4. Clinical Guidelines for Liver Transplantation (PDF) - British ...

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Guidebook for the Solid Organ Transplant Programme Chapter 4 4.5 Pediatric Transplantation 4.5.1 INTRODUCTION While the general principles of liver transplantation are similar in children and adults, a number of additional factors must be considered for the pediatric patient. First, the size of the pediatric patient may affect the transplant outcome. Candidates weighing less than 10 kg may be at high risk for transplant complications and the nutritional status of any young patient with liver disease is a major concern. Second, the immunization status of a child referred for liver transplant evaluation requires thorough review. Children who are potential transplant candidates should receive an accelerated immunization schedule whose goal is to complete as many of the primary immunizations as possible prior to the transplant. Third, the vessels that supply blood to the liver may be quite small in caliber, especially in young infants. Abnormalities of the hepatic vasculature are relatively common in children and the risk for post-transplant vessel blockage is higher for those infants with small caliber vessels. A thorough radiological assessment of the liver vessels is crucial for the pediatric patient prior to undergoing a liver transplant. Finally, particular attention must be paid to the child’s environment. The psychosocial needs of the child, the reliability of the child’s caregivers, the stability of the home environment and religious or cultural beliefs need to be assessed to ensure adequate and responsible care of the transplanted child after discharge. 4.5.2 WHEN TO REFER As part of the liver transplantation protocol, potential pediatric candidates will undergo a thorough preoperative evaluation of their liver disease to determine their eligibility for transplantation. We prefer to see potential candidates early in their disease course as this enables us to anticipate any problems as well as to correct any disease associated complications. In addition, it affords the transplantation team an opportunity to become familiar with the patient and their family. In a child with liver disease, the presence of one or more of the following features indicates significant hepatic dysfunction and warrants a referral for transplant evaluation: Progressive jaundice Diminishing hepatic synthetic function (hypoalbuminemia, coagulopathy unresponsive to vitamin K, hypoglycemia) The onset of encephalopathy Progressive cholestasis/pruritus/refractory cholangitis Portal hypertension with its complications (variceal bleeding, ascites, hypersplenism) Growth retardation despite aggressive nutritional therapy Poor quality of life Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 27 See Page 1 for disclaimer
Guidebook for the Solid Organ Transplant Programme Chapter 4 4.5.2 WHEN TO REFER CONT. The ultimate goal of the transplant evaluation process is to: Confirm the diagnosis Evaluate alternative therapies Determine potential disease complications Decide if there are any contraindications for transplant Initiate aggressive nutritional therapy Review medications Ensure appropriate immunization schedule Educate and prepare patient and family 4.5.3 WHAT HAPPENS DURING ASSESSMENT All pediatric candidates are evaluated by members of the pediatric transplantation team following which a decision is made as to whether the candidate is suitable for transplant. This pediatric multidisciplinary team includes the following consultants: Surgeon, Gastroenterologist, Intensivist, Microbiologist, Radiologist, Anaesthesiologist, Pathologist, Psychiatrist, Clinical Nurse, Ethicist, Social Worker, Dietician and Transplantation Coordinator. Other consultants whose expertise may be needed include Nephrologists, Hematologists, Neurologists, Respirologists, Immunologists, etc. During the assessment, a complete history and physical examination is performed and a number of tests are obtained to assess the extent of the liver disease and confirm the diagnosis. The patient is screened for a variety of viruses and the immunization schedule is reviewed. A complete nutritional assessment with aggressive dietary management to maximize the growth of infants with liver disease is an integral part of the pediatric transplant evaluation. During the assessment phase, the transplant team also provides patients and their families with information about liver transplantation, including the risks and benefits of the procedure and the transplantation process. The following tests are routinely completed during this assessment phase: Complete blood count Assessment of liver function: AST, ALT, gamma GT, alk phos, total and direct bilirubin, total protein albumin, PT, PTT, Factor V Assessment of renal function: serum electrolytes, BUN, Ca, creatinine, PO4, Mg, U/A, urinary electrolytes, GFR Other biochemistries: glucose, amylase, immunoglobulins, cholesterol, triglycerides Viral screen: serology for CMV, Hep A IgM, HBsAg, HBcAb, HBsAb, HIV, EBV, Hep C PPD Blood group and match Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 28 See Page 1 for disclaimer
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