Ascites liver transplant

Liver transplantation should be considered in patients with refractory ascites. 

Decompensated liver disease is complicated by jaundice, refractory ascites, bacterial peritonitis, coagulopathy, and variceal bleeding and may require liver transplantation. The number of liver transplants for decompensated cirrhosis doubled from 1990 to 2004, when 5845 cadaveric (orthotopic) liver transplants were performed (65). 

Veno-occlusive disease (VOD) differs from Budd-Chiari syndrome in that it consists of occlusive fibrosis of the small intrahepatic veins. VOD may present as either an acute form with sudden ascites, liver enlargement and rapidly rising bilirubin, or as a chronic form with fibrosis and cirrhosis. One of the main causes of VOD is the use of cyclophosphamide or alkalating agents during conditioning for bone marrow transplantation, where it occurs in up to 20% of cases. Other causes include irradiation, antineoplastic drugs, pyrrolizidine alkaloids and alcohol. 

Indications The indication for a peritoneovenous shunt (PVS) must be viewed critically, (s. tab. 16.14) Before any decision is taken on the shunt implantation, the indication for TIPS or a possible liver transplantation must be considered and discussed with the patient. Liver transplantation provides a real opportunity to eliminate ascites permanently - generally also with a longer survival time. (197, 202, 206, 208, 222, 223)... 

It may indeed be necessary to postpone the transplantation or to bridge the period prior to the transplantation owing to ascites factors or other particular difficulties, including the absence of a suitable liver transplant. To this end, the peritoneovenous shunt and TIPS are suitable temporary operative steps. Indeed, it is these techniques which actually make subsequent liver transplantation possible. Thus PVS and TIPS are principally indicated if it is not (or not yet) possible to carry out a liver transplantation. 

Cirera, I., Navasa, M., Rlmola, A., Garda-Pagan, J.C., Grande, L., Garcia-Valdecasas, J.C., Fuster, J., Bosch, J., Rodes, J. Ascites after liver transplantation. Liver Transplant. 2000 6 157-162... 

Intestinal transplantation is combined with liver transplantation in 46% of cases, because of terminal liver failure (93). Of 78 patients who had received parenteral nutrition for more than 2 years n — 66) and/ or had short bowel syndrome and could not be weaned from parenteral nutrition (n = 12), 58 developed chronic cholestasis and 37 developed one or more severe liver complication (serum bilirubin concentration 60 pmol/l, factor V (proaccelerin) 50%, portal hypertension, encephalopathy, ascites, bleeding from the gastrointestinal tract, or histological findings consisting of extensive fibrosis and cirrhosis) after 6 (3-132) months and 17 (2-155) months respectively. Liver disease was responsible for deaths in 6.5% of the patients (22% of deaths). 

HPI AH is a 57-year-old man who just received an orthotopic liver transplant for hepatitis C cirrhosis. PMH includes hepatitis C cirrhosis, ascites, and hepatic encephalopathy. 

Assuming conservatively that 10% of all chronic hepatitis C patients (2.7 rmlUon) were eligible for therapy in the United States, with 70% of patients having HCV genotype 1, the estimated cost for the pharmaceuticals alone would be approximately 4 billion. However, the cost of not treating HCV could lead to future costs associated with hospitalizations related to ascites, cirrhosis, variceal hemorrhage, HCC, and liver transplantation. 

Transplantation of the liver essentially gives patients with refractory portal ascites a chance to start a new life. However, in the presence of large-scale ascites, the surgeon is faced with a number of specific problems such as overdilated and thin abdominal walls, existing hernia, spontaneous bacterial peritonitis, significant volume displace-... 

Intensive care Patients with ALE or with decompensated chronic liver insufficiency (such as coma stages II-IV, refractory ascites, hepatorenal syndrome, disseminated intravascular coagulation, gastrointestinal bleeding) require monitoring and treatment in an intensive care unit, preferably in a transplantation centre. (7,13,60, 66, 77)... 

A 51-year-old man, with a 9-year history of renal insufficiency and an alcohol intake of 4 U/week, underwent transplant nephrectomy. At surgery, ascites and liver cirrhosis were noted. A needle biopsy of the liver 1 month later showed nodular regenerative hyperplasia but no cirrhosis. There were subendothehal vacuolated cells, suggestive of modified stellate cells, and there was adjacent focal perisinusoidal fibrosis. His medications included one multivitamin/mineral supplement per day containing vitamin A 4000 lU. His vitamin A concentration was 1045 (reference range 490-720) ng/ml. Viral and antibody studies were negative. 

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