Liver Transplant (Wakil 7/23/25)

 A recording of this presentation is available HERE (check back if link not active).

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Thank you to Dr. Adil Wakil, CPMC liver transplant hepatologist, who kicked off Grand Rounds this year with a presentation on Liver Transplant.

He reminded us that the liver is the largest internal organ vital for metabolism, responsible for a plethora of functions including:

• energy metabolism
• protein metabolism
• bile production
• alpha 1 antitrypsin production
• immune function (with innate immune cells)
• lipoprotein metabolism (including converting LDL)

In addition, the liver receives "secondary wastewater" from the body, receiving 80% of portal vein flow as well as gut flow (from the SMA, splenic vein, IMA, etc).

Elevations of AST/ALT > 1000 occur in only three conditions: viral hepatitis, toxin-induced, and shock liver (i.e. ischemic)

Lab abnormalities provide us clues about the type of hepatic injury:

• hepatocellular injury: AST/ALT/LDH
• cholestatic injury: ALK Phos, GGT, Bilirubin
• synthetic capacity: INR/albumin and prealbumin/lipoproteins

**INR is best predictor of prognosis

Chronic vs. Acute Liver Disease

Chronic: long course (years), portal hypertension, encephalopathy, sometimes irreversible (though new evidence showing remodeling is possible)

• alcohol, 
• metabolic dysfunction (MASLD) 
• High fructose corn syrup has lead to huge increases in obesity in America (since the 1980s), combination of addiction and epigenetics)

Acute: short course (< 8 weeks), rare to see portal hypertension & encephalopathy, commonly see acute cerebral edema, often reversible

• HAV, HBV, toxin-induced, HCV (now most commonly seen in prison population)

Liver Failure

parenchymal: cholestatic changes, jaundice, weakness, fatigue, coagulopathy, HCC

portal hypertension: splenomegaly, GIB, ascites/SBP, encephalopathy, hepatopulmonary

Assessing for Decompensated Cirrhosis

Child's Criteria (CTP score: https://www.hepatitis.va.gov/cirrhosis/background/child-pugh-calculator.asp)

CTP A: 5-6 points

CTP B and C >7 points denotes decompensated cirrhosis>> transplant referral

MELD 3.0 (https://optn.transplant.hrsa.gov/data/allocation-calculators/meld-calculator/) is used to predict 90 day mortality, revised 2023 to correct for inequities in organ assignments for for female patients). MELD max score is 40. A MELD of >15 predicts that risk of surgery for transplant is smaller than the risk of dying from liver disease.

Liver transplant began in the US in the 1960s

Now >11,000 Liver Transplants/year in the US

Survival rates: 96% @ 1 year, 88% @ 5 year, 71% @ 10 year

Much of improved survival is attributable to immunosuppressant therapies, especially Tacrolimus

Patients with alcoholic liver disease (ALD) are not excluded from assessment for liver transplantation but most demonstrate (1) insight into their disorder (2) a period of prolonged abstinence (not quantified).