heart transplantation medical surgical .pptx

transplantation of heart

1. HEART AND LIVER TRANSPLANTATION

2. DEFINITION A surgical procedure in which a diseased heart is replaced with a healthy heart from a deceased person.

3. INDICATIONS NYHA CLASS PHYSICAL MANIFESTATION I No limitation of physical activity, no dyspnea , fatigue or palpitations with ordinary activity II Slight limitation of physical activity, patients have fatigue, palpitations, and dyspnea with ordinary physical but are comfortable at rest. III Marked limitation of activity, less than ordinary physical activity results in symptoms, but patients are comfortable IV Symptoms are present at rest and any physical exertion exacerbates the symptoms

4. Systolic heart failure with severe functional limitations and /or refractory symptoms despite maximal medical therapy. NYHA functional class III-IV Maximal oxygen uptake (VO 2 max) of < 12-14 ml/kg/min exercise testing Cardiogenic shock not expected to recover Ischemic heart disease Intractable ventricular arrhythmias Severe symptomatic hypertrophic or restrictive cardiomyopathy Congenial heart disease in which severe fixed pulmonary hypertension Cardiac tumors with low likelihood of metastasis

5. CONTRA INDICATIONS ABSOLUTE Elevated pulmonary artery pressures Irreversible severe renal, hepatic or pulmonary disease Kidney dysfunction Chronic liver dysfunction Recent or un resolved pulmonary infarction Active uncontrolled infection Active malignancy or recent malignancy with high risk or recurrence RELATIVE Advanced age (> 70 yrs) Diabetes mellitus with end organ damage and/or poor glycemic control Obesity Severe cachexia or malnutrition Systemic disease with a high probability of recurrence in the transplanted heart. Severe peripheral vascular disease or cerebrovascular disease. History of multiple prior sternotomies High level of allo senstization

6. PSYCHOLOGICAL CONTRAINDICATIONS ABSOLUTE CONTRAINDICATION Inadequate social support Illicit substance abuse Alcohol dependence Nicotine abuse Active psychotic symptoms Dementia History of multiple suicide attempts

7. STATUS - 1A Mechanical circulatory support such as left and /or right ventricular assist device(may be listed for 30 days at any point after being implanted) Total artificial heart Intra aortic balloon pump Extracorporeal membrane oxygenator(ECMO) Mechanical circulatory support with objective medical evidence of significant device infection, mechanical failure or life threatening ventricular arrhythmias Continuous mechanical ventilation Continuous infusion of a single high dose intravenous inotrope or multiple intravenous inotropes , in addition to continuous hemodynamic monitoring of left ventricular filling pressure

8. STATUS -1B Left and/or right ventricular assist device implanted Continuous infusion of intravenous ionotropes STATUS 2 A candidate who does not meet the criteria for status 1A or 1B

9. CRITERIA FOR DETERMINING BRAIN DEATH Mechanism of brain injury is sufficient to account for irreversible loss of brain function Absence of reversible causes of CNS depression CNS depressant drugs Hypothermia (<32 C) Hypotension (MAP < 55mmHg) Absence of neuromuscular blocking drugs that may confound the results of the neurologic exam No spontaneous movements, motor responses, or posturing No gag or cough reflexes No corneal or pupillary light reflexes No oculovestibular reflex (cold calorics )

10. Confirmatory test A pnea test for minimum of five minutes following: No respiratory movements Pco2>55 mmHg pH <7.40 No intracranial blood flow

11. DONOR EVALUATION Age <55 yrs Absence of significant structural abnormalities LVH (wall thickness >13mm by echocardiography) Significant valvular dysfunction Significant congenital cardiac abnormality Significant coronary artery disease Adequate physiologic function of donor heart LVEF>45% Achievement of target hemodynamic criteria after hormonal resuscitation and hemodynamic management Negative hepatitis C antibody, hepatitis B surface antigen and HIV serologies Absence of active malignancy or overwhelming infection

12. HEART TRANSPLANTATION SURGICAL PROCEDURE

13. ORTHOTOPIC HEART TRANSPLANTATION The recipient’s diseased heart is removed, and the donor allograft is inserted anatomically in its place.

