359.1 🎓 醫孞生版

359.1.0.1 📌 䞀頁重點

359.1.0.1.1 Indications

359.1.1 Most Common Indications (US/Europe)

  • Alcoholic liver disease (top in many countries)
  • HCV cirrhosis (declining with DAAs)
  • MASH/MASLD cirrhosis (rising — top in some)
  • HBV cirrhosis
  • Cryptogenic cirrhosis
  • Autoimmune liver disease (PBC, PSC, AIH)
  • Metabolic (Wilson, hemochromatosis, alpha-1 AT)
  • Vascular (Budd-Chiari)
  • Polycystic liver disease

359.1.2 Acute Liver Failure (See Ch360)

  • Acetaminophen, viral, autoimmune, ischemic, Wilson, idiopathic
  • King’s College Criteria + MELD

359.1.3 Hepatocellular Carcinoma (HCC)

  • Milan Criteria: single ≀ 5 cm OR ≀ 3 nodules each ≀ 3 cm, no vascular invasion, no extrahepatic spread
  • UCSF Criteria (extended): single ≀ 6.5 cm OR ≀ 3 tumors each ≀ 4.5 cm, total ≀ 8 cm
  • Downstaging strategies to bring into criteria
  • MELD exception points

359.1.4 Other Special Indications

  • Early hilar cholangiocarcinoma (Mayo protocol with neoadjuvant chemoradiation)
  • Acute alcoholic hepatitis (selected, strict psychosocial)
  • Hepatopulmonary syndrome (HPS) — MELD exception
  • Portopulmonary HTN (POPH) — MELD exception
  • Familial amyloid polyneuropathy (FAP) — MELD exception
359.1.4.0.1 Contraindications

359.1.5 Absolute

  • Severe extrahepatic disease (uncontrolled malignancy, severe systemic infection)
  • Severe cardiopulmonary disease
  • Active substance abuse (within 3-6 months)
  • Severe psychosocial issues (non-adherence, no support)
  • Anatomic obstacles
  • Cholangiocarcinoma extrahepatic (except Mayo protocol)
  • Active HIV with severe disease (changing — controlled HIV acceptable)

359.1.6 Relative

  • Age > 70 (with good function)
  • BMI > 40
  • Active alcohol use < 6 months (varies by center)
  • Severe portal vein thrombosis
  • Recurrent disease (HCV, HBV, autoimmune)
  • Multiple comorbidities
359.1.6.0.1 Donor Selection

359.1.7 Deceased Donor (DD)

  • DBD (donation after brain death) — standard
  • DCD (donation after circulatory death) — expanding
  • Expanded criteria (older, comorbid) — for older recipients
  • ABO matching essential
  • Size matching

359.1.8 Living Donor (LD)

  • Right lobe for adult recipient (60-65% of liver volume)
  • Left lobe for pediatric or smaller recipient
  • Donor must be healthy + adequate liver volume
  • Donor evaluation extensive
  • Recovery 4-6 weeks
  • Mortality ~ 0.5%

Taiwan dominant approach: living donor (deceased donor shortage)

359.1.9 Split Liver

  • Adult right lobe + pediatric left lobe (or smaller)
  • Helps shortage

359.1.10 Domino Transplant

  • FAP patient’s liver → second recipient
  • Patient receives transplant

359.1.11 Machine Perfusion

  • Normothermic + hypothermic
  • Improves donor pool
  • Allows extended preservation
  • Real-time assessment
359.1.11.0.1 Pre-Transplant Evaluation

359.1.12 Components

  • Medical (cardiac, pulmonary, renal, metabolic)
  • Hepatologic (severity, etiology)
  • Surgical (anatomy, prior surgeries)
  • Psychosocial (mental health, addiction, support)
  • Financial
  • Patient education

359.1.13 Specific Tests

  • Echocardiogram, stress test, cath if needed
  • Pulmonary function
  • Renal function
  • HIV, hepatitis serology
  • Cancer screening
  • Bone density
  • Imaging (CT/MRI)
  • HLA typing + crossmatch
359.1.13.0.1 Allocation (US Model)

359.1.14 MELD-Based

  • MELD-Na or MELD 3.0
  • Higher score = priority
  • Exception points for specific conditions

359.1.15 Status 1A (Highest Priority)

  • Acute liver failure with life expectancy < 7 days
  • Graft non-function within 7 days of transplant
  • Pediatric: HCC + Wilson + others

359.1.16 Pediatric PELD Score

  • Different system
  • Bilirubin, INR, albumin, growth, age
359.1.16.0.1 Immunosuppression

359.1.17 Induction

  • Basiliximab (IL-2 receptor antagonist) — most
  • ATG for high-risk
  • High-dose steroids

359.1.18 Maintenance Triple Therapy

  • Tacrolimus (CNI) — most centers
  • Cyclosporine (alternative)
  • Mycophenolate mofetil (MMF) — antiproliferative
  • Prednisone — tapered

