Liver transplantation

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LIVER TRANSPLANTATION

Learn more about liver transplantation.

What is a liver transplant? A liver transplant is the process of replacing a sick liver with a donated, healthy liver. Currently about 1500 liver transplants are being performed each year in India.

Who needs a liver transplant? A liver transplant is needed when a person’s liver fails to perform its functions and there is no hope that the functions will recover with medical treatment. The commonest indication for a liver transplant is cirrhosis (scarring) of the liver.

Common causes of liver cirrhosis are

  • Chronic Hepatitis B
  • Chronic Hepatitis C
  • Alcoholic liver disease
  • Fatty liver disease (NASH)
  • Genetic diseases
  • Autoimmune liver diseases

Liver transplants are also done for treatment of liver cancer, acute liver failure and certain bile duct diseases.

What are the results of liver transplantation? Most patients return to a regular lifestyle six months to a year after a successful liver transplant. Eating a healthy diet, exercising regularly, and taking recommended medications are important factors to staying healthy. Nearly 90 percent of liver transplant patients are alive at one year after their transplant and nearly 75 percent alive five years after their transplants.

What are the signs of advanced liver disease or cirrhosis? People who have advanced liver disease may have many of the following problems: Jaundice – yellowing of the skin or eyes Itching Dark, tea-coloured urine Ascites – an abnormal amount of fluid in the abdomen Vomiting of blood Tendency to bleed Encephalopathy – mental confusion, forgetfulness

What are the kinds of a liver transplant? Most transplant livers come from a donor who has died. This is known as cadaveric liver transplantation or deceased donor liver transplantation.  Sometimes a healthy person donates part of his or her liver for a specific patient. This is known as living donor liver transplantation. All donated livers and living donors are tested before transplant surgery. The testing makes sure the donor liver works as it should, matches your blood type, and is the right size, so it has the best chance of working in your body.

Adults usually receive the entire liver from a deceased donor. Sometimes only a portion of a whole liver from a deceased donor is used to fit a smaller person (split liver transplantation). In some cases, a liver from a deceased donor is split into two parts. The smaller part may go to a child, and the larger part may go to an adult.

Sometimes a healthy living person will donate part of his or her liver to a patient, usually a family member. This type of donor is called a living donor.  The donor must have major abdominal surgery to remove the part of the liver that will be transplanted into the patient. The amount of liver that is donated will be about 50% of the recipient’s current liver size. Within 6-8 weeks, both the donated pieces of liver and the remaining part in the donor grow to normal size.

Both types of transplants usually have good results.

Who will evaluate me for a liver transplant?  If a liver transplant is recommended, a team of doctors from the Integrated Liver Care team will perform a transplant evaluation. The ILC team consists of a transplant coordinator, a hepatologist (liver specialist), transplant surgeons, dietician, physiotherapist and social worker. It may be necessary to other specialists depending on the recipient’s age and health problems.

A social worker assesses and helps develop the patient’s support system, a central group of people on whom the patient can depend throughout the transplantation process. A positive support group is very important to a successful outcome. The social worker also checks to see that the recipient is taking medications appropriately.

On completion of evaluation, the ILC team discusses the case in a multidisciplinary meeting and takes a decision on whether the recipient is suitable for a transplant.

The liver specialist and the primary doctor manage the person’s health issues until the time of transplantation.

What is done during a surgery for liver transplantation? Liver transplantation is a major operation that takes place only in specialized transplant centers. During a liver transplantation, the surgeon removes the diseased liver and replaces it with a healthy one.  The diseased liver is removed through an abdominal incision. The liver’s blood supply (portal vein, inferior vena cava, and hepatic artery) and the biliary system are all connected to the new liver after it is placed into the abdominal cavity. Persons who have liver transplants require intensive care and close monitoring after their operation.

After surgery, the patient is taken to the intensive care unit, is monitored very closely with several machines. The patient will be on a respirator, a machine that breathes for the patient, and will have a tube in the windpipe bringing oxygen to the lungs. Once the patient wakes up and can breathe alone, the tube and respirator are removed. The patient will have several blood tests, X-ray films, and ECGs during the hospital stay. Blood transfusions may be necessary. The patient leaves the intensive care unit once he or she is fully awake, able to breathe effectively, and has a normal temperature, blood pressure, and heart rate, usually after about 3-4 days. The patient is then moved to a room with fewer monitoring devices for a few days longer before going home.

