Liver Transplantation

What Is a Liver Transplant?

A liver transplant is a surgical procedure that replaces someone’s diseased liver with all or part of a healthy one from another person, who’s called a donor.

When Is a Liver Transplant Needed?

The liver is your largest internal organ. An adult’s weighs about 3 pounds. It’s just below your diaphragm on the right side of your belly. Your liver does many important things, including making proteins and breaking down nutrients from food to help your body make energy.

You might need a transplant if your liver doesn’t work the way it should. This is called liver failure.

Liver failure can happen suddenly as a result of viral hepatitis, drug-induced injury, or infection. This is called acute or fulminant hepatic failure.

It can also be the end result of a long-term problem (chronic). Conditions that can cause chronic liver failure include:

• Chronic hepatitis with cirrhosis
• Primary biliary cholangitis, a rare condition in which your immune system destroys your bile ducts
• Sclerosing cholangitis, scarring and narrowing of the bile ducts inside and outside your liver, causing bile to back up
• Biliary atresia, a rare liver disease that affects newborns
• Alcohol overuse
• Liver cancers such as hepatocellular carcinoma
• Wilson's disease, which causes unusual levels of copper throughout your body, including in your liver
• Hemochromatosis, in which your body has too much iron
• Alpha-1 antitrypsin deficiency, an unusual buildup of a protein called alpha-1 antitrypsin in your liver, resulting in cirrhosis

How Do People Get Selected for Liver Transplants?

Your doctor may recommend a liver transplant if they’ve ruled out all other treatments for your condition and if they think you’re healthy enough for surgery. They’ll refer you to a transplant center. There, you’ll talk with specialists and have tests to find out whether you can get a transplant.

Each center has different rules about who can have a transplant. You might not be able to get one if you have:

• A severe infection
• Problems with alcohol or drug use
• Cancer outside your liver
• Serious heart or lung disease

You or your caregivers will also need to understand and follow your doctor’s directions after the surgery, including medications that you’ll take for the rest of your life.

Your Liver Transplant Team

A team of specialists will help you every step of the way. They include:

• A liver specialist (called a hepatologist)
• A transplant surgeon
• A transplant coordinator, usually a registered nurse who specializes in the care of liver transplant patients. This person will be your main contact with the transplant team.
• A social worker to discuss your support network of family and friends, employment, and financial needs
• A psychiatrist to help you deal with issues that might come along with a transplant, such as anxiety and depression
• An anesthesiologist
• A chemical dependency specialist to help if you have a history of alcohol or drug use
• A financial counselor to act as a go-between for you and your insurance company

Which Tests Are Required Before Getting a Liver Transplant?

Bring all medical records, X-rays, liver biopsy slides, and a record of your medications to your evaluation for a liver transplant. The team might do tests including:

• CT, which uses X-rays and a computer to make pictures of your liver. CTs and chest X-rays will also check your heart and lungs.
• Doppler ultrasound to find out whether the blood vessels to and from your liver are open
• Echocardiogram to check your heart
• Pulmonary function studies to look at how well your lungs exchange oxygen and carbon dioxide
• Blood tests to learn more about your blood and to check how well your liver is working. You’ll also be screened for HIV, other viruses (such as herpes and Epstein-Barr), and hepatitis.

How Does the Liver Transplant Waiting List Work?

If you meet the criteria for a transplant but don’t have a donor lined up, the center will put you on a waiting list. It lists patients according to their blood type, body size, and medical condition (how ill they are). Each patient is given a priority score based on three blood tests (creatinine, bilirubin, and INR). The score is known as MELD (model of end-stage liver disease) in adults and PELD (pediatric end-stage liver disease) in children.

Patients who have the highest scores and acute liver failure get top priority for a liver transplant. If their condition gets worse, their scores rise, and their priority for transplant goes up. This way, the transplants go to people who need them the most.

It's hard to say how long you might have to wait to get a liver. Your transplant coordinator is always available to discuss where you are on the waiting list.

Where Does a Liver for a Transplant Come From?

You might get a liver from a donor who’s alive or one who’s died.

Living donor

In a living donor liver transplant, your doctor will take part of a healthy person’s liver and implant it in you. Both liver segments will grow back to their regular size in a few weeks.

Deceased donor

A donor who’s died may have had an accident or head injury. Their heart is still beating, but they’re legally dead because their brain has stopped working permanently. The donor is usually in an intensive-care unit. The team turns off life support in the operating room during the transplant.

The donor’s identity and the details of their death are confidential.

Depending on your condition, you might have a “domino” liver transplant. This is when a young person who has a metabolic liver disease gets a liver from a healthy donor. But rather than destroying the young person’s liver, doctors give it to an older patient who has a more diseased liver. It can take decades for the older person to have signs of the metabolic disease. Or they may never get it at all. Domino transplants help widen the pool of people who can donate organs.

Who Can Be a Liver Transplant Donor?

A living donor may be a relative, a spouse, a friend, or an unrelated "Good Samaritan." They’ll have complete medical and psychological tests to keep risks as low as possible. Blood type and body size are crucial to finding a match. A donor younger than 60 years old is ideal.

