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Sunday, January 27, 2008

Who needs liver transplant

Absolute indications for liver transplant
Ascites (fluid in the belly) Recurrent collection, not responding to diuretic medicines or repeated removal by needle
GI bleed Vomiting blood or passing blood in stool, more than once
SBP Spontaneous infection in the fluid in the belly (Polymorph cell count >250/cc)
Coma Repeated admission to hospital for loss of orientation and conscious state
Serum Albumin Measurement consistently below 3.5 Gm/dl
Prothrombin time Measurement in patient sample 5 seconds above the control lab value (or INR>1.5)
Total bilurubin Serum total bilurubin >6 mg/dl, especially in patients with bile outflow problems like- PSC & PBC

Majority of patients with sudden (acute) liver failure who meet the internationally accepted criterion will die without liver transplant at the appropriate time. Some of the criterion include- Prothrombin time > 100 seconds, worsening level of conciousness, rapidity of onset of coma, onset of kidney failure and moderate jaundice accompanying coma. Liver failure caused by viral hepatitis-A invariably recovers spontaneously except in 2% of patients. Liver failure caused by liver poisons (chemicals and drugs) are invariably fatal without a transplant. Patients with severe acute liver failure should be admitted to center with facility for emergency liver transplantation, whenever possible. The outcome of acute liver failure patients without transplant depends on the cause, reporting time, early correct medical therapy and provision of good intensive care. Invariably all patients with cirrhosis will need liver transplant at some point in time. The only absolute contraindications being HIV infection and wide spread cancer (primary or secondary). Tranplant is not advisable in patients with heart and lung failure as well as in those with systemic infections(TB), severe malnutrition and cancer without liver cirrhosis.

One cannot survive for more than 24 hours in the absence of the liver. The functioning of the liver can be deranged by acute illness such as alcoholism, viral hepatitis or sepsis. Most of these illness recover spontaneously , but few take a downhill path resulting in fulminant failure. Since no tested artificial liver support system are yet available ,many people die without liver transplantation . Birth defects, viral infection and alcohol abuse also cause a gradual crippling of liver function resulting in a state called cirrhosis. In this state much many of the liver tissue get replaced with scar tissue , causing strangulation of blood supply in the liver .As a result there is damming of blood in the portal veins .As nature seeks alternative routes to empty the blood . Multiple channels are created to shunt the blood away from the constricted liver into the veins draining into the heart .When the pressure in these channels exceeds in the limit they may break down causing massive bleeding .In some patients it may be terminal event . The blood that bypass the toxin removal process in the liver ,eventually reaches the brain causing several neuropsychiatric disturbances

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