Encephalopathy, ascites, bilirubin >51 μmol/L, albumin <28 g/L, INR >2.3 — 1-year survival without transplant <35%.
All values in mg/dL. Minimum value for each variable = 1.0 (to avoid negative log). Maximum creatinine = 4.0 mg/dL (or if on dialysis).
MELD-Na = MELD + 1.32 × (137 − Na) − [0.033 × MELD × (137 − Na)]
Used when serum Na <137 mmol/L. Hyponatraemia worsens prognosis independently of MELD. Na capped at 125 and 137 for calculation.
UK equivalent: 5.395 × ln(INR) + 1.485 × ln(creatinine) + 3.13 × ln(bilirubin) − 81.565 × ln(Na) + 435. Score ≥49 required for listing in UK.
Nurses play a central role in monitoring patients on the waiting list — early identification of deterioration is key to timely relisting upgrade.
Hospital upgrade criteria: MELD ≥25, refractory ascites, recurrent SBP, progressive encephalopathy, HRS development — escalate immediately to transplant coordinator.
LDLT uses a partial hepatectomy from a living donor — right lobe (60–65% of liver) most common for adult recipients. Both donor and recipient livers regenerate. Donor safety is paramount: donor mortality risk ~0.1–0.5% for right hepatectomy.
Deceased donor liver split between two recipients (adult + paediatric). Requires careful surgical planning; left lateral segment to child, right extended lobe to adult.
ICU Priority on Arrival: Systematic ABCDE assessment. Liver transplant patients arrive ventilated. Establish haemodynamic targets, review drain outputs, confirm graft viability with Doppler — first 72 hours are critical.
Albumin preferred colloid. Avoid normal saline in large volumes (hyperchloraemic acidosis). Target euvolaemia — avoid fluid overload (hepatic vein congestion impairs graft function).
Catastrophic failure of graft function from first 24–72h. Immediate re-listing required.
Action: Emergency surgical re-listing. Notify transplant team immediately.
Most common vascular complication. Early HAT: first 72h. Risk increased in LDLT.
Daily Doppler ultrasound first 72h. Report any absent waveform immediately. Surgical thrombectomy/re-anastomosis window is narrow — time-critical.
Drain bilirubin >3× serum bilirubin confirms bile leak. ERCP/MRCP for localisation. CT abdomen if collection.
| Type | Timing | Mechanism | Presentation | Management |
|---|---|---|---|---|
| Hyperacute | Minutes–hours | Pre-formed antibodies (ABO incompatibility) | Graft failure immediately in theatre; prevented by ABO matching | Prevented — ABO matching mandatory. Emergency re-transplant if occurs |
| Acute Cellular (ACR) | 6–30 days | T-cell mediated immune attack on bile ducts and portal tracts | Fever, RUQ pain, jaundice, elevated AST/ALT/ALP/bilirubin, reduced bile | Pulsed methylprednisolone 1g IV ×3 days. Most respond within 48–72h |
| Chronic Rejection | Months–years | Ductopenic rejection — progressive bile duct loss | Slowly rising bilirubin, ALP/GGT >> AST/ALT, ductopenia on biopsy | Tacrolimus optimisation, consider switch to mTOR inhibitor; may need re-transplant |
| Antibody-Mediated (AMR) | Variable | Donor-specific antibodies (DSA) targeting vascular endothelium | Mixed LFT pattern, microvascular injury on biopsy, positive DSA serology | Plasmapheresis, IVIG, rituximab; specialist centre management |
Report to medical team immediately if ≥2 of these are present post-transplant:
Liver biopsy — Banff grading for ACR: Grade I (mild, portal inflammation), Grade II (moderate, perivenular involvement), Grade III (severe, necrosis). Prepare patient for procedure; check platelets and INR first.
High-risk interaction — Azole antifungals markedly increase tacrolimus levels. Fluconazole, voriconazole, itraconazole inhibit CYP3A4 — can increase tacrolimus levels 3–5 fold. Dose reduction and intensive level monitoring mandatory.
Non-compliance with immunosuppression is the single most common cause of late graft loss. Patient education, blister packs, family involvement, and regular level monitoring are essential strategies.
Affects 20–40% of liver transplant recipients. Driven by tacrolimus (insulin resistance), prednisolone (glucose intolerance), pre-existing risk factors (NASH, obesity in GCC patients).
Affects >60% post-transplant. Caused by CNI vasoconstriction, steroid-related sodium retention.