Hospitals will check possible donors for liver problems or other things, including:

• Liver disease
• Overuse of alcohol or drugs
• Cancer
• Infections
• Hepatitis
HIV

What Happens When They Find a Liver Transplant Match?

A transplant coordinator will contact you when they’ve found a possible donor liver. Don’t eat or drink anything after they tell you to go to the hospital. When you get there, you’ll probably have more blood tests, an electrocardiogram, and a chest X-ray. You also may meet with the anesthesiologist and a surgeon. If the donor liver is approved, the transplant will go ahead. If not, you’ll go home.

What Happens During the Liver Transplant Operation?

Liver transplants usually take 6 to 12 hours. Your surgeons will take out your liver and replace it with the donor liver. Because a transplant is a major procedure, the surgeons will put several tubes in your body. These tubes are necessary to help your body do certain things during the operation and for a few days afterward.

What Complications Are Associated With Liver Transplant?

A liver transplant is a complex procedure that may have complications soon afterward or many years later.

Rejection

Your immune system destroys things that invade your body. But it can’t tell the difference between your transplanted liver and unwanted invaders, such as viruses and bacteria. So your immune system may attack your new liver. This is called a rejection episode. About 64% of liver transplant patients have some kind of organ rejection, most within the first 90 days. You’ll get anti- rejection medications to prevent an immune attack.

Infection

The drugs that you take to keep your body from rejecting your new liver weaken your immune system. They’re called immunosuppressants. They make you more likely to get an infection. This problem goes away over time.

Liver function problems

About 1% to 5% of new livers don’t work as well as they should or don’t work at all. If it doesn’t get better quickly, you might need a second transplant.

Surgical risks

Complications related to the operation include:

• Clots in the artery that takes blood from your heart to your liver (called hepatic artery thrombosis) or in the vein that takes blood from your intestines, pancreas, and spleen to your liver (portal vein thrombosis)
• Bile leaking out of your bile ducts and into your belly
• Narrowed bile ducts
• Bleeding
• Infection of the surgical wound

Return of disease

Some conditions that cause liver failure can still damage or destroy your new liver. These include:

• Hepatitis C
• Primary sclerosing cholangitis
• Fatty liver disease

Cancer

People who have an organ transplant have a 25% higher chance of getting skin cancer than the rest of the population. Immunosuppressant drugs can also make you more likely to get other cancers, including a rare condition called post- transplant lymphoproliferative disorder (PTLD).

What Are Anti-Rejection Medications?

You’ll need to take at least one immunosuppressant for the rest of your life. You might get a mix of a calcineurin inhibitor (CNI) such as cyclosporine (Neoral) or tacrolimus (Prograf); a glucocorticoid such as prednisone (Medrol, Prelone, Sterapred DS); and a third agent such as azathioprine (Imuran), everolimus (Afinitor, Zortress), mycophenolate mofetil (CellCept), or sirolimus (Rapamune).

These drugs can have serious side effects. Along with a higher chance of infection, they can cause:

• Bone loss
• Diabetes
• High blood pressure
• High cholesterol
• Kidney damage
• Weight gain

Other drugs and supplements can affect how these medications work. Talk to your doctor before taking anything new or if you have concerns about side effects.

When Will I Be Able to Go Home After a Liver Transplant?

The average hospital stay after a liver transplant is 2 to 3 weeks. Some patients go home sooner, but others have to stay longer.

The nursing staff and your transplant coordinator will start to get you ready for discharge soon after you move from the intensive care unit (ICU) to the regular nursing floor. They’ll give you a discharge manual, which reviews much of what you need to know before you go home.

You’ll learn how to take new medications and how to check your blood pressure and pulse. You’ll also learn the signs of rejection and infection, and you’ll know when it's important to call your doctor.

Many people have to be admitted to the hospital again, especially within the first year after a transplant. This is usually for treatment of a rejection episode or infection.

After a Liver Transplant

Follow-up care

Your first return appointment will probably be about 1 to 2 weeks after you leave the hospital. You’ll see your transplant surgeon and transplant coordinator. A social worker or a member of the psychiatric team may also be available. After that, you’ll have follow-ups 3, 6, 9, and 12 months after the transplant and then once a year for the rest of your life.

Your primary care doctor should be notified when you have your transplant and when you’re discharged. Though your transplant center will handle most problems related to the transplant, your primary care doctor will remain an important part of your medical care.

Self-care

Some lifestyle changes can protect your overall health after a liver transplant.

• Eat a healthy, balanced diet. Limit salt, cholesterol, fat, and sugar. A dietitian or nutritionist can help you make a meal plan.
• Don’t eat grapefruit or drink grapefruit juice. They can affect how some immunosuppressants work.
• Don’t eat unpasteurized milk products or raw eggs, meat, or fish.
• Don’t drink alcohol or use it in food if you have a history of alcohol use disorder.
• Get regular exercise.
• Don’t smoke.
• Limit your contact with things that can carry germs, such as soil, mosquitoes, ticks, rodents, reptiles, birds, and water from lakes or rivers.
• If you’re planning to travel, especially to a developing country, talk to your care team about how to lower risks at least 2 months before you leave.

Liver Transplant Outlook

Your outlook after a liver transplant depends on several things, including the condition that caused your liver failure. About 88% of patients live at least a year after their transplant, and 73% live at least 5 years.

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