14. After the sternotomy, the ascending aorta is cannulated close to the aortic arch, venous return cannulae are inserted into both the superior and inferior cavae , and the patient is placed on CPB. The cavae are encircled with tourniquets to isolate all of the venous return from the heart, the ascending aorta is clamped close to the aortic arch, and the recipient heart is then excised.

15. BIATRIAL TECHNIQUE A standard median sternotomy is used, the great vessels are cannulated , and cardiopulmonary bypass is instituted after anticoagulation and standard hypothermia are achieved

16. BICAVAL TECHNIQUE The anastomotic sites of the bicaval technique include the left atrial cuff, which contains the orifices of pulmonary veins, the superior and inferior vena cava, as well as the aorta and the main pulmonary artery.

17. HETEROTOPIC HEART TRANSPLANTATION It is a rarely performed procedure in which the recipient’s heart remains in place, and the donor heart is attached to its right side so that the flow in each is in parallel, permitting the recipient’s heart to continue to pump blood, particularly through the lungs. This procedure is primarily reserved for patients with pulmonary hypertension as a strategy to avoid acute right heart failure in the unconditioned donor heart and in cases in which there is a marked difference in size of the donor and recipient

18. IMMUNO SUPPRESSION Agents used for induction therapy include cytolytic agents such as the murine monoclonal antibody, antibody ornithine ketoacid transaminase (OKT3) or polyclonal antithymocyte agents or antilymphocyte agents ( atgam , thymoglobulin).

19. CALCINEURIN INHIBITORS

20. CYCLOSPORINE 4-8mg/kg/d in 2 divided doses, titrated to keep therapeutic 12 hours trough levels

21. TACROLIMUS 0.05-0.1 mg/kg/d in 2 divided doses, titrated to keep therapeutic 12 trough level

22. AZATHIOPRINE 1.5-3.0mg/kg/d MAJOR TOXICITIES Bone marrow suppression Hepatitis Pancreatitis Malignancy

23. MYCOPHENOLATE MOFETIL 1000-3000 mg/kg/d in 2 divided dose MAJOR TOXICITIES Gastrointestinal disturbances(nausea, diarrhea)

24. SIROLIMUS 1-3mg/d, titrated to keep therapeutic 24h trough level MAJOR TOXICITIES Oral ulcerations Hypercholesterolemia and Hypertriglyceridemia Poor wound healing Lower extremity edema Interstitial pneumonitis Leukopenia Anemia Thrombocytopenia Nephrotoxicity when used concurrently with calcineurin inhibitors

25. EVEROLIMUS 1.5-3.0 mg/d in 2 divided doses

26. PREDNISONE 1mg/kg/d in divided doses, tapered to 0-0.5mg/kg/d by 6 -12mg MAJOR TOXICITIES Weight gain Hypertension Hyperlipidemia Osteopenia Hyperglycemia Poor wound healing Salt and water retention Proximal myopathy Cataracts Peptic ulcer disease Growth retardation

27. LIVER TRANSPLANTATION

28. DEFINITION Liver Transplantation is a procedure where a diseased liver is removed from a patients body and is replaced with a new liver that is taken from a deceased donor or a part of the liver is extracted from a live donor who is considered as a donor after multiple tests.

29. TRANSPLANT TEAM Liver specialist ( hepatologist ) Transplant surgeons Transplant coordinator, usually a registered nurse who specializes in the care of liver-transplant patients (this person will be your primary contact with the transplant team) Social worker to discuss your support network of family and friends, employment history, and financial needs Psychiatrist to help you deal with issues, such as anxiety and depression, which may accompany a liver transplant Anesthesiologist to discuss potential anesthesia risks Chemical dependency specialist to aid those with history of alcohol or drug abuse Financial counselor to act as a liaison between a patient and his or her insurance companies

