Liver Transplant

Overview

A liver transplant is considered when the liver no longer functions adequately (liver failure). Liver failure can happen suddenly (acute liver failure) as a result of viral hepatitis, drug-induced injury or infection. Liver failure can also be the end result of a long-term problem. The following conditions may result in chronic liver failure:

• Chronic hepatitis with cirrhosis.

• Primary biliary cholangitis (previously called primary biliary cirrhosis, a rare condition where the immune system inappropriately attacks and destroys the bile ducts)

• Sclerosing cholangitis (scarring and narrowing of the bile ducts inside and outside of the liver, causing the backup of bile in the liver)

• Biliary atresia (a rare disease of the liver that affects newborns)
  Alcoholism

• Wilson's disease (a rare inherited disease with abnormal levels of copper throughout the body, including the liver)

• Hemochromatosis (a common inherited disease where the body has too much iron)

• Alpha-1 antitrypsin deficiency (an abnormal buildup of alpha-1 antitrypsin protein in the liver, resulting in cirrhosis)

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 and acute liver failure are given the highest priority for liver transplantation. As they become more ill, their scores rise and their priority for transplant increases, allowing for the sickest patients to be transplanted first. A small group of patients who are critically ill from acute liver disease have the highest priority on the waiting list. It's impossible to predict how long a patient will wait for a liver to become available. Your transplant coordinator is always available to discuss where you are on the waiting list. 

There are two types of liver transplant options: living donor transplant and deceased donor transplant.

Living donor:

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, friend or even unrelated "Good Samaritan," 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. ABO blood type compatibility is preferable as well as donors less than 60 years of age. 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. 

Deceased Donor:

In deceased donor liver transplants, the donor may be a victim of an accident 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 and life support is withdrawn in the operating room during the transplant. The identity of a deceased donor and circumstances surrounding the person's death are kept confidential. 

Hospitals will evaluate all potential liver transplant donors for evidence of liver disease, alcohol or drug abuse, cancer, or infection. Donors will also be tested for hepatitis, HIV, and other infections. If this screening does not reveal problems with the liver, donors and recipients are matched according to blood type and body size. Age, race, and sex are not considered. The transplant team will discuss transplantation options with you at a pre-transplant evaluation, or you can contact the transplant team for more information. When a liver has been identified, a transplant coordinator will contact you. Make sure that you do not eat or drink anything once you have been called to the hospital. The transplant coordinator will notify you of any additional instructions. When you arrive at the hospital, additional blood tests, an electrocardiogram, and a chest X-ray will generally be taken before the operation. You also may meet with the anesthesiologist and a surgeon. If the donor liver is found to be acceptable, you will proceed with the transplant. If not, you will be sent home to continue waiting.Liver transplants usually take from 6 to 12 hours. During the operation, surgeons will remove the non-functioning liver and will replace it with the donor 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.Two of the most common complications following liver transplant are rejection and infection.

Rejection:

Your immune system works to destroy foreign substances that invade the body. But the immune system can't distinguish between your transplanted liver and unwanted invaders, such as viruses and bacteria. So, your immune system may attempt to attack and destroy your new liver. This is called a rejection episode. About 64% of all liver-transplant patients have some degree of organ rejection, most within the first 90 days of transplant. Anti-rejection medications are given to ward off the immune attack.

Infection:

Because anti-rejection drugs that suppress your immune system are needed to prevent the liver from being rejected, you are at higher risk for infections. This problem lessens as time passes. Not all patients have problems with infections, and most infections can be treated successfully as they happen.After the liver transplant, you will receive medications called immunosuppressants. These drugs slow or suppress your immune system to prevent it from rejecting the new liver. Most transplant centers use either two of three agents. This typically involves a combination 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), mycophenolate mofetil (CellCept), sirolimus (Rapamune), or everolimus (Zortress, Afinitor). You will require at least one immunosuppressant for the life of the liver transplant.

The average hospital stay after a liver transplant is 2 weeks to 3 weeks. Some patients may be discharged in less time, while others may be in the hospital much longer, depending on any complications that may arise. You need to be prepared for both possibilities. To provide a smooth transition from hospital to home, the nursing staff and your transplant coordinator will begin to prepare you for discharge shortly after 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.You will learn how to take new medications and how to monitor your own blood pressure and pulse. As you do these things regularly, you will become a participant in your own health care. Before your discharge, you will also learn the signs of rejection and infection, and will know when it's important to call your doctor.

Readmission after discharge is common, especially within the first year after a transplant. The admission is usually for treatment of a rejection episode or infection.Your first return appointment after a liver transplant will generally be scheduled about 1 to 2 weeks after discharge. During this visit, you will see the transplant surgeon and transplant coordinator. If needed, a social worker or a member of the psychiatric team may also be available. After that, follow-up is 3, 6, 9 and 12 months from the date of the transplant, and then once a year for the rest of your life. Patients usually return to their transplant hospital approximately 4 months after the transplant. If a T-tube was inserted during the operation, it will be removed by the transplant surgeon at this time.Your primary care doctor should be notified when you receive your transplant and when you are discharged. Though most problems related to the transplant will need to be taken care of at the transplant hospital, your primary care doctor will remain an important part of your medical care.