Assessment of Graft Liver Function During Liver Transplantation SC 梁祥光

1. Assessment of Graft Liver Function During Liver Transplantation SC 梁祥光

2. What are we concerned about during liver transplantation?

3. Are the conditions of the patient stable? • Does the transplanted liver work?

4. What kinds of monitors or predictors are available?

5. For monitoring of vital signs: ECG, Swan-Ganz, CVP, A-line, oximeter, electrolyte, acid-base, urine output, body temperature

6. With regard to liver function, which predictors can be useful?

7. What are these ideas based on?

8. The functions of the liver • catabolic & anabolic functions (carbohydrate, fat & protein metabolism) • production of bile • production & execretion of bilirubin • immunological functions(cytokines & interferons) • scavenging & filtration of endotoxins & bacteria • storage of vitamin B12 & glycogen • biotransformation & elimination of drugs & xenobiotics

9. Ideal agents • nontoxic & lack pharmacological effects • administration • rate-determining steps of elimination • route of elimination • measurement • protein-binding • cost • reliable assay • generally available Gao L et al, Anaesth Intens Care 2000; 28: 375-85

10. Predictors or markers of liver functions(1) Hepatologist • prothrombin ratio • plasma enzymes(GOT, GPT) • bilirubin • albumin

11. Predictors or markers of liver functions(2) Anaesthetist • capacity-limited, binding-insensitive hepatic elimination neuromuscular blocking agent, aminopyrine, caffeine • capacity-limited, binding-sensitive hepatic elimination erythromycin • flow-limited elimination ICG, galactose J. W. Sear, Br. J. Anaesth. 2002 88: 757-760.

12. ICG • 95% albumin-binding • liver function & blood flow • IV injection(0.5mg/kg), blood sample(2ml at 5min intervals for 15-30min) • ICG elimination rate & graft liver function ICG clearance>200mi/min good liver function ICG clearance<200mi/min death, prolonged intensive care, retransplantation Gao L et al, Anaesth Intens Care 2000; 28: 375-85

13. Rocuronium(1) Aminosteroidal muscle relaxant Elimination Major(80%): liver Minor: kidney Metabolite: 17-desacetylrocuronium Assay train-of-four gas chromatographic-mass spectrometry L Gao, Br. J. Anaesth. 2002 88: 764-770

14. Rocuronium(2) What is observed in the administration of rocuronium? • pleohepatic phase rocuronium’s clearance is slightly less than that of patient with liver disease undergoing nontransplantation surgery and healthy control subjects • anhepatic phase rocuronium’s clearance is similar to that in the pleohepatic phase Dennis M Fisher et al, anesthesiology 1997; 86:1306-16

15. Rocuronium(3) • neohepatic phase decreased plasma rocuronium concentration compared with that during the anhepatic phase L Gao, Br. J. Anaesth. 2002 88: 764-770

16. Rocuronium(4) • postoperative outcome Fig 1 Percentage change in plasma recuronium concentration between neohepatic and anhepatic phases in patients who died after surgery and those who survived. L Gao, Br. J. Anaesth. 2002 88: 764-770

17. What can we do in the future? Prediction of prognosis? ↓ Sensitivity and specificity? ↓ D/D(surgical procedure, rejection)? ↓ Management? ↓ Outcome?

18. Thanks for your attention!