30. INDICATIONS Children Biliary atresia Neonatal hepatitis Congenital hepatic fibrosis Byler’s disease Alpha -Antitrypsin deficiency Inherited disorders of metabolism Wilson’s disease Tyrosinemia Glycogen storage diseases Lysosomal storage diseases Familial hypercholesterolemia Primary hyperoxaluria type I Hemophilia Adults Primary biliary cirrhosis Secondary biliary cirrhosis Primary sclerosing cholangitis Autoimmune hepatitis Caroli’s disease Cryptogenic cirrhosis Chronic hepatitis with cirrhosis Hepatic vein thrombosis Fulminant hepatitis Alcoholic cirrhosis Chronic viral hepatitis Primary hepatocellular malignancies Hepatic adenomas Nonalcoholic steatohepatitis Familial amyloid polyneuropathy

31. CONTRAINDICATION Absolute Uncontrolled extra hepatobiliary infection Active, untreated sepsis Uncorrectable, life-limiting congenital anomalies Active substance or alcohol abuse Advanced cardiopulmonary disease Extra hepatobiliary malignancy (not including nonmelanoma skin cancer) Metastatic malignancy to the liver Cholangiocarcinoma AIDS Life-threatening systemic diseases

32. Relative Age >70 Prior extensive hepato biliary surgery Portal vein thrombosis Renal failure Previous extrahepatic malignancy (not including nonmelanoma skin cancer) Severe obesity Severe malnutrition/wasting Medical noncompliance HIV seropositivity Intrahepatic sepsis Severe hypoxemia secondary to right-to-left intrapulmonary shunts (PO2 < 50 mmHg) Severe pulmonary hypertension (mean PA pressure >35 mmHg) Uncontrolled psychiatric disorder

33. MELD score

34. LIVING DONOR TRANSPLANTATION Is a procedure where a part of liver is taken from a living doctor, who is supposed to be considered after undergoing a large number of medical and psychological tests in order to avoid any sort of risk. The donor can be a blood relative, spouse or a friend who is considered positive for the procedure. It is necessary that the donor must be leading a healthy lifestyle and should be a non alcoholic.

35. CADAVERIC TRANSPLANTATION Is a procedure where the liver is taken from a deceased individual, in medical terms an individual whose brain has stopped working is considered to be dead. After considering certain tests and other formalities the transplantation procedure is executed. The identity of the donor and the circumstances under which the donor died are kept confidential

36. AUXILIARY LIVER TRANSPLANTATION The first is in the cases of patients with acute liver failure in whom a partial graft is used to provide support to the patient’s diseased liver while it recovers. Once the native liver returns to normal function, the graft is removed and immunosuppression is withdrawn. The second case is for patients with functional congenital or metabolic disorders affecting a normal liver. Implanting a partial graft while preserving the native liver allows correction of the metabolic disorder while avoiding a full liver transplant

37. PARTIAL GRAFT TRANSPLANTATION Partial liver grafts are used at times. It may be necessary to provide partial support for metabolic needs due to a specific or complete metabolic deficiency . In the latter case, one of the major preconditions is that the volume of the graft must be sufficient inorder to have the capacity to sustain life in the patient immediately after transplantation

38. SPLIT LIVER TRANSPLANTATION This alternative involves dividing a liver in two parts and depends on who the intended recipients are. If those sharing the graft are an adult and a child, the liver will be divided into a right lobe that includes also the segment IV and a partial left graft that includes segments II and III. Whereas, if theliver is to be divided between two adults, it will be split in two, the right lobe (segments V to VIII) and the left lobe (segments Ito IV).

39. RETRANSPLANTATION The main causes have to be divided in early (hepatic artery thrombosis or primary graft non-function) and late (chronic rejection or recurrence of the primary liver disease). The timing of retransplantation represents a key point in both patient and graft survival. Patients with a retransplantation interval less than 30 days display lower survival rates when compared to those with later retransplantation

40. PRETRANSPLANTATION HISTORY Risk factors for viral hepatitis: transfusions, intravenous drug abuse, tattoos, other parenteral exposure Family history of liver disease Associated disorders: hypothyroidism, osteoporosis, infertility, arthritis Onset, duration, and description of symptoms and complications: jaundice, lethargy, bleeding disorders, pruritus , confusion, ascites, edema, malenic stools, abdominal pain, bone pain or fractures, chronic diarrhea, gynecomastia (in men), amenorrhea (in women) Current and past medical history: hospitalizations, surgeries Social history: exposure to alcohol, drugs, toxins, tobacco products Status of immunizations

