Liver Transplantation

The answer first

Liver transplantation is the definitive treatment for end-stage chronic liver disease, acute liver failure, and selected hepatocellular carcinoma, and the physician's role spans four phases: deciding who is referred (recognising decompensation and applying listing criteria), managing the patient while waiting (preventing and treating the complications of cirrhosis and portal hypertension), overseeing the post-transplant immunosuppressive and infectious prophylaxis regimen, and surveillance for the late complications of graft dysfunction, disease recurrence, opportunistic infection, and metabolic and cardiovascular disease. ^{[1] [3]} The answer-first approach is to establish the indication, quantify prognosis with the Model for End-stage Liver Disease (MELD) score, exclude absolute contraindications, address reversible decompensation, and time the transplant to the sickest-first allocation principle. ^{[1] [2]}

For the FRACP candidate, the liver-transplant long case rewards a one-sentence synthesis ("a 58-year-old man with hepatitis C cirrhosis and a single 3-cm hepatocellular carcinoma within Milan criteria, MELD 22, listed for deceased-donor transplant"), a defensible knowledge of the immunosuppressive and infectious prophylaxis regimen, and a structured plan for the complications of the next decade — recurrence of primary disease, metabolic syndrome, chronic rejection, opportunistic infection, and de novo malignancy. ^{[3] [12]}

References12ShowHide

1. [1]Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease Hepatology, 2001.PMID 11172350
2. [2]Wiesner R, Edwards E, Freeman R, et al. Model for end-stage liver disease (MELD) and allocation of donor livers Gastroenterology, 2003.PMID 12512033
3. [3]Mazzaferro V, Regalia E, Doci R, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis N Engl J Med, 1996.PMID 8594428
4. [4]McAlister VC, Haddad E, Renouf E, et al. Cyclosporin versus tacrolimus as primary immunosuppressant after liver transplantation: a meta-analysis Am J Transplant, 2006.PMID 16827858
5. [5]Rodríguez-Perálvarez M, Guerrero-Misas M, Thorburn D, et al. Maintenance immunosuppression for adults undergoing liver transplantation: a network meta-analysis Cochrane Database Syst Rev, 2017.PMID 28362060
6. [6]Kaltenborn A, Schrem H Mycophenolate mofetil in liver transplantation: a review Ann Transplant, 2013.PMID 24346057
7. [7]Allen UD, Preiksaitis JK Post-transplant lymphoproliferative disorders, Epstein-Barr virus infection, and disease in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice Clin Transplant, 2019.PMID 31230381
8. [8]Kalil AC, Mindru C, Botha JF, et al. Risk of cytomegalovirus disease in high-risk liver transplant recipients on valganciclovir prophylaxis: a systematic review and meta-analysis Liver Transpl, 2012.PMID 22887929
9. [9]Montano-Loza AJ, Mason AL Recurrence of primary biliary cholangitis after liver transplantation: A Japanese perspective Hepatol Commun, 2017.PMID 29404467
10. [10]Visseren T, Darwish Murad S, et al. Recurrence of primary sclerosing cholangitis, primary biliary cholangitis and auto-immune hepatitis after liver transplantation Best Pract Res Clin Gastroenterol, 2017.PMID 28624107
11. [11]Price JC, Terrault NA Treatment of hepatitis C in liver transplant patients: interferon out, direct antiviral combos in Liver Transpl, 2015.PMID 25604355
12. [12]Jiménez-Pérez M, González-Grande R, Omonte Guzmán E, et al. Metabolic complications in liver transplant recipients World J Gastroenterol, 2016.PMID 27605877