Liver Transplants
What is liver transplantation?
Liver transplantation is a life-saving operation for children and adults with certain liver diseases when no other treatment is available. The operation involves taking out the diseased liver and replacing it with a liver of suitable size and blood type. Overall, about 60-75 of adult patients and 80-90% of children survive a liver transplantation and resume normal lives although they continue to need medication to prevent rejection.
Unfortunately, many patients succumb to liver disease before transplantation can be undertaken. Public awareness of the need for organ donation is an important element in the overall success of liver transplantation.
Which liver diseases are the most common?
The majority of patients who come to liver transplantation with chronic liver disease have developed cirrhosis of the liver. Cirrhosis refers to scarring of the liver and this results in abnormalities in the function of the liver. These abnormalities may threaten the patient's life and usually include problems with bleeding and infections. Patients who develop acute liver disease may require urgent transplantation and often have no prior history of liver disease. These patients may develop liver failure with serious blood clotting abnormalities as well as deep coma. Without urgent transplantation, most patients with acute liver diseases will die. In adult patients, causes of chronic liver disease leading to cirrhosis include viral hepatitis (usually type B or type C), alcohol related liver disease, and autoimmune liver diseases including primary biliary cirrhosis and acute fulminant liver failure (adults and children)
What diseases are treated by liver transplantation?
Liver transplants may be performed for a number of acute or chronic liver diseases. Patients with acute liver diseases usually require urgent transplantation within a matter of days to weeks. Patients with chronic liver disease may undergo elective liver transplantation unless they experience worsening of their liver disease, in which case, urgent transplantation may be required in these patients.
What about children and liver disease?
Thousands of children, from infants to adolescents, have liver disease, and many die from it each year. Some are born with a liver disease, others contract it at birth or early in life. The more common types of liver diseases that affect children are: chronic active hepatitis, Biliary Atresia, galactosemia, Wilson disease, alpha-1antitrypsin deficiency, tyrosinemia and Reye's syndrome.
Advances in liver transplantation offer hope for children with severe, irreversible liver disease.
What about cancer of the liver?
Cancers of the liver are not usually treated with transplantation. Most liver cancers begin elsewhere in the body and spread to the liver. These patients are not curable with liver transplantation. Unfortunately, most liver tumors or cancers that have started in the liver usually grow to large size without being detected and are therefore rarely curable by liver transplantation. Many liver transplant centers, however, have protocols to treat patients who have small or early stage cancers with transplantation and chemotherapy.
There is still much to be learned about cancer that originates in the liver. Liver cancer can be caused by hepatitis B, which is probably the major cause of liver cancer worldwide. It is often associated with cirrhosis and can be caused by certain parasites, drugs and environmental toxins.
Is liver transplant a last resort, when everything else has failed?
It is well known that liver transplantation is highly successful if performed prior to patients becoming critically ill. If the patients are allowed to deteriorate to the terminal stages of their liver disease, the success of liver transplantation is poor. However, if other medical or surgical options are available for the patients which will either restore them to or maintain them in a good to excellent quality of life, then transplantation should be delayed. An additional factor in the decision about the timing of referral of a patient for transplant is the fact that even after a patient is placed on the national waiting list for a liver transplant, the time it takes to find a suitable donor liver can be over a year for some patients.
How is the decision made to transplant?
The decision to transplant is made in consultation of all individuals involved including the patient and/or family with a clear understanding of the risks involved.
The decision that a patient is a suitable candidate for transplantation involves an evaluation by the liver transplant team. This usually involves traveling to the transplant center and meeting with the physicians and surgeons as well as the transplant coordination's, social workers, dietitians, and other members of the transplant team. After the evaluation of the patients is completed most transplant centers have a medical review board which reviews the data on every patient who is a candidate for transplant. If no contraindications are discovered, the committee will approve the patient as a transplant candidate. Once approved, then patients are placed on the national waiting list.
What are the major risks before, during and after transplantation?
Before the transplant, the major risk is the development of severe complications of the liver disease. These complications may result in the patient's death or complications may develop which render a patient an unacceptable risk for transplantation. The risks associated with transplant surgery are common to all forms of major surgery and include bleeding and infection. Unique to liver transplantation is the difficulty in removing the diseased liver, especially in patients who have had prior operations on their liver or gallbladder. Additionally, major blood vessels must be connected in order to transplant the donor liver. Clotting of these vessels may result in severe damage to the transplanted liver with need for a second liver transplant. The function of the transplanted liver must also be good to excellent or the patient will not recover. Late complications which may develop in patients who have received a liver transplant include rejection, a variety of infections, or complications related to the anti-rejection drugs.
What are the overall chances of surviving a liver transplant?
