Liver transplantation pre-surgical management: Difference between revisions
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== Overview == | == Overview == | ||
Pre-surgical management for liver transplantation includes laboratory testings such as [[ABO blood group system|ABO-Rh blood typing]], Liver biochemical and function tests ([[Alanine transaminase|alanine aminotransferase]], [[aspartate aminotransferase]], [[alkaline phosphatase]], [[bilirubin]], [[international normalized ratio]], [[Complete blood count]], [[Creatinine clearance]],[[Sodium|serum sodium]], [[Alpha fetoprotein|serum alpha-fetoprotein]], and [[Calcium]] and [[vitamin D]] levels. Cardiological testings include [[electrocardiogram]], [[cardiac stress testing]], [[Echocardiography]] , [[Pulse oximetry]] and [[ABG]]. | |||
== Liver transplantation pre-surgical management == | == Liver transplantation pre-surgical management == | ||
=== '''Laboratory testing''' === | === '''Laboratory testing''' === | ||
* ABO-Rh blood typing | * [[ABO blood group system|ABO-Rh blood typing]] | ||
* Liver biochemical and function tests (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, bilirubin, international normalized ratio | * Liver biochemical and function tests ([[Alanine transaminase|alanine aminotransferase]], [[aspartate aminotransferase]], [[alkaline phosphatase]], [[bilirubin]], [[international normalized ratio]] | ||
* Complete blood count | * [[Complete blood count]] | ||
* Creatinine clearance | * [[Creatinine clearance]] | ||
* Serum sodium | * [[Sodium|Serum sodium]] | ||
* Serum alpha-fetoprotein | * [[Alpha fetoprotein|Serum alpha-fetoprotein]] | ||
* Calcium and vitamin D levels | * [[Calcium]] and [[vitamin D]] levels | ||
* Serologies for cytomegalovirus, Epstein-Barr virus, varicella, human immunodeficiency virus, hepatitis A, hepatitis B, hepatitis C, rapid plasma reagin | * Serologies for [[cytomegalovirus]], [[Epstein Barr virus|Epstein-Barr virus]], [[varicella]], [[Human Immunodeficiency Virus (HIV)|human immunodeficiency virus]], [[hepatitis A]], [[hepatitis B]], [[hepatitis C]], [[Rapid plasma reagent|rapid plasma reagin]] | ||
* Urinalysis | * [[Urinalysis]] | ||
* Urine drug screen | * Urine drug screen | ||
=== '''Cardiopulmonary evaluation''' === | === '''Cardiopulmonary evaluation''' === | ||
* | * [[Electrocardiogram]]<ref name="pmid14762853">{{cite journal| author=Krowka MJ, Mandell MS, Ramsay MA, Kawut SM, Fallon MB, Manzarbeitia C et al.| title=Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database. | journal=Liver Transpl | year= 2004 | volume= 10 | issue= 2 | pages= 174-82 | pmid=14762853 | doi=10.1002/lt.20016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14762853 }}</ref> | ||
* | * '''Cardiac stress testing''' <ref name="pmid9346688">{{cite journal| author=Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y| title=Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation. | journal=Liver Transpl Surg | year= 1996 | volume= 2 | issue= 6 | pages= 426-30 | pmid=9346688 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9346688 }}</ref> | ||
* | * [[Exercise stress testing|Noninvasive stress testing]] is suggested in liver transplantation candidates with no active cardiac conditions if there are multiple risk factors for [[Coronary heart disease|coronary artery disease]] present.<ref name="pmid22763103">{{cite journal| author=Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL et al.| title=Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. | journal=J Am Coll Cardiol | year= 2012 | volume= 60 | issue= 5 | pages= 434-80 | pmid=22763103 | doi=10.1016/j.jacc.2012.05.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22763103 }}</ref> | ||
* If initial noninvasive testing is abnormal, [[cardiac catheterization]] is indicated. | |||
* If clinically significant [[coronary artery stenosis]] are present, patients should be evaluated for revascularization prior to transplantation. | |||
* If initial noninvasive testing is abnormal, cardiac catheterization is indicated. | * '''[[Echocardiography]]''' | ||
* If clinically significant coronary artery | * We obtain [[Transthoracic echocardiography|transthoracic contrast-enhanced echocardiography]] to look for evidence of [[valvular heart disease]] or [[portopulmonary hypertension]]. | ||
* '''Echocardiography''' | * '''[[Pulse oximetry]] and [[ABG]]''' | ||