41. EVALUATION BEFORE TRANSPLANTATION LABORATORY TEST URINE ANALYSIS STOOL ANALYSIS GASTRO INTESTINAL STUDIES PULMONARY TEST RADIOGRAPHIC STUDIES OTHERS

42. CADAVER DONOR SELECTION Cadaver donor liver for transplantation are procured primarily from victims of head trauma. Organs from brain-dead donors up to age 60 are acceptable if the following criteria are met: hemodynamic stability, adequate oxygenation, absence of bacterial or fungal infection, absence of abdominal trauma, absence of hepatic dysfunction, and serologic exclusion of hepatitis B and C viruses and HIV.

43. Compatibility in ABO blood group and organ size between donor and recipient are important considerations in donor selection. Allocation based on the Child- Turcotte -Pugh (CTP) score, which uses five clinical variables (encephalopathy stage, ascites, bilirubin, albumin, and prothrombin time) and waiting time, has been replaced by allocation based upon urgency alone, calculated by the Model for End-Stage Liver Disease (MELD) score

44. DETERMINING DONOR SUITABILITY The two criteria necessary for matching a donor liver to a recipient are blood type and body size. In very urgent situations, the donor blood type (e.g., type A) may not be compatible with that of the recipient (e.g., type 0). Despite this incompatibility, such liver transplantations can be successful. There may be some early postoperative complications, such as mild hemolysis, higher incidence of acute cellular rejection, and increased postoperative hepatic vascular and biliary complications, but innovative use of immunosuppressive regimens and plasmapheresis have improved graft survival of patients with recipient-donor ABO incompatibility.

45. LIVING-DONOR TRANSPLANTATION Being in good health Having a blood type that matches or is compatible with the recipient's Having a charitable desire of donation without financial motivation Being between 18 and 60 years old Being of similar or bigger size than the recipient Have no chronic medical problems or history of major abdominal surgery The donor must undergo testing to ensure that the individual is physically fit. Driven by the shortage of cadaver organs, living-donor transplantation involving the more sizable right lobe is being considered with increasing frequency in adults. Living-donor transplantation can reduce waiting time and cold-ischemia time; is done under elective, rather than emergency, circumstances; and may be lifesaving in recipients who cannot afford to wait for a cadaver donor.

46. LIVING LIVER DONOR COMPLICATIONS Grade I complications are not life-threatening and do not result in permanent disability. Grade II complications require medications or transfusion. Grade III can be potentially life-threatening and require invasive therapy such as & return to the operating room. Grade IV leads to disability or death

47. ORTHOTOPIC TRANSPLANTATION A segment of the inferior vena cava attached to the liver is taken from the donor as well. The same parts are removed from the recipient and replaced by connecting the inferior vena cava, the hepatic artery, the portal vein and the bile ducts. In the adult procedure, once the right lobe is removed from the donor, the donor right hepatic vein is anastomosed to the recipient right hepatic vein remnant, followed by donor-to-recipient anastomoses of the portal vein and then the hepatic artery. Finally, the biliary anastomosis is performed, duct-to-duct if practical or via Roux-en-Y anastomosis.

48. HETEROTOPIC LIVER TRANSPLANTATION In which the donor liver is inserted without removal of the native liver, has met with very limited success and acceptance, except in a very small number of centers.

49. REDUCED-SIZE LIVER TRANSPLANTATION Transplants part of a donor liver into a patient. It is possible to divide the liver into eight pieces, each supplied by a different set of blood vessels. Two of these pieces have been enough to save a patient in liver failure

50. SURGICAL PROCEDURE Liver transplanta­tion surgery can be divided into three stages: Recipient hepatectomy, Vascular anastomoses with donor liver, and Biliary anastomosis

51. RECIPIENT HEPATECTOMY Stage 1 is the longest and most difficult part of the surgery, because it involves removal of the native liver. It is complicated even more by coagulopathies, adhesions, portal hypertension, and venous collaterals. A centrifugal pump cycles the blood out through iliac and portal vein cannulas and returns it to the central circu­lation through the axillary or subclavian vein