This depends on many factors, but approximately 75% of all patients coming to liver transplantation survive the first year after transplantation. Most centers report that over 95% of their patients who survive the first year survive each year after the first. However, patients who are in good condition going into the transplant have survival rates of as high as 90% at one year, patients who are critically ill and confined to the Intensive Care Unit have survival rates of less than 50%. This again indicates the importance of early referral of patients for transplantation and the need to transplant patients before they become critically ill.
How long does it take to recover?
Recovery time depends in large part on how ill the patient was prior to their transplant and how well the transplanted liver works after the transplant. Most patients who are admitted to the hospital from home for their transplant will spend 2-3 days in the Intensive Care Unit and 2-3 weeks in the hospital. Patients who are critically ill at the time of their transplant may spend 2-3 weeks in the Intensive Care Unit and 2-3 months in the hospital.
What happens during this recovery period?
While patients are in the Intensive Care Unit, there is very careful monitoring of all body functions. Once patients are sent to the transplant ward, they are usually beginning to resume eating a normal diet as well as being out of bed and walking in the halls. In addition to physical therapy and intensive nutritional support, patients will be changing from anti-rejection medicines given by vein to anti-rejection medicines taken exclusively by mouth. As the patient's condition stabilizes and their liver function normalizes, the frequency that blood tests need to be taken decreases. Additionally, as time passes, the liver requires less anti-rejection medicine to prevent rejection and the frequency of lab work may decrease from three times a week to as infrequently as once a month within the first year after transplant.
If the transplanted liver fails to function, or is rejected, what can be done?
The degree of liver failure may vary from patient to patient. Patients with severe liver failure due either to rejection, clotting of blood vessels, or poor initial function of the transplant will often require a second transplant. It is rare for a third or fourth transplant to be performed. As of yet, there is no artificial liver device which is clinically available for routine use. However, most patients who develop rejection can be treated and, in most cases, the transplanted liver will respond and a second transplant will not be necessary.
What side effects do patients commonly experience from medications used to prevent rejection?
All the medicines used to prevent rejection increase the patient's susceptibility to infections and all transplant recipients on anti-rejection medicine are more prone to develop certain types of cancers. Each medication has its own side effects. Steroids can cause fluid retention, puffiness of the face, worsening of diabetes, and bone loss (osteoporosis). Cyclosporine and Prograf can cause kidney damage as well as high blood pressure. All patients should be informed of the possible side effects. All patients will be educated about how to take care of their transplants and all patients will be educated about how to take their anti-rejection medication, as well as what side effects to look out for.
Do recipients of liver transplants take medicines for the rest of their lives?
Yes. It appears most likely that all patients undergoing liver transplantation will require anti-rejection medicines for the rest of their lives. However, over time, the amount of anti-rejection medicine becomes less as the body becomes more tolerant of the transplanted liver. Most centers attempt to lower the amount of anti-rejection medicine to the smallest dose required to prevent rejection in all transplant recipients. Some centers are also selectively eliminating one or more of the anti-rejection medicines. If this is to be done, it must be done under close supervision by the transplant center.
Are patients more susceptible to other infections?
Once the patient has stabilized after their transplant, they are not receiving such high doses of anti-rejection medication that they are likely to pick up serious infections from individuals around them. However, they are at high risk for developing infection from organisms that reside in their own body. Most centers require that transplant recipients take long-term antibiotics by mouth to prevent certain unusual types of lung infections. In addition, they may be required to take anti-viral medications, especially if they have developed a viral infection following their transplant. Most important is the fact those patients who are on anti-rejection medications are at higher risk of becoming seriously ill with any infection. Therefore, any significant illness should be reported immediately to either the primary care physician or the liver transplant team. No over-the-counter medications should be taken without approval of the transplant team.
What about physical activity after the transplant?
Most patients are able to return to normal or near-normal quality of life after their transplant. There is absolutely no reason patients with a well-functioning transplant cannot participate in vigorous physical exercise within three to six months after their successful transplant. Many liver transplant recipients take part in the National and Regional Transplant Olympics which are held yearly.
What about sexual activity?
As with other physical activities, sexual activity may be resumed when desired. Birth control should be used when appropriate in sexually active transplant recipients. Many women who have lost their menstrual periods due to the severity of their liver disease will begin to have periods again once they have recovered from their transplant.
Can there be a recurrence of the original disease in the transplanted liver?
If hepatitis, either B or C, caused the liver disease, then recurrences are likely. Other types of liver disease do not usually recur following successful transplantation.
From the description, patients with successful liver transplants seem very healthy. How long can this good health last?
It is the impression of most transplant surgeons and physicians that a patient's life-span should not be significantly decreased by the fact that they underwent a liver transplant. Probably because of the unique ability of the liver to repair itself from minor damage, there is no reason to assume that a transplanted liver cannot function adequately for an indefinite period of time. It is important to stress, however, that patients with a transplant continue to be at risk of complications throughout their life. Long-term medical follow-up is therefore required of all patients who have undergone transplantation.
