Review Article
2018 Clinical Update in Liver Transplantation

https://doi.org/10.1053/j.jvca.2019.02.004Get rights and content

Liver transplantation (LT) continues to be the gold standard for treating end-stage liver disease, and challenges that are posed to the anesthesiologist during transplantation are well known. Successful liver transplantation requires knowledge, recognition, and treatment of hemodynamic and metabolic disturbances by the anesthesiologist. End-stage liver disease causes unique derangements to the clotting cascade, increasing risk both for hemorrhagic and thrombotic events. Cirrhotic cardiomyopathy may be masked for years because of low systemic vascular resistance in cirrhosis, and overt heart failure can be precipitated by LT. Surveys of high-volume transplant centers show an overall transesophageal echocardiography (TEE) use rate of 95%. Guidelines on the use of TEE in LT have mirrored safety findings in several studies and suggest TEE may be used for patients with esophageal varices if the benefit outweighs the risk. This review will cover organ system dysfunction in liver cirrhosis and the implications for liver cirrhosis patients and review recent advances in pathophysiology and treatments. In addition, the authors will highlight the concept of enhanced recovery after surgery and how it pertains to the LT patient population. Lastly, the authors review recent advances in organ preservation and optimization.

Section snippets

Hypocoagulability

As the primary synthetic organ involved in coagulation, ESLD causes unique derangements to the clotting cascade, increasing risk for both hemorrhagic and thrombotic events.1, 2 Management of coagulation can be challenging, and traditional laboratory testing, such as prothrombin time and the calculated international normalized ratio, guide transfusion of allogenic blood products to correct deficiencies of clotting factors.3 However, these tests offer an incomplete picture of actual coagulation,

Thromboelastography

TEG, first described in 1948 as a method to measure blood clotting, was first used in 1985 by Kang et al. for LT evaluation.4, 5 The use of TEG in 62% of LT centers and in other settings, such as trauma, obstetrics, and cardiothoracic surgery, demonstrates its ability to evaluate whole blood samples for coagulation.6 Despite the routine use of TEG in ESLD patients, the normal values are derived from healthy volunteers and may not represent ESLD patients. Within LT patients, Wang et al.

Hypercoagulability and Thromboembolism

As noted earlier, patients with ESLD can present with unbalanced coagulation and be both hypo- and hypercoagulable. The idea of “auto-anticoagulation” has been replaced with a better understanding of the tenuous nature of hemostasis in the LT patient.17, 18 Traditional testing demonstrates abnormal prothrombin time or international normalized ratio results, but other changes lead to enhanced coagulation and risk for intracardiac thrombus or thromboembolic events during LT.

Hypercoagulability

ELSD results in several alterations that favor thrombosis; levels of von Willebrand factor, factor VIII, and plasminogen activator inhibitor-1 are increased, and levels of protein C and antithrombin III are decreased, as seen in Table 2.17, 19,20 The activity of von Willebrand factor is further enhanced by an ADAMTS13 deficiency, the enzyme responsible for cleaving von Willebrand factor.20 Hypercoagulability in ESLD patients was highlighted in a meta-analysis showing a significant risk of

Thromboembolic Events

Right-sided intracardiac thrombus (ICT) and pulmonary embolism (PE) are the most feared thrombotic complications during LT because of the high mortality rate; a review of LT from 2002 to 2013 found that ICT and PE were responsible for approximately 20% of all 24-hour mortalities.27 The incidence of intraoperative ICT or PE ranges from 1% to 6%, although an incidence of 24% was reported in a study that used transesophageal echocardiography (TEE) during LT.17, 28 ICT and PE have been associated

Cirrhotic Cardiomyopathy and Echocardiography

The hemodynamic profile of ESLD was first described over 60 years ago, which includes a decrease in peripheral resistance, hyperdynamic circulation with increased cardiac output, and typically low arterial systolic blood pressure. Altered systemic vascular resistance (SVR) leads to redistribution of plasma volume, and portal hypertension stimulates the release of endothelial vasodilators.37 In response, sympathetic activation increases contractility and renal sodium and water retention.38 A

Cardiovascular Evaluation

Cardiac failure is the third most common cause of morbidity and mortality in LT for patients who survive the first year and was the most common cause in 40% of cases after rejection and infection and in a review of 30-day mortality.41, 43,44 In the immediate postoperative period, increases in blood pressure and SVR occur as normal liver function, and portal vein pressures are restored, which can lead to cardiac decompensation in patients with CM.37 As such, the importance of identifying masked

TEE As An Intraoperative Monitor

Liver transplantation carries significant cardiovascular risk, with cardiac arrest occurring in up to 5% of cases, usually during the reperfusion phase.47 There are multiple causes to hemodynamic collapse during reperfusion, including vasoplegia, ICT or PE, acidosis, hypothermia, and electrolyte disturbances that impair contractility.41 TEE is an invaluable tool for successful diagnosis and management of these complications during all phases of LT.48 Shillcutt et al. analyzed TEE findings

Enhanced Recovery After Surgery

Whereas Enhanced Recovery After Surgery (ERAS) programs are becoming standard in different surgical subspecialties including liver surgery, the implementation within the ESLD and LT population is still developing.58 Components of a successful program focus on minimizing stress responses that shift anabolic to catabolic processes and that release neuroendocrine hormones and immunologic modulation. The downstream effects of these changes result in impaired homeostasis and impair recovery from the

Organ Preservation and Optimization

Despite all the advancements in liver transplantation, including preservation solutions, surgical technique, and hematological management, the major limitation in treating individuals with end-stage liver disease is the availability of donor organs, specifically the availability of quality donor organs, because there are many available organs that are not considered for transplantation for various reasons.71, 72 It is estimated that with sufficient donor organs, up to 30% of deaths within the

Conclusion

In conclusion, the anesthesiologist should remain knowledgeable and competent regarding complex physiological systems, their interplay within the liver transplant patient, and the rapidly progressing field of liver transplant. These few topics are some of the ever-changing components of the field of transplantation. The role of the anesthesiologist in optimizing the patient to undergo transplantation, especially if there can be more time between identifying patients and undergoing LT, will be

Conflict of interest

The authors declare no conflicts of interest.

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