359.1.19 Tacrolimus-Sparing Approaches

  • mTOR inhibitor (sirolimus, everolimus) for CAV / CKD / HCC
  • Belatacept (CTLA-4 Ig) less common

359.1.20 Steroid-Free Protocols

  • Some centers
  • Patient selection
359.1.20.0.1 Complications

359.1.21 Surgical (Early)

Vascular: - Hepatic artery thrombosis (HAT) — most serious - Portal vein thrombosis - IVC obstruction - Treatment: thrombolysis, revascularization, retransplant

Biliary: - Anastomotic stricture - Biliary leak - Stone formation - Treatment: ERCP with stenting, balloon dilation, surgery

Other: - Bleeding - Wound infection - Bile leak

359.1.22 Rejection

Acute Cellular Rejection (ACR): - Most common in first 6 months - ↑ LFT - Biopsy: portal lymphocytic infiltrate - Banff scoring - Treatment: pulse methylprednisolone; rATG for refractory

Antibody-Mediated Rejection (AMR): - Donor-specific antibodies (DSAs) - Microvascular injury - Treatment: plasmapheresis + IVIG + rituximab + bortezomib

Chronic Rejection: - Ductopenia (vanishing bile duct syndrome) - Difficult to treat

359.1.23 Infections

Bacterial: - Surgical site, abdomen - Pulmonary - C. difficile

CMV (most common viral): - D+/R- highest risk - Valganciclovir prophylaxis 3-12 months - Treatment: ganciclovir IV → valganciclovir oral

EBV + PTLD: - D+/R- highest risk - Monitor EBV PCR - Reduce IS + rituximab

Fungal: - Candida, Aspergillus - Risk in early period

Pneumocystis (PCP): - TMP-SMX prophylaxis

359.1.24 Recurrence of Original Disease

  • HCV: previously universal (now cured with DAAs post-transplant)
  • HBV: prevented with antivirals + HBIG; lifelong
  • HCC: 10-20% recurrence rate
  • PSC: 30%+ recurrence
  • PBC: 20-30% recurrence (often mild)
  • AIH: recurrence common; manage IS
  • MASH: recurrence common (metabolic)

359.1.25 Malignancy (Post-Transplant)

  • Skin cancer (SCC > BCC)
  • PTLD (EBV-driven)
  • Solid organ cancers
  • HCC recurrence

359.1.26 Other

  • Cardiovascular: HTN, dyslipidemia, NODAT
  • Renal: CNI nephrotoxicity (25-30% develop ESRD)
  • Metabolic: NODAT, hyperlipidemia, obesity, metabolic syndrome
  • Bone: osteoporosis
  • Mental health: depression, anxiety
359.1.26.0.1 Outcomes

359.1.27 Survival

  • 1-year graft: 85-90%
  • 5-year graft: 70-75%
  • 10-year graft: 55-65%

359.1.28 Patient Survival

  • 1-year: 90%+
  • 5-year: 75-80%
  • 10-year: 65-70%

359.1.29 Quality of Life

  • Generally excellent
  • Most return to work / activities

359.1.30 Indication-Specific

  • HCC: depends on staging
  • Alcohol: depends on abstinence + psychosocial
  • AIH: good with IS
359.1.30.0.1 Special Topics

359.1.31 Acute Alcoholic Hepatitis Transplant

  • Traditional 6-month abstinence rule challenged
  • Early transplant in select severe AH
  • Mathurin 2011 (France) + US protocols
  • Strict psychosocial assessment

359.1.32 Hilar Cholangiocarcinoma + LT (Mayo Protocol)

  • Early stage (I, II)
  • Neoadjuvant chemoradiation + endoscopic brush biopsy
  • Strict selection
  • Mayo + select centers
  • Reasonable outcomes

359.1.33 Living Donor LT (LDLT)

  • Common in Taiwan
  • Right lobe for adult; left for pediatric
  • Donor recovery ~ 4-6 weeks
  • Donor mortality ~ 0.5%
  • Better than DD outcomes in some

359.1.34 Domino Liver Transplant

  • FAP patient → second recipient
  • Special considerations

359.1.35 Machine Perfusion

  • Normothermic (NMP)
  • Hypothermic (HMP)
  • Reduces injury + extends preservation + assessment
  • Increasing utilization

359.1.36 Xenotransplantation (Pig Liver)

  • Investigational
  • 2024 early human trials
  • Future direction

359.1.36.1 🩺 床邊速查

  • LT indications: end-stage cirrhosis, ALF, HCC within Milan, hilar CCA (Mayo), select acute AH, metabolic
  • Allocation: MELD-Na or MELD 3.0 priority + exception points
  • Donor types: DD (DBD or DCD) + LD; Taiwan LD predominant
  • Immunosuppression: tacrolimus + MMF + prednisone (triple)
  • Recurrence: HCV cured with DAAs; HBV prevented with antivirals; PSC 30%+
  • CMV + EBV-PTLD common infections
  • Outcomes: 1-yr 90%, 5-yr 75%
  • Acute AH transplant (early): select severe with strict criteria