Care Of Liver Transplant Patients Research Articles

Case report on nutrition management in liver transplant

Liver transplantation or hepatic transplantation is a procedure of replacing diseased liver with a healthy liver. It needs cautious post-operative care including nutritional intervention. We present a 65 year old patient underwent a liver transplant due to acute liver failure. The patient’s diet history revealed a daily intake of carbohydrates and fats but inadequate protein intake. The patient’s nutritional interventions were analyzed and evaluated through hospital recalls and proper follow up visits. In studies, hospital recall on 7 day of post-surgery showed a great improvement in calorie and protein intake. The discharge diet plan included a well-balanced diet with protein, carbohydrates and fat intake to ensure nutritional care for the patient’s recovery. Nutritional intervention plays a vital role in post-operative care of liver transplant patients. This case study signifies the importance of personalized dietary intervention to resolve PEM, improve nutritional intake while supporting successful surgical outcome and recovery .

CAQ Corner: Technical considerations in liver transplantation (101 for hepatologists).

Orthotopic liver transplantation (OLT) remains the only treatment for end stage liver disease and acute liver failure. Following significant advances in surgical technique and critical care since the first successful liver transplant by Dr. Starzl in 1967, liver transplantation has become a safer and more standardized procedure [1]. The goal of this article is to review technical considerations of liver transplantation that will aid in the perioperative care of liver transplant patients.

Change in the wheelhouse

The care of liver transplant patients is one of the most rewarding albeit challenging efforts in all of clinical medicine. Access to liver transplantation has transformed the management of advanced chronic liver disease, acute liver failure, and unresectable primary hepatic malignancies. Availability of effective and nontoxic immunosuppression and remarkable surgical expertise has allowed liver transplantation to be undertaken in an increasingly decompensated cohort of patients of advanced liver disease with excellent patient and graft outcomes. Advances in other areas of medicine have also profoundly affected liver transplantation. At one time, hepatitis B infection of the graft appeared to be an almost insoluble problem despite the use of hepatitis B immunoglobulin. Now the introduction of effective antiviral agents has transformed this indication for liver transplant into one of the most successful. In a similar vein, all oral therapy for hepatitis C will dramatically improve transplant outcomes for this common indication for liver transplant. As has happened with hepatitis B, we can anticipate that fewer patients with hepatitis C will require transplantation for decompensated cirrhosis as an increasing number of infected patients are cured with oral regimens. However, the increasing prominence of nonalcoholic fatty liver disease as the etiology of decompensated cirrhosis and hepatocellular carcinoma suggests that the demand for liver transplant will not diminish for the foreseeable future. Lack of donor organs will continue to be the major factor limiting transplant numbers, although we can anticipate that ongoing efforts in xenotransplantation and stem cell research may mitigate donor shortage in the future. Liver Transplantation since its founding has been the trusted chronicler of the advances and challenges in our field. Its editorial teams have included many of the visionaries who have helped make liver transplant the definitive intervention for patients with liver disease who have no other prospect for survival. As the journal transitions from the able stewardship of Jack Lake and John Roberts, we will continue to publish on all aspects of liver transplant, reflecting its multidisciplinary nature. A number of innovations will be introduced in its pages, including a section highlighting the challenges of liver transplant across the globe. In addition, as the management of advanced chronic liver disease is integral to successful transplant outcomes, we also welcome manuscripts addressing issues in the care of decompensated cirrhosis. We ask your support and welcome your feedback as we continue to build on our strengths including a focus solely on liver transplantation, our international reach, and our long-standing presence in the field.

