Liver transplant patients & rehabilitation concerns Jen Hokanson PTA Trish Beck PT.

Liver transplant patients & Liver transplant patients & rehabilitation concernsrehabilitation concerns

Jen Hokanson PTA Jen Hokanson PTA

Trish Beck PTTrish Beck PT

AnatomyAnatomy Largest organ in the body (weighs 3-4 Largest organ in the body (weighs 3-4

pounds-size of a football)pounds-size of a football) Located in right upper quadrantLocated in right upper quadrant Connected to diaphragm by ligamentsConnected to diaphragm by ligaments Within 1/2 inch of pericardiumWithin 1/2 inch of pericardium Connected to small intestine via bile ductConnected to small intestine via bile duct Filters about 1450ml of blood per minuteFilters about 1450ml of blood per minute Contains 10% of body’s blood volume Contains 10% of body’s blood volume Capable of 80-90% regenerationCapable of 80-90% regeneration

Functions of the LiverFunctions of the Liver

Blood flow through the liver (29% of Blood flow through the liver (29% of total cardiac output)total cardiac output)

Reservoir function (able to store up Reservoir function (able to store up to 1 extra liter of blood)to 1 extra liter of blood)

Lymph function(1/2 of lymph is Lymph function(1/2 of lymph is made by the liver)made by the liver)

Hepatic macrophage system Hepatic macrophage system (resists infections)(resists infections)

Metabolic functions of Metabolic functions of the liverthe liver

Carbohydrate metabolismCarbohydrate metabolism Fat metabolismFat metabolism Manufactures proteinsManufactures proteins Storehouse for vitamins, minerals & Storehouse for vitamins, minerals &

sugarssugars Blood coagulantsBlood coagulants IronIron Metabolizes drugs, hormones, toxinsMetabolizes drugs, hormones, toxins

Excretory and Secretory FunctionsExcretory and Secretory Functions

Bile:Bile:– aids production of aids production of

an alkaline an alkaline reactionreaction

– absorption of fats absorption of fats – breakdown of breakdown of

cholesterolcholesterol

Substances Substances excreted into bileexcreted into bile

– bilirubin: bilirubin: endproduct of endproduct of hemoglobin hemoglobin degradationdegradation

– 95% of the bilirubin 95% of the bilirubin ends up in the gut ends up in the gut and 5% goes into and 5% goes into the urinethe urine

Symptoms of liver Symptoms of liver dysfunction and their dysfunction and their

causescauses

Confusion caused by increased Confusion caused by increased ammoniaammonia

Bleeding due to prolonged clotting timeBleeding due to prolonged clotting time Itching/jaundice due to increased Itching/jaundice due to increased

bilirubinbilirubin Fluid retention caused by low albuminFluid retention caused by low albumin Kidney damage shown by elevated Kidney damage shown by elevated

creatininecreatinine

Liver PathologiesLiver Pathologies

TYPES OF HEPATITISTYPES OF HEPATITIS Hepatitis A-infectious hepatitisHepatitis A-infectious hepatitis Hepatitis B-most common formHepatitis B-most common form Hepatitis C-most transplants Hepatitis C-most transplants Hepatitis D- IV drug users Hepatitis D- IV drug users Hepatitis EHepatitis E

CirrhosisCirrhosis

Alcoholic cirrhosisAlcoholic cirrhosis Chronic Hepatitis B, Chronic Hepatitis B,

C, or DC, or D HemochromatosisHemochromatosis Wilson’s diseaseWilson’s disease Alpha-1, antitrypsin Alpha-1, antitrypsin

deficiencydeficiency Glycogen storage Glycogen storage

diseasedisease

Bile duct obstruction Bile duct obstruction (PSC, PBC)(PSC, PBC)

Prolonged exposure Prolonged exposure to environmental to environmental toxinstoxins

Cardiac cirrhosisCardiac cirrhosis Severe reaction to Severe reaction to

drugsdrugs Parasitic infectionsParasitic infections

Symptoms of CirrhosisSymptoms of Cirrhosis

Loss of appetiteLoss of appetite Nausea & Nausea &

vomitingvomiting Loss of weightLoss of weight Increased liver Increased liver

sizesize ItchingItching AscitesAscites

JaundiceJaundice Esophageal Esophageal

varicesvarices EncephalopathyEncephalopathy Sensitivity to Sensitivity to

toxins (drugs & toxins (drugs & alcohol)alcohol)

Liver Pathologies cont.Liver Pathologies cont.

