Liver Transplantation

Liver transplantation can be lifesaving for patients with FHF. However, the scarcity of donor organs and the rapidity of clinical deterioration with FHF limit transplant as an option for many patients. The one-year survival for orthotopic liver transplant for FHF at UCSF has been approximately 90%, although this is higher than other studies suggesting a 50 to 75% one-year survival.

Early contact with a transplant center hepatologist is essential. It is better not to wait until the patient is intubated and in deep coma to contemplate transfer to a transplant center. Timing is critical once a diagnosis of FHF is established. Indeed, at UCSF we have listed particularly ill patients for transplant while arranging for transfer to our facility. The current system for organ allocation allows high-priority ("status 1") listing for patients with FHF. Early referral is important so that the patient may be listed early for transplant, and also examined while still lucid. Many patients die or develop contraindications to transplant, such as brain herniation or refractory sepsis, while awaiting a donor organ. Although patients with FHF are listed as soon as possible after presentation, the decision to actually proceed with transplant at our center is made when an acceptable organ is identified, typically within 48 to 72 hours after listing. The decision to proceed with transplant can be a very difficult one because there is the possibility, particularly with FHF of rapid onset, of complete recovery, and liver transplantation requires that the patient remain on lifelong immunosuppression. Counterbalanced against this, the patient with FHF can rapidly deteriorate, so that if transplantation is initially deferred, there may not be another opportunity because the availability of donor organs is unpredictable. The rationale for extracorporeal liver assist devices (see Chapter 121,"Primary Biliary Cirrhosis") is to support the patient and prevent complications of FHF (eg, cerebral edema), thus allowing time for liver regeneration and recovery of liver function. If successful, this would potentially obviate the need for transplant, or at least preventing progressive deterioration while awaiting transplant, thereby acting as a "bridge" to transplant. Hepatocyte transplant has a similar rationale. Living donor transplant, which has become commonplace for treatment of chronic endstage liver disease, has also been used in the setting of FHF, although there are significant ethical concerns with the very rapid evaluation of potential donors that is required. Auxiliary or heterotopic liver transplant has also been used as a means of supporting the patient, allowing for regeneration of the patient's liver and ultimately withdrawal of immunosuppression. Total hepatectomy has also been performed while waiting for a donor organ. The rationale behind this procedure is that removal of the severely diseased liver and its byproducts may have a salutary effect on hemodynamics and intracranial pressure (ICP).

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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