In the current era of markedly increased median Model for End-Stage Liver Disease (MELD) score at transplantation, clinicians face multiple perioperative challenges related to liver transplantation. During Saturday’s Liver Transplant SIG Program, attendees were given updates on the best methods for managing patients with acute liver failure (ALF) and those with hyponatremia in the perioperative period.
“As opposed to cirrhosis, where the primary pathological phenomenon is fibrosis, portal hypertension and imminent liver failure, we are talking about a macroinflammatory process where primarily the most concerning complications are neurological, particularly cerebral edema,” said Constantine J. Karvellas, MD, SM, FRCPC, Associate Professor of Medicine at the University of Alberta.
According to Dr. Karvellas, timely recognition of ALF is critically important, as are the management decisions that influence outcomes.
“Management of ALF patients is based on few randomized trials; however, basic neurocritical care and ICU supportive care are currently the mainstay,” Dr. Karvellas said.
One of the biggest concerns with ALF is development of cerebral edema, which is the cause of death in about 25% of patients. Therefore, the primary management focus is to protect the brain using simple neuroprotective measures such as raising the head of the bed to 30 degrees, minimizing suctioning or cough using lidocaine, sedating agitated patients, actively treating fever, maintaining a serum sodium at 145-150 mmol/L, and monitoring intracranial pressure in selected patients.
Additionally, improving ICU care and surgical techniques are improving post-transplant mortality. Data from a 2010 study looking at the European Liver Transplant Registry showed that prior to 1984 the one-year survival post-transplant was 38% compared with 77% from 2005-2008.
Moving forward, the field should focus on the need for improved prognostic methods and biomarkers, Dr. Karvellas said.
Next, Michael D. Leise, MD, of the department of gastroenterology and hepatology at Mayo Clinic, presented information on the appropriate perioperative management of hyponatremia.
“Hyponatremia in cirrhosis is defined by a serum sodium value of <130 mEq/L and the prevalence in patients with cirrhosis and ascites is about 22%,” Dr. Leise said. The effect of hyponatremia on patients is considerable. Patients may experience complications of cirrhosis such as renal failure or bacterial infection, have decreased quality of life, an increased risk of 90-day mortality and post-transplant morbidity, and, possibly, a decrease in post-transplant survival. One of the biggest concerns for most providers is osmotic demyelination syndrome (ODS), which has devastating outcomes that underscore the importance of chronic hyponatremia management. Currently, the best perioperative management strategy to avoid ODS is to avoid an increase in serum sodium of >8 mEq/L in 24-hour period. However, how to best accomplish this has not been well studied.
Among the basic general strategies that clinicians can use to correct chronic hypovolemic hyponatremia are the cautious use of normal saline and withdrawal of diuretic. The management of hypervolemic hyponatremia – which is the majority of patients – is determined by the anticipated time to liver transplant. Management strategies may include withdrawal of diuretics, removal of the potential offending drugs, water restrictions, correction of hypokalemia, use of 25% albumin with or without furosemide, arginine vasopressin receptor antagonists, and 3% saline.
Overall though, there is not a lot of data available in this area, Dr. Leise said. “We need more data and the only way that is going to come about is through cooperation from centers in doing multi-site prospective studies in this area,” he said