SURGICAL REVIEW
Liver transplantation in a critically ill patient Katherine Jacobson, MMS, PA-C; Andrew Cameron, MD, PhD; Alison C. Essary, DHSc, PA-C
ABSTRACT The United Network for Organ Sharing recently changed its policies for liver allocation to give patients with severe hepatic failure priority due to their greater risk of morbidity and mortality. This case illustrates the benefit of transplant in critically ill patients. Keywords: liver failure, critical illness, liver transplant, hepatorenal syndrome, simultaneous liver-kidney transplant, MELD score
CASE A 60-year-old man with end-stage liver disease secondary to nonalcoholic steatohepatitis was admitted to the hospital for management of decompensated liver failure and evaluation for liver transplant. His recent history included the diagnosis of cirrhosis 4 months earlier and multiple hospitalizations for associated complications. His past medical history is significant for hypertension, hyperlipidemia, type 1 diabetes, and obstructive sleep apnea. His surgical history included a lumbar spinal fusion complicated by a left flank hernia, which was repaired surgically. The patient had no history of abdominal surgery. His social history was significant for tobacco use and remote history of alcohol use. The patient was happily married with good social support at home. On physical examination, the patient was afebrile with normal vital signs. He was intermittently confused. He was cachectic and appeared jaundiced with notable scleral icterus. His left lung was clear to auscultation, with decreased breath sounds on the right lung. His abdomen was distended with visibly tortuous subcutaneous veins, but was nontender. He had bilateral lower-extremity edema, worse on the right side than on the left. Significant laboratory values are listed in Table 1. Documentation from previous hospital admissions supported complications of liver failure, including biliary Katherine Jacobson practices in transplant surgery at Johns Hopkins University in Baltimore, Md. Andrew Cameron is director of liver transplantation and an associate professor of surgery at Johns Hopkins University. Alison C. Essary is director of student affairs and an associate professor in the College of Health Solutions at Arizona State University in Phoenix. The authors have disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000447003.89090.8b Copyright © 2014 American Academy of Physician Assistants
38
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FIGURE 1. Cavo-caval anastomosis
sepsis with vancomycin-resistant Enterococcus (VRE) and severe hepatic encephalopathy. During this hospital admission, the patient had therapeutic paracentesis multiple times to treat massive ascites. He eventually developed spontaneous bacterial peritonitis and was treated empirically with antibiotics, although cultures were negative for bacterial growth. Despite thrombocytopenia and an elevated International Normalized Ratio (INR), he developed bilateral lower-extremity deep vein thrombosis (DVT). Anticoagulation was contraindicated due to recent intraabdominal bleeding, so an inferior vena cava (IVC) filter was placed. Volume 27 • Number 6 • June 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Liver transplantation in a critically ill patient
TABLE 1.
Key points A new UNOS Share 35 policy gives patients with severe hepatic failure priority for liver transplantation due to their greater risk of morbidity and mortality. The patient’s MELD score is used to determine risk of death. Patients with high MELD scores also are more likely to have renal failure than patients with lower scores. Simultaneous liver-kidney transplantation could benefit these patients.
