Evaluation of addition of EEG to MELD score on the short term outcome after Living Donor Liver Transplantation (LDLT)

Abstract

Liver Transplantation is the treatment of choice for patients with decompensated cirrhosis, acute liver failure or small hepatocellular carcinomas (HCCs).

The greatest proportion of deaths or retransplants after LT occur soon after transplantation. The causes of death and graft loss vary according to the interval from transplantation, with infection and intraoperative and perioperative causes accounting for nearly 60% of deaths and graft losses in the first posttransplant year. After the first year, death due to acute infections declines, whereas malignancies and cardiovascular causes account for a greater proportion of deaths. The recurrence of the pretransplant condition, especially hepatitis C virus (HCV) or autoimmune liver disease, is an increasingly important cause of graft loss the longer the patient survives transplantation for these etiologies. Today, death (or a need for retransplantation) attributable to acute or chronic allograft rejection is uncommon throughout the first 10 years after transplantation.

The transplanted liver becomes partially tolerant of immune-mediated injury, so the requirement for immunosuppression declines after the first 90 days. The continued use of immunosuppression carries inevitable consequences: an increased risk of bacterial, viral, and fungal infections, which can be recurrent or newly acquired; metabolic complications such as hypertension, diabetes mellitus (DM), hyperlipidemia, obesity, and gout; and hepatobiliary or extrahepatic de novo cancers [including posttransplant lymphoproliferative disorder (PTLD)]. The combination of the complications of immunosuppression and the recurrence of the underlying liver disease translates into a heavy burden of ill heath for many LT recipients.

Typically, clinical features of liver failure and portal hypertension resolve rapidly after LT, and they are not usual after the first 3 months. Liver tests are routinely monitored after LT. When liver tests are elevated for a healthy recipient, the course of action will depend on the severity and type of abnormality (cholestatic, hepatitic, or other).

Hepatic artery thrombosis (HAT) or stenosis may present clinically after 3 months.

There is no reliable marker for determining the effective level of immunosuppression; therefore, the choice of the agent (or agents) and doses given will be determined by the clinical, laboratory, and histological response.

The majority of LT recipients need lifelong immunosuppression to maintain graft function. A very small number of LT recipients develop operational tolerance to the allograft and do not require long-term immunosuppression.

Late rejection is defined as rejection that has its onset more than 90 days after transplantation. Traditionally, 2 forms have been recognized: cellular rejection and ductopenic rejection. Liver tests in patients with late-onset cellular rejection show nonspecific abnormalities with a rise in serum bilirubin and aminotransferases.

Bone loss and fracturing are seen with 2 distinct phases after LT. In the first 4 postoperative months, there is accelerated bone loss in almost all liver recipients. After the first 4 postoperative months with normal allograft function, bone metabolism improves, and in the osteopenic patient, there will be a gain in bone mass over the next postoperative years with a gradual reduction in the incidence of fractures.