B52. Indications for liver and pancreas transplantation
Liver transplantation
Liver transplantation is one of the more common forms of organ transplantation. It may be performed from living or deceased donors. It’s performed in an orthotopic fashion, i.e. the native liver is removed and the donor liver is placed in its place.
Indications
- HCC within the Milan criteria
- Decompensated cirrhosis from any cause, if MELD score is > 15
- Liver related diseases with systemic manifestations
The MELD (Model for End-Stage Liver Disease) score assesses the risk of dying from chronic liver disease based on serum bilirubin, INR, and creatinine. When the score is > 15, the risk of dying from cirrhosis is greater than the risk of dying from the liver transplant surgery.
Contraindications
- MELD < 15
- Alcohol or drug abuse
- HCC outside the Milan criteria
- Severe heart or lung disease
- HIV/AIDS
- Extrahepatic malignancy
Procedure of transplantation
Liver may be transplanted from living or brain dead donor. In case of a brain-dead donor, the entire liver is transplanted. In case of a living donor, a only a portion of the donor liver is removed and transplanted. The liver has an exceptional ability to regenerate, and so the liver in both the donor and recipient will grow to almost normal size.
Complications
- Hepatic artery thrombosis
- Biliary leakage
Pancreas transplantation
Pancreas transplantation is a treatment for type 1 diabetes, and the only treatment which can make patients insulin independent and euglycaemic. However, the lifelong immunosuppressive treatment may be more harmful than the alternative lifelong insulin therapy, and so a risk/benefit analysis must be taken into account.
Pancreas transplantation may be performed alone (pancreas transplant alone, PTA), simultaneously as kidney transplant (simultaneous pancreas-kidney, SPK), or after kidney transplant (pancreas after kidney, PAK). Diabetes mellitus harms the kidneys, and so by treating the underlying problem in diabetic patients simultaneously as the kidney transplant, we can increase the lifetime of the transplant kidney. PAK has the disadvantage of the patient encountering two sets of foreign antigens (one from the pancreas donor and one from the kidney donor).
Indications of pancreas transplantation alone
- Type 1 diabetic with normal or subnormal kidney function, if:
- At least 2 episodes of hypoglycaemic coma
- Severe gastroparesis
- Other frequent, severe complications of diabetes
Indications of simultaneous pancreas and kidney transplantation
- Type 1 diabetic with end-stage kidney disease, if the patient does not have:
- Contraindication against either organ transplant
- Ischaemic heart disease
- Major amputation
Criteria for pancreas donation
- Good general condition
- BMI < 30
- No alcohol abuse
- No pancreatitis
- No vascular disease
- Age 4 – 40 years
Procedure of transplantation
Transplantation may involve whole organ transplantation (pancreas transplantation), or islet transplantation, where only Langerhans islets are transplanted. Whole organ transplantation has higher rates of long-term success, but higher morbidity due to the surgery.
Pancreas transplantation involves taking the whole pancreas from a cadaveric donor, still attached to a small portion of the duodenum. The pancreas is placed in the pelvis and arterially anastomosed to the iliac artery, and venously anastomosed to a branch of the iliac vein or the portal vein. The duodenal segment is connected to a loop of bowel or the urinary bladder, which receives the transplant pancreatic exocrine secretions. The native pancreas is left intact.
Islet transplantation involves harvesting >500 000 islets from multiple cadaver pancreases which are infused via a percutaneous catheter into the portal vein of the recipient, allowing them to engraft in the liver.