Further complications included pneumonia, pulmonary edema secondary to fluid overload, and subsequent hypoxic respiratory failure. The patient was given imipenem, which improved the pneumonia and his respiratory status. He developed acute renal failure that was ultimately attributed to hepatorenal syndrome, and required continuous venovenous hemodialysis (CVVHD) throughout his 10-day stay in the medical ICU. He experienced multiple complications while in the medical ICU. TRANSPLANT SURGERY CONSULTATION The transplant surgery service and cardiology were consulted to evaluate the patient for transplant. The comprehensive evaluation also included cancer screening and psychosocial and insurance clearance. The patient’s cancer screening was negative and he was approved for transplant from both a psychosocial and insurance perspective. One critical component of transplant evaluation is calculating the extent of a patient’s hepatic failure using the Model for End-stage Liver Disease (MELD) score. This scoring system uses creatinine, serum total bilirubin, and INR values to predict 3-month mortality in patients with liver failure who do not receive a transplant. The higher the MELD score, the higher the chance of mortality. If the patient has undergone dialysis more than twice in the previous week or is on CVVHD, as was this patient, the MELD score is calculated with a creatinine of 4. The patient’s MELD score was 41, indicating that a calculated risk of death from his liver disease alone was 91% over 3 months.1 The patient’s presurgical cardiac clearance included a dobutamine stress echocardiogram, which was negative for ischemic changes and wall motion abnormalities. Given the patient’s risk factors for coronary artery disease, cardiology recommended that the patient undergo preoperative cardiac catheterization. The catheterization revealed 70% stenosis of the proximal left anterior descending (LAD) artery and 90% stenosis of the right coronary artery (RCA). According to the American Heart Association guidelines for coronary artery bypass graft (CABG) surgery, proximal LAD stenosis and significant one- or two-vessel
The patient’s laboratory values Pretransplant
Posttransplant
Platelets
26x109/L
140x109/L
Blood urea nitrogen
83 mg/dL
20 mg/dL
Creatinine
3.6 mg/dL
1.8 mg/dL
Total bilirubin
29 mg/dL
0.3 mg/dL
INR
2.1
1.1
disease are an indication for CABG, even if the patient is asymptomatic. Because of the patient’s severe liver disease, undergoing cardiac surgery before transplant was not feasible. The cardiology consultant risk-stratified the patient as acceptable nonetheless. Transplant patients are started on lifelong immunosuppression at the time of surgery, making it important to evaluate the patient’s overall risk of infection. On CT scan, the patient’s pneumonia had largely resolved with a course of imipenem and his respiratory status was markedly improved. He was oxygenating well on 2.5 L/minute of supplemental oxygen via nasal cannula. Cultures of urine
Failing to identify aberrant liver anatomy could mean sacrificing sources of arterial blood supply to the donor liver. and sputum were positive for Candida glabrata. In anticipation of transplant and immunosuppression, the patient was being treated with micafungin. Because both sources of infection were well controlled on antibiotics and the patient was not septic, the infectious disease consultant cleared the patient for transplant. Additionally, due to the diagnosis of hepatorenal syndrome and the need for CVVHD throughout his hospitalization, the patient was evaluated for kidney transplant. Consequently, the patient was listed for liver and possible kidney transplant with a plan to obtain a biopsy of the native kidney during surgery. If the biopsy revealed evidence of nonreversible chronic disease, the patient would receive a kidney transplant at the same time as the liver transplant. If the native kidney biopsy did not show any permanent changes, the patient would undergo liver transplant alone.
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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39
SURGICAL REVIEW
Liver implantation was completed with the anastomosis of four vessels: • The recipient IVC was clamped with a side-biting caval clamp and the donor vena cava sewn to the recipient vena cava, creating the cavo-caval anastomosis (Figure 1) with a running 3-0 nonabsorbable polypropylene suture (the “piggy-back” technique). • End-to-end anastomosis of the portal vein (Figure 2) was completed with a running 6-0 nonabsorbable polypropylene suture. The caval and portal vein clamps were released and the liver was reperfused. The patient tolerated reperfusion well without hemodynamic instability and FIGURE 2. Portal vein, hepatic artery, and common bile duct anastomosis the liver appeared in excellent condition (Figure 3). The patient’s coronary artery disease and poor pulmonary • Following reperfusion, the hepatic artery was reconstatus made him a high-risk surgical candidate. However, structed end-to-end using interrupted 6-0 nonabsorbable the severity of his liver disease was such that the only polypropylene suture. lifesaving effort was liver transplantation. • Finally, the donor gallbladder was removed and the bile duct was reconstructed end-to-end using interrupted 5-0 SURGICAL INTERVENTION absorbable polytrimethylene carbonate suture. The patient was listed for liver with possible kidney transA biopsy of the patient’s native kidney was performed