How long will I stay in hospital after transplantation? The average hospital stay after surgery is 1-3 weeks. The patient may be required to remain in Bangalore for up to three months for close follow-up.

What medications does one need to take after transplantation? The patient will be on immune suppressive medication for the rest of his or her life to prevent the body rejection of the new liver. The patient may also require vitamins and calcium and other mineral supplements.

What are the common complications after a liver transplantation? Acute rejection. Most rejection happens while you are still in the hospital, but it can happen at any time. Rejection can be treated with drugs. The patient may need a liver biopsy. Recurrence of liver disease. The diseases that damaged your liver in the first place may come back in the new liver. The disease can often be treated easily, but sometimes a second transplant is needed. Cancer. People who have organ transplants are at a higher risk for some cancers, especially skin cancer. These cancers may spread faster than they do in people without transplants. Because of this, the patient will need to get screened for cancer. Medical complications. Transplant patients can get infections, high blood pressure, diabetes, high cholesterol, thinning of the bones, and become obese.

What medical follow-up is required after liver transplantation? Lifelong medical follow-up is required. You will be required to remain in contact with our transplant centre. Our coordinators will contact you periodically and advise you about blood tests and follow-up visits.

Traditionally the most common type of transplantation, this procedure uses a liver that becomes available when a person dies and his or her family donates the organ for transplantation.

Deceased donor livers come from people who have died suddenly, usually from an accident or bleed into the brain. After a series of tests and establishment of a diagnosis of brain death by certified professionals, some r families make the decision to donate their loved ones organs so that someone else will have a chance to live a better life.

It isn’t necessary to match the donor and recipient for age, sex or race. All donors are screened for hepatitis viruses and the HIV virus. All deceased donor organs are tested extensively to help ensure that they don’t pose a health threat to the recipient. Also, many studies – such as ABO blood type and HLA matching – are required for matching kidneys, and some test are performed to ensure that the organs are functioning properly.

As soon as a deceased donor is declared brain-dead, the liver is removed in a process of organ recovery and placed in a special preservative solution. It is then stored in ice  to keep the temperature at four degrees. The harvested liver needs to be transplanted within 12  hours of recovery – which is why recipients are often called to the hospital in the middle of the night or at short notice.

Waiting times for a deceased donor liver vary depending on the patient’s severity of illness, blood type, and overall demand. Patients have to be registered with the appropriate state body ( Zonal coordination committee of Karnataka (ZCCK)or the Kerala Network for organ sharing (KNOS)). Because the liver is able to regenerate, it is possible for a deceased donor organ to be divided, with each half transplanted into a different recipient. Sometimes called “split-liver” transplantation, this resourceful allocation of scarce donor organs enables more patients to receive transplants.

Living donor liver transplantation, is a complex technique, that involves transplanting the donor’s right portion of liver into the recipient, after removal of the diseased organ. A liver may be divided in two parts, because each lobe has its own arterial and venous blood supply and drains bile through two separate ducts that join together outside the liver. Livers can regenerate and, after three to four weeks after transplant, grow to its original size both in the donor and recipient. Donor hospitalization after surgery is usually five to seven days provided no complications arise. The donor may return to normal life after four to six weeks. Strict criteria are used to select the donor so as to prevent any complications.

Why Living Donor Liver Transplantation?  By knowing facts about liver transplants, you can make an informed decision about being a donor. Approximately 20,000 patents need liver transplants in India every year, yet less than 600 patients actually receive a transplant.Many adult patients cannot survive the wait times for a deceased-donor liver. Because there is a long waiting list for those needing transplants, 1 out of 4 patients who need a new liver will die before one becomes available.  When considering facts about liver transplants, remember that the liver is one of the few organs that will grow back if a portion of it is removed.What are the advantages of a live organ donation? Living donor liver transplantation is now an accepted method, used more commonly because of the severe lack of livers from recently deceased donors. The live donor procedure also allows greater flexibility for the patient because the procedure may be done for people who are in the lower stages of liver disease. A living-donor transplant means a patient can have a transplant before their liver failure gets worse. It means a shorter wait time for a liver. Because the surgery can be planned in advance, the chance for a successful transplant is better. The quality of the liver may be better, because living donors are usually young, healthy adults who have gone through a complete medical evaluation. With a living-donor transplant, the preservation time (the time when the liver is outside the body) is shorter.Who can donate? The donor may be a family member, such as a parent, sister, brother, or adult child. The donor can also be a husband or wife. It is against the law for people to sell their body parts.In general, liver donors must: Be at least 18 years old Be in good health with no major medical or mental illnesses Be a non-smoker for at least 4 to 6 weeks before surgery Be able to understand and follow instructions before and after surgery Have a compatible blood type Have an emotional tie with the recipient Not have a selfish motive for donating Have a similar body size Be able to go through certain medical tests like blood work, radiology studies, and a liver biopsy A person should feel no pressure to donate part of his or her liver; nor should any money be given or received.

