Immunosuppression primer

Schedule

Conference/didactics

• Interns don't go to liver clinic
• In 750 Welch Road (exit through front of Children's, cross street, door is on the R side of the building on the outside)
• Th didactics and Fri journal club mandatory; go to selection meeting if possible

Rounds

• Liver service has PAs that will also get numbers/see patients
• PAs take care of ICU orders/ICU notes
• PAs take care of all discharge order recs and discharge summaries on liver
• Pre-round with fellow, pharmacy resident
• Attending (multi-disciplinary) rounds usually some time in morning - pharmacy, social work, dietician, etc.

Consent

• Admission orders - there is an order set, usually fellow will take care of it, but of note patients need both Admit to obs/pre-procedure (C1, for pre-op) and an Admit to Inpatient order (post-op)
• "IP TRS Liver Transplant Preop"
• basically just check all the boxes if unsure...this order set is missing the pre-op EKG
• Type and cross for 4 u pRBC, and max # of FFP, cryo, platelets (need to go into the transfusion order set)
• If HBV/HCV, get a PCR with the other labs
• Recipient: consent x 3 (transplant consent only found on C1 unit)
• Organ transplantation - find out from fellow if 'high risk' to check the box
• CDC means patient engaged in high risk activities (IV drug use, multiple blood transfusions in past) that even though all the blood tests we have were negative, there still may be risk of bloodborne disease
• DCD: deceased cardiac donor. Due to mode of death, these donors are slightly higher risk of non-functioning
• OR
• Consent should read "Orthotopic liver transplant with venovenous bypass, possible intraoperative continuous renal replacement therapy". The CRRT part may not be needed if pt is healthy/coming in from home.
• Blood transfusion
• Recipient H&P: .livertransplantadmit smartphrase
• Etiology of ESLD
• Extent of decompensation - ascites, encephalopathy, variceal bleeding, etc
• Previous abdominal surgery
• Pulse exam (femoral, DP/PT bilaterally) - important for cannulation during bypass

Liver anatomy

• Blood supply
• Portal vein (80%)
• L/R hepatic arteries (20%)
• Falciform ligament separates medial/lateral L lobe

 MELD score

• Sodium
• Dialysis 
• Cr
• Bili
• INR

Plan

• Admit to ICU post-operatively
• q6 CBC, CMP, coags
• LFTs should peak at 24-48 hours then decrease over the next week.

Complications

• R pleural effusion - 

  may affect ventilation, necessitating drainage.

• Hepatic edema/impaired graft perfusion secondary to aggressive resuscitation and increased intravascular volume.
• Be conservative with fluid resuscitation
• Renal failure-Elevation of creatinine and BUN observed in nearly all transplant patients secondary to ATN, hepatorenal syndrome.
• Usually self-limiting, but may necessitate therapy with loop diuretics or renal replacement therapy.
• Electrolytes - graft increases demand for Mg and PO4
• Blood transfusion - citrate decreases Mg and Ca
• Careful of rapid correction of chronic hyponatremia (goal serum Na 125-130)
• Thrombocytopenia-Preoperative portal hypertension results in splenomegaly and platelet sequestration.
• Platelet dysfunction secondary to renal and hepatic failure may be improved acutely with DDAVP.
• Biliary leak: RUQ pain, fever, persistent elevation of bilirubin, liver enzymes. Biloma on CT. Treated with endoscopic stent or percutaneous drainage. Possible surgical revision if duct is ischemic.
• Hepatic artery thrombosis - Persistent elevation or increasing liver enzymes, poor graft function. Diagnosed with U/S, CT angiography, MRA. Treated with immediate revascularization.
• Graft rejection
• Hyperacute rejection-Secondary to preformed Ab to graft antigen. Extremely rare. Necessitates retransplantation
• Acute Cellular Rejection-70% of patients 5 to 14 days following transplant. Heralded by fever, jaundice, elevation of liver enzymes. Diagnosed by liver biopsy. Demonstrates endothelialitis and non-suppurative cholangitis.