Liver transplantation and

heart transplantation
Prof. Ileana Constantinescu
The single most effective therapy for end stage
liver failure (ESLF) is liver transplantation (LT).
European Liver Transplant Registry:

70.000 LT have been performed in 137 centres
around Europe.
UK: currently 680 liver transplants are performed
yearly.
More than 6000 patients have been transplanted
RO: about 30-50-60 LT/year

Unfortunately the supply cannot meet demand

Indications for LT - adults
Common:
1. Alcoholic liver disease (ALD)
2. Cryptogenic cirrhosis
3. Primary biliary cirrhosis
4. Primary sclerosing cholangitis (PSC)
5. Hepatitis (B, C, non-A, non-B)
6. Hepatocellular cancer
7. Autoimmune hepatitis

Indications for LT - adults
Rare:
1. Haemochromathosis
2. Wilsons disease
3. 1-antitrypsin deficiency
4. Budd-Chiari syndrome
5. Polycystic disease
6. Hyperoxaluria, familial hypercholesterolaemia
7. Porphyrias, amyloidosis, neuroendocrine
tumours (e.g. carcinoid)


Indications for LT in children
Biliary atresia
Familial cholestasis syndromes
Metabolic disorders:
Cystic fibrosis
1-antitrypsin deficiency
Crigler-Najjar type 1
Wilsons disease
Unresectable tumours (e.g. hepatoblastomas)
Acute liver failure viral, drugs (e.g. paracetamol
toxicity), autoimmune

Contraindications to liver
transplantation
Absolute:
1. Infection
2. Malignancy outside the hepatobiliary system
3. Secondary hepatic malignancy
4. Active drug or alcohol abuse
5. Advanced cardiopulmonary disease

Contraindications to liver
transplantation
Relative:
1. Age over 65 years
2. Portal vein thrombosis
3. Renal failure not associated with liver disease
4. Intrahepatic sepsis
5. HIV
Emmergencies for LT
Paracetamol poisoning
Diuretic-resistant ascites
Hepatopulmonary syndromes
Chronic hepatic encephalopathy
Persistent and intractable pruritus
Familial amyloidosis
Primary hyperlipidaemias
Polycystic liver disease

Work-up for liver transplantation
Assessment for conventional deceased donor
1. Blood group
2. Conventional liver screen/liver biopsy for
steatosis
3. Viral screening
4. HLA typing: HLA-A, B, DRB1
5. Tumor markers: AFP, CA 19-9, CEA, CA 125,
CA 15-3, 2-microglobulin, total and free PSA

Work-up for liver transplantation
Assessment for liver donation
1. Blood group
2. Conventional liver screen/liver biopsy for steatosis
3. Viral screening
4. HLA typing: HLA-A, B, DRB1
5. Tumor markers: AFP, CA 19-9, CEA, CA 125, CA 15-3,
2-microglobulin, total and free PSA
6. To exclude occult thromboembolic disorders:
abnormalities for PT, protein C, protein S,
antithrombine III, factor V Leiden, factor VIII,
cardiolipin , antiphospholipin
Immunology of liver transplantation
in the recipient
AB0 compatibility
Viral screening
Child Pugh score: A, B, C
MELD score (Model for End-stage Liver Disease)
3.8 x log
e
(bilirubin mg/dL) + 11.2 x log
e
(INR) + 9.6
log
e
(creatinine mg/dL) + 6,4 (aetiology: 0 if
cholestatic or alcoholic, 1 otherwise)

Immunology of liver transplantation
in the recipient
Histocompatibility testing plays little role in selecting an
individual recipient for LT for a particular donor
Class I HLA matching may significantly improve patient
graft survival.
In the liver tissue HLA class I antigens are to be found
only on the biliar epithelium, but not on the hepatocytes
HLA class II antigens are present in Kupffer cells and
endotelial cells.
Cytotoxic antibodies
Crossmatch a positive crossmatch is associated with a
higher likelihood of early rejection episodes.
Heart transplantation
Indications adults
1. Coronary-related heart failure
2. Cardiomyopathies : valvular, mixt diagnoses,
adult congenital, retransplantation

Indications paediatrics (<16 years)
1. Cardiomyopathy
2. Congenital heart disease
Recipient assesment protocol for
heart transplantation
Full blood count, plateletes, coagulation screening
Blood group
Uree, electrolytes, liver function, thyroid function
Microbiology
Viral screening
Fasting glucose and lipids
ECG
Chest X Ray
Estimation of peak O2 consumption (VO2max)
Carotid/peripheral artery Doppler
Recipient assessment protocol for
heart transplantation
AB0 compatibility
Immunological matching
Anti-HLA antibodies 10%
> 25% rejection
HLA typing for A, B, DRB1
Crossmatch
Chronic transplant dysfunction in transplanted
hearts remains the most common cause of graft
loss after the first year postTx.