Episode 68: Liver transplant with Meera Gupta

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We learn about liver transplant with Dr. Meera Gupta, transplant surgeon at the University of Kentucky Healthcare Transplant Center, and surgical director of the Kidney and Pancreas Transplant Program. We discuss eligibility, triage, the peri-operative course, and important post-op complications.

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Takeaway lessons

1. Liver transplant eligibility is based on need, not time on the list. The MELD score (MELD 3 now, including albumin) is used for this, with MELD >9 (historically >15) considered the cutoff for transplant potentially exceeding the risk of not transplanting.
2. Livers can now be placed on warm perfusion pumps, allowing continued viability for much longer. This is mainly used in donors who died from cardiac death, those with high BMI or similar risks for primary non-function (i.e. the transplanted liver never starts working), and longer transport distances or expected operative times.
3. Incision is a large right subcostal incision, extended as needed. The liver hilum is dissected, preserving the feeding vessels. Caval clamping may be tested, then the liver is removed. This anhepatic phase in minimized to <60 minutes, preferably <45 minutes. The new liver is then anastomosed to the portal veins, vena cava, hepatic artery, and the bile duct. Some instability can occur during reperfusion, such as right heart strain, electrolyte abnormalities, or volume shifts.
4. Patients will usually remain intubated post-op, lines in place. Sedation ideally is limited so the patient can rouse and confirm the absence of encephalopathy. Systolic BP is closely watched (goal >90), as diastolic BP tends to be low in most liver failure patients. Hepatopulmonary patients can rest on the vent a little longer and are expected to remain on oxygen for the time being. Patients can be fed once extubated and stable.
5. High-dose steroids are loaded up front and then tapered, and oral immunosuppression initiated soon after.
6. Some AKI is common. Colloid like albumin is favored early.
7. Chronic thrombocytopenia is common and is monitored to determine when DVT prophylaxis can be started. Platelets >20k are targeted.
8. If INR >2, vitamin K is given empirically. FFP is usually not given prophylactically. Bleeding is usually considered a little preferable to clotting, in terms of ease of treatment.
9. A liver duplex is performed in the first 24 hours to ensure the new vascular supply is patent.