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LIVER TRANSPLANTATION FOR ACUTE LIVER FAILURE (ALF)

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LIVER TRANSPLANTATION FOR ACUTE LIVER FAILURE (ALF). The Hungarian Liver Transplant Program. Signs of Liver Failure. Encephalopathy Coagulopathy Metabolic disturbances Renal insuffitiency Vulnerability to infections Hemodynamic disturbances IS IT ACUTE OR CHRONIC?. Forms of ALF.

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  1. LIVER TRANSPLANTATION FOR ACUTE LIVER FAILURE (ALF) The Hungarian Liver Transplant Program

  2. Signs of Liver Failure • Encephalopathy • Coagulopathy • Metabolic disturbances • Renal insuffitiency • Vulnerability to infections • Hemodynamic disturbances • IS IT ACUTE OR CHRONIC?

  3. Forms of ALF • Hyperacute form, within 6 days • Acute form, between 8-28 days • Subacute form, icterus for 5-12 weeks

  4. Prognosis and Staging in ALF Before liver transplantation was available: 30-60% of stage II-III. patients survived ALF Mortality was 80% in stage IV. To determine the stage has a high prognostic value King’s College Criteria

  5. Balancing urgency and outcomeNet benefit-/“Transplant window“-concept “too late” Mortality Med. Therapy Transplantation “Transplantation window” “too early” benefit -> Increasing organ failure ->

  6. Viral hepatitis Drugs Wilson’s disease Hypoperfusion Leukemia Autoimmune hepatitis Neonatal haemochromatosis Unknown 61% 14% 6% 3% 2% 2% 2% 2% Etiology of ALF in Children (n=161)

  7. Distribution of Viruses in the Same Study • Non A-E 40% • Hepatitis A 13% • Hepatitis B 5% • EBV 1% • Herpesvirus 1% • Adenovirus 1% • Echovirus 1%

  8. Other Rare Causes of ALF • Budd-Chiari syndrome • Veno-occlusive disease • X-linked lymphoproliferative disease • Type 1 tyrosinemia • Metabolic bile acid disturbance • Fruktose intolerance • Sepsis, cholangitis

  9. Drugs Causing ALF • Extensive necrosis • Valproate, halothane, mushroom • Centrilobular necrosis • Paracetamol, diazepam, rifampicin • Periportal necrosis • Cocain, phosphorus • Steatosis • NSAID, tetracycline • Veno-occlusiv disease • Azathioprine, cyclophosphamide

  10. Cadaver, living and multiorgan donations in Hungary % -14,7% -2% -5,4%

  11. Number of liver transplants in Hungary 1995-2009.

  12. Etiology for OLT

  13. Etiology within (ALF) Acute Liver Failure

  14. Comparison ALF vs. Chronic EtiologiesDonor demographics

  15. Comparison ALF vs. Chronic EtiologiesRecipient demographics

  16. Comparison ALF vs. Chronic EtiologiesPerioperative data

  17. Comparison ALF vs. Chronic EtiologiesPostoperative complications I.

  18. Comparison ALF vs. Chronic EtiologiesPostoperative complications II.

  19. Comparison ALF vs. Chronic EtiologiesLaboratory - GOT

  20. Comparison ALF vs. Chronic EtiologiesLaboratory - prothrombin

  21. Comparison ALF vs. Chronic EtiologiesLaboratory - serum bilirubine

  22. Comparison ALF vs. Chronic EiologiesCumulative patient survival

  23. Comparison ALF vs. Chronic EtiologiesCumulative graft survival

  24. OLT-ALF in Children - Hungary No possibility of transport 1 or 2 cases per year • 9 children got a new liver: - mushroom 4- Wilson 1- drug induced 1- unknown 3 • 2 living donations • 1 hepatocyte transplantation

  25. Ethical Questions - Hungary PNF? (no) possibility of retransplantation living donation hepatocyte transplantation Eurotransplant

  26. Liver allocation rules ETNational prioritization - Mechanisms of balancing International HU Open obligations (based on previous HU-Tx) Mechanism for balancing National Transplantable/Elective MatchMELD (= urgency) Ischemic time (regional factor) Waiting time International LabMELD Ischemic time (regional factor) Waiting time Outside ET HU Elective

  27. Waiting time HU Liver-transplantFirst HU Liver-Tx [n=1254] Pediatric (<16 yrs) Adult (16+ yrs) n=201 (16%) n=1053 (84%) Median waiting time: 2 d (both groups)

  28. Eurotransplant? THE SOLUTION

  29. Summary • OLT-ALF proportion is similar to ELTR data • Original disease remains unclear in a big proportion of the cases • OLT-ALF early mortality is higher than that of for all other indications • Prolonged survival is equal (better) than in case of chronic etiologies • All donors came from Hungary; good results without networking background

  30. Eurotransplant THE SOLUTION!!!