الفهرس 
Patho-physiology of End-Stage Liver Disea se (ESLD)Disea se (ESLD)Only 14 pages are availabe for public view
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Abstract
OLT has become an accepted therapy for end stage liver disease in children and adults as well as certain hepatic malignancies. The liver transplantation patient is highly demanding in the technical aspect of surgery and the medical aspects of patient support before and after transplantation. The anesthetic Intraoperative management of the transplant procedure is divided into the preanhepatic, anhepatic, neohepatic (reperfusion) stages as described under surgical consideration.
Considering the numerous synthetic and metabolic functions of the liver, the manifestations of end-stage liver disease extend to virtually every other organ system and anaesthetic management must include protection of other organs damaged by liver failure.
Advanced liver disease results in two cardinal pathophysiologic abnormalities: Hepatocellular failure and portal hypertension. Portal hypertension is rarely a clinical problem in acute liver failure, but can cause complications in cirrhotics even when hepatocellular function is relatively well preserved. The importance of these two factors is recognized in the Child-Turcotte- Pugh classification, a prognostic tool in patients with cirrhosis.
Manifestations of hepatic decompensation include variceal bleeding, ascites, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, portopulmonary hypertension, and hepatocellular carcinoma.
The onset of renal failure in a patient with cirrhosis or acute liver failure (ALF, also known as ”fulminant liver failure”) is alarming because it raises the possibility of the hepatorenal syndrome (HRS). HRS is a distinct form of renal failure that occurs in the setting of severe liver disease. HRS is the most frequently fatal complication of cirrhosis, because nearly half of patients die within 2 weeks of this diagnosis.
The Classification of HRS is: Type 1: cirrhosis with rapidly progressive acute renal failure, Type 2: cirrhosis with subacute renal failure, Type 3: cirrhosis with types 1 or 2 HRS superimposed on chronic kidney, Type 4: fulminate liver failures with HRS disease or acute renal injury.
In the hepatic transplantation scenario, renal dysfunction episodes are very frequent and complicate both the management and the outcome of these patients. Care provided by anesthesiologists and the surgical procedure are more difficult when moderate to severe renal insufficiency is present.
Impaired renal function because of either AKI or CKD is common in patients with liver cirrhosis or fulminant hepatic failure presenting for OLT evaluation.
Prevention and monitoring of renal disease post–liver transplantation should include routine screening for albuminuria and measurement of GFR, management of hypertension and post transplant diabetes millets (PTDM), and minimal use of nephrotoxic agents.
The choice of dialysis modality including (CRRT), (PD), or intermittent hemodialysis (HD) is predominantly based on the clinical condition of the patient, the availability of the resources, and the expertise of the medical staff. In critically ill or hemodynamically unstable patients or in those at risk for pulmonary edema, both PD and CRRT may offer therapeutic advantages over intermittent HD because they better preserve hemodynamic stability and permit continuous volume control. Nonetheless, over the past decade, CRRT has gained increased popularity over PD as the treatment of choice for hemodynamically unstable patients despite the lack of objective data concerning the superiority of one modality over another.