JaundiceJaundice– ObstructiveObstructive– HemolyticHemolytic

AscitesAscites PruritisPruritis Hepatic Hepatic

EncephalopathyEncephalopathy Portal Portal

HypertensionHypertension

XanthomasXanthomas Poor ClottingPoor Clotting Vit K Vit K

malabsorptionmalabsorption FatigueFatigue Muscle LossMuscle Loss TumorsTumors TraumaTrauma

Bone Mineral DensityBone Mineral Density taken by photon absorptomety taken by photon absorptomety Measured in gm/cm2 Measured in gm/cm2 usually lumbar or femurusually lumbar or femur Normal loss of BMD is 1-2%/yr after Normal loss of BMD is 1-2%/yr after

age 25 (accelerate in women after 50)age 25 (accelerate in women after 50) In chronic liver disease: In chronic liver disease:

– decrease in osteoblastic functiondecrease in osteoblastic function– increase osteoclastic functionincrease osteoclastic function– loss continues up to 3 mo after loss continues up to 3 mo after

transplanttransplant

Liver diseasesLiver diseases Primary Biliary Primary Biliary

CirrhosisCirrhosis(PBC)-(PBC)-destroys the ducts that destroys the ducts that drain bile in the liverdrain bile in the liver

destruction of the ducts destruction of the ducts makes it difficult for the makes it difficult for the liver to perform its liver to perform its normal tasks normal tasks

affects the middle-agedaffects the middle-aged PBC affects women 10 PBC affects women 10

times more then mentimes more then men

Conditions associated Conditions associated with PBC with PBC

– Osteoporosis Osteoporosis – Inflammatory Inflammatory

ArthritisArthritis– Thyroid disordersThyroid disorders– Sicca syndrome(tear Sicca syndrome(tear

glands and salivary glands and salivary glands fail to glands fail to produce enough produce enough moisture)moisture)

Liver DiseasesLiver Diseasescont.cont.

Primary Sclerosing Primary Sclerosing CholangitisCholangitis(PSC)-(PSC)-the ducts inside and the ducts inside and outside the liver are outside the liver are narrowed narrowed

most often affects most often affects people in their 30’s, people in their 30’s, 40’s and 50’s40’s and 50’s

more common in more common in men men

Symptoms:Symptoms:– fatiguefatigue– itching (pruritis).itching (pruritis).– jaundice(due to jaundice(due to

buildup of bilirubin)buildup of bilirubin)– diarrheadiarrhea– fever & chills.fever & chills.

Associated Associated DiseasesDiseases– OsteoporosisOsteoporosis– Inflammatory Bowel Inflammatory Bowel

Disease.Disease.

Liver DiseasesLiver Diseasescont.cont.

FHF-Fulminant FHF-Fulminant Hepatic failureHepatic failure

Wilson’s DiseaseWilson’s Disease Budd ChiariBudd Chiari ALD-alcoholic ALD-alcoholic

liver diseaseliver disease

HCC-HCC-hepatocellular hepatocellular carcinomacarcinoma

polycystic disease polycystic disease Familial Familial amyloidosisamyloidosis

primary oxalosisprimary oxalosis HemochromatosisHemochromatosis

Preventing Liver Preventing Liver DiseaseDisease

Limit alcohol intakeLimit alcohol intake Avoid exposure to man-made chemicalsAvoid exposure to man-made chemicals Maintain adequate personal hygieneMaintain adequate personal hygiene Avoid excessive intake of cholesterol and Avoid excessive intake of cholesterol and

saturated fats.saturated fats. Limit use of drugs(acetaminophen, antibiotics, Limit use of drugs(acetaminophen, antibiotics,

sulfa drugs) that can be harmful to the liver.sulfa drugs) that can be harmful to the liver. Be careful with questionable bacteria (“herbal” Be careful with questionable bacteria (“herbal”

tea).tea).