52. VASCULAR ANASTOMOSES WITH A DONOR LIVER Stage 2 comprises the four vascular anastomoses: suprahepatic inferior vena cava, infrahepatic vena cava, hepatic artery, and portal vein. If venovenous bypass is used, it is removed after the intrahepatic vena cava anastomosis and before the hepatic artery anastomosis

53. BILIARY ANASTOMOSIS Stage 3 can be achieved by choledo­chojejunostomy (bile duct to jejunum) or by choledochocholedo­chostomy (bile duct to bile duct). Choledochojejunostomy is performed in patients who have diseased bile ducts, such as those with biliary atresia or sclerosing cholangitis . It is also known as a Roux-en- Y procedure

54. NON HEPATIC COMPLICATIONS OF LIVER TRANSPLANTATION Fluid overload Arrhythmias Congestive heart failure Cardiomyopathy CARDIOVASCULAR INSTABILITY

55. PULMONARY COMPROMISE Pneumonia Pulmonary capillary vascular permeability Fluid overload

56. RENAL DYSFUNCTION Prerenal azotemia Hypoperfusion injury (acute tubular necrosis) Drug nephrotoxicity Renal blood flow secondary to 􀁂 intraabdominal pressure

57. HEMATOLOGIC Anemia 2° to gastrointestinal and/or intraabdominal bleeding Hemolytic anemia, aplastic anemia Thrombocytopenia

58. INFECTION Bacterial: early, common postoperative infections Fungal/parasitic: late, opportunistic infections Viral: late, opportunistic infections, recurrent hepatitis

59. NEUROPSYCHIATRIC Seizures Metabolic encephalopathy Depression Difficult psychosocial adjustment

60. MALIGNANCY B-cell lymphoma ( posttransplantation lymphoproliferative disorders) De novo neoplasms (particularly squamous cell skin carcinoma

61. HEPATIC COMPLICATIONS OF LIVER TRANSPLANTATION Hepatic Dysfunction Common after Major Surgery Pigment load Hemolysis Blood collections (hematomas, abdominal collections) Intrahepatic Early Early Hepatotoxic drugs and anesthesia Hypoperfusion (hypotension, shock, sepsis) Benign postoperative cholestasis

62. Late Transfusion-associated hepatitis Exacerbation of primary hepatic disease Post hepatic Biliary obstruction Renal clearance of conjugated bilirubin (renal dysfunction)

63. PRIMARY NONFUNCTION Is characterized by post transplantation encephalopathy, coagulopathy, minimal bile output, and progressive renal and multisystem failure, with increasing serum lactate and rapidly rising liver enzyme levels and histologic evidence of hepatocyte necrosis in the absence of any vascular compromise.

64. With improved donor selection and management, operative techniques, reducing cold ischemia times, and newer preservative solutions, the risk of primary nonfunction has decreased. Patients with initial dysfunction, also known as primary graft dysfunction, might recover with support, but those who progress to show evidence of extrahepatic complications, such as hemodynamic instability, renal failure, or other organ system dysfunction, can require urgent retransplantation .

65. HEMORRHAGE AND HYPOVOLEMIC SHOCK Continuous monitoring of coagulation parameters during surgery. Use of antifibrinolytic agents Decompression of spenchnic circulation by veno -venous bypass or temporary porto-caval shunt. Maintenance of recipient's core temperature Assess the patient’s vital signs and other indicators of fluid volume hourly and note trends indicating hypovolemia ; hypotension; weak, rapid, irregular pulse; oliguria; decreased level of consciousness; and signs of peripheral vasoconstriction. Monitor the patient’s hematocrit and hemoglobin levels daily. Maintain patency of all I.V. lines, and reserve 2 units of blood in case the patient needs a transfusion. Accurate measurements of hemodynamic function, such as arterial blood pressure, peripheral blood pressure, central venous pressure, pulmonary artery pressure, PAOP or "wedge" pressure, urinary output, patency of drains, and bile totals are assessed frequently to evaluate true volume status.

66. Hepatic Artery Stenosis and Thrombosis Angiography is the gold standard for diagnosis. In cases of early documentation of the problem (i.e., within 24-48 hours), urgent revascularization can result in arterial patency. However, a significant number of patients treated in this manner still require retransplantation because of biliary complications, persistent biliary sepsis, and intra-abdominal infection.

