Curtis K. Argo, MD Liver Transplantation Evaluation: Essential Work-Up Essential Work Up Curtis K. Argo, MD, MS VGS/ACG Regional Postgraduate Course Williamsburg, VA September 13, 2015 Objectives • Discuss determining readiness for transplantation – when is the right time to refer for transplantation evaluation? • Describe the key aspects of liver transplantation medical evaluation ACG/VGS/ODSGNA Regional Postgraduate Course - Williamsburg Copyright 2015 American College of Gastroenterology 1
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Curtis K. Argo, MD
Liver Transplantation Evaluation:
Essential Work-UpEssential Work Up
Curtis K. Argo, MD, MS
VGS/ACG Regional Postgraduate Course
Williamsburg, VA
September 13, 2015
Objectives• Discuss determining readiness for
transplantation – when is the right time to refer for transplantation evaluation?
• Describe the key aspects of liver transplantation medical evaluation
ACG/VGS/ODSGNA Regional Postgraduate Course - Williamsburg Copyright 2015 American College of Gastroenterology
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Curtis K. Argo, MD
Transplantation Readiness
–Confirm cirrhosis• Clinical diagnosis
– Imaging (nodular liver and/or splenomegaly + presence of varices on EGD or varices/ascites on imaging + thrombocytopenia
Bi• Biopsy-proven– Nice but often not necessary unless mixed
signals
Transplantation Readiness
• Likely to survive without a transplant?– Child’s class/CTP score
CTP class: A = 5-6, B = 7-9, C = 10-15
ACG/VGS/ODSGNA Regional Postgraduate Course - Williamsburg Copyright 2015 American College of Gastroenterology
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Curtis K. Argo, MD
Transplantation Readiness• Likely to survive without a transplant?
No: Child’s class C = CTP > 10–No: Child s class C = CTP > 10–30-35% mortality in 1 year
–Probably: Child’s class B = CTP 7-9–20% mortality in 5 years
Y Child’ l A CTP 5 6–Yes: Child’s class A = CTP 5-6–90% survival for ≥ 5 years
Transplantation Readiness• Likely to survive without a transplant?
MELD score– MELD score
Wiesner R et al. Gastroenterology 2003.
ACG/VGS/ODSGNA Regional Postgraduate Course - Williamsburg Copyright 2015 American College of Gastroenterology
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Curtis K. Argo, MD
Transplantation Readiness• Likely to survive long-term without a
transplant?transplant?
–No: MELD > 20– >10% mortality in 3 months
–Unlikely: MELD = 15-195 10% mortality in 3 months–5-10% mortality in 3 months
–Possibly: MELD = 10-12–<5% mortality in 3 months
–Yes: MELD < 10
Transplantation Readiness• Likely to survive without a transplant?
MELD score vs CTP score– MELD score vs. CTP score
MELD appears to bemore sensitive than CTPo e se s t e t a Cin predicting mortality
Wiesner R et al. Gastroenterology 2003.
ACG/VGS/ODSGNA Regional Postgraduate Course - Williamsburg Copyright 2015 American College of Gastroenterology
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Curtis K. Argo, MD
Transplantation Readiness• Likely to survive without a transplant?
Presence of portal hypertensive– Presence of portal hypertensive complications
– MELD exception to 22 points in selected cases that meet Milan criteria
AASLD guideline 2005
ACG/VGS/ODSGNA Regional Postgraduate Course - Williamsburg Copyright 2015 American College of Gastroenterology
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Curtis K. Argo, MD
Transplantation Evaluation• Basic but Important Questions
– Can the patient survive the operation and the p pimmediate postoperative period?
• Nutrition ● Comorbidities
• Functional status ● Age
– Can the patient be expected to comply with the complex post-transplant medical regimen?p p p g
• Past behavior predicts future behavior
• Addiction
– Does the patient have other comorbidities that could severely compromise graft function or patient survival – futile? AASLD guideline 2005
Transplantation Evaluation• Age
– No specific age limitationp g• Patients age >70 have had reduced long-term post-
transplant survival, mainly due to death from malignancies or perioperative complications
• Coronary Artery Disease– RFs: smoker, age>50, DM, personal or FmHx, g , , p
– Increased perioperative mortality in CAD pts
– Stress echo is best studied, but there is no consensus on best risk stratifying test
– Catheterization is indicated in any positive test
ACG/VGS/ODSGNA Regional Postgraduate Course - Williamsburg Copyright 2015 American College of Gastroenterology
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Curtis K. Argo, MD
Transplantation Evaluation• High risk features for transplant in
NASH/cryptogenic cirrhosisyp g– ≥ 60 years old
– BMI ≥ 30
– Pre-transplant Diabetes +
– Pre-transplant HTN +
Dil 0% 1 li i k i l• Dilemma: 50% 1-year mortality risk in largest retrospective cohort of transplanted NASH cirrhosis pts (n=98) in patients with all 4 of these risk factors (n=18)
Malik SM et al, AJT 2009
Transplantation Evaluation• Substance abuse/addiction – Use vs. Abuse
– Abuse: demonstration of dependence through ti d b t d it ti ff tcontinued substance use despite negative effects
on health, family, job, or legal status
– Use: intermittent use of substance that does not have the above negative ramifications and is remediable with relatively conservative measures
UVA’ li• UVA’s policy– We do not condone use of any illegal, illicit drug in
any transplant candidate
– Alcoholic abstinence of at least 6 consecutive months is required prior to listing for liver transplant
ACG/VGS/ODSGNA Regional Postgraduate Course - Williamsburg Copyright 2015 American College of Gastroenterology
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Curtis K. Argo, MD
Transplantation Evaluation• Obesity• BMI > 40 is strongly
associated with reducedassociated with reduced 30-day, 1-yr, and 2-yr post-transplant survival
• BMI > 35 is associated with reduced 5-yr survival
• Our cutoff for transplant listing at UVA is BMI ≤ 40listing at UVA is BMI ≤ 40
– If the patient is a viable liver transplant candidate from psychosocial perspective, then tertiary referral is recommended for critical care management and urgent evaluation