* We obtain transthoracic contrast-enhanced echocardiography to look for evidence of valvular heart disease or portopulmonary hypertension. | * Patients should undergo pulse oximetry to screen for [[hepatopulmonary syndrome]]. | ||
* '''Pulse oximetry and ABG''' | * Patients should have a blood gas obtained while breathing room air and undergo [[Transthoracic echocardiography|transthoracic contrast-enhanced echocardiography]]. | ||
* Patients should undergo pulse oximetry to screen for hepatopulmonary syndrome. | * Testing to rule out other causes includes a [[Chest X-ray|chest radiograph]], [[pulmonary function tests]], and chest [[computed tomography]]. | ||
* | |||
* Testing to rule out other causes includes a chest radiograph, pulmonary function tests, and chest computed tomography. | |||
=== '''Cancer screening''' === | === '''Cancer screening''' === | ||
* Abdominal CT scanning or magnetic resonance imaging | * Abdominal [[Computed tomography|CT]] scanning or [[magnetic resonance imaging]]. | ||
* Screening for cervical cancer, breast cancer, and prostate cancer should be obtained when indicated | * Screening for [[cervical cancer]], [[breast cancer]], and [[prostate cancer]] should be obtained when indicated. | ||
* | * Skin testing or [[interferon-gamma release assay]] for [[tuberculosis]] | ||
* | * Treatment may be initiated prior to transplantation or deferred until after transplantation, depending on the clinical assessment of the patient. | ||
* Patients from endemic areas should be screened for [[Coccidioidomycosis|coccidiomycosis]] or [[Strongyloidiasis|strongyloides]]. | |||
* Patients from endemic areas should be screened for coccidiomycosis or strongyloides. | * Several vaccinations are recommended prior to liver transplantation including [[hepatitis A]], [[hepatitis B]], [[pneumococcus]], [[influenza]], [[diphtheria]], [[pertussis]], and [[tetanus]]. | ||
* Several vaccinations are recommended prior to liver transplantation including hepatitis A, hepatitis B, pneumococcus, influenza, diphtheria, pertussis, and tetanus. | |||
==== '''Hepatic imaging and HCC staging''' ==== | ==== '''Hepatic imaging and HCC staging''' ==== | ||
* Hepatic imaging should be obtained to assess the vasculature | * Hepatic imaging should be obtained to assess the vasculature and for tumor staging. | ||
* If cross-sectional imaging cannot be obtained, the hepatic vasculature can be assessed with transabdominal ultrasonography with Doppler imaging or contrast-enhanced ultrasonography | * This is typically done with multiphase [[Contrast enhanced CT|contrast-enhanced CT]] scanning or [[MRI|contrast-enhanced MRI]]. | ||
* If cross-sectional imaging cannot be obtained, the hepatic vasculature can be assessed with transabdominal [[ultrasonography]] with Doppler imaging or contrast-enhanced ultrasonography. | |||
==== '''Upper endoscopy''' ==== | ==== '''Upper endoscopy''' ==== | ||
* Upper endoscopy should be performed in patients with cirrhosis or portal hypertension to evaluate for varices. | * [[Upper endoscopy]] should be performed in patients with [[cirrhosis]] or [[portal hypertension]] to evaluate for [[varices]]. | ||
==== '''Bone density testing''' ==== | ==== '''Bone density testing''' ==== | ||
* Patients should be screened for osteoporosis with bone density testing. If osteoporosis is present, treatment should be initiated prior to transplantation. | * Patients should be screened for [[osteoporosis]] with bone density testing. | ||
* Oral bisphosphonates should be used with caution in patients with esophageal varices | * If [[osteoporosis]] is present, treatment should be initiated prior to transplantation. | ||
* Oral [[bisphosphonates]] should be used with caution in patients with [[esophageal varices]]. | |||
==References== | |||
{{Reflist|2}} | |||
Latest revision as of 23:29, 19 December 2017
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
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Liver trasnsplantation Microchapters |
Overview
Pre-surgical management for liver transplantation includes laboratory testings such as ABO-Rh blood typing, Liver biochemical and function tests (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, bilirubin, international normalized ratio, Complete blood count, Creatinine clearance,serum sodium, serum alpha-fetoprotein, and Calcium and vitamin D levels. Cardiological testings include electrocardiogram, cardiac stress testing, Echocardiography , Pulse oximetry and ABG.