Psychosocial IssuesPsychosocial Issues

Patient experiences Patient experiences a roller coaster of a roller coaster of emotions in the emotions in the transplant sequence transplant sequence

Patients need to be Patients need to be taught consistent taught consistent and appropriate and appropriate informationinformation

Psychosocial Eval Psychosocial Eval (performed by (performed by S.W.)S.W.)– referralreferral– relationshiprelationship– reactionsreactions– rolesroles– resourcesresources– recommendationsrecommendations

Pre transplant teachingPre transplant teaching

Medical historyMedical history Lab findings-Lab findings-

especially (BMD especially (BMD and hemoglobin)and hemoglobin)

x-rays results-x-rays results-looking for looking for osteoporosis, osteoporosis, compression compression fractures, etc.fractures, etc.

ExaminationExamination postureposture strengthstrength current activity current activity

levellevel ROMROM mental statusmental status

PT program for pre PT program for pre liver transplant patientliver transplant patient

Spinal protection education and Spinal protection education and performanceperformance

StrengtheningStrengthening Cardiovascular activity as able Cardiovascular activity as able

(walking, bike, stair climbing)(walking, bike, stair climbing) AVOID: lifting, twisting, high impact AVOID: lifting, twisting, high impact

sports/activities, joint jarring sports/activities, joint jarring activitiesactivities

Precautions for post-Precautions for post-transplant patientstransplant patients

Do not treat the patient if you have Do not treat the patient if you have a cold, cough, etc.a cold, cough, etc.

Wash hands prior to entering the Wash hands prior to entering the room and put gloves on.room and put gloves on.

Post-Op Liver Post-Op Liver Transplant EvaluationTransplant Evaluation

HistoryHistory Laboratory resultsLaboratory results MedicationsMedications ExaminationExamination

– edemaedema– ascitesascites– mental statusmental status– jaundicejaundice

PT program PT program includes:includes:– AROM & CKC AROM & CKC

exercisesexercises– stretchesstretches– stair climbingstair climbing– avoid lifting over 10 avoid lifting over 10

pounds, twisting, pounds, twisting, kyphosiskyphosis

– body mechanics body mechanics instruction instruction

Post transplant back Post transplant back painpain

Caused by:Caused by:– prolonged position prolonged position

during surgeryduring surgery– loss of abdominal loss of abdominal

strengthstrength– increased weight due increased weight due

to fluid retentionto fluid retention– continued loss of continued loss of

bone mineral density bone mineral density for 3 months post-opfor 3 months post-op

Treatment:Treatment:– superficial heatsuperficial heat– mild extension mild extension

exercise (upper exercise (upper back extension in back extension in sitting position)sitting position)

– proper body proper body mechanics mechanics

– log rolling and log rolling and proper positioning proper positioning

Post Transplant Post Transplant OsteoporosisOsteoporosis

FACTORSFACTORS Original diseaseOriginal disease decreased physical decreased physical

activityactivity diuretic usediuretic use decreased estrogen decreased estrogen

in womenin women hyperparathyroidismhyperparathyroidism smokingsmoking

TREATMENTTREATMENT 1200-1500mg 1200-1500mg

calcium per daycalcium per day adequate vitamin Dadequate vitamin D minimal steroid useminimal steroid use hormone replacementhormone replacement exercise & avoid exercise & avoid

smokingsmoking moderate sodium moderate sodium

intakeintake

Diabetes Mellitus and Diabetes Mellitus and Post Transplant Post Transplant

PatientsPatients

Post transplant risk factors for DM Post transplant risk factors for DM include positive family history, include positive family history, cadaveric transplant recipient, cadaveric transplant recipient, older age, African American or older age, African American or Hispanic ethnicity Hispanic ethnicity

Cadaveric transplant recipients are Cadaveric transplant recipients are more prone to DM due to steroids more prone to DM due to steroids used vs. living related donorused vs. living related donor

Post Transplant DM Post Transplant DM TreatmentTreatment

Self monitoring of blood sugarSelf monitoring of blood sugar weight maintenanceweight maintenance exerciseexercise dietdiet insulin or an oral agentinsulin or an oral agent

Perceived exertion Perceived exertion scalescale

Use it instead of target heart rate Use it instead of target heart rate graph as patient’s medications can graph as patient’s medications can increase heart rateincrease heart rate

encompasses sensation of encompasses sensation of exertion, physical stress, and exertion, physical stress, and fatiguefatigue

have patient stay around 11 or 12 have patient stay around 11 or 12 on the scaleon the scale

