359.4 📋 章末速蚘 Summary

359.4.1 🔑 䞀句話瞜結

Liver transplant (LT) = definitive treatment for end-stage liver disease + acute liver failure台灣 ~ 1,500-2,000 LT since program inception, living donor predominant (deceased donor shortage)indicationsend-stage cirrhosis (decompensated) + ALF + HCC within Milan criteria (single ≀ 5 cm OR ≀ 3 ≀ 3 cm, no vascular/extrahepatic) + early hilar cholangiocarcinoma (Mayo protocol) + select acute alcoholic hepatitis + metabolic + HPS/POPH/FAPallocationMELD-Na (since 2016) or MELD 3.0 (2023) priority + exception points for HCC + HPS + POPH + FAP + CCA + cystic fibrosiscontraindicationsactive malignancy outside liver + severe cardiopulmonary disease + active substance abuse < 3-6 months + severe psychosocial issues + cholangiocarcinoma extrahepatic (except Mayo protocol) + active uncontrolled HIVdonor typesdeceased donor (DBD or DCD expanding) + living donor (right or left lobe) + split + domino (FAP) + machine perfusion (NMP, HMP — extending preservation + improving donor pool)immunosuppression triple therapytacrolimus (CNI) + MMF + prednisone with induction (basiliximab or rATG); mTOR inhibitor (sirolimus, everolimus) for CNI nephrotoxicity / HCC recurrence preventioncomplications(1) surgical — hepatic artery thrombosis (HAT) most serious early, biliary anastomotic stricture/leak; (2) rejection — acute cellular (pulse steroids) + antibody-mediated (plasmapheresis + IVIG + rituximab + bortezomib) + chronic ductopenia (vanishing bile duct); (3) infections — CMV (D+/R- highest, valganciclovir prophylaxis 3-12 mo) + EBV + PTLD (reduce IS + rituximab) + PCP (TMP-SMX prophylaxis) + fungal + bacterial; (4) malignancy — skin SCC + PTLD (B-cell, EBV-driven) + solid organ; (5) recurrence of disease — HCV now cured with post-LT DAAs, HBV prevented with antivirals + HBIG, PSC 30%+ recurrence, PBC 20-30%, AIH common; (6) CV (NODAT + HTN + dyslipidemia) + renal CNI nephrotoxicity (25-30% develop ESRD)outcomes1-year 90%+, 5-year 75%, 10-year 60%; QoL generally excellentspecial topicsearly liver transplant for select severe alcoholic hepatitis (Mathurin 2011 + ELITAH protocols, strict psychosocial assessment); Mayo protocol for hilar cholangiocarcinoma (neoadjuvant chemoradiation + LT); acute-on-chronic liver failure (ACLF) new category — ICU + LT evaluation; machine perfusion + DCD expansion + xenotransplantation pig liver 2024 emerging。

359.4.2 💊 治療粟芁

  • immunosuppression maintenancetacrolimus (trough 8-10 early, 5-8 long-term) + MMF (1-2 g daily) + prednisone (tapered) standard triple
  • inductionbasiliximab (IL-2 receptor antagonist) for most + ATG (rATG / Thymoglobulin) for high-risk
  • CNI nephrotoxicityconsider mTOR inhibitor (sirolimus, everolimus) switch
  • HCC post-LTmTOR inhibitor may reduce recurrence
  • CMV prophylaxisvalganciclovir 3-12 months (D+/R- highest risk)
  • PCP prophylaxisTMP-SMX
  • HBV post-LTantivirals (entecavir or tenofovir) + HBIG combination → recurrence < 5%
  • HCV post-LTDAA treatment post-stabilization (curable)
  • acute cellular rejectionpulse methylprednisolone 500-1000 mg × 3 days; rATG for refractory
  • antibody-mediated rejectionplasmapheresis + IVIG + rituximab + bortezomib
  • PTLDreduce IS + rituximab (CD20+) + chemo for high-grade

359.4.3 🎯 盧醫垫的考前提醒

  1. LT indications: end-stage cirrhosis (decompensated) + ALF + HCC Milan criteria + Mayo protocol hilar CCA + select acute AH + metabolic liver disease (Wilson, hemochromatosis, alpha-1 AT)
  2. Milan Criteria for HCC (memorize): single ≀ 5 cm OR ≀ 3 nodules each ≀ 3 cm, no vascular invasion, no extrahepatic spread; UCSF criteria extended (≀ 6.5 cm single or ≀ 3 each ≀ 4.5 cm total ≀ 8)
  3. MELD-Na (since 2016) + MELD 3.0 (2023) for allocation; MELD 3.0 adds female sex + albumin; better discrimination
  4. MELD exception pointsHCC + HPS (hepatopulmonary) + POPH (portopulmonary HTN) + FAP + CCA (Mayo) + cystic fibrosis + polycystic liver
  5. donor types in Taiwan: living donor predominant (deceased donor shortage) — right lobe for adult, left for pediatric; ~ 0.5% donor mortality + 4-6 week recovery
  6. immunosuppression triple therapy: tacrolimus + MMF + prednisone (standard); induction basiliximab or rATG; mTOR inhibitor (sirolimus, everolimus) for CNI nephrotoxicity / HCC recurrence prevention / cardiac allograft vasculopathy
  7. HAT (hepatic artery thrombosis) most serious early complication: emergency revascularization or retransplant
  8. post-LT infection prophylaxis: valganciclovir for CMV (D+/R- highest) 3-12 months + TMP-SMX for PCP + antifungal selected + watch for EBV → PTLD
  9. disease recurrence post-LT: HCV now curable with DAAs, HBV prevented with antivirals + HBIG, PSC 30%+ recurrence (most), PBC 20-30%, AIH common — manage IS
  10. early LT for severe alcoholic hepatitis (Mathurin 2011 + ELITAH): strict psychosocial assessment + abstinence support + select cases — challenges traditional 6-month rule