plant. Organs quickly became available from a 68-year-old and revealed no significant chronic changes with no sigbrain-dead donor with normal liver function tests and a nificant glomerulosclerosis. Therefore, we did not proceed normal liver biopsy. The liver anatomy was normal with with kidney transplant. After hemostasis was ensured, a single hepatic artery, portal vein, and common bile duct. three 19-French round drains were passed through the skin The donor kidney also had normal anatomy. and placed beneath the right lobe, left lateral section, and During the organ procurement operation, inspect the hilum of the liver and put to bulb suction. The fascia was arterial anatomy of the liver. Between 10% and 15% of closed in two layers and the skin approximated with staples. patients have aberrant anatomy, in which the left or right During surgery, the patient required seven units of packed hepatic artery, which normally arises from the celiac trunk, red blood cells, nine units of fresh frozen plasma, and four instead originates from the left gastric artery or the superior packs of platelets. Estimated blood loss was 5 L. The patient mesenteric artery, respectively.2 Anatomy must be identified remained intubated and was transferred to the surgical before procurement, as failing to identify aberrant anatomy ICU for recovery. could result in inadvertently sacrificing sources of arterial blood supply to the donor liver. POSTOPERATIVE COURSE Orthotopic liver transplant surgery can be divided into On postoperative day 1, the patient was hemodynamically two parts: hepatectomy and liver implantation. In our stable and successfully extubated. Initially, the output from patient, the surgery began with a bilateral subcostal one of his drains appeared bilious and was concerning for incision. After the surgeon entered the abdomen, 5 L of a bile leak, but this resolved in the first week following bloody ascites were evacuated from the peritoneal space surgery. On postoperative day 2, he was restarted on and the liver was noted to be grossly cirrhotic. The liver CVVHD. The bile cultures from the OR were positive for was carefully mobilized and the porta hepatis was dis- VRE and the patient was started on a course of linezolid. sected. The common bile duct, hepatic artery, and portal The remainder of his ICU course was complicated by his vein were individually ligated and divided. Due to the poor respiratory status and overall deconditioning after patient’s history of biliary VRE, bile samples were taken months of being in the hospital before the transplant. He and sent to the lab for culture. Next, the liver was mobifailed multiple swallow studies. Therefore, he was reintulized off of the IVC. The hepatic veins were divided with bated for bedside placement of a percutaneous gastrostomy a gastrointestinal anastomosis stapling device. The hep- tube to provide nutritional support. The day following the atectomy was successfully completed and the liver sent procedure he was successfully extubated. Enteral nutrition to pathology. was started. 40
www.JAAPA.com
Volume 27 • Number 6 • June 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Liver transplantation in a critically ill patient
On postoperative day 19, the patient’s respiratory status and renal function had improved significantly. He was switched to intermittent hemodialysis and was stable enough for transfer from the ICU to the transplant surgical unit. The patient remained in the hospital for 2 months after his transplant. Throughout his stay in the hospital he underwent aggressive physical and occupational therapy. He was extremely deconditioned, but slowly improved with therapy. Enteral nutrition continued as he gradually began to take in nutrition by mouth. His postoperative course was complicated by a xiphoid wound infection that required surgical incision and drainage. He also developed a right lower-extremity DVT. He was started on a heparin infusion, but then FIGURE 3. Transplanted liver following reperfusion fell and required sutures to his occiput. Heparin was discontinued and he was switched to aspirin scores are more likely to have renal failure than those with for anticoagulation due to his high fall risk. lower MELD scores. The survival benefit of simultaneous At multiple times during his recovery, he was taken off liver-kidney transplant is seen only in a specific category of hemodialysis, but his renal function ultimately did not of liver transplant recipients with hepatorenal syndrome. recover and he continues to require intermittent hemodiPatients with liver failure who have been on dialysis longer alysis. He was eventually discharged to inpatient reha- than 3 months are the only patients who have improved bilitation and continues to recover at home. His most recent survival when given simultaneous liver-kidney transplant laboratory values are shown in Table 1. compared to liver transplant alone.4 DISCUSSION In June 2013, the United Network for Organ Sharing (UNOS) changed the donor liver allocation process to benefit patients similar to the patient presented here. The change in allocation, called Share 35, gives preference, within regions, to patients with MELD scores of 35 or higher—that is, patients who are at higher risk of dying while on the waiting list for liver transplant. Before this change, a donor liver would be given preferentially to a local recipient regardless of how the patient’s MELD score compared to other patients in the same region. Share 35 broadened the patient population on the waiting list considered for an available liver and gives preference to any patient with a MELD score over 35 in a given region.3 For instance, our institution is in Maryland and our region includes Delaware, District of Columbia, New Jersey, Pennsylvania, and West Virginia. A donor liver is made available first in the local area to any patient with a MELD score of 35 or higher. If no local recipient has a high MELD score, the liver is made available to any patient in the region with a MELD score of 35 or higher. Our patient, who had a MELD score of 40, would not have survived without liver transplantation. Share 35 also could affect the rate of simultaneous liverkidney transplants because patients with higher MELD