67. Portal Vein Stenosis and Thrombosis Treatment is by surgical intervention in early post-transplantation and by percutaneous transhepatic dilation or stenting of the stricture later after liver transplantation. If left untreated, it can progress to complete thrombosis of the vein or severe graft dysfunction and hemodynamic instability secondary to massive ascites

68. Hepatic Outflow Obstruction Be alert for signs and symptoms of acute vascular obstruction in the right upper quadrant Cramping pain or tenderness, nausea, and vomiting. Notify the practitioner immediately if any occur. As ordered, prepare for emergency thrombectomy . Maintain I.V. Infusions, check and document The patient’s vital signs, and maintain airway patency .

69. HEPATIC FAILURE Monitor nasogastric tube drainage for upper GI bleeding. Frequently assess the patient’s neurovascular status. Note development of peripheral edema and ascites. Monitor the patient’s renal function by checking urine output, blood urea nitrogen levels, and serum creatinine and potassium levels. Monitor serum amylase levels daily .

70. WOUND INFECTION OR ABSCESS Assess the incision site daily, and report any inflammation, tenderness, drainage, or other signs and symptoms of infection. Change the dressing daily or as needed. Note and report any signs or symptoms of peritonitis or abscess, including fever, chills, leukocytosis(or leukopenia with bands), and abdominal pain, tenderness, and rigidity. Take the patient’s temperature every 4 hours. Collect abdominal drainage for culture and sensitivity studies. Document the color, amount, odor,and consistency of drainage. Assess the patient for signs of infection in other areas, such as the urinary tract, respiratory system, and skin. Document and report any signs of infection.

71. PULMONARY INSUFFICIENCY OR FAILURE Pleural effusion • Pulmonary edema • Pneumonia • Pneumothorax or hemothorax • Atelectasis • Paralysis of right diaphragm

72. Maintain ventilation at prescribed levels. Monitor the patient’s arterial blood gas levels, and change ventilator settings, as ordered. Auscultate for abnormal breath sounds every 2 to 4 hours. Suction the patient as needed. The patient may require changes in ventilatory settings, suctioning to remove secretions, or administration of pharmacologic agents to correct acid-base imbalances. While the patient is on ventilatory support, pneumonia can be avoided by maintaining the head of bed elevated at 30 degrees, turning the patient frequently, providing good oral care, and brushing the patient's teeth. After extubation, patients must be encouraged to perform incentive spirometry exercises and to turn, cough, and deep-breathe frequently to help prevent atelectasis and pneumonia. Respiratory treatments with bronchodilators, prophylactic antimicrobials, and chest physiotherapy also may be used

73. ARTERIAL HYPERTENSION The general principles of AHT treatment are similar to those used in the general population, including low sodium diet and weight loss. Specific measures include the reduction in CNI doses and early steroid withdrawal within the first 3-6 months post-transplantation. Care must be taken in relation to possible drug interactions between immunosuppressive agents and anti-hypertensive drugs. The drugs of first choice are those that induce vasodilatation as calcium antagonists. Inhibitors of the angiotensin converter enzyme and the loop diuretics are also used.

74. NEUROLOGIC COMPLICATIONS Most neurologic complications are related to the degree of pre transplantation encephalopathy caused by hepatic encephalopathy or electrolyte disturbances, in particular hyponatremia, as well as the idiosyncratic central nervous system effects of metabolic abnormalities caused by immunosuppressive agents, most notably the CNIs( calcineurin inhibitors). These drugs can produce a wide clinical spectrum of signs and symptoms, from mild tremor and acute confusion to status epilepticus . CNI-related neurotoxicity occurs in approximately 25% of liver transplant recipients. These could be dose-related and include impaired mentation or confusion, psychosis, dysphasia, mutism , cortical blindness, extrapyramidal syndromes, quadriplegia, encephalopathy, seizures, and coma.

