Liver transplant patients & rehabilitation concerns

1. Liver transplant patients & rehabilitation concerns Jen Hokanson PTA Trish Beck PT

2. Anatomy • Largest organ in the body (weighs 3-4 pounds-size of a football) • Located in right upper quadrant • Connected to diaphragm by ligaments • Within 1/2 inch of pericardium • Connected to small intestine via bile duct • Filters about 1450ml of blood per minute • Contains 10% of body’s blood volume • Capable of 80-90% regeneration

3. Functions of the Liver • Blood flow through the liver (29% of total cardiac output) • Reservoir function (able to store up to 1 extra liter of blood) • Lymph function(1/2 of lymph is made by the liver) • Hepatic macrophage system (resists infections)

4. Metabolic functions of the liver • Carbohydrate metabolism • Fat metabolism • Manufactures proteins • Storehouse for vitamins, minerals & sugars • Blood coagulants • Iron • Metabolizes drugs, hormones, toxins

5. Bile: aids production of an alkaline reaction absorption of fats breakdown of cholesterol Substances excreted into bile bilirubin: endproduct of hemoglobin degradation 95% of the bilirubin ends up in the gut and 5% goes into the urine Excretory and Secretory Functions

6. Symptoms of liver dysfunction and their causes • Confusion caused by increased ammonia • Bleeding due to prolonged clotting time • Itching/jaundice due to increased bilirubin • Fluid retention caused by low albumin • Kidney damage shown by elevated creatinine

7. Liver Pathologies TYPES OF HEPATITIS • Hepatitis A-infectious hepatitis • Hepatitis B-most common form • Hepatitis C-most transplants • Hepatitis D- IV drug users • Hepatitis E

8. Alcoholic cirrhosis Chronic Hepatitis B, C, or D Hemochromatosis Wilson’s disease Alpha-1, antitrypsin deficiency Glycogen storage disease Bile duct obstruction (PSC, PBC) Prolonged exposure to environmental toxins Cardiac cirrhosis Severe reaction to drugs Parasitic infections Cirrhosis

9. Loss of appetite Nausea & vomiting Loss of weight Increased liver size Itching Ascites Jaundice Esophageal varices Encephalopathy Sensitivity to toxins (drugs & alcohol) Symptoms of Cirrhosis

10. Jaundice Obstructive Hemolytic Ascites Pruritis Hepatic Encephalopathy Portal Hypertension Xanthomas Poor Clotting Vit K malabsorption Fatigue Muscle Loss Tumors Trauma Liver Pathologies cont.

11. Bone Mineral Density • taken by photon absorptomety • Measured in gm/cm2 • usually lumbar or femur • Normal loss of BMD is 1-2%/yr after age 25 (accelerate in women after 50) • In chronic liver disease: • decrease in osteoblastic function • increase osteoclastic function • loss continues up to 3 mo after transplant

12. Primary Biliary Cirrhosis(PBC)-destroys the ducts that drain bile in the liver destruction of the ducts makes it difficult for the liver to perform its normal tasks affects the middle-aged PBC affects women 10 times more then men Conditions associated with PBC Osteoporosis Inflammatory Arthritis Thyroid disorders Sicca syndrome(tear glands and salivary glands fail to produce enough moisture) Liver diseases

13. Primary Sclerosing Cholangitis(PSC)-the ducts inside and outside the liver are narrowed most often affects people in their 30’s, 40’s and 50’s more common in men Symptoms: fatigue itching (pruritis). jaundice(due to buildup of bilirubin) diarrhea fever & chills. Associated Diseases Osteoporosis Inflammatory Bowel Disease. Liver Diseasescont.

14. FHF-Fulminant Hepatic failure Wilson’s Disease Budd Chiari ALD-alcoholic liver disease HCC-hepatocellular carcinoma polycystic disease Familial amyloidosis primary oxalosis Hemochromatosis Liver Diseasescont.

15. Preventing Liver Disease • Limit alcohol intake • Avoid exposure to man-made chemicals • Maintain adequate personal hygiene • Avoid excessive intake of cholesterol and saturated fats. • Limit use of drugs(acetaminophen, antibiotics, sulfa drugs) that can be harmful to the liver. • Be careful with questionable bacteria (“herbal” tea).

16. Patient experiences a roller coaster of emotions in the transplant sequence Patients need to be taught consistent and appropriate information Psychosocial Eval (performed by S.W.) referral relationship reactions roles resources recommendations Psychosocial Issues

17. Medical history Lab findings-especially (BMD and hemoglobin) x-rays results-looking for osteoporosis, compression fractures, etc. Examination posture strength current activity level ROM mental status Pre transplant teaching

18. PT program for pre liver transplant patient • Spinal protection education and performance • Strengthening • Cardiovascular activity as able (walking, bike, stair climbing) • AVOID: lifting, twisting, high impact sports/activities, joint jarring activities

19. Precautions for post-transplant patients • Do not treat the patient if you have a cold, cough, etc. • Wash hands prior to entering the room and put gloves on.

