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  • End-stage liver disease in patients who meet the minimal criteria for placement on the liver transplantation list as defined by the American Association for the Study of Liver Diseases.
  • Fulminant acute liver failure.
  • Hepatocellular carcinoma fulfilling Milan criteria (tumor > 2 cm but < 5 cm or up to three tumors each < 3 cm).
  • Some pediatric metabolic liver diseases as defined by the United Network for Organ Sharing (UNOS).

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Absolute

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  • Recidivism to alcohol and drug abuse (6-month abstinence- free period essential).
  • Significant portal venous thrombosis that precludes venous reconstruction.
  • Extrahepatic malignancies.
  • Systemic sepsis and certain untreated chronic infections (eg, tuberculosis, Mycobacterium avium-intracellulare).
  • In the case of hepatocellular carcinoma:
    • Vascular or biliary tree invasion.
    • Tumors outside Milan criteria.

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Relative

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  • Significant cardiopulmonary disease or other medical illnesses, with the exception of liver or biliary tree specific disease and renal disease.
  • Certain chronic infections (eg, HIV infection).
  • Profound physical deconditioning.
  • Advanced age (older than 70 years).
  • Poor psychosocial support (eg, homeless).
  • Inability to obtain immunosuppressive medications.

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  • The patient should be supine.
  • The left arm is extended and the axilla prepped in the sterile field (to provide access to the left axillary vein should venovenous bypass be required).
  • The right arm can be tucked or extended.

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  • All patients are admitted to the ICU. The majority of patients remain intubated with the anticipation of extubation on postoperative day 1.
  • Serial laboratory values are obtained (complete blood count, coagulation function, liver function tests).
  • Immunosuppression.
  • Oral medications (especially immunosuppression) are provided via nasogastric tube.
  • Infections and other postoperative complications are treated in a similar manner to all other ill patients (ie, do not overtreat because the patient has undergone transplantation).
  • Adequate nutritional support is of paramount importance in chronically malnourished patients with liver failure.
  • Volume overload should be avoided.

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  • Potential complications are numerous.
    • Acute renal insufficiency is common.
    • Other specific complications include infections (bacterial, fungal, and viral), rejection, biliary complications, bleeding, primary nonfunction, hepatic artery thrombosis, and portal vein thrombosis.

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