Steroids and mTOR inhibitors (sirolimus/everolimus) cause dyslipidaemia. Monitor annually.
Calcineurin inhibitors (tacrolimus, cyclosporine) cause afferent arteriolar vasoconstriction, leading to chronic nephrotoxicity. Up to 20% develop CKD stage 3+ by 5 years.
Immunosuppressed patients in the Gulf have dramatically elevated skin cancer risk due to intense UV exposure. Annual dermatology review, high-SPF sunscreen daily, protective clothing and sun avoidance during peak hours (10am–4pm) are essential post-transplant advice for GCC patients.
Live vaccines are CONTRAINDICATED post-transplant: MMR, varicella, yellow fever, oral typhoid, live influenza (intranasal). Risk of disseminated live vaccine disease in immunosuppressed state.
Ideally complete vaccines before transplant — better immune response when not immunosuppressed.
| Feature | ACR | Chronic | AMR |
|---|---|---|---|
| Timing | 6–30 days | Months–years | Variable |
| Dominant LFT | ALT/AST + ALP/bili | Bilirubin + ALP | Mixed |
| Mechanism | T-cell | Ductopenic | DSA/antibody |
| Biopsy finding | Portal inflammation, Banff grade I–III | Bile duct loss | Microvascular injury |
| Treatment | Pulse methylprednisolone | Tacrolimus optimise | Plasmapheresis, IVIG |
| Drug | Key Side Effects | Monitoring | Exam Pearls |
|---|---|---|---|
| Tacrolimus | Nephrotoxicity, tremor, headache, NODAT, hypertension, alopecia | Trough levels, eGFR, BG, BP | Narrow therapeutic index; azoles dramatically raise levels |
| Mycophenolate Mofetil | Leucopenia, thrombocytopenia, anaemia, GI (diarrhoea, nausea) | FBC weekly ×4 then monthly | Teratogenic — women of childbearing age need contraception |
| Prednisolone | NODAT, hypertension, osteoporosis, Cushingoid features, peptic ulcer | BG, BP, bone density (DEXA) | Never stop abruptly; most centres withdraw by 3–6 months |
| Sirolimus/Everolimus (mTOR) | Hyperlipidaemia, mouth ulcers, impaired wound healing, pneumonitis | Lipids, sirolimus levels, LFTs | Avoid early post-transplant — impairs wound healing. Used CNI-sparing |
A: 3.78×ln(bilirubin mg/dL) + 11.2×ln(INR) + 9.57×ln(creatinine mg/dL) + 6.43
Remember: minimum value for all inputs = 1.0. Creatinine maximum = 4.0 (or dialysis). Score 6–40+ used for waitlist priority.
A: Pulsed methylprednisolone 1g IV daily ×3 days
Gold standard diagnosis is liver biopsy (Banff grading). ACR occurs 6–30 days post-transplant. 80–90% respond to steroid pulse.
A: 5–10 ng/mL (long-term maintenance)
Early (0–3 months): 5–15 ng/mL. Sample as trough — immediately before morning dose. Levels taken at consistent time.
A: Azole antifungals (fluconazole, voriconazole) — CYP3A4 inhibition causes 3–5-fold level rise
Can cause acute tacrolimus toxicity: AKI, neurotoxicity, tremor. Dose reduction + intensive monitoring mandatory when combined.
A: Single nodule ≤5cm OR ≤3 nodules each ≤3cm, no macrovascular invasion, no extrahepatic disease
5-year survival >70% within Milan criteria. Exceeding criteria = higher recurrence risk. AFP monitoring 6-monthly post-transplant.
A: All live vaccines — MMR, varicella (VZV), yellow fever, oral typhoid, live influenza (FluMist/LAIV)
Risk: disseminated live vaccine disease. Inactivated influenza, pneumococcal, hepatitis B/A, COVID-19 — all safe and recommended.
A: Non-compliance with immunosuppression
Also: chronic rejection, recurrence of original disease (HCV pre-DAA era, HCC, NAFLD), chronic CNI nephrotoxicity. Patient education on medication adherence is the single most impactful nursing intervention long-term.
A: Urgent Doppler ultrasound — absent/reduced hepatic artery flow = emergency surgical/radiological intervention
Daily Doppler monitoring for first 72h post-transplant. Early HAT within 72h requires emergency thrombectomy or re-transplant. Report sudden LFT spike (AST >1000) immediately — could be vascular.