MULTIDISCIPLINARY APPROACH FOR PATIENTS

1
MULTIDISCIPLINARY APPROACH FOR PATIENTS WITH
FULMINANT HEPATIC FAILURE UNDER THE ERA OF
LIVING DONOR LIVER TRANSPLANTATION
First Department of Surgery, Hokkaido
University, Sapporo, JAPAN
Tsuyoshi SHIMAMURA, Hiroyuki FURUKAWA, Tomomi
SUZUKI, Masahiko TANIGUCHI, Minoru OOTA, Toshiya
KAMIYAMA, Michiaki MATSUSHITA and Satoru TODO
2
BACKGROUND 1
Fulminant Hepatic Failure (FHF)
Outcome after conventional treatment Acute
(lt10days) 50 Subacute (lt8weeks) 20 Lat
e onset (8weekslt) 5
Duration between liver dysfunction and onset
of grade II encephalopathy
3
BACKGROUND 2
Fulminant Hepatic Failure (FHF)
Outcome after diseased donor liver
transplantation (DDLTx) - Recovery without
LTx 20 - Mortality while awaiting
LTx 40 due to fulminant clinical course -
Undergoing LTx 40 due to organ
shortage successful LTx 70
perioperative neurological deficit 10
4
OBJECT
To determine the efficacy of multidisciplinary
approach A. Pretransplant management with
Apheresis, ICP monitoring, Hypothermia B.
Living donor liver transplantation (LDLTx)
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PATIENT
FHF referrals (from September 1997) 61
17 (27.9) Socio-medical problems
44
Apheresis
LDLTx
Recovery (n14, 22.9)
Listed (n20, 32.8)
Not listed (n10, 16.4)
No donor (n3) Rejected (n5) Socioeconomical
(n2)
LDLTx () (n17, 27.9)
Died before LTx (n3, 4.9)
Uncontrolled bleeding (n1) Infection (n1) Brain
death (n1)
6
ALGORISM (Evaluation and Treatment)
Diagnosis of FHF Apheresis (Hemofiltration (HF)
Plasma exchange)
Coma grade
Coma grade
ICP monitoring
Hypothermia (ICPgt20mmHg) (CPPlt50mmHg)
Deterioration
Improvement
Transplantation
Transplantation
Continue apheresis
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APHERESIS METHOD
HemofiltrationFiltration72-96L/day
Plasma Exchange 3.2L / day
Filtration Dialysis Filtration Dialysis
40
30
Clearance (ml/min)
20
10
100
1000
10000
Molecular size
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SURVIVORs (without LDLTx)
Case Age Etiology Type 1 23 Unknown Subacute 2
16 Unknown Acute 3 10 Unknown Subacute 4 1
Unknown Acute 5 24 Drug Acute 6 23 HBV
Acute 7 63 Unknown Subacute 8 34 Unknown
Subacute 9 34 Unknown Subacute 10 51
Unknown Subacute 11 37 Unknown
Acute 12 31 Unknown Acute 13 38 Unknown
Subacute 14 26 HBV Acute
9
38 yo Female Subacute FHF (Unknown Etiology)
Transfer to our hospital
Discharge on 41
100(L/day) 0
Hemofiltration
1500 1250 1000 750 500
PEx 3.2L
IV III II I
Liver Volume (ml)
Hepatic Coma
0.8 0.6 0.4 0.2 0
30
D/T ratio
20
T-Bil (mg/dl)
10
0
7/18
7/25
8/1
8/8
8/15
8/22
8/29
9/5
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ICP MONITORING AND HYPOTHERMIA
ICP(mmHg) Case Coma I
mmediate Just before LTx End of LTx Hypothermia
1 III-IV 47 10 18 28hr30min 2 III 32 21 24 4hr20
min 3 III 22 15 14 4hr30min 4 III 27 12 14 19hr3
0min 5 IV 21 14 9 32hr10min
Duration of hypothermia before LTx
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TIME COURSE UNTIL LDLTx
ONSET OF LIVER DYSFUNCTION
REFERRAL
On referral (n1) Within 3 days (n3) 4 7 days
(n8) More than 7 days (n5)
Median 5.0 days
EVALUATION FOR LDLTx
LISTING
With in 24 hours (n9) 25-48 hours (n3) More
than 48 hours (n5)
Median 24 hours
OPERATION
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TRANSPLANT CASE
Case Age Cause Coma Procedure Graft 1 22 HBV
III-IV APOLT Left lobe 2 41 Unknown II APOLT Lef
t lobe 3 56 Unknown II APOLT Left
lobe 4 35 HBV III APOLT Left lobe 5 28 HBV III A
POLT Left lobe 6 27 Unknown III Standard Right
lobe 7 31 Unknown III Standard Right
lobe 8 49 Unknown II Standard Right
lobe 9 54 Unknown II Standard Right
lobe 10 49 Unknown IV Standard Left
lobe 11 35 HEV III Standard Left
lobe 12 59 HBV IV Standard Left
lobe 13 25 Unknown III Standard Left
lobe 14 33 Unknown III Standard Right
lobe 15 53 HBV IV Standard Left lobe 1 5
Unknown III Standard Left lobe 2 12 Wilsons
D III Standard Left lobe
ADULT
CHILD
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OUTCOME of TRANSPLANT CASE (Survival 82.4)
ADULT
94mo
1
2
Died ABO incompatible Died of chronic
rejection and cholangitis
3
4
5
6
7
Survivor
8
9
10
Died Sepsis
11
No neurological deficit nor brain death
12
13
30mo
14
Died Sepsis
15
CHILD
1
2
0
20
40
60
80
100
Postoperative months
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SUMMARY

• Among those who could have received apheresis
  therapy,
• overall survival rate reached 63.6
• (conventional therapy 31.8, LDLTx 31.8)
• Apheresis therapy was effective not only as a
  conventional therapy but also as a bridge to
  liver transplantation maintaining the patients in
  favorable condition
• ICP monitoring and hypothermia was useful for
  preoperative
• management of patients with progressive coma
• 4. Indication for LTx was more clarified through
  apheresis therapy
• While FHF patients treated with a conventional
  therapy,
• potential living donors could have enough time
  for decision making and precise evaluation

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CONCLUSION
Multidisciplinary approach, particularly with
the use of apheresis, is mandatory for the
treatment of patients with FHF