10/15/12 Liver Transplants: Donors, Waiting Lists, Screening, Surgery, and More

Article Link: http://www.webmd.com/digestive-disorders/digestive-diseases-liver-transplantation

Digestive Disorders Health Center

Liver Transplantation
The liver is the body's largest internal organ, weighing about 3 pounds in adults. It is located below the diaphragm on the right side of the abdomen. The liver performs many complex functions in the body, including: Produces most proteins needed by the body. Metabolizes, or breaks down, nutrients from food to produce energy, when needed. Prevents shortages of nutrients by storing certain vitamins, minerals and sugar. Produces bile, a compound needed to digest fat and to absorb vitamins A, D, E, and K. Produces most of the substances that regulate blood clotting. Helps the body fight infection by removing bacteria from the blood. Removes potentially toxic byproducts of certain medications. When Is a Liver Transplant Needed? A liver transplant is considered when the liver no longer functions adequately (liver failure). Liver failure can occur suddenly (acute liver failure) as a result of infection or complications from certain medications, for example. 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 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 (malformation of the bile ducts). 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 accumulation of alpha-1 antitrypsin protein in the liver, resulting
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10/15/12 Liver Transplants: Donors, Waiting Lists, Screening, Surgery, and More

in cirrhosis). Liver cancer. How Are 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 medical history and a variety of tests. Many health care facilities offer an interdisciplinary approach to evaluate and select candidates for a liver transplant. This interdisciplinary health care team may include the following professionals: Liver specialist (hepatologist). Transplant surgeons. Transplant coordinator, usually a registered nurse who specializes in the care of liver-transplant patients (this person will be your primary contact with the transplant team). Social worker to discuss your support network of family and friends, employment history, and financial needs. Psychiatrist to help you deal with issues, such as anxiety and depression, which may accompany a liver transplant. Anesthesiologist to discuss potential anesthesia risks. Chemical dependency specialist to aid those with history of alcohol or drug abuse. Financial counselor to act as a liaison between a patient and his or her insurance companies. Which Tests Are Required Before Getting a Liver Transplant? You will need to bring all previous doctor records, X-rays, liver biopsy slides, and a record of medications to your pre-evaluation for a liver transplant. To complement and update previous tests, some or all of the following diagnostic studies are generally performed during an evaluation. Computed tomography, which uses X-rays and a computer to generate pictures of the liver, showing its size and shape. Doppler ultrasound to determine if the blood vessels to and from the liver are open. Echocardiogram to help evaluate the heart. Pulmonary function studies to determine the lungs' ability to exchange oxygen and carbon dioxide. Blood tests to determine blood type, clotting ability, and biochemical status of blood and to gauge liver function. AIDS testing and hepatitis screening are also included. If specific problems are identified, additional tests may be ordered. How Does the Liver Transplant Waiting List Work? 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
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Liver Transplants: Donors, Waiting Lists, Screening, Surgery, and More

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. A small group of patients who are critically ill from acute liver disease have the highest priority on the waiting list. It is 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. Where Does a Liver for a Transplant Come From? 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, 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. 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. The identity of a deceased donor and circumstances surrounding the person's death are kept confidential. Screening for Liver Transplant Donors 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, AIDS, 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. What Happens When They Find a Liver Transplant Match? When a liver has been identified, a transplant coordinator will contact you by telephone or by pager. Make sure that you do not eat or drink anything once you have been called to the hospital. The transplant
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10/15/12 Liver Transplants: Donors, Waiting Lists, Screening, Surgery, and More

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 surgical resident. 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. What Happens During the Liver Transplant Operation? Liver transplants usually take from six to 12 hours. During the operation, surgeons will remove the 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 the body. These tubes are necessary to help your body carry out certain functions during the operation and for a few days afterward. Tube Placement A tube will be placed through your mouth into the windpipe (trachea) to help you breathe during the liver transplant operation and for the first day or two following the operation. The tube is attached to a ventilator that will expand your lungs mechanically. A nasogastric (N/G) tube will be inserted through the nose into your stomach. The N/G tube will drain secretions from your stomach and it will remain in place for a few days until your bowel function returns to normal. A tube called a catheter will be placed in your bladder to drain urine. This will be removed a few days after the operation. Three tubes will be placed in your abdomen to drain blood and fluid from around the liver. These will remain in place for about one week. In most cases, the surgeon will place a special tube, called a T-tube, in the bile duct. The T-tube will drain bile into a small pouch outside of your body so it can be measured several times daily. Only certain transplant patients receive a T-tube, which remains in place for five months. The tube causes no discomfort and does not interfere with daily activities. What Complications Are Associated With Liver Transplant? 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. The immune system, however, cannot distinguish between your transplanted liver and unwanted invaders, such as viruses and bacteria. Therefore, your immune system may attempt to attack and destroy your new liver. This is called a rejection episode. About 70% of all liver-transplant patients have some degree of organ rejection prior to discharge. 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 increased risk for infections. This problem diminishes as time passes. Not all patients have problems with infections, and most infections can be treated successfully as they occur. What Are Anti-rejection Medications?
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10/15/12 Liver Transplants: Donors, Waiting Lists, Screening, Surgery, and More

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. They may include azathioprine (Imuran), Cellcept (mycophenolate mofetil), prednisone (Deltasone, Kedral, Medrol, Orasone, Prelone, Sterapred DS), cyclosporine (Neoral), Prograf (a brand of tacrolimus, also known as FK506), and Rapamune (sirolimus). You must take these drugs exactly as prescribed for the rest of your life. When Will I Be Able to Go Home After a Liver Transplant? The average hospital stay after a 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 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 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. 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. What Follow-Up Is Necessary After a Liver Transplant? Your first return appointment after a liver transplant will generally be scheduled about one week to two 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. All patients return to their transplant hospital approximately five months after the transplant. If a T-tube was inserted during the operation, it will be removed by the transplant surgeon at this time. All patients are scheduled to return to the hospital at their one-year transplant anniversary date and annually thereafter. 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.

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10/15/12 Liver Transplants: Donors, Waiting Lists, Screening, Surgery, and More

Race Influences Liver Transplants Donating Part of Liver Relatively Safe Slideshow: A Visual Guide to Hepatitis Liver Transplants Safe for HIV Patients Liver Transplant: No Methadone Users Need Apply, Please The Legacy of Organ Donation Hepatitis B Resources See All Liver Transplant Topics
WebMD Medical Reference SOURCE: The American Liver Foundation
Reviewed by Venkat Mohan, MD on March 01, 2010

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