FOLLOW-UP Following liver transplant, our patient continues to require intermittent hemodialysis. One could argue that, in retrospect, this patient should have undergone a simultaneous liver-kidney transplant. However, the patient only required 10 days of dialysis before transplant and the intraoperative native kidney biopsy showed no chronic damage. Thousands of patients with ESRD die every year while waiting for a kidney transplant. Because no data supported giving our patient a simultaneous kidney transplant, the kidney initially procured for him was given to a patient waiting for a kidney transplant. This ultimately improved the overall health and quality of life of two patients. JAAPA REFERENCES 1. Mayo Clinic. MELD Score and 90-Day Mortality Rate for Alcoholic Hepatitis. http://www.mayoclinic.org/meld/ mayomodel7.html. Accessed October 30, 2013. 2. Cameron A, Yersiz H, Busuttil RW. Liver donation: surgical techniques. Transplantation Reviews. 2005;19:108-114. 3. Organ Procurement and Transplantation Network (OPTN). Policy 9: Allocation of Livers and Liver-Intestines. http://optn. transplant.hrsa.gov/ContentDocuments/OPTN_Policies.pdf. Accessed March 10, 2014. 4. Locke JE, Warren DS, Singer AL, et al. Declining outcomes in simultaneous liver-kidney transplantation in the MELD era: ineffective usage of renal allografts. Transplantation. 2008;85(7):935-942.
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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41
Liver transplantation in a critically ill patient Katherine Jacobson, MMS, PA-C; Andrew Cameron, MD, PhD; Alison C. Essary, DHSc, PA-C
ABSTRACT The United Network for Organ Sharing recently changed its policies for liver allocation to give patients with severe hepatic failure priority due to their greater risk of morbidity and mortality. This case illustrates the benefit of transplant in critically ill patients. Keywords: liver failure, critical illness, liver transplant, hepatorenal syndrome, simultaneous liver-kidney transplant, MELD score
CASE A 60-year-old man with end-stage liver disease secondary to nonalcoholic steatohepatitis was admitted to the hospital for management of decompensated liver failure and evaluation for liver transplant. His recent history included the diagnosis of cirrhosis 4 months earlier and multiple hospitalizations for associated complications. His past medical history is significant for hypertension, hyperlipidemia, type 1 diabetes, and obstructive sleep apnea. His surgical history included a lumbar spinal fusion complicated by a left flank hernia, which was repaired surgically. The patient had no history of abdominal surgery. His social history was significant for tobacco use and remote history of alcohol use. The patient was happily married with good social support at home. On physical examination, the patient was afebrile with normal vital signs. He was intermittently confused. He was cachectic and appeared jaundiced with notable scleral icterus. His left lung was clear to auscultation, with decreased breath sounds on the right lung. His abdomen was distended with visibly tortuous subcutaneous veins, but was nontender. He had bilateral lower-extremity edema, worse on the right side than on the left. Significant laboratory values are listed in Table 1. Documentation from previous hospital admissions supported complications of liver failure, including biliary Katherine Jacobson practices in transplant surgery at Johns Hopkins University in Baltimore, Md. Andrew Cameron is director of liver transplantation and an associate professor of surgery at Johns Hopkins University. Alison C. Essary is director of student affairs and an associate professor in the College of Health Solutions at Arizona State University in Phoenix. The authors have disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000447003.89090.8b Copyright © 2014 American Academy of Physician Assistants
38
www.JAAPA.com
FIGURE 1. Cavo-caval anastomosis
sepsis with vancomycin-resistant Enterococcus (VRE) and severe hepatic encephalopathy. During this hospital admission, the patient had therapeutic paracentesis multiple times to treat massive ascites. He eventually developed spontaneous bacterial peritonitis and was treated empirically with antibiotics, although cultures were negative for bacterial growth. Despite thrombocytopenia and an elevated International Normalized Ratio (INR), he developed bilateral lower-extremity deep vein thrombosis (DVT). Anticoagulation was contraindicated due to recent intraabdominal bleeding, so an inferior vena cava (IVC) filter was placed. Volume 27 • Number 6 • June 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Liver transplantation in a critically ill patient
TABLE 1.
