LIVER TRANSPLANT
What is Liver Transplantation?
Liver transplantation is a surgery that is performed to remove a diseased liver in order to replace it with a healthy one. Such surgeries have been done for over 38 years. Several people who have had liver transplants go on to lead perfectly normal lives.
When does one require a liver transplant?
Liver disease severe enough to require a liver transplant can come from many causes. In adults, the most common reason for liver transplantation is cirrhosis. Cirrhosis is a condition in which the liver slowly deteriorates and malfunctions due to chronic injury. Scar tissue replaces healthy liver tissue, partially blocking the flow of blood through the liver. Cirrhosis can be caused by viruses such as hepatitis B and C, alcohol, autoimmune liver diseases, buildup of fat in the liver, and hereditary liver diseases. Many people who develop cirrhosis of the liver due to excessive use of alcohol also need a liver transplant. Abstinence from alcohol and treatment of complications for 6 months will usually allow some of them to improve significantly and these patients may survive for prolonged periods without a transplant. For patients with advanced liver disease, where prolonged abstinence and medical treatment fails to restore health, liver transplantation is the treatment.
In children, the most common reason for liver transplantation is biliary atresia. Biliary atresia is a rare condition in newborn infants in which the common bile duct between the liver and the small intestine is blocked or absent. Bile ducts, which are tubes that carry bile out of the liver, are missing or damaged in this disease, and obstructed bile causes cirrhosis. Bile helps digest food. If unrecognized, the condition leads to liver failure. The cause of the condition is unknown. The only effective treatments are certain surgeries or liver transplantation.
Other reasons for transplantation are liver cancer, benign liver tumors, and hereditary diseases. Primary liver cancers develop at a significantly higher rate in cirrhotic livers as compared to normal livers, particularly in patients having liver disease secondary to Hepatitis B. Liver Transplantation at an early stage of liver cancer may result in long-term survival for select patients. However, cancers of the liver that begin somewhere else in the body and spread to the liver are not curable with a liver transplant.
How candidates for liver transplant determined?
Evaluations by specialists from a variety of fields are needed to determine if a liver transplant is appropriate. The evaluation includes a review of your medical history and a variety of tests. The transplant team will arrange blood tests, X – rays, and other tests to help make the decision about whether you need a transplant and whether a transplant can be carried out safely. Other aspects of your health-like your heart, lungs, kidneys, immune system, and mental health-will also be checked to be sure that you’re strong enough for the surgery.
Can anyone with liver problems get a transplant?
You cannot have a transplant if you have:
• cancer in another part of your body
• serious heart, lung, or nerve disease
• active alcohol or illegal drug abuse
• an active, severe infection
• inability to follow your doctor’s instructions
How is the transplant decision made?
The decision is taken in consultation with all individuals involved in the patient’s care, doctors as well as the patient’s family. The patient and family’s input is vital and it is important that they clearly understand the risks & benefits involved with transplantation.
How long does it take to get a new liver?
If you become an active liver transplant candidate, your name will be placed on a waiting list. Patients are listed according to blood type, body size, and medical condition (how Ill they are). Each patient is given a priority score based on three simple blood tests (creatinine, bilirubin, and INR). The score is known as the MELD (model of end stage liver disease) score in adults and PELD (pediatric end stage liver disease) in children.
Patients with the highest scores are transplanted first. As they become more ill, their scores will increase and therefore their priority for transplant increases, allowing for the sickest patients to be transplanted first. It is impossible to predict how long it will take for a liver to become available. Your transplant coordinator will always be available to discuss where you are placed on the waiting list. While you wait for a new liver, it would be best if you and your doctor discuss what you can do to stay strong for the impending surgery. You can also begin learning about taking care of a new liver.
Where does a liver for transplant come from?
There are two types of liver transplant options: living donor transplant and deceased donor transplant.
Living donor liver transplants are an option for some patients with end-stage liver disease. This involves removing a segment of liver from a healthy living donor and implanting it into a recipient. Both the donor and recipient liver segments will grow to normal size in a few weeks.
The donor, who may be a blood relative, spouse, or friend, will have extensive medical and psychological evaluations to ensure the lowest possible risk. Blood type and body size are critical factors in determining who is an appropriate donor. All living donors and donated livers are tested before transplant surgery. The testing makes sure the liver is healthy, matches your blood type, and is the right size so it has the best chance of working in your body.
Recipients for the living donor transplant must be active on the transplant waiting list. Their health must also be stable enough to undergo transplantation with excellent chances of success.
In deceased donor liver transplant, the donor may be a victim of an accident, brain hemorrhage or head injury. The donor’s heart is still beating, but the brain has stopped functioning. Such a person is considered legally dead, because his or her brain has permanently and irreversibly stopped working. At this point, the donor is usually in an intensive-care unit. The liver is donated, with the consent of the next of kin, from such individuals. Whole livers come from people who have just died. This type of donor is called a cadaveric donor. The identity of a deceased donor and circumstances surrounding the person’s death are kept confidential.
Do the donor and the recipient have to be matched by tissue type, sex, age, etc.?
No. For liver transplants, the only requirements are that the donor and recipient need to be of approximately the same size, and of compatible blood types. No other matching is necessary.
What happens if there are two suitable recipients for a donated liver?
This is unusual in practice but the decision would be to transplant the patient with the more urgent need. A small group of patients who are critically ill from acute liver disease have the highest priority on the waiting list.
What happens in the hospital?
When a liver has been identified for you, you will be prepared for surgery. When you arrive at the hospital, additional blood tests, an electrocardiogram, and a chest X-ray will generally be taken before the operation. If your new liver is from a living donor, both you and the donor will be in surgery at the same time. If your new liver is from a person who has recently died, your surgery starts when the new liver arrives at the hospital.
How long would surgery take?
Liver transplants usually take from 4 to 14 hours. During the operation, surgeons will remove your liver and will replace it with the donor liver. The surgeon will disconnect your diseased liver from your bile ducts and blood vessels before removing it. The blood that flows into your liver will be blocked or sent through a machine to return to the rest of your body. The surgeon will put the healthy liver in place and reconnect it to your bile ducts and blood vessels. Your blood will then flow into your new liver. Because a transplant operation is a major procedure, surgeons will need to place several tubes in your body. These tubes are necessary to help your body carry out certain functions during the operation and for a few days afterward.
What happens during this recovery period?
Initially in the intensive care unit there is very careful monitoring of all body functions, including the liver. Once the patient is transferred to the ward, the frequency of blood testing, etc. is decreased, eating is allowed and physiotherapy is prescribed to regain muscle strength. The drug or drugs to prevent rejection are initially given by vein, but later by mouth. During the transplantation, frequent tests are done to monitor liver function and detect any evidence of rejection.
When will I be able to go home?
The average hospital stay after liver transplant is two weeks to three weeks. Some patients may be discharged in less time, while others may be in the hospital much longer, depending on how the new liver is working and on complications that may arise. You need to be prepared for both possibilities. Once you are transferred from the intensive-care unit to the regular nursing floor you will be given a discharge manual, which reviews much of what you will need to know before you go home. In the hospital, you will slowly start eating again. You will first start with clear liquids, then switch to solid food as your new liver starts to function. You will learn how to take care of yourself and to use your new medications to protect your new liver. As you perform these functions regularly, you will become an important participant in your own healthcare. Before your discharge, you will also learn the signs of rejection and infection and will know when it is important to call your doctor. The patient’s willingness to stick to the recommended post-transplantation plan is essential to a good outcome.