**2.3. Evaluation of renal function**

investigations should be undertaken for patients who have three or more associated risk factors of the following: diabetes, left ventricular hypertrophy, history of CAD, age > 60 years,

• computerized cardiac tomography which allows calculating the calcium score; this is a rapid and non-invasive way to measure calcium deposits in the coronary vessel wall as an expression of coronary stenosis; results are measured in Ca scores: a Ca of >100 score car-

Valvular dysfunctions in the cirrhotic patient on the transplant list are poorly studied. The evaluation of such a patient should include the severity of the valve dysfunction, either stenosis or regurgitation, the degree of alteration of myocardial contractility and the clinical presence of signs of insufficient cardiac output. Several cases of simultaneous liver transplantation and aortic valve replacement for tight aortic stenosis were reported in the cirrhotic patient [6].

Chronic liver disease can affect both the pleural space and the pulmonary parenchyma. The two pulmonary conditions characteristic of the cirrhotic patient are hepatopulmonary syndrome and pulmonary hypertension. The two syndromes exclude each other, and their pathophysiology depends on predominant vasodilator or vasoconstrictor elements resulting

**Portopulmonary hypertension** is a pulmonary hypertension syndrome with vascular obstruction, coexisting with portal hypertension. The portopulmonary syndrome has important hae-

All patients proposed for transplantation should be screened for portopulmonary hypertension as the postoperative evolution depends on it. It might be suspected in the case of a right branch block on ECG. Echocardiography can detect pulmonary hypertension and can evaluate it, but correct values are obtained by right heart catheterization. Depending on the mean pressure in the pulmonary artery (PAPm), hypertension is classified in mild (PAPm

Severe pulmonary hypertension excludes the patient from liver transplantation; moderate form may benefit from vasodilator drug treatment in pre-transplant [4]. Decision to perform liver transplant in this case depends on the response to therapy and is taken by the transplant

**Hepatopulmonary syndrome** is characterized by hypoxemia secondary to intrapulmonary shunt due to vascular dilation. In contrast with pulmonary hypertension that may be

25–34 mmHg), moderate (PAPm 35–44 mmHg) and severe (PAPm >45 mmHg).

modynamic consequences with minor changes in blood gases.

smoking, hypertension, dyslipidaemia and obesity [4, 9].

212 Organ Donation and Transplantation - Current Status and Future Challenges

• stress echocardiography using dobutamine, adenosine or dipyridamole,

ries a moderate risk of cardiac events and a score of >400 a high risk [10].

Several types of investigations have been proposed:

• myocardial perfusion scintigraphy,

**2.2. Pulmonary system**

from liver dysfunction.

team on an individual basis.

Renal dysfunction in the cirrhotic patient is due to a decreased blood volume due to vasodilation, with a decrease in glomerular filtration. It may not be reflected correctly in serum creatinine levels; the end-stage liver disease patient often has a less muscle mass and a low creatinine production. Higher sensitivity tests are cystatin C or NGAL (neutrophil gelatinaseassociated lipocalin).

Two types of kidney dysfunction are related to cirrhosis: hepatorenal syndrome is type 1 with rapid deterioration in renal function (doubling serum creatinine or increasing it to >2.5 mg/dl in less than 2 weeks) and a type 2 with slower evolution.

The occurrence of renal dysfunction can be precipitated by haemorrhage and infection [4, 16]. Preoperative renal dysfunction increases the risk of adverse development of postoperative complications.

#### **2.4. Coagulation status**

Coagulation abnormalities are caused by reduced concentrations of vitamin K-dependent factors and an imbalance between procoagulant and anticoagulant factors. Standard coagulation tests do not reflect rebalanced haemostasis and must not be used to predict the risk of bleeding. Procoagulant factors must not be administered unless signs of bleeding are present [17].

The Guidelines of the European Society of Anaesthesia regarding cirrhotic patients do not recommend routine preoperative correction of international normalized ratio (INR) (1.5–5) using fresh-frozen plasma but advise correction through point of care tests: rotational thromboelastometry or thromboelastography [18].