Key points A new UNOS Share 35 policy gives patients with severe hepatic failure priority for liver transplantation due to their greater risk of morbidity and mortality. The patient’s MELD score is used to determine risk of death. Patients with high MELD scores also are more likely to have renal failure than patients with lower scores. Simultaneous liver-kidney transplantation could benefit these patients.
Further complications included pneumonia, pulmonary edema secondary to fluid overload, and subsequent hypoxic respiratory failure. The patient was given imipenem, which improved the pneumonia and his respiratory status. He developed acute renal failure that was ultimately attributed to hepatorenal syndrome, and required continuous venovenous hemodialysis (CVVHD) throughout his 10-day stay in the medical ICU. He experienced multiple complications while in the medical ICU. TRANSPLANT SURGERY CONSULTATION The transplant surgery service and cardiology were consulted to evaluate the patient for transplant. The comprehensive evaluation also included cancer screening and psychosocial and insurance clearance. The patient’s cancer screening was negative and he was approved for transplant from both a psychosocial and insurance perspective. One critical component of transplant evaluation is calculating the extent of a patient’s hepatic failure using the Model for End-stage Liver Disease (MELD) score. This scoring system uses creatinine, serum total bilirubin, and INR values to predict 3-month mortality in patients with liver failure who do not receive a transplant. The higher the MELD score, the higher the chance of mortality. If the patient has undergone dialysis more than twice in the previous week or is on CVVHD, as was this patient, the MELD score is calculated with a creatinine of 4. The patient’s MELD score was 41, indicating that a calculated risk of death from his liver disease alone was 91% over 3 months.1 The patient’s presurgical cardiac clearance included a dobutamine stress echocardiogram, which was negative for ischemic changes and wall motion abnormalities. Given the patient’s risk factors for coronary artery disease, cardiology recommended that the patient undergo preoperative cardiac catheterization. The catheterization revealed 70% stenosis of the proximal left anterior descending (LAD) artery and 90% stenosis of the right coronary artery (RCA). According to the American Heart Association guidelines for coronary artery bypass graft (CABG) surgery, proximal LAD stenosis and significant one- or two-vessel
The patient’s laboratory values Pretransplant
Posttransplant
Platelets
26x109/L
140x109/L
Blood urea nitrogen
83 mg/dL
20 mg/dL
Creatinine
3.6 mg/dL
1.8 mg/dL
Total bilirubin
29 mg/dL
0.3 mg/dL
INR
2.1
1.1
disease are an indication for CABG, even if the patient is asymptomatic. Because of the patient’s severe liver disease, undergoing cardiac surgery before transplant was not feasible. The cardiology consultant risk-stratified the patient as acceptable nonetheless. Transplant patients are started on lifelong immunosuppression at the time of surgery, making it important to evaluate the patient’s overall risk of infection. On CT scan, the patient’s pneumonia had largely resolved with a course of imipenem and his respiratory status was markedly improved. He was oxygenating well on 2.5 L/minute of supplemental oxygen via nasal cannula. Cultures of urine
Failing to identify aberrant liver anatomy could mean sacrificing sources of arterial blood supply to the donor liver. and sputum were positive for Candida glabrata. In anticipation of transplant and immunosuppression, the patient was being treated with micafungin. Because both sources of infection were well controlled on antibiotics and the patient was not septic, the infectious disease consultant cleared the patient for transplant. Additionally, due to the diagnosis of hepatorenal syndrome and the need for CVVHD throughout his hospitalization, the patient was evaluated for kidney transplant. Consequently, the patient was listed for liver and possible kidney transplant with a plan to obtain a biopsy of the native kidney during surgery. If the biopsy revealed evidence of nonreversible chronic disease, the patient would receive a kidney transplant at the same time as the liver transplant. If the native kidney biopsy did not show any permanent changes, the patient would undergo liver transplant alone.
