David Mutimer
MD, FRCP, FRACP
Queen Elizabeth Hospital. UK


As increasing numbers of patients survive the challenges of the
perioperative period, focus has shifted from 1-year survival(a traditional
measure of the transplant unit`s success) to factors affecting long-term graft
and patient outcome, and factors that influence quality of life.
Timing of Referral in
Chronic Liver Disease
 Clinical decompensation of chronic liver disease is the most common
indication for liver transplantation. Physicians should consider referral to a
transplant unit when the anticipated survival of the patient may be less than 1
year, or when the liver disease is responsible for an unacceptable quality of life
(e.g. refractory pruritus in primary biliary cirrhosis). It should be remembered
that patients with compensated cirrhosis may have an excellent intermediate-
term prognosis; thus, cirrhosis per se is not an indication for referral to the
transplant unit. Although it was not designed to determine the timing of
patient referral, many clinicians use the Child-Pugh scoring system for an
assessment of disease stage and severity.
 · Most patients with class A disease are at too early a stage for
transplantation.
 · Patients with class B disease should be discussed with the transplant unit.
· Patients in class C should be referred for transplant assessment.
 Specific events in the natural history of chronic liver disease that should
prompt referral include diuretic-resistant ascites(when a modest dose of
diuretic fails to resolve the ascites or clearance can be achieved only at the
expense of serum electrolyte derangement); spontaneous bacterial peritonitis
(usually observed in the context of diuretic-resistant ascites); hepatorenal
failure; hepatic encephalopathy; and portal hypertensive bleeding(in the
context of advanced liver dysfunction).
The Operation
 Most transplantations involve complete hepatectomy followed by
implantation of the new liver in the orthotopic position(orthotopic liver
transplantation). Typically, the normal vascular anatomy is restored and end-
to-end choledochocholedochostomy(sometimes over a T-tube) is performed.
When the recipient bile duct is diseased(as in primary sclerosing cholangitis),
Roux-en-Y choledochoenterostomy may be performed.
 In selected patients with metabolic liver disease(e.g. Crigler-Najjar
syndrome), auxiliary partial orthotopic liver transplantation may be performed;
this requires left lateral segmentectomy of the recipient`s liver followed by
placement of nondiseased donor liver segments in the orthotopic space. It
may be used in the treatment of selected patients with fulminant hepatic
failure, in whom the auxiliary organ may provide life-saving hepatic function
pending possible recovery of the native diseased liver.
Graft Rejection
 Acute cellular rejection causes early biochemical dysfunction and is confirmed
by liver biopsy. Acute rejection usually responds to high-dose corticosteroids
and seldom causes graft loss. Chronic, irreversible graft rejection typically
develops during the first year post-transplantation and is associated with
progressive jaundice. It affects fewer than 5% of recipients. The histological
features are characteristic and include degeneration of interlobular bile ducts
("vanishing bile duct syndrome") and small artery occlusion by lipidladen
macrophages. Treatment is unsatisfactory and most patients require
retransplantation.
Opportunistic Infection
 Serious fungal infection may occur in the context of a complicated
postoperative course. Selected high-risk patients are suitable for antifungal
prophylaxis.
 Symptomatic cytomegalovirus infection occurs in 10 to 20% of patients.
However, improved diagnostic techniques(e.g. polymerase chain reaction
analysis) and new approaches to prophylaxis and prevention(e.g. oral
ganciclovir in those at high risk) have almost eliminated the risk of life-
threatening infection. Other opportunistic infections are now rare.
Recurrent Liver Disease
 Diseases that may recur in the transplanted liver include viral hepatitis
(though prevention of recurrent hepatitis B virus infection is usually possible2),
primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune hepatitis,
genetic haemochromatosis and alcoholic liver disease. Recurrent disease has
little impact on short-term graft and patient outcome. However, recurrent HCV
infection can be aggressive and rapid progression to graft cirrhosis may be
observed.
The Future
 Short-term graft and patient outcome are excellent, and results are now
improved because of refinement of the recipient selection process, improved
surgical and anaesthetic techniques, and advances in the prevention and
treatment of graft rejection and opportunistic infections. In the future, the
long-term morbidity associated with immunosuppression must be reduced, and
recurrent liver diseases, particularly HCV infection, must be prevented and/or
treated.■ 기사 요지 

 본지 자매지 메디칼프로그레스(Medcal Progress) 4월호에 게재된 글로 간이식에 관한 내
용이다.
 상당수의 의사들이 간이식을 결정하는 간질환 상태를 평가하는데 있어 `Child-Pugh` 평가
등급을 활용하고 있다. A등급의 경우 이식여부를 결정하기에 너무 이르며, B등급 분류환자는
이식센터와의 협의가 필요한 단계이고, C등급은 간이식 평가를 의뢰해야 하는 단계로 분류된
다.
 이식술 후에는 심각한 진균감염증 발생위험이 있는 만큼, 고위험군 환자의 경우 항진균예방
이 필요하다. 10~20%의 환자에게서 사이토메갈로바이러스 감염증이 발생하지만, 진단 및
예방기술의 발달로 생명을 위협하는 수준의 감염위험은 줄고 있다. 정리·이상돈 기자
sdlee@kimsonline.co.kr
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