What are the tests needed for evaluation of a living donor? People who want to donate their liver go through a complete medical exam to make sure their liver is healthy and that it is safe for them to donate. Safety is important for both the donor and the recipient

Medical evaluation is done (a) To make sure the donor does not have any health problems, like diabetes or heart conditions, that could increase the risks of problems during and after the surgery, (b) To make sure the donor liver that is the right size for the recipient.

The general tests performed as part of the evaluation include: Physical examination. A complete physical examination is performed as part of the evaluation. Blood tests  Donor’s blood type (it should be compatible with the recipient’s blood type.) Liver and kidney function tests Cholesterol, blood sugar tests, blood counts The donor is also tested for viruses such as hepatitis B, hepatitis C, and HIV             Ultrasound/MRI/CT scan. These tests are done to get images of the liver to make sure the donor’s bile ducts, arteries, and veins are the right fit for the intended recipient. These tests also measure the volumes of the liver that will go to the recipient, and make sure that it is adequate. Additionally, they are used to assess the piece of the liver that will remain in the donor to ensure that it is sufficient. Chest X-ray, EKG and Cardiac Echocardiogram. These are standard tests done before any major operation to check for lung or heart problems. Consultation. Every donor will meet with several doctors for a complete assessment. All donors will also have a comprehensive psychosocial assessment to talk about their reasons for donating a liver and to make sure they are in a stable mental condition for the surgery.

What happens during the operation? An upper abdominal incision, in the shape of an inverted ‘L’ is made to expose the liver. The liver anatomy is re-checked, and an X-Ray of the bile ducts obtained (cholangiogram) to ensure patient safety. The donor’s liver is split into two parts. One part is removed for the transplant. The wound is then closed with suture or staples.

Donors stay in the hospital from 4 to 7 days after surgery, longer if problems occur. The first night after surgery is usually spent in the intensive care unit (ICU). The next day, the patient may be moved to the general surgical floor where nurses have experience caring for liver donors. The nurses will encourage one to get out of bed and sit in a chair the day after surgery and to walk as soon as able.

What are the potential complications of surgery? As with any major surgery, there are risks. There is a 10 to 25 percent chance a donor could have complications from the surgery. A donor may develop some problems during or right after the operation; they might also experience problems later. Surgical problems include bleeding, infection, bile leaks, or damage to the bile tree (the ducts that run through the liver). Other risks can come from anesthesia and general surgery.

It is quite helpful to talk to a donor who has already gone through the surgery and can talk about his or her experience.

How long does recovery take? You may be in hospital for a week, if all is well. It takes about 4 weeks to recover from surgery.  Most donors recover fully after the operation and can do normal activities within a few months after the surgery.

Concerns after Liver Transplant Surgery

 

There are many new things a person experiences after liver transplantation. Before you leave the hospital, our team will provide all the instructions you and your family will need to take care of you. Three to four months after the operation, most patients have recovered fully, returned to work, and are enjoying active lives. Our goal is to provide expert care and excellent follow-up, so to make the extent and quality of your life appreciably better than before. We urge you to always keep in touch with us as well as with your local doctor for your ongoing care.

How long will my new liver last ? Liver transplant can have excellent outcomes. Recipients have been known to a normal life over 30 years after the operation. On an average 90% of patients are doing well after one year of transplant. About 75% are doing well at 5 years after transplant. The outcome of transplant is dependent on many factors such as the cause of your primary liver disease, age, associated illnesses, and severity of illness at the time of transplant.

Transplant recipients directly contribute to the success of their transplant. Failure to comply with the medications (immunosuppressants) is the number one cause of failure of the transplanted liver. Close follow-up with the transplant team and your primary doctor can help ensure a good outcome. Careful attention to medication schedules, lifestyle changes, and avoidance of infection are all important ways to prolong one’s life after transplantation.