Liver transplantation pre-surgical management
Laboratory testing
- ABO-Rh blood typing
- Liver biochemical and function tests (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, bilirubin, international normalized ratio
- Complete blood count
- Creatinine clearance
- Serum sodium
- Serum alpha-fetoprotein
- Calcium and vitamin D levels
- Serologies for cytomegalovirus, Epstein-Barr virus, varicella, human immunodeficiency virus, hepatitis A, hepatitis B, hepatitis C, rapid plasma reagin
- Urinalysis
- Urine drug screen
Cardiopulmonary evaluation
- Electrocardiogram[1]
- Cardiac stress testing [2]
- Noninvasive stress testing is suggested in liver transplantation candidates with no active cardiac conditions if there are multiple risk factors for coronary artery disease present.[3]
- If initial noninvasive testing is abnormal, cardiac catheterization is indicated.
- If clinically significant coronary artery stenosis are present, patients should be evaluated for revascularization prior to transplantation.
- Echocardiography
- We obtain transthoracic contrast-enhanced echocardiography to look for evidence of valvular heart disease or portopulmonary hypertension.
- Pulse oximetry and ABG
- Patients should undergo pulse oximetry to screen for hepatopulmonary syndrome.
- Patients should have a blood gas obtained while breathing room air and undergo transthoracic contrast-enhanced echocardiography.
- Testing to rule out other causes includes a chest radiograph, pulmonary function tests, and chest computed tomography.
Cancer screening
- Abdominal CT scanning or magnetic resonance imaging.
- Screening for cervical cancer, breast cancer, and prostate cancer should be obtained when indicated.
- Skin testing or interferon-gamma release assay for tuberculosis
- Treatment may be initiated prior to transplantation or deferred until after transplantation, depending on the clinical assessment of the patient.
- Patients from endemic areas should be screened for coccidiomycosis or strongyloides.
- Several vaccinations are recommended prior to liver transplantation including hepatitis A, hepatitis B, pneumococcus, influenza, diphtheria, pertussis, and tetanus.
Hepatic imaging and HCC staging
- Hepatic imaging should be obtained to assess the vasculature and for tumor staging.
- This is typically done with multiphase contrast-enhanced CT scanning or contrast-enhanced MRI.
- If cross-sectional imaging cannot be obtained, the hepatic vasculature can be assessed with transabdominal ultrasonography with Doppler imaging or contrast-enhanced ultrasonography.
Upper endoscopy
- Upper endoscopy should be performed in patients with cirrhosis or portal hypertension to evaluate for varices.
Bone density testing
- Patients should be screened for osteoporosis with bone density testing.
- If osteoporosis is present, treatment should be initiated prior to transplantation.
- Oral bisphosphonates should be used with caution in patients with esophageal varices.
References
- ↑ Krowka MJ, Mandell MS, Ramsay MA, Kawut SM, Fallon MB, Manzarbeitia C; et al. (2004). "Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database". Liver Transpl. 10 (2): 174–82. doi:10.1002/lt.20016. PMID 14762853.
- ↑ Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y (1996). "Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation". Liver Transpl Surg. 2 (6): 426–30. PMID 9346688.
- ↑ Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL; et al. (2012). "Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation". J Am Coll Cardiol. 60 (5): 434–80. doi:10.1016/j.jacc.2012.05.008. PMID 22763103.