Candida albicans arteritis transmitted by preservation fluid after liver transplantation

Fungal infections remain among the main causes of mortality in the chronically immunosuppressed liver transplant (LT) patient. Bacterial and fungal contamination of preservation fluid (PF), in which grafts are stored, represents a potential source of infection for recipients. A 54-year-old patient underwent LT for chronic alcoholic cirrhosis. Mycological culture of the liver PF was positive for Candida albicans. The patient received antimycotic prophylaxis for 4 weeks in absence of clinical and serological signs of infection. He was urgently readmitted 4 months later with hemobilia caused by an arterial pseudoaneurysm that was fistulized in the biliary anastomosis. After an unsuccessful embolization, arterial resection and reconstruction and a biliodigestive anastomosis were performed, with an uneventful postoperative course. Pathology found a mycotic arteritis of the graft artery. Mycotic culture of the arterial segment confirmed the presence of the same Candida albicans genotype previously isolated in the PF. Mycotic arteritis is one of the possible complications of yeast contamination of PF. Surgeons and physicians involved in the care of LT patients should be aware of this potentially lethal complication and adopt all the available means for early detection.

Simulation: a teaching tool for liver transplantation anesthesiology

Anesthesia for liver transplantation (ALT) requires extensive preparation and rapid recognition of changing clinical conditions. Owing to the proliferation of transplant centers, greater number of anesthesia providers need training in specific skills required to treat these patients. These cases are no longer limited to few transplant centers; therefore, reduction of cases in individual centers has created a need for simulation training to prepare and supplement clinical experience. We have developed an ALT simulation course for senior anesthesia residents which combines didactic sessions with live-patient-based and mannequin-based simulation. Outcomes have been measured using pre- and post-simulation course quizzes as well as a survey given at the end of the month-long ALT rotation. Twenty-four senior anesthesiology residents (n = 24) have completed the ALT simulation course. Residents had an average score of 75% ± 10% on the pre-simulation quiz, which increased to 92% ± 6.5% on the post-simulation quiz (p < 0.001). Furthermore, survey scores indicated that residents noted that the course provided an improvement in their preparedness, confidence, anticipation, and understanding of the importance of communication skills in the care of this patient population. The ALT simulation course provided a standardized in-depth exposure to clinical issues involved in the perioperative care of liver transplant patients.

Impact of a Pharmaceutical Care Program on Liver Transplant Patients’ Compliance With Immunosuppressive Medication: A Prospective, Randomized, Controlled Trial Using Electronic Monitoring

Compliance with immunosuppressive therapy plays a major role in the long-term success of organ transplantation. Thus, strategies to promote compliance in posttransplant care are of particular interest. At the pharmacy department of the University Hospital Mainz, a program for pharmaceutical care of organ transplant patients has been developed for the first time ever. The main objective of the presented study was to examine the influence of this program on liver transplant patients' compliance with immunosuppressive therapy. To measure compliance, medication event monitoring systems were used. Dosing compliance (DC) was calculated for each patient and the mean DC was compared between the two groups. Further direct and indirect methods of measuring compliance served to confirm the electronic compliance data. Pharmaceutical care of liver transplant patients led to a significant increase in compliance with the immunosuppressive therapy. The mean DC of the intervention group was 90%+/-6% compared with 81%+/-12% in the control group (P=0.015). Only two patients (10%) in the intervention group and nine patients (43%) in the control group showed a DC less than 80% (P=0.032). Furthermore, patients in the intervention group were more likely to achieve target blood levels. Patients who received pharmaceutical care with traditional patient care showed significantly better compliance with their immunosuppressive medication than patients who received only traditional patient care. Pharmaceutical care proved to be an effective intervention that should be implemented in posttransplant care.

Intensive Care Unit Management of Liver Transplant Patients: A Formidable Challenge for the Intensivist

Patients with end-stage liver disease, particular following liver transplantation, are a major challenge for the intensivist. The recipient is at risk for cardiac decompensation, respiratory failure following reperfusion, and kidney failure. This review will focus on these topics to provide useful information concerning pathophysiology and treatment. Intensivists, who are involved in the postoperative care of liver transplant patients, have to be aware of these problems.

