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The Selection of Patients for Hepatic Transplantation and the Place of Chemical Pathology in the Postoperative Management

Although there were many setbacks in the early days of hepatic transplantation, the recent results are more encouraging. Starzl in Denver has four patients alive, the longest survivor being 14 months after operation (Starzl, 1969). In the joint King's College Hospital and Addenbrooke's Hospital series there are two patients alive and well at six and five months (Williams et al., 1969). It is our policy to consider hepatic transplantation as a form of treatment for patients who would otherwise have a prognosis of less than six months. Because of the magnitude of the operation, it has been restricted to patients less than 60 years of age. Patients with primary malignant hepatic tumours form one such group (Lawrence et al., 1966) but unfortunately, up to a third have metastases at the time of operation and undetected metastases are a hazard. Four of StarzI's patients succumbed to metastases some months after transplantation and deposits were found in lymph nodes in one of our patients who died from infection at 10 weeks. Other suitable groups of recipients include children with biliary atresia who seldom survive early childhood and patients with advanced decompensated cirrhosis. In selecting potential recipients careful clinical assessment must be supported by laboratory data. Liver function tests serve as a preoperative baseline, and the patterns of disturbance have varied according to the underlying disease process. One patient with a hepatoma had entirely normal liver function and another with a carcinoma of the hepatic ducts had a serum bilirubin of 42 mg/loo ml and an alkaline phosphatase of 159 KA. units/loo ml. It was the poor prognosis in these patients rather than any particular biochemical criteria which determined the decision to perform hepatic transplantation. Electrolyte disturbances, particularly the hypokalaemia so often associated with the cirrhosis, were sought. Glucose tolerance is often impaired in patients with severe liver disease and one patient was an insulin dependent diabetic. Two others became frankly diabetic while on postoperative immunosuppression with prednisone, and a preoperative glucose tolerance test may help to predict this development. Polyuria and polydipsia in another patient with a cholangiocarcinoma undergoing preoperative assessment was found to be associated with a fasting serum