75. BONE COMPLICATIONS Osteopenia is a frequent finding in patients with advanced, chronic liver disease, particularly in those with cholestatic disease. Globally, 20-40% of liver transplant recipients present atraumatic bone fractures; this prevalence rises to 65% in patients transplanted due to cholestatic disease and in retransplant patients

76. The most frequent locations are the vertebrae and the ribs. Multiple factors have been implicated, such as hormonal changes associated with the pathogenesis of the liver disease, prolonged immobilization, and immunosuppressive treatment, particularly steroids. Indeed, immunosuppression by itself affects bone density through its influence on the cytokines that intervene in bone metabolism. In addition, some of the drugs directly suppress osteoblast function, inhibit intestinal absorption of calcium, and stimulate its secretion through the kidneys. Calcium, vitamin D, calcitonine and biphosphonates have been used to avoid post-transplantation osteoporosis, but no consensus has been reached yet as to the best approach

77. DYSLIPIDEMIA With the exception of patients with cholestatic disease, who frequently present hypercholesterolemia tied to bile secretion alteration, most cirrhotic patients have synthesis-reduction related hypocholesterolemia . The etiology of post-transplantation hyperlipidemia involves many factors, such as the diet, genetic predisposition, de novo DM, post transplantation kidney dysfunction, and immunosuppressive treatment. In particular, steroids play a significant role in hyperlipidemia onset mediated by increased hepatic secretion of VLDL and of its conversion to LDL.

78. The use of CNI is also related with the development of hypercholesterolemia and hyper triglyceridemia . Sirolimus is a relatively new immunosuppressive drug that has as a major side effect the development of hyperlipemia . Treatment is focused on patients with persistent dyslipidemia, particularly if they have concurrent cardiovascular risk factors. Appropriate diet, weight reduction, strict control of DM and arterial hypertension along with smoking or drinking cessation are initial measures.

79. ELECTROLYTE IMBALANCES AND OTHER METABOLIC ABNORMALITIES Almost any metabolic imbalance can occur after OLT. This is not surprising, considering the magnitude of the physiologic stress of surgery, fluid shifts, multitude of pharmacologic agents administered, and multisystem complications. The most common imbalances, however, are hypokalemia , hyperkalemia , hyperglycemia, and hypomagnesemia . Hypokalemia can occur as a side effect of potassium-wasting diuretic therapy, intracellular fluid shifts secondary to metabolic alkalosis, hypothermia, insulin therapy, and corticosteroid therapy. Rarely, if the serum potassium level is monitored regularly and supplementation given when indicated, hypokalemia from any cause is significant enough to produce physical signs.

80. Hyperkalemia is more often seen after transplantation, beginning 1 to 2 weeks after OLT. It is caused by renal tubular acidosis secondary to CNI use. It is easily manageable with a dietary regimen. Rarely, patients need to be placed on mineralocorticoids or potassium- chelating agents. The main cause of hyperglycemia in liver transplant patients is preexisting diabetes mellitus. Other important causes are corticosteroids and CNIs. Drug-induced hyperglycemia is usually transient and improves after discontinuation of steroids and reduction in dosage of CNIs. Less than 5% of these patients require long-term treatment

81. Hypomagnesemia is another phenomenon after OLT. Many patients are hypomagnesemic from malnutrition before transplantation, and the condition is exacerbated during the postoperative period. The exact nature of this problem is not completely understood. However, contributing postoperative factors are believed to include diuretic therapy and the renal effects of CNIs. Routine monitoring of the serum magnesium level and supplementation with IV or oral magnesium may be indicated.

82. TRANSPLANT REJECTION Clinical signs suggesting rejection are fever, right upper quadrant pain, and reduced bile pigment and volume Leukocytosis may occur, but the most reliable indicators are increases in serum bilirubin and aminotransferase levels. Radiographic visualization of the biliary tree and/or percutaneous liver biopsy

83. CAUSES OF GRAFT REJECTION MEDICAL COMPLICATION Early (0-90 days after transplantation) Hyperacute rejection Delayed graft function Acute rejection Acute calcineurin inhibitor Nephrotoxicity Dehydration Other drug toxicities Infection Late (>90 days after transplantation) Acute rejection Calcineurin inhibitor toxicity Chronic rejection Dehydration Other drug toxicities Infection BK virus nephropathy