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.JAAPA.com
39
SURGICAL REVIEW
Liver implantation was completed with the anastomosis of four vessels: • The recipient IVC was clamped with a side-biting caval clamp and the donor vena cava sewn to the recipient vena cava, creating the cavo-caval anastomosis (Figure 1) with a running 3-0 nonabsorbable polypropylene suture (the “piggy-back” technique). • End-to-end anastomosis of the portal vein (Figure 2) was completed with a running 6-0 nonabsorbable polypropylene suture. The caval and portal vein clamps were released and the liver was reperfused. The patient tolerated reperfusion well without hemodynamic instability and FIGURE 2. Portal vein, hepatic artery, and common bile duct anastomosis the liver appeared in excellent condition (Figure 3). The patient’s coronary artery disease and poor pulmonary • Following reperfusion, the hepatic artery was reconstatus made him a high-risk surgical candidate. However, structed end-to-end using interrupted 6-0 nonabsorbable the severity of his liver disease was such that the only polypropylene suture. lifesaving effort was liver transplantation. • Finally, the donor gallbladder was removed and the bile duct was reconstructed end-to-end using interrupted 5-0 SURGICAL INTERVENTION absorbable polytrimethylene carbonate suture. The patient was listed for liver with possible kidney transA biopsy of the patient’s native kidney was performed plant. Organs quickly became available from a 68-year-old and revealed no significant chronic changes with no sigbrain-dead donor with normal liver function tests and a nificant glomerulosclerosis. Therefore, we did not proceed normal liver biopsy. The liver anatomy was normal with with kidney transplant. After hemostasis was ensured, a single hepatic artery, portal vein, and common bile duct. three 19-French round drains were passed through the skin The donor kidney also had normal anatomy. and placed beneath the right lobe, left lateral section, and During the organ procurement operation, inspect the hilum of the liver and put to bulb suction. The fascia was arterial anatomy of the liver. Between 10% and 15% of closed in two layers and the skin approximated with staples. patients have aberrant anatomy, in which the left or right During surgery, the patient required seven units of packed hepatic artery, which normally arises from the celiac trunk, red blood cells, nine units of fresh frozen plasma, and four instead originates from the left gastric artery or the superior packs of platelets. Estimated blood loss was 5 L. The patient mesenteric artery, respectively.2 Anatomy must be identified remained intubated and was transferred to the surgical before procurement, as failing to identify aberrant anatomy ICU for recovery. could result in inadvertently sacrificing sources of arterial blood supply to the donor liver. POSTOPERATIVE COURSE Orthotopic liver transplant surgery can be divided into On postoperative day 1, the patient was hemodynamically two parts: hepatectomy and liver implantation. In our stable and successfully extubated. Initially, the output from patient, the surgery began with a bilateral subcostal one of his drains appeared bilious and was concerning for incision. After the surgeon entered the abdomen, 5 L of a bile leak, but this resolved in the first week following bloody ascites were evacuated from the peritoneal space surgery. On postoperative day 2, he was restarted on and the liver was noted to be grossly cirrhotic. The liver CVVHD. The bile cultures from the OR were positive for was carefully mobilized and the porta hepatis was dis- VRE and the patient was started on a course of linezolid. sected. The common bile duct, hepatic artery, and portal The remainder of his ICU course was complicated by his vein were individually ligated and divided. Due to the poor respiratory status and overall deconditioning after patient’s history of biliary VRE, bile samples were taken months of being in the hospital before the transplant. He and sent to the lab for culture. Next, the liver was mobifailed multiple swallow studies. Therefore, he was reintulized off of the IVC. The hepatic veins were divided with bated for bedside placement of a percutaneous gastrostomy a gastrointestinal anastomosis stapling device. The hep- tube to provide nutritional support. The day following the atectomy was successfully completed and the liver sent procedure he was successfully extubated. Enteral nutrition to pathology. was started. 40
www.JAAPA.com