Perceived exertion Perceived exertion scalescale

6 (minimal effort: relaxing in a chair)6 (minimal effort: relaxing in a chair) 7 very, very light7 very, very light 88 9 very light9 very light 1010 11 fairly light11 fairly light 12 12 13 somewhat hard13 somewhat hard 14 14 15 hard15 hard 1616 17 very hard17 very hard 1818 19 very, very hard19 very, very hard 20 (maximal effort: jogging up a steep hill)20 (maximal effort: jogging up a steep hill)

ExercisesExercises

Warm-up exercisesWarm-up exercises Conditioning Phase(walking, Conditioning Phase(walking,

bicycling)bicycling) Cool-down exercisesCool-down exercises Warm-up and cool-down exercises Warm-up and cool-down exercises

are important to allow for gradual are important to allow for gradual raising or slowing down of the heart raising or slowing down of the heart rate thus preventing dizzinessrate thus preventing dizziness

Immunosuppressive Immunosuppressive PharmacologyPharmacology

Tacrolimus “FK506” (Prograf) Tacrolimus “FK506” (Prograf) Cyclosporine (Sandimmune, Neoral)Cyclosporine (Sandimmune, Neoral) Corticosteroids(prednisone, Corticosteroids(prednisone,

methylprednisone)methylprednisone) Azathioprine (Imuran)Azathioprine (Imuran) ATGAM and ThymoglobulinATGAM and Thymoglobulin Mycophenolate Mofetil (Cellcept)Mycophenolate Mofetil (Cellcept)

Tacrolimus”FK506”(ProgrTacrolimus”FK506”(Prograf)af)

CardiovascularCardiovascular– HypertensionHypertension– Myocardial hypertrophyMyocardial hypertrophy

CNS,Musculoskeletal,Misc.CNS,Musculoskeletal,Misc.– HA, tremor, paresthesias, HA, tremor, paresthesias,

seizures,coma and encephalopathy.seizures,coma and encephalopathy. Acute nephrotoxicityAcute nephrotoxicity HepatotoxicityHepatotoxicity

Cyclosporine Cyclosporine (Sandimmune,Neoral)(Sandimmune,Neoral)

Acute and chronic nephrotoxicityAcute and chronic nephrotoxicity Hypertension (65-85% of patients)Hypertension (65-85% of patients) hepatotoxicityhepatotoxicity CNS-seizures, paresthesias, CNS-seizures, paresthesias,

HA,tremor, shakingHA,tremor, shaking GI,dermatologic(gingivitis),endocriGI,dermatologic(gingivitis),endocri

ne.ne.

CorticosteroidsCorticosteroids(prednisone)(prednisone)

CardiovascularCardiovascular– hypertension,cardiomyopathyhypertension,cardiomyopathy

CNSCNS– tremors, neuritis, psychosistremors, neuritis, psychosis

MusculoskeletalMusculoskeletal– Cushing’s Syndrome,osteoporosisCushing’s Syndrome,osteoporosis

EndocrineEndocrine– increases blood sugarincreases blood sugar

Misc. PharmacologyMisc. Pharmacology

AntibioticsAntibiotics Pain medicationsPain medications Antihypertensive medicationsAntihypertensive medications Oral bowel decontamination Oral bowel decontamination

solutionsolution

Routine Lab TestsRoutine Lab Tests Alkaline PhosphataseAlkaline Phosphatase

– normal range: male 98-251 U/L,female 81-312 normal range: male 98-251 U/L,female 81-312 U/LU/L

BilirubinBilirubin– normal range: total=less than 1.1 mg/dL, normal range: total=less than 1.1 mg/dL,

direct=0.0-0.3direct=0.0-0.3 Serum Asparate Aminotransferase (SGOT, AST)Serum Asparate Aminotransferase (SGOT, AST)

– normal range: 12-31 U/Lnormal range: 12-31 U/L Serum Alanine Aminotransferase (SGPT, ALT, GPT) Serum Alanine Aminotransferase (SGPT, ALT, GPT)

– normal range: male 10-45 U/L, female 9-29 U/Lnormal range: male 10-45 U/L, female 9-29 U/L

Routine Lab TestsRoutine Lab Testscont.cont.

