
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 • Hyperacute form, within 6 days • Acute form, between 8-28 days • Subacute form, icterus for 5-12 weeks
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
Balancing urgency and outcomeNet benefit-/“Transplant window“-concept “too late” Mortality Med. Therapy Transplantation “Transplantation window” “too early” benefit -> Increasing organ failure ->
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)
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%
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
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
Cadaver, living and multiorgan donations in Hungary % -14,7% -2% -5,4%
Comparison ALF vs. Chronic EtiologiesPostoperative complications I.
Comparison ALF vs. Chronic EtiologiesPostoperative complications II.
Comparison ALF vs. Chronic EtiologiesLaboratory - prothrombin
Comparison ALF vs. Chronic EtiologiesLaboratory - serum bilirubine
Comparison ALF vs. Chronic EiologiesCumulative patient survival
Comparison ALF vs. Chronic EtiologiesCumulative graft survival
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
Ethical Questions - Hungary PNF? (no) possibility of retransplantation living donation hepatocyte transplantation Eurotransplant
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
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)
Eurotransplant? THE SOLUTION
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
Eurotransplant THE SOLUTION!!!