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Treating patients with end-stage liver disease: Are we ready?
- Dr. Mino R. Mitri, M.D., C.M., M.Ed., FRCPC
mino.mitri@ubc.ca
Treating patients with end-stage liver disease: Are we ready? Dr. - - PowerPoint PPT Presentation
Treating patients with end-stage liver disease: Are we ready? Dr. - - PowerPoint PPT Presentation
Treating patients with end-stage liver disease: Are we ready? Dr. Mino R. Mitri, M.D., C.M., M.Ed., FRCPC mino.mitri@ubc.ca No Conflict of Interest 157 patients 157 6 patients transplanted Criteria Liver Palliative Care
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No Conflict of Interest
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157 patients
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157 patients 6 transplanted
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Liver Transplant Palliative Care Approach
Criteria
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Liver Transplant Palliative Care Approach
Criteria
=
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“…advanced chronic liver disease when the limits of medical therapy have been reached.” AASLD 2013
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“Patients should be selected if expected survival in the absence of transplantation is one year or less, or if the patient had an unacceptable quality of life because of liver disease.” EASL 2015
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“Patients should be selected if expected survival in the absence of transplantation is one year or less, or if the patient had an unacceptable quality of life because of liver disease.” EASL 2015
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“An a approach t that i improves t the q qua uality o
- f life of
patients a and t their families f facing t the p problem associ ciated wi with life-threa eaten ening i illnes ess, t through t the prevention a and r relief o
- f suffering b
by means o
- f early
identification a and i impeccable a assessment a and treatment o
- f pain a
and o
- ther p
problems, p physical, psychological a and s spiritual.”
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Liver Transplant
Palliative Care Patient with ESLD
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Hawley, 2014
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Hawley, 2014
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Compensated Cirrhosis
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Compensated Cirrhosis 6-12 years
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Compensated Cirrhosis Decompensated Cirrhosis
6-12 years
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Compensated Cirrhosis Decompensated Cirrhosis
6-12 years 2 years
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Class A Class B Class C
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Class A Class B Class C 1 year survival 100% 80% 45%
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Model for End-Stage Liver Disease (MELD) Score
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15
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20-25% Death
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5-10% Clinical Deterioration
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< 2 months
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10%
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“…well enough to undergo evaluation and listing, but sick enough to have developed signs of progression to a terminal state”.
Fox, 2014
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Liver Transplant
Palliative Care Patient with ESLD
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Liver Transplant
Palliative Care Patient with ESLD
+
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Hawley, 2014
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Treating patients with end-stage liver disease: Are we ready?
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Treating patients with end-stage liver disease: Are we ready?
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Patient Care
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Patient Care ESLD
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Patient Care Cancer ESLD
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Ascites Cirrhotic Cardiomyopathy Gastroesophageal Varices Hepatic Encephalopathy Hepatic Hydrothorax Hepatocellular Carcinoma Hepatopulmonary Syndrome Hepatorenal Syndrome Portal Vein Thrombosis Portopulmonary hypertension Spontaneous Bacterial Peritonitis
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Ascites Cirrhotic Cardiomyopathy Gastroesophageal Varices Hepatic Encephalopathy Hepatic Hydrothorax Hepatocellular Carcinoma Hepatopulmonary Syndrome Hepatorenal Syndrome Portal Vein Thrombosis Portopulmonary hypertension Spontaneous Bacterial Peritonitis
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Portal Hypertension Non-Portal Hypertension vs
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Portal Hypertension Non-Portal Hypertension vs
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Spirinolactone Furosemide 5:2 ratio
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Furosemide
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Furosemide X
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Spirinolactone Furosemide 100mg : 40mg
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< 2gm / day
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Large Volume Paracentesis (>5L)
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Large Volume Paracentesis (>5L)
6-8gm of Albumin per extra liter
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Malignancy Cirrhosis
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Peritoneovenous Shunting Malignancy Cirrhosis
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Transjugular Intrahepatic Portosystemic Shunt (TIPS) Peritoneovenous Shunting Malignancy Cirrhosis
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Portal Vein
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Hepatic Vein Portal Vein
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Ascites Cirrhotic Cardiomyopathy Gastroesophageal Varices Hepatic Encephalopathy Hepatic Hydrothorax Hepatocellular Carcinoma Hepatopulmonary Syndrome Hepatorenal Syndrome Portal Vein Thrombosis Portopulmonary hypertension Spontaneous Bacterial Peritonitis
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Ammonia (NH3)
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Bloodstream
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Ammonia (NH3) Bloodstream
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Ammonia (NH3) Bloodstream
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Ammonia (NH3) Bloodstream Ammonium (NH4+)
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Ammonia (NH3) Bloodstream Ammonium (NH4+)
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Ammonia (NH3) Bloodstream Ammonium (NH4+)
Lactulose 30-45mL PO TID-QID
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Ammonia (NH3) Bloodstream Ammonium (NH4+)
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Ammonia (NH3) Bloodstream Ammonium (NH4+)
Rifaximin 550mg PO BID or 400mg TID
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(Peng et al., 2018)
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(Peng et al., 2018)
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(Peng et al., 2018)
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(Peng et al., 2018)
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Always prescribe lactulose
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Go REALLY low and REALLY slow
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Opioids Fentanyl Oxycodone Hydromorphone Morphine Tramadol Codeine Methadone
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Opioids Fentanyl Oxycodone Hydromorphone Morphine Tramadol Codeine Methadone
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Non-Opioids Carbamazepine Nortriptyline Acetaminophen Pregabalin Gabapentin NSAIDs
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Non-Opioids Carbamazepine Nortriptyline Acetaminophen Pregabalin Gabapentin NSAIDs
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Patient Care Cancer ESLD
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Ascites Cirrhotic Cardiomyopathy Gastroesophageal Varices Hepatic Encephalopathy Hepatic Hydrothorax Hepatocellular Carcinoma Hepatopulmonary Syndrome Hepatorenal Syndrome Portal Vein Thrombosis Portopulmonary hypertension Spontaneous Bacterial Peritonitis
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Treating patients with end-stage liver disease: Are we ready?
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Treating patients with end-stage liver disease: Are YOU ready?
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- Dr. Mino R. Mitri, M.D., C.M., M.Ed., FRCPC
mino.mitri@ubc.ca