20. History Laboratory results Medications Examination edema ascites mental status jaundice PT program includes: AROM & CKC exercises stretches stair climbing avoid lifting over 10 pounds, twisting, kyphosis body mechanics instruction Post-Op Liver Transplant Evaluation

21. Caused by: prolonged position during surgery loss of abdominal strength increased weight due to fluid retention continued loss of bone mineral density for 3 months post-op Treatment: superficial heat mild extension exercise (upper back extension in sitting position) proper body mechanics log rolling and proper positioning Post transplant back pain

22. FACTORS Original disease decreased physical activity diuretic use decreased estrogen in women hyperparathyroidism smoking TREATMENT 1200-1500mg calcium per day adequate vitamin D minimal steroid use hormone replacement exercise & avoid smoking moderate sodium intake Post Transplant Osteoporosis

23. Diabetes Mellitus and Post Transplant Patients • Post transplant risk factors for DM include positive family history, cadaveric transplant recipient, older age, African American or Hispanic ethnicity • Cadaveric transplant recipients are more prone to DM due to steroids used vs. living related donor

24. Post Transplant DM Treatment • Self monitoring of blood sugar • weight maintenance • exercise • diet • insulin or an oral agent

25. Perceived exertion scale • Use it instead of target heart rate graph as patient’s medications can increase heart rate • encompasses sensation of exertion, physical stress, and fatigue • have patient stay around 11 or 12 on the scale

26. Perceived exertion scale • 6 (minimal effort: relaxing in a chair) • 7 very, very light • 8 • 9 very light • 10 • 11 fairly light • 12 • 13 somewhat hard • 14 • 15 hard • 16 • 17 very hard • 18 • 19 very, very hard • 20 (maximal effort: jogging up a steep hill)

27. Exercises • Warm-up exercises • Conditioning Phase(walking, bicycling) • Cool-down exercises • Warm-up and cool-down exercises are important to allow for gradual raising or slowing down of the heart rate thus preventing dizziness

28. Immunosuppressive Pharmacology • Tacrolimus “FK506” (Prograf) • Cyclosporine (Sandimmune, Neoral) • Corticosteroids(prednisone, methylprednisone) • Azathioprine (Imuran) • ATGAM and Thymoglobulin • Mycophenolate Mofetil (Cellcept)

29. Tacrolimus”FK506”(Prograf) • Cardiovascular • Hypertension • Myocardial hypertrophy • CNS,Musculoskeletal,Misc. • HA, tremor, paresthesias, seizures,coma and encephalopathy. • Acute nephrotoxicity • Hepatotoxicity

30. Cyclosporine (Sandimmune,Neoral) • Acute and chronic nephrotoxicity • Hypertension (65-85% of patients) • hepatotoxicity • CNS-seizures, paresthesias, HA,tremor, shaking • GI,dermatologic(gingivitis),endocrine.

31. Corticosteroids(prednisone) • Cardiovascular • hypertension,cardiomyopathy • CNS • tremors, neuritis, psychosis • Musculoskeletal • Cushing’s Syndrome,osteoporosis • Endocrine • increases blood sugar

32. Misc. Pharmacology • Antibiotics • Pain medications • Antihypertensive medications • Oral bowel decontamination solution

33. Routine Lab Tests • Alkaline Phosphatase • normal range: male 98-251 U/L,female 81-312 U/L • Bilirubin • normal range: total=less than 1.1 mg/dL, direct=0.0-0.3 • Serum Asparate Aminotransferase (SGOT, AST) • normal range: 12-31 U/L • Serum Alanine Aminotransferase (SGPT, ALT, GPT) • normal range: male 10-45 U/L, female 9-29 U/L

34. Routine Lab Testscont. • Blood glucose • normal range 70-100mg/dL • Creatinine • normal range: male 0.8-1.2 mg/dL,female 0.6-0.9mg/dL • Cyclosporine • normal range will vary with each person, depending on the combination of immunosuppressant medications and the length of time since the transplant

35. Routine Lab Testscont. • Hemoglobin (Hgb) • normal range: male 12.9-16.6g/dL,female 11.6-14.9g/dL • Potassium (K+) • normal range: 3.6-4.8mEq/L • White Blood Count • normal range: male 4.1-10.9x10(9)/L,female 4.0-10.4x10.9(9)/L

36. Child-Turcotte-Pugh Scoring System • This scoring system (which is also called CTP score) is based on the following: • level of encephalopathy • amount of ascites • labs work (bilirubin, INR, and albumin levels)

37. Status of people who need a liver transplant • Status 1 fulminant hepatic failure, primary graft non-function, pediatrics • Status 2A in ICU with <7 days life expectancy • Status 2B 10pts on CTP or 7pts with refractory ascites, refractory variceal bleeding, hepatorenal syndrome, or history of spontaneous bacterial peritonitis • MEDICAL URGENCY 1>2A>2B>3

38. Low Bacteria Diet • No fresh fruit and vegetables except: Thick skinned fruits that can be washed and peeled can be eaten. • Avoid all cheese products. • No yogurt. • Pasteurized fruit juices only.

39. Liver Transplant Statistics • 13,749 waiting for a liver transplant as of 9/99. • In 1998, 4,450 liver transplants were performed • Currently there are 126 liver transplant centers

40. Improvements in Liver Transplants • 1) Split: The 2 lobes go to 2 different recipients (20% of donors meet criteria for split liver) • 2)Live donor: Parent or genetic match gives left lobe. Within 2 weeks the donors residual liver grows to size needed. Recipients liver also grows to size needed. • 3)use of marginal donors (for example: using older donors)

41. Clinical findings age precipitating event physical exam past history hospital course Lab Values blood group, HLA+/- aminotransferases billirubin coagulation profile serology cultures blood gases Donor Assessment