Liver transplantation contraindications

Medicaments Glucocorticoids are contraindicated. Administration of interferon a is more dangerous than helpful. Other medicaments should not be used unless this is absolutely necessary — it must be noted that the disturbed metabolism may alter in unforeseen ways. In contrast, misoprostol (153) and lamivudine (141, 248, 250) showed remarkably positive effects. Especially in fulminant hepatitis B, administration of lamivudine (100 mg/day) proved to be effective. In patients with reactivation due to cytostatic therapy after liver transplantation, lamivudine was much more efficacious than famciclovir. 

As the management of liver transplantation has improved, absolute and relative contraindications have been established. Relative contraindications may question the success of LT in some cases. Obesity leads to an increased rate of postoperative complications, but it does not influence the survival rate. (396, 403) (s. tab. 40.16) Contraindications should also be considered in urgent LT due to acute liver failure - possibly accompanied by necrotizing pancreatitis, septic shock and problems with assisted respiration. Visceral inversion is not deemed to be a contraindication a successful LT was indeed carried out under such conditions by G.B. Rlintmalm et al. in 1993. 

Tab. 40.16 Absolute and relative contraindications for liver transplantation. (The relative contraindications should be determined for each individual case)...

Medical management of hepatic encephalopathy is mainly nsed for patients who do not yet meet the criteria for liver transplantation or for patients awaiting liver transplantation. It must be underscored that severe neuropsychiatric symptoms in patients with severe liver disease must not be considered as contraindications but instead as clear indications for liver transplantation. 

In addition to improved survival for patients who undergo TACE for unresectahle disease, there have been reports of patients whose tumor has shrunk enough to permit resection or liver transplantation and provide a chance for cure. Despite these benefits, TACE is considered a palliative treatment option. Surgical resection is the only procedure that can be performed with curative intention, therefore, TACE should be reserved for patients who are not surgical candidates. This is the only absolute contraindication to TACE. Table 10.2 summarizes a list of relative contraindications. 

The status of liver transplantation is reviewed with emphasis upon the current survival statistics and the quality of life to be expected in survivors. Present day indications and contraindications for the procedure are reviewed.The operative procedure and the peri-operative problems which are to be expected following a successful transplant are discussed. 

Patency of the portal vein should be assessed, as portal vein thrombosis may occur in patients with end-stage cirrhosis. Portal vein thrombosis is not a contraindication to liver transplant, but requires modification of the surgical technique to create extra-anatomical venous grafts (Fig. 4.2.11). 

The patency of hepatic veins and the inferior vena cava should be evaluated. Transjugular intrahepatic portal-systemic shunts (TIPS), when present, should be assessed for patency and their location should be described (Fig. 4.2.13). The distal end of the TIPS should be in the right hepatic vein when being positioned in the inferior vena cava it constitutes a contraindication to liver transplantation. 

Typical side effects are constitutional in nature, including a flu-like syndrome within 6 hours after dosing in more than 30% of patients that tends to resolve upon continued administration. Other potential adverse effects include thrombocytopenia, granulocytopenia, elevation in serum aminotransferase levels, induction of autoantibodies, nausea, fatigue, headache, arthralgias, rash, alopecia, anorexia, hypotension, and edema. Severe neuropsychiatric side effects may occur. Absolute contraindications to therapy are psychosis, severe depression, neutropenia, thrombocytopenia, symptomatic heart disease, decompensated cirrhosis, uncontrolled seizures, and a history of organ transplantation (other than liver). Alfa interferons are abortifacient in primates and should not be administered in pregnancy. 

Absolute contraindications to use of interferon include current or past psychosis or severe depression, neutropenia or thrombocytopenia, organ transplant (except liver), symptomatic heart disease, decompensated cirrhosis, and uncontrolled seizures. Relative contraindications to interferon include uncontrolled diabetes and autoimmune disorders. 

Cyclosporin suppresses cell-mediated immune reactions and some humoral immunity. It is indicated in the prophylaxis of organ rejection in kidney, liver, and heart allogeneic transplants in conjunction with adrenal corticosteroid therapy treatment of chronic rejection in patients previously treated with other immunosuppressive agents increased tear production in patients whose tear production is presumed to be suppressed because of ocular inflammation associated with keratoconjunctivitis sicca (ophthalmic emulsion). Gengraf, Neorai Used for treatment of severe active rheumatoid arthritis (RA) where disease is not adequately responsive to methotrexare treatment of adult, non-immunocompromised patients with severe, recalcitrant, plaque psoriasis who have failed to respond to a least one systemic therapy or in patients for whom other systemic therapies are contraindicated, or cannot be tolerated. 

Tylenol is not contraindicated in clients with kidney transplants it is contraindicated in clients with liver disorders. 

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