Volume 27 • Number 6 • June 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Liver transplantation in a critically ill patient
On postoperative day 19, the patient’s respiratory status and renal function had improved significantly. He was switched to intermittent hemodialysis and was stable enough for transfer from the ICU to the transplant surgical unit. The patient remained in the hospital for 2 months after his transplant. Throughout his stay in the hospital he underwent aggressive physical and occupational therapy. He was extremely deconditioned, but slowly improved with therapy. Enteral nutrition continued as he gradually began to take in nutrition by mouth. His postoperative course was complicated by a xiphoid wound infection that required surgical incision and drainage. He also developed a right lower-extremity DVT. He was started on a heparin infusion, but then FIGURE 3. Transplanted liver following reperfusion fell and required sutures to his occiput. Heparin was discontinued and he was switched to aspirin scores are more likely to have renal failure than those with for anticoagulation due to his high fall risk. lower MELD scores. The survival benefit of simultaneous At multiple times during his recovery, he was taken off liver-kidney transplant is seen only in a specific category of hemodialysis, but his renal function ultimately did not of liver transplant recipients with hepatorenal syndrome. recover and he continues to require intermittent hemodiPatients with liver failure who have been on dialysis longer alysis. He was eventually discharged to inpatient reha- than 3 months are the only patients who have improved bilitation and continues to recover at home. His most recent survival when given simultaneous liver-kidney transplant laboratory values are shown in Table 1. compared to liver transplant alone.4 DISCUSSION In June 2013, the United Network for Organ Sharing (UNOS) changed the donor liver allocation process to benefit patients similar to the patient presented here. The change in allocation, called Share 35, gives preference, within regions, to patients with MELD scores of 35 or higher—that is, patients who are at higher risk of dying while on the waiting list for liver transplant. Before this change, a donor liver would be given preferentially to a local recipient regardless of how the patient’s MELD score compared to other patients in the same region. Share 35 broadened the patient population on the waiting list considered for an available liver and gives preference to any patient with a MELD score over 35 in a given region.3 For instance, our institution is in Maryland and our region includes Delaware, District of Columbia, New Jersey, Pennsylvania, and West Virginia. A donor liver is made available first in the local area to any patient with a MELD score of 35 or higher. If no local recipient has a high MELD score, the liver is made available to any patient in the region with a MELD score of 35 or higher. Our patient, who had a MELD score of 40, would not have survived without liver transplantation. Share 35 also could affect the rate of simultaneous liverkidney transplants because patients with higher MELD
FOLLOW-UP Following liver transplant, our patient continues to require intermittent hemodialysis. One could argue that, in retrospect, this patient should have undergone a simultaneous liver-kidney transplant. However, the patient only required 10 days of dialysis before transplant and the intraoperative native kidney biopsy showed no chronic damage. Thousands of patients with ESRD die every year while waiting for a kidney transplant. Because no data supported giving our patient a simultaneous kidney transplant, the kidney initially procured for him was given to a patient waiting for a kidney transplant. This ultimately improved the overall health and quality of life of two patients. JAAPA REFERENCES 1. Mayo Clinic. MELD Score and 90-Day Mortality Rate for Alcoholic Hepatitis. http://www.mayoclinic.org/meld/ mayomodel7.html. Accessed October 30, 2013. 2. Cameron A, Yersiz H, Busuttil RW. Liver donation: surgical techniques. Transplantation Reviews. 2005;19:108-114. 3. Organ Procurement and Transplantation Network (OPTN). Policy 9: Allocation of Livers and Liver-Intestines. http://optn. transplant.hrsa.gov/ContentDocuments/OPTN_Policies.pdf. Accessed March 10, 2014. 4. Locke JE, Warren DS, Singer AL, et al. Declining outcomes in simultaneous liver-kidney transplantation in the MELD era: ineffective usage of renal allografts. Transplantation. 2008;85(7):935-942.
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.JAAPA.com
41