The evolution of liver transplantation practices

Over the last 40 years, liver transplantation developed from a compassionate attempt to save the lives of patients with end stage liver disease into a sophisticated therapy, for which 1-year survival rates now approach 90%. To understand the evolution of anesthetic perioperative care, its origin needs to be considered. The implications of this evolution on patient outcomes are important and have not been comprehensively reviewed. This article attempts to fill this gap. Policies for allocating organs continue to evolve in order to better serve those in greatest need as more reliable predictors of pretransplant mortality emerge. Novel approaches to increase the number of organs available for transplantation include donation after cardiac death, living donation and extending the criteria for organ acceptance. Progress in intraoperative hemostatic management and blood loss control, understanding renal physiology, and early extubation protocols are improving outcomes, and contribute to the slowly expanding evidence base for anesthetic perioperative care in liver transplantation. The evidence for perioperative best practices in liver transplantation is at a nascent stage. Increased multicenter and international collaborative research in perioperative anesthetic care of liver transplant patients is needed to extend this body of knowledge required to improve transplant outcomes.

Physician predictions of graft survival following liver transplantation

Introduction. Due to the scarcity of cadaveric livers, clinical judgment must be used to avoid futile transplants. However, the accuracy of human judgment for predicting outcomes following liver transplantation is unknown. The study aim was to assess expert clinicians’ ability to predict graft survival and to compare their performance to published survival models. Materials and methods. Pre-transplant case summaries were prepared based on 16 actual, randomly selected liver transplants. Clinicians specializing in the care of liver transplant patients were invited to assess the likelihood of 90-day graft survival for each case using (1) a 4-point Likert scale ranging from poor to excellent, and (2) a visual analog scale denoting the probability of survival. Four published models were also used to predict survival for the 16 cases. Results. Completed instruments were received from 50 clinicians. Prognostic estimates on the two scales were highly correlated (median r=0.88). Individual clinicians’ predictive ability was 0.61±0.13, by area under the receiver operating characteristic curve. The performance of published models was MELD 0.59, Desai 0.66, Ghobrial 0.61, and Thuluvath 0.45. For three cases, clinicians consistently overestimated the probability of survival (87±10%, 89±9%, 86±9%); these patients had early graft failures caused by postoperative complications. Discussion. Clinicians varied in their ability to predict survival for a set of pre-transplant scenarios, but performed similarly to published models. When clinicians overestimated the chance of transplant success, either sepsis or hepatic artery thrombosis was involved; such events may be hard to predict before surgery.

Perioperative Care of Liver Transplant Patients in Brazil

International Anesthesiology Clinics: September 2006 - Volume 44 - Issue 4 - p 111-119 doi: 10.1097/01.aia.0000210809.70040.72

Controversies in liver transplantation

The success of liver transplantation continues to grow at a rapid pace in improved survival, immunosuppression, and technical advancements. These improvements however have led to many more choices and decisions regarding selection of donors, recipients, and who should or should not be transplanted. Furthermore, the challenges facing the care providers of these patients transplanted have now evolved to management of recurrent disease, metabolic, and side effects of immunosuppression, rather than initial graft function. Set in this environment, controversies exist regarding what strategies will maximize outcomes. The American Association for the Study of Liver Disease/International Liver Transplantation Society Transplant Course gives us the opportunity to explore these controversial topics. Given the continued donor shortage, how can we optimally match recipients with the proper graft? This topic will be addressed in Session I (Which Recipients Should Receive Which Graft). Use of extended donors has broadened the donor pool, but what is the down side for the recipient? When should a split graft be considered in an adult? Should the allocation system be altered to match donor and recipients? And finally when should you not consider transplantation. Session II (Difficult Scenarios: Can We Transplant?) attends to the difficult scenarios in selection of recipients and those with co-morbid diseases that may impact long-term survival. Should alcoholic hepatitis be considered an indication for transplantation? What are the implications for donation rates? Under what circumstances should retransplantation be considered? Especially with the high rate of recurrent hepatitis C, should these patients be considered given a poorer reported outcome? Regarding the impact of renal failure or diabetes mellitus, should this be part of the recipient selection process? Most everyone agrees that acute liver failure patients should be given an opportunity for transplantation. Unfortunately many still die prior to transplantation; can we improve the management and selection criteria to give many more a chance? Hepatocellular carcinoma has risen as one of the leading indications for transplantation. Management prior to transplantation varies both in techniques and geographically. What is the optimal management and has it lead to improved survival post transplant? Lastly, in Session III (Challenging Problems in Long-Term Follow-Up) issues in management of common difficult clinical scenarios in the liver transplant patient will be addressed. Recurrent hepatitis C is universal with up to 30% losing their graft due to recurrent disease. What progress has been made in predicting who may be at high risk and what advancements in treatment have been made? Long-term use of immunosuppression may lead to renal dysfunction in up to 20% of patients. What strategies can be used to prevent this devastating complication? Furthermore, the lack of proper immunosuppression may lead to chronic rejection. How do we manage this condition? What are the outcomes? Two of the most common causes of death in long-term survivors are recurrent tumor and cardiovascular related deaths. How can we surveillance patients to reduce this risk? This course will provide a starting point to evaluate these controversial areas in liver transplantation. It is our intentions through interactions/discussions of faculty and course participants that advancement through further education will improve the care of liver transplant patients. On behalf of my course co-director, Dr. Andrew Burroughs, I thank the authors for the time required in the preparation/writing of the supplement and look forward to the talks and discussions.