What will be my quality of life after liver transplantation ? The first 2-3 months following transplantation are the most difficult. By the time of discharge from the hospital patients are able to care for themselves, with some minor restrictions. Our team will prepare you well before discharge so that you can take your medications and take care of yourself at home.  Our social worker, nutritionist and physiotherapist will teach you about diet, exercise and other general activities. Most patients can return to work within 3 to 6 months after a transplant. Playing sports, performing healthy exercise, socializing, and traveling for business and pleasure are all possible. We always hope that most of our patients who undergo liver transplantation can lead “normal” lives.

We have a Transplant support group that meets once every month. It is attended by patients who have had organ transplants. After your transplant, this group is an excellent means of support and information. You can interact with other patients and share their problems. We urge you to attend these meetings. It is organized by our Social worker.

Can my liver disease come back after transplant ? Certain liver diseases, like hepatitis C and autoimmune liver disease can reappear in the new liver. We will advise you on the incidence of recurrence of specific liver diseases. We will monitor you very closely to help prevent recurrence.

How much pain will occur after the surgery ? There is pain after liver transplant surgery, however it is generally not as severe as with other abdominal surgeries. Pain is generally tolerable and may last up to one week. You will receive adequate pain relief after surgery so as to make you comfortable. You may experience some numbness around the scar site. This is because nerves are cut during the initial abdominal incision. These nerves usually regenerate over a period of 3 to 6 months and sensations return.

What medications do I need after my transplant ? Patients must take several medications after a liver transplant. There are medicines to prevent rejection (immunosuppressants), to prevent infection (antibiotics), and vitamin and mineral supplements. if you have preexisting diseases such as diabetes, high blood pressure, you will need medications for these diseases as well. At discharge, approximately 7 to 10 different type of medicines may be prescribed. The number of medicines are reduced over time. By 6 to 12 months, most patients are taking only 2 to 3 medicines. It is important to remember that immunosuppressants are required for the rest of the life. if you miss your medicine, alter the dose or stop taking the medicine, it can lead to rejection and failure of the liver.

What side effects can occur due to medications prescribed after transplant ? Medications do have side effects. Typical side effects are high blood pressure, diabetes, mood changes, bone and muscle weakness, kidney dysfunction, nausea, vomiting, diarrhea, and headache. Most patients will experience some side effects initially, but these often diminish over time as dose of medicines are reduced. When side effects are severe, the medicines can often be adjusted or changed to improve tolerance.

Can I return to work after my transplant ? Yes, patients are encouraged to return to work after transplantation. It customarily takes around 3 months before returning to work is feasible. Initially light work may be recommended. From the start of the transplant process, we encourage our patients to consider their long-term employment goals so that they can rejoin work in a timely manner.

Can I drink alcohol after my transplant ? No. Alcohol toxic to the liver. We advice our patients not to drink even a small amount of alcohol. Alcohol can interfere with the metabolism of certain medications. We advise our patients not to smoke as well.

Can I have sex after my liver transplant ? Yes. Sexual activity can resume early after discharge from the hospital. Because of illness, many patients experience lack of sexual desire prior to transplant. This usually gets better after transplant. We encourage patients to be in a long-term monogamous relationship. Birth-control methods should be discussed with your transplant team and implemented when sexual activity resumes.

Will I be able to have children after my transplant ? Many couples are able to have children after liver transplantation with minimal risk to the mother and baby. Women are advised to wait at least one year following transplantation before trying to conceive. It is important to discuss such plans with the transplant team. They will need to carefully evaluate the health and medication regimen of women who wish to become pregnant. Planning the pregnancy and receiving close follow-up care throughout is very important.

Can I get in touch with the family of my donor ? Transplant recipients often want to thank the donor’s family. Direct interaction is not encouraged. You can however write a letter and give it to our Social worker who will forward it to the donor family via the organ procurement agency.

