Makindo Medical Notes

🩺 Liver transplantation is the definitive treatment for acute or chronic liver failure. 🚧 The main limiting factor is the shortage of donor organs. Living donors (usually family members) are increasingly used.

📖 About

• ✅ Highly successful and effective treatment for liver failure.
• 🔄 Can be done acutely (fulminant failure) or electively (chronic disease).
• 👵 Usually offered to patients <65 years.
• 📊 MELD (Model for End-Stage Liver Disease) score helps prioritise patients on the waiting list.

🫀 Source of Transplant

• 💀 Deceased donor (orthotopic): Liver from a recently deceased individual, transplanted into recipient.
• 🫂 Living donor: A segment of liver from a healthy donor (often a family member). Both segments regenerate within weeks.
• 🔑 Factors: ABO blood type compatibility, donor <60 yrs, appropriate size match.

🔪 The Procedure

• “Mercedes-Benz” incision used (rooftop + vertical extension).
• ⏱️ Surgery takes 6–12 hours.
• Non-functioning liver is removed → replaced with donor liver.

🚨 Acute Need for Transplant

• 💊 Paracetamol overdose.
• 🦠 Fulminant viral hepatitis.

📏 King’s College Criteria

• Arterial pH <7.3 after 24h OR
• PT >100 sec, Creatinine >300 μmol/L, and Grade III–IV encephalopathy.

• PT >100 sec OR
• 3 of: Age <10 or >40, >1 week from jaundice → encephalopathy, PT >50 sec, Bilirubin >300 μmol/L, drug-induced cause.

📌 Indications (Chronic/Advanced Disease)

• Primary biliary cholangitis (PBC).
• Recurrent variceal haemorrhage.
• Intractable ascites or SBP.
• Refractory encephalopathy.
• Severe jaundice or synthetic dysfunction (low albumin, ↑INR).
• Fulminant hepatic failure (any cause).

🧾 Pre-Operative Work-up

• 🧪 Bloods: FBC, LFTs, coagulation, U&E, glucose.
• 📉 Crossmatch at least 10 units RBC.
• 📈 ECG & CXR to check fitness.
• 🖼️ Abdominal USS (if not done in last 4 months).

🛑 Contraindications

• ❌ Extra-hepatic malignancy.
• ❌ Active uncontrolled sepsis (e.g. SBP).
• ❌ Widespread liver metastases.

⚠️ Complications

• 💀 Death, 💉 haemorrhage, 🦠 sepsis.
• ⛔ Acute rejection (immune-mediated).
• Chronic rejection → graft loss.

💊 Prevention of Rejection

• Calcineurin inhibitors: Ciclosporin, Tacrolimus.
• Immunosuppressants: Azathioprine.
• Adjunct: Steroids.

📊 Risk of Rejection

• ⬆️ High risk: previous rejection, younger patients, females, autoimmune disease (AIH, PBC).
• ⬇️ Lower risk: malnourished patients, renal failure.

📚 Exam tip for OSCEs: Always mention King’s College Criteria in fulminant hepatic failure stations. Discuss both **indications** (e.g. variceal bleeds, refractory ascites) and **contraindications** (malignancy, sepsis).