Blood glucose Blood glucose – normal range 70-100mg/dLnormal range 70-100mg/dL

CreatinineCreatinine– normal range: male 0.8-1.2 mg/dL,female normal range: male 0.8-1.2 mg/dL,female

0.6-0.9mg/dL0.6-0.9mg/dL CyclosporineCyclosporine

– normal range will vary with each person, normal range will vary with each person, depending on the combination of depending on the combination of immunosuppressant medications and the immunosuppressant medications and the length of time since the transplantlength of time since the transplant

Routine Lab TestsRoutine Lab Testscont.cont.

Hemoglobin (Hgb)Hemoglobin (Hgb)– normal range: male 12.9-16.6g/dL,female normal range: male 12.9-16.6g/dL,female

11.6-14.9g/dL11.6-14.9g/dL Potassium (K+)Potassium (K+)

– normal range: 3.6-4.8mEq/Lnormal range: 3.6-4.8mEq/L White Blood CountWhite Blood Count

– normal range: male 4.1-10.9x10(9)/L,female normal range: male 4.1-10.9x10(9)/L,female 4.0-10.4x10.9(9)/L4.0-10.4x10.9(9)/L

Child-Turcotte-Pugh Child-Turcotte-Pugh Scoring SystemScoring System

This scoring system (which is also This scoring system (which is also called CTP score) is based on the called CTP score) is based on the following:following:– level of encephalopathylevel of encephalopathy– amount of ascites amount of ascites – labs work (bilirubin, INR, and albumin labs work (bilirubin, INR, and albumin

levels)levels)

Status of people who need Status of people who need a liver transplanta liver transplant

Status 1 fulminant hepatic failure, primary Status 1 fulminant hepatic failure, primary graft non-function, pediatricsgraft non-function, pediatrics

Status 2A in ICU with <7 days life Status 2A in ICU with <7 days life expectancy expectancy

Status 2B Status 2B 10pts on CTP or 7pts with 10pts on CTP or 7pts with refractory ascites, refractory variceal refractory ascites, refractory variceal bleeding, hepatorenal syndrome, or history bleeding, hepatorenal syndrome, or history of spontaneous bacterial peritonitisof spontaneous bacterial peritonitis

MEDICAL URGENCY 1>2A>2B>3MEDICAL URGENCY 1>2A>2B>3

Low Bacteria DietLow Bacteria Diet

No fresh fruit and vegetables No fresh fruit and vegetables except: Thick skinned fruits that except: Thick skinned fruits that can be washed and peeled can be can be washed and peeled can be eaten.eaten.

Avoid all cheese products.Avoid all cheese products. No yogurt.No yogurt. Pasteurized fruit juices only.Pasteurized fruit juices only.

Liver Transplant Liver Transplant StatisticsStatistics

13,749 waiting for a liver 13,749 waiting for a liver transplant as of 9/99.transplant as of 9/99.

In 1998, 4,450 liver transplants In 1998, 4,450 liver transplants were performedwere performed

Currently there are 126 liver Currently there are 126 liver transplant centers transplant centers

Improvements in Liver Improvements in Liver TransplantsTransplants

1) Split: The 2 lobes go to 2 different 1) Split: The 2 lobes go to 2 different recipients (20% of donors meet criteria for recipients (20% of donors meet criteria for split liver)split liver)

2)Live donor: Parent or genetic match 2)Live donor: Parent or genetic match gives left lobe. Within 2 weeks the donors gives left lobe. Within 2 weeks the donors residual liver grows to size needed. residual liver grows to size needed. Recipients liver also grows to size needed. Recipients liver also grows to size needed.

3)use of marginal donors (for example: 3)use of marginal donors (for example: using older donors)using older donors)

Donor AssessmentDonor Assessment

Clinical findingsClinical findings– age age – precipitating precipitating

eventevent– physical examphysical exam– past historypast history– hospital coursehospital course

Lab ValuesLab Values– blood group, blood group,

HLA+/-HLA+/-– aminotransferasesaminotransferases– billirubinbillirubin– coagulation profilecoagulation profile– serologyserology– culturescultures– blood gasesblood gases