Diseases

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. Many healthcare facilities offer an interdisciplinary approach to evaluate and to select candidates for liver transplantation. This interdisciplinary healthcare 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 the liver transplantation.
• 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.

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. 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.

After the liver transplant, you will receive medications called immunosuppressants. These medications slow or suppress your immune system to prevent it from rejecting your 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.

Two of the most common complications following liver transplant are rejection and infection. Rejection Your immune system works to destroy foreign substances that invade your 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 25% 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. More than 80% of transplanted livers are still functioning at the end of the first year. 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.

Your first return appointment after a liver transplant will generally be scheduled about one week after discharge and regularly scheduled intervals after that. During these visits, you will see the transplant surgeon, and/or transplant hepatologist and the 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.

Liver transplants usually take from six hours to 12 hours. During the operation, surgeons will remove your 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. Tube placement

• A tube will be placed through your mouth into your 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 your 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 may be placed in your abdomen to drain blood and fluid from around the liver. These will remain in place for about one week.
• In some cases, the surgeon will place a special tube, called a T-tube, in your 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 four to five months. The tube causes no discomfort and does not interfere with daily activities.

When a liver has been identified for you, 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 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.

Liver transplantation 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 or it can be the end result of a long-term problem. The following conditions may result in liver failure:

• Chronic hepatitis with cirrhosis.
• Primary biliary cirrhosis (a condition where the immune system inappropriately attacks and destroys the bile ducts causing liver failure).
• Sclerosing cholangitis (scarring and narrowing of the bile ducts inside and outside of the liver causing the backup of bile in the liver which can lead to liver failure).
• Biliary atresia (malformation of the bile ducts).
• Alcoholism
• Wilson's disease (a rare inherited disease with abnormal deposition of copper throughout the body, including the liver, causing it to fail).
• Hemochromatosis (a common inherited disease where the body is overwhelmed with iron).
• Alpha-1 antitrypsin deficiency (an abnormal accumulation of alpha-1 antitrypsin protein in the liver, resulting in cirrhosis).
• Liver cancer

The average hospital stay after liver transplant is 10 to 14 days. Some patients may be discharged in less time, while others may be in the hospital much longer, depending on 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 your 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 transplantation. The admission is usually for treatment of a rejection episode or infection.

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 to months. 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 transplant, 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 your transplantation options with you at the time of your pre-transplant evaluation, or you can contact the transplant team for more information.

You will need to bring all of your previous doctor records, X-rays, liver biopsy slides and a record of medications to your pre-evaluation for a liver transplant. To complement and to update previous tests, some or all of the following diagnostic studies are generally performed during your 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 your liver are open.
• Echocardiogram to help evaluate your heart.
• Pulmonary function studies to determine your 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.