Mistakes in ... Booklet 2020 - 14

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Mistakes in... 2020

Transplant surgeon
and anaesthetist
Psychiatrist, psychologist
and social worker
Addiction specialist
Figure 2 | The transplant evaluation process in
patients with alcohol-related liver disease.

hepatitis when they are selected via a strict
multidisciplinary consensus (2-year survival
of 77%, risk of relapse of 11.5%).24 Under the
umbrella of the Italian Association for the Study of
the Liver, our centre in Padova started a program
of early liver transplantation in patients with
alcoholic hepatitis who are not responding to
medical therapy. Our protocol mimics that
conceived by Mathurin et al.,24 as we believe this
approach can bring transparency and consensus
when making such difficult decisions.

Mistake 2 Assuming the patient is too old or
too obese for liver transplantation
Liver transplant candidates may have
demographic (e.g. age) and/or clinical (e.g.
obesity) characteristics that make it borderline
whether or not it is safe for them to undergo liver
A patient may ask if being 70 is too old to get a
new liver. Although it is unclear whether there is an
age above which liver transplantation should be
contraindicated, it's clear that liver transplantation
should not be ruled out just because the patient is
a certain age. A few preliminary reports have
suggested that recipients over 65 years old
may have a worse outcome than their younger
counterparts, but physiological age seems more
important than chronological age.2 Indeed,
excellent results have been reported in recipients
older than 65 as long as they are selected carefully
(especially with regard to cardiovascular and
pulmonary comorbidities).25,26
The proportion of registrants older than 65
years of age has increased considerably both in
Europe and the United States,27 and it is expected
to increase further due both to the aging
population present in Western societies and
to changes in liver transplantation indications
(i.e. the decrease in liver transplantation for
HCV-decompensated cirrhosis and its increase
for NASH-related cirrhosis and/or NASH-related
hepatocellular carcinoma [HCC]). Age per se must
not, therefore, disqualify candidates for liver

transplantation, and the final decision for
listing an 'old' candidate (70 years of age or
older) should be taken after a multidisciplinary
discussion with the transplant team.2
Another frequent dilemma is whether a patient
is too obese for transplantation. A very high body
mass index (BMI) presents technical challenges
when performing transplant surgery, but it's
unclear whether it is associated with an increased
risk of complications or death.28 Class III obesity
(BMI ≥40) at the time of liver transplantation
was associated with worse outcomes in a recent
analysis of the United Network for Organ Sharing
database,29 but high BMI was not associated with
an increased risk of death in two other studies
when adjusted for ascites.30,31 So far, no upper limit
of BMI that makes a candidate too 'difficult' to be
transplanted has been identified.
As with older patients, obese patients do need
particularly careful assessment prior to listing.28
Expertise in selection and post-operative
management of obese patients who undergo
abdominal surgery is increasing, and we hope this
will improve the outcome of obese patients
undergoing liver transplantation. To ensure
a balanced evaluation of the benefits and risks, as
well as to evaluate the indication for bariatric
surgery as an adjunct to liver transplantation,
obese patients should be referred to tertiary
centres with extensive experience in the field.

Mistake 3 Not paying enough attention
to sarcopenia in patients awaiting liver
The management of patients awaiting liver
transplantation can be very challenging.
Treatment of complications related to portal
hypertension, bridging treatments for HCC,
frequent hospitalizations, real-time updates of
patient status, and so on, make it easy to forget
about skeletal muscle abnormalities,
including sarcopenia. In the past few years,
however, particular emphasis has been given to
this issue by the transplant community, as
sarcopenia was found to be an independent
predictor of clinical outcomes. Sarcopenia-
defined as a "generalized and progressive loss of
skeletal muscle mass, strength, and function"-
is present in up to 70% of patients with
decompensated cirrhosis,32 and is associated
with an increased risk of liver decompensation,
increasing morbidity and mortality both before
and after liver transplantation.33,34
Evaluation of muscle mass should be
performed in the work-up of all patients with
cirrhosis at the time of listing.2,3 In the transplant
setting, the diagnosis of sarcopenia is particularly
easy, as the quantification of muscle mass can be
obtained by looking at the CT scan required for
liver transplantation evaluation. In our clinical
practice, we calculate the skeletal muscle index
(SMI) at the L3 level, and we define a patient as

sarcopenic if they have an SMI <50cm2/m2 (male)
or <39cm2/m2 (female).
Although a CT scan is the gold standard for the
diagnosis of sarcopenia,35 there are other simple
tests that are immediately available in daily
practice and that can be used to stratify patient
risk, including the "Liver Frailty Index" (grip
strength, chair stands, and balance). This index
evaluates residual physical function, thus being a
surrogate of sarcopenia, and independently
correlates with the risk of death.36
Treatment of sarcopenia is based on dietary
intervention. Patients should consume
30-35kcal/kg of dry body weight/day (with
50-60% of calories as carbohydrates and 20-30%
as fat), including 1.2-1.5g of protein/kg of dry
body weight/day. Meat consumption is not
prohibited for patients with hepatic encephalopathy,
but vegetables and/or dairy proteins may be more
beneficial for the removal of ammonia via the
glutamine pathway. It is important to shorten
the duration of the fasting period, as prolonged
fasting is associated with enhanced and
uncontrolled proteolysis. In patients with
cirrhosis, the inclusion of a long-acting energy
source containing complex carbohydrates
(e.g. pasta, bread, rice, potatoes) in the late
evening followed by an early morning protein
supplement provides great benefit for the
prevention of muscle loss. In our practice, we
recommend that patients with decompensated
cirrhosis have 5-6 meals per day, including a late
dinner and an early breakfast.
Strong evidence supporting the utility of
physical exercise in reversing sarcopenia in
patients with cirrhosis is lacking, but it is
reasonable to expect that gentle physical
therapy may prevent further muscle loss.
Physical exercise should be customized and
always coupled with appropriate nutritional
supplementation.37 If it can be tolerated, we
encourage our patients to walk for 40-50 minutes
three to four times per week.

Mistake 4 Thinking that patients with
cirrhosis and HCC can be transplanted
only if the tumour is within the Milan
For patients with HCC, recipient selection is of the
utmost importance for determining the risk of HCC
recurrence and patient survival. Morphological
criteria based on tumour size and number were
introduced in 1996-the Milan criteria-and
quickly became the 'conventional criteria' after
being incorporated in the Barcelona Clinic Liver
Cancer and United Network for Organ Sharing systems.38 According to the EASL guidelines,2,11 liver
transplantation is the first-line option for HCC that is
within the Milan criteria (a single HCC ≤5cm or
multiple HCCs ≤3 nodules ≤3cm in size, without
vascular invasion) but unsuitable for resection.
Patients with HCC beyond the Milan criteria can


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