CUIDADOS DE ENFERMERÍA AL TRASPLANTADO HEPÁTICO EN UCI.

In this work we want to stress the necessity and importance of a practice guide for the nursing care of liver transplant patients. This guide must emphasize the coordination between the resources, the different hospital sections involved and the components of the multidisciplinary team which participates in this process of care.

Psychiatric aspects of liver transplantation.

Psychiatry plays an essential role in the selection and preoperative care of liver transplant patients. Unique to liver transplantation are the preponderance of candidates with alcoholic end-stage organ failure and also the reversibility of encephalopathy with postoperative normalization of hepatic function. The expense of liver transplantation necessitates documentation of quality of life among recipients. It can also be postulated that a "ripple effect" does occur, in which favorable operative outcomes provide a meaningful and beneficial effect on social networks of transplant candidates and on society in general.

Postoperative Care After Liver Transplantation

The proliferation of liver transplant services across the country during the next 5 years will be an interesting phenomenon to observe. An enlightened approach to the process require answers to several essential questions, many of which are discussed elsewhere in this issue of Seminars. Regardless of how the future distribution of services sorts out, many physicians will face an increasing likelihood that their services will be requested in the long-term management of liver transplant recipients. In this report, the care of liver transplant patients is discussed, including that involving the immediate post-operative phase, the in-hospital recovery, and the early and long-term care of outpatients. The discussion is limited to the more common problems that these patients experience. Information from available literature is interspersed with our experience to provide a personal approach to the diagnosis and treatment of both complications and normal post-transplant clinical concerns. Part of what the reader should obtain from a general review of a complex subject is an awareness of the amount of information that the review does not contain. We have touched the surface of a large number of topics, but have come up far short of a comprehensive coverage of all aspects of the postoperative care of the liver recipient. It is hoped that we have provided enough information to serve the reader as an initial foundation for building a more complete understanding of the management of liver transplant patients.

Role of the Nurse in the Multidisciplinary Team Approach to Care of Liver Transplant Patients

Nursing plays an important contributory role in the multidisciplinary team approach to patient care. The nurse who is responsible for the care of liver transplant patients requires special preparation to meet the patient's needs during the critical phases of the liver transplant process. In the hospital setting, a primary nursing-care delivery system enhances the nurse's role in supporting the goal of patient recovery. Primary nursing places the accountability and responsibility for planning, administering, and evaluating the care of the liver transplant patient with the primary nurse. The transplant nurse acts as a key link in the communication network within the multidisciplinary team, and effective communication is essential in the care of the liver transplant patient. For achievement of a life-style of independence after transplantation, the patient is assisted by the nurse, who provides instruction in such areas as diet, medications, monitoring of vital signs, and record keeping. Although the nurse is only one member contributing to the care of liver transplant patients, the nurse's role in the success of treatment is vital.