Liver and Pancreas Transplantation

More than 6,000 liver transplantations are performed annually in the United States. Enhancements in patient selection and surgical technique and the availability of more powerful immunosuppressive agents have resulted in steady improvement in patient survival. As a result, liver transplantation has been accepted as the standard of care for patients with severe acute or chronic liver disease in whom conventional modalities of therapy have failed. The major obstacle to patients receiving the procedure is the critical shortage of donor organs. Many more recipients of liver transplantation are now receiving the bulk of their care from general internists, gastroenterologists, and primary care physicians. As a result, recognition of potential long-term complications and the need for appropriate immunizations and regular screening visits have become increasingly important. This chapter discusses who qualifies as a candidate for liver transplantation, contraindications to transplantation, timing of transplantation, operative procedures, complications of transplantation (e.g., perioperative and surgical complications, immunologic complications, infectious complications, complications of medical and immunosuppressive therapy, and disease-specific complications), and transplantation outcome. Pancreas transplantation, which aims at providing physiologic insulin replacement, is a therapy that reliably achieves euglycemia in patients with type 1 diabetes mellitus. The discussion of pancreas transplantation focuses on topics such as evaluation of candidates for transplantation (including islet transplantation); contraindications to transplantation; operative procedures; outcome survival; and the effect of transplantation on disorders associated with type 1 diabetes mellitus. The figures show estimated 3-month survival as a function of the Model for End-Stage Liver Disease (MELD) score, the sections of the liver that can be used for transplantation, an algorithm for evaluation of patients with type 1 diabetes mellitus being considered for pancreas transplantation, and an illustration of enteric drainage technique used in whole pancreas transplantation. The tables provide the common indications for liver transplantation, the scoring system for the Child-Turcotte-Pugh classification of liver disease severity, drug interactions with immunosuppressants, and immunization recommendations for liver transplant patients. This chapter contains 4 highly rendered figures, 4 tables, 101 references, 5 MCQs, and 1 teaching slide set.