Liver Transplant – A Multidisciplinary team Approach

Who are the key members of a liver transplant team ? The following is a description of liver transplant team members who will care for you before, during and after the transplant.Hepatologist (Liver Transplant Physician) Just as before surgery, the hepatologist continues managing patients’ medical care following transplantation. The hepatologist and surgeon guide the transplant team through the recovery and monitor any possible rejection or infection of the new liver. To help prevent rejection, the hepatologist and surgeon will determine what immunosuppressive medications are needed. The hepatologist and surgeon will also oversee the post-transplant follow-up care.Transplant Surgeon The transplant surgeons assess the patient before surgery, perform the liver transplant and help guide the patient through recovery. The surgeon, along with the hepatologist and ICU team, monitors the patients vital signs and the function of the transplanted liver to ensure it is working properly. Additionally, they decide what medications you’ll take and observe the wound to see that it is healing as necessary.Anesthesiologist The anesthesiologist administers a general anesthetic prior to the liver transplant surgery and monitors the heart and lung function throughout the operation.Operating room staff The Operating room has specially trained highly skilled personnel such as dedicated nurses, technical support staff , pharmacists and paramedical workers who take care of all the requirements of  complex operations such as transplantation.Diagnostic and interventional radiologist Radiologists are doctors who are experts in interpreting X-rays, ultrasound, CT scan and MRI scans and thus help with ascertaining the diagnosis. Interventional radiologists perform interventions such as biopsies, embolisation and stenting of bile ducts and blood vessels using ultrasound or CT scan to guide the procedure. Some of these techniques are extremely useful to treat certain complications that may occure after liver transplantation. Interventional radiologists also treat liver cancers by using techniques such as radiofrequency ablation, microwave ablation, transarterial chemoembolization and radioembolization.

Hospitalist/ Physician Assistant The physician assistant is a healthcare professional who assists the physician with patient care. The hospitalist provides day-to-day management of patients in the hospital, both before and after liver transplantation and works closely with the transplant surgeon and hepatologist to deliver care.

Infectious disease specialists After transplantation, patients are on medications to suppress their immune system and are therefore vulnerable to a number of infections. Some of these infections can be complex and difficult to diagnose and treat. Thus it is extremely important to have doctors specialized in the care and the management of infections after transplantation. They manage the patients both before transplant by suggesting correct vaccines and antibiotics as well as after after transplantation.

Transplant  Coordinators The transplant  coordinators are in charge of coordinating all aspects of the transplant process, including the pre-transplant evaluation, transplant hospitalization and post-transplant follow-up. Their many responsibilities include patient and family education throughout the entire transplant process and ongoing communication. The transplant coordinators are also involved in the organ procurement and retrieval process, as well as community and professional education. They are an integral part of the transplant team and work very closely with all of the physicians including the referring doctor, the transplant surgeons and the hepatologists.

Transplant Nurses The hospital’s staff nurses are responsible for coordinating the efforts of all the caregivers. Nurses spend the greatest amount of time with the patient, they are in the unique position to evaluate the well-being, meet the immediate needs and act as a link among the various team members. They are available to provide a range of services, interventions and expertise, and to represent the best interest. The nursing staff is committed to keeping the patient well-informed about every aspect of the health care needs and emphasizes patient education. They offer instruction and information both formally and informally, and try to include the family or caregiver(s) in the learning process.

Social Worker The liver transplant social worker is part of the Liver Transplant Team and involved with you from the time of the initial evaluation. The social worker provides the team with a psychosocial assessment that includes a social history and assessment of the patient’s and family’s coping abilities, motivation, compliance and support system. Practical issues such as who will stay with the patient after discharge from the hospital are assessed. When necessary, the social worker can offer suggestions about how to initiate fundraising.

The social worker provides counseling and emotional support to the patient and the family, from the time of evaluation through post-discharge. Additionally, a Liver Transplant Support Group, facilitated by the social worker, provides both inpatients and outpatients with a comfortable place to share questions, concerns and experiences.

Clinical Dietician/Nutritionist A registered clinical dietician evaluates the nutritional status and helps with any related problems. The dietician helps the patient and the family to understand the nutritional needs and restrictions. Some patients are placed on a special diet, and the nutritionist will help educate the patient about best food practices. If the appetite is poor, the nutritionist will provide nutritional supplements to increase the caloric intake.

Psychiatrist It is not uncommon for patients with liver disease facing a transplant or those who have already undergone transplantation (or their families) to have difficulty in dealing with their hospitalization and/or illness. Psychosocial help and guidance is especially important for patients who have dealt with addiction issues in the past.

Physical Therapist It is very important to for patients to be on a physical therapy program in the months and weeks before transplant. Regular breathing exercises and exercise for the limbs help in maintaining muscle mass and are an essential component of the recovery process after transplant. Special exercise programs are supervised by a physical therapist. These exercise programs are designed specifically for transplant patients. The physical therapy program has to be continued after the patient leaves the hospital.