84. CAUSES OF GRAFT REJECTION MECHANICAL COMPLICATION Early (0-90 days after transplantation) Lymphocele Ureteric obstruction Urine leak Vascular thrombosis Late (>90 days after transplantation) Renal artery stenosis Ureteric obstruction Urine leak Vascular thrombosis

85. TYPES OF ALLOGRAFT REJECTION a) Hyperacute rejection: Occur within minutes to days after transplantation Primarily mediated by ABO or preformed anti-HLA antibodies Characterised by intravascular thrombosis and interstitial haemorrhage Liver transplants are relatively resistant

86. b)Acute rejection Usually occurs during first six months T cell dependent May be cell-mediated, antibody-mediated or both Usually reversible with additional immunosuppressive Therapy.

87. c) Chronic rejection Most common cause of long-term allograft loss Occurs over months to years Secondary to T and B cell processes Characterised by myointimal proliferation in graft arteries leading to ischaemia and fibrosis Vanishing bile duct syndrome

88. NURSING MANAGEMENT Before liver transplantation Instruct the patient and his family about the transplant, necessary diagnostic tests, immunosuppressant medications, and rejection risk. Review information about the equipment and procedures, such as cardiac monitoring, ET tube, NG tube, abdominal drainage tubes, indwelling urinary catheter, and arterial lines. Reassure the patient that discomfort should be minimal and that the equipment will be removed as soon as possible. Administer ordered medications such as immunosuppressant agents. Review incentive spirometry and range of motion (ROM) exercises with the patient. Make sure that an informed consent form has been signed. Instruct family members in measures to control infection and minimize rejection after transplantation and advise them to have all their immunizations up to date. Provide emotional support to the patient and his family.

89. After liver transplantation Assess the patient’s cardiopulmonary and hemodynamic status, including vital signs, oxygen saturation, and cardiac rhythm, at least every 15 minutes in the immediate postoperative period and then hourly or as indicated by his condition. Mean arterial and pulmonary artery pressures are monitored continuously. Cardiac output, central venous pressure, pulmonary capillary wedge pressure, arterial and mixed venous blood gases, oxygen saturation, oxygen demand and delivery, urine output, heart rate, and blood pressure are used to evaluate the patient’s hemodynamic status and intravascular fluid volume. Liver function tests, electrolyte levels, the coagulation profile, chest x-ray, electrocardiogram, and fluid output, including urine, bile, and drainage from Jackson-Pratt tubes, are monitored closely.

90. Monitor the patient’s temperature frequently, at least every hour initially and then every 2 to 4 hours. He may be hypothermic in the initial postoperative phase, and it’s important to reestablish normal body temperature. Later in the postoperative phase, monitor the patient for fever and signs of infection. Monitor laboratory tests, especially liver enzymes, bilirubin, electrolytes, coagulation studies, and CBC. Assess insertion sites for indications of bleeding. Assess the incision site closely for oozing or active bleeding. If the patient has an NG tube, assess drainage color at least every 2 hours Institute strict infection control precautions. Administer prophylactic antibiotics and postoperative drugs, such as corticosteroids and immunosuppressants , as ordered. Assist with extubation as soon as possible (usually within 4 to 6 hours), and administer supplemental oxygen as needed. Encourage coughing, deep breathing, and incentive spirometry .

91. Monitor the patient’s intake and output at least hourly, and notify the practitioner if output is less than 30 ml/hour. Maintain fluids at 2,000 to 3,000 mL /day, or as ordered, to prevent fluid overload. Maintain the patient on nothing by mouth status with NG decompression, and attach the NG tube to low intermittent suction until bowel sounds return. Change the patient’s position at least every 2 hours, getting him out of bed and to the chair within 24 hours if his condition is stable. liver is responsible for the storage of glycogen and the synthesis of protein and clotting factors, these substances need to be monitored and replaced in the immediate postoperative period.

92. Continually assess the patient for signs and symptoms of acute rejection, such as malaise, fever, graft enlargement, and diminished graft function (typically 7 to 14 days after the transplant. To ease emotional stress, plan care to allow rest and provide as much privacy as possible. Allow family members to visit and comfort the patient as much as possible. Teach the patient and his family about danger signs and symptoms and the need to report these immediately.