Assistant professor of Hepatology Alexandria University LDLT Amany Saleh Elyamany Assistant professor of Hepatology Faculty of Medicine Alexandria University

Natural history studies of cirrhosis find that the development of decompansation is associated with a decreased median survival from greater than 12 years to 2 years.

Each transplant program has its own program specific guidelines.  AASLD has created recommendations for candidate evaluation and selection for transplantation when a patient develops a decompensation, reaches a CTP score of ≥ 7, or reaches a MELD score of ≥ 10 

MELD scoring system was adopted February 2002 to prioritize patients with ESLD for organ allocation.  The MELD score deteremines "sickness of the liver" and is a mathematically derived number based upon a score calculated using serum bilirubin, INR, and creatinine.  It was originally developed by a team at the Mayo Clinic in Rochester, Minnesota to predict survival after the placement of a TIPS in patients with cirrhosis. Ideally, the timing of liver transplantation occurs when the risk of dying from the liver disease is greater than the risk of dying from the surgical procedure.

Indications for Living Donor Liver Transplantation

Contraindications for Living Donor Liver Transplantation (Exclusion criteria)

Pre-transplant Evaluation (LDLT)

Evaluating a potential donor Donor safety is paramount.

Donor Criteria for LDLT

Treatment of Underlying Liver Diseases

Patients with end-stage liver disease and with GFR less than 30 ml/min, or hepatorenal syndrome requiring renal replacement therapy more than 8–12 weeks, and patients with renal biopsy revealing more than 30% fibrosis and glomerulosclerosis would benefit from receiving both liver and kidney calculated using the Modification of Diet in Renal Disease 6 (MDRD6) formula,

Different types of liver transplantation

cyclosporine (CsA) and tacrolimus (Tac) bind to cytoplasmic receptors (cyclophilin and FK-binding protein 12, respectively), and the resulting complexes inactivate calcineurin, a pivotal enzyme in T cell receptor signalling. Calcineurin inhibition prevents IL2 gene transcription, thereby inhibiting T cell IL production. AZA is a prodrug of 6-mercaptopurine that inhibits inosine monophosphate dehydrogenase (IMPDH) and reduces purine synthesis, affecting T and B lymphocyte proliferation [269]. Mycophenolic acid is the active metabolite of MMF and is a selective, non-competitive inhibitor of IMPDH. Sirolimus (SRL) and everolimus (EVR) are inhibitors of the mammalian target of rapamycin (mTOR). Their immunosuppressive activity is related to the blockade of IL-2 and IL-15 induction of proliferation of T and B lymphocytes.

Surgical complications Vascular complications Biliary tract complications

Medical complications

Prevention and treatment of HBV recurrence

Prophylaxis in patients receiving livers from anti-HBc positive donors

Management of patients transplanted for alcoholic liver disease

Management of HCC recurrence

Management of renal dysfunction

Prevention and treatment of infections

Prevention and treatment of diabetes, hypertension, cardiovascular disease (metabolic syndrome), bone disease and de novo tumours

Lifestyle in the long-term follow-up