatty-liver

Above is a fatty liver which makes it very difficult to distinguish the liver parenchyma

hepatitis

This is what acute hepatitis looks like on USS. The liver looks ‘brighter’.

The radiologist can also see vessels such as varices, abdominal collaterals, reversed/blocked portal flow and associated ascites etc.

Cirrhosis can be seen but only at an advanced stage so these imaging modalities are not so useful for the early detection of liver disease. Of CT, USS and MRI – MRI is the best at picking up cirrhosis but it is also the most expensive and difficult to access test.

Hepatocellular Carcinoma

The above conditions are all benign, but what we really want to spot are the cancers. These primary cancers normally occur in those with pre-existing liver disease.

Diagnosis can be very tricky if the timing goes wrong which is why you need a skilled radiology team.

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Above are some images of HCCs. They tend to be surrounded by areas of necrosis as the tumour develops a rim of dead tissue around it.

Treatment options include:

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Sorafenib, TACE, transarterial chemoembolization, resection and transplant

This is where we are now in 2016 but there are many other investigation and treatment options under investigation. So we can now tell what’s probably going on without doing a biopsy, most of the time. There is still significant margin for improvement.

Next up: Liver disease in pregnancy.