Liver Transplant
Doctors may recommend a liver transplant to treat liver failure. Failure may be due to disease or injury, and the most common categories of disease are cirrhosis from hepatitis or alcohol, cholestatic disorders, metabolic diseases and certain cancers. It is possible to have liver failure due to viral infections, toxins, or medication reactions. The person who needs the transplant is evaluated by a liver transplant team and if they are found to be suitable, his or her name is placed on the waitlist. When a donated liver becomes available, it is surgically removed from the donor and transplanted into the patient.
Because the liver has the ability to regenerate, in some cases a portion of the liver from a living donor can be removed and transplanted within a recipient with liver failure. Both the donor and recipient will regenerate a liver back to normal size.
This type of transplantation is increasing rapidly.
Among 7,502 patients who underwent liver transplants in 1997 and 1998, about 80% survived for at least three years afterwards.
Step 1: Evaluating candidates for liver transplantation
A team of specially trained staff evaluates the patient to establish whether he or she would be a good candidate for a liver transplant. The staff includes people with special skills in a range of areas. The people who may be on the team include:
- Hepatologist (medical liver specialists)
- Transplant surgeons
- Social workers, psychologists, and/or psychiatrists
- Nurses
- Transplant coordinators
A liver transplant is only offered to people who have irreversible, chronic liver failure. Other medical or surgical treatments for liver problems have usually been tried before consideration of liver transplant. The liver failure may have been caused by problems such as:
- Cirrhosis, a chronic disease of the liver due to alcohol or other causes
- Viral hepatitis (B, C, D)
- Sudden liver failure
- Biliary atresia, an obstruction of the bile ducts caused by their failure to develop normally before birth
- Certain metabolic disorders such as Wilson disease, an inherited disorder in which the body has too much copper
- Drug-induced liver injury
- Noncancerous tumors of the liver and certain cancerous tumors of the liver or bile duct
- Problems with the major blood vessels that supply the liver
Successful liver transplants have been conducted on newborn infants, children and adults including people past the age of 70.
The evaluating team considers many factors to decide whether a person should be placed on the wait list for transplantation. The person's general health and suitability for major surgery are taken into account. Risk factors are considered carefully and may result in a recommendation against transplant surgery.
A liver transplant would not be performed for people with certain conditions. These include:
- Most cancers, unless successfully treated at least five years previously
- Infections that cannot be completely treated or cured, such as tuberculosis
- Severe lung or kidney problems that would make the operation too risky
It is a normal reaction of the body to reject the donated organ. Anti-rejection drugs are prescribed to prevent this rejection. The candidate must be willing to take anti-rejection medicines indefinitely to keep the body from rejecting the donor liver. The person will also need lifelong follow-up by health care professionals.
Step 2: Waiting
If a person is a suitable candidate for a liver transplant, their name is put on a waiting list for an organ. Unfortunately, there are many more people on the wait list than there are organs available each year. There are currently more than 18,000 people in the U.S. waiting for a donor liver. Waiting time may extend several years.
People waiting for donor livers are grouped by the severity of illness and other medical factors such as blood type. Within any given group, livers are allocated based on the length of time a person has been on the wait list.
A new system, the Model for End-stage Liver Disease (MELD) has recently replaced the previous 3 medical severity stages for liver transplant candidates with chronic liver diseases with a scale that goes from 6 to 40. The MELD system is based on three simple to measure laboratory tests, and the MELD score is predictive of death within 3 months (the higher the score, the higher the risk of death). Candidates with sudden, acute liver failure (status 1) are still allocated organs ahead of all other waiting patients. A system similar to MELD has been developed for children (PELD), which utilizes the same three laboratory tests in addition to a fourth blood test and a measure of growth failure.
Step 3: The Transplant Surgery
If the donor is living, they will receive general anesthesia and the transplant of the liver into the recipient will occur immediately after the removal of the organ from the donor. Therefore, the patient receiving the transplant is prepared for surgery within the same time frame as the donor. They, too, will receive general anesthesia.
When a cadaveric liver becomes available, time is critical. The liver must be transplanted into the patient receiving the organ within 12 to 18 hours. A team of surgeons and anesthesiologists performs an operation to remove the liver from the donor. Additional surgical teams may be present to remove other organs. After the liver is removed from the donor, it is preserved and packed for transport. Although the donor is brain dead, this procedure is treated like any other operation using standard surgical practices and sterile techniques. Once the operation is complete and the incisions are closed, the donor's body is prepared for funeral or cremation. Organ procurement surgery respects the body and an open casket funeral is possible if desired.
In the meantime, a recipient is located and prepared for surgery. Preparation involves administration of general anesthesia. The transplant of the liver begins with an incision in the upper part of the abdomen. First, the diseased liver is removed. When the new liver is placed within the recipient, the blood vessels from the donor liver must be connected to the recipient's blood vessels. Next, the blood flow is restored. The bile duct, which carries bile made in the liver to the intestine, is also connected. After the transplant is complete, the incision is closed. The patient will begin recovery in the intensive care unit (ICU).
Step 4: After Transplant Surgery
Following liver transplant surgery, the patient may remain on an artificial breathing machine for the first 24 to 48 hours of recovery. Depending on progress, some patients are moved out of the ICU in a few days. Generally, he or she will also begin eating within the week following surgery. Total hospital stay can be a little as 1 week, and is typically a couple of weeks.
Because the organ will be identified as foreign by the recipient's immune system, rejection of the new liver is always a possibility. Powerful drugs called immunosuppressants are given starting at the time of liver transplant surgery to try to prevent rejection. Within the first few weeks following transplantation, blood tests are done to confirm that correct dosage of medication is being dispensed.
Prior to discharge, the transplant team reviews information with the patient, gives instruction for follow-up care and medications, and answers the patient's questions. A prescribed rehabilitation program will continue at home including exercise, nutrition, and the continuation of immunosuppression and other medications. The signs of rejection are also discussed with the patient and family.
Living donors do not have to take any specific medications or maintain a special diet as a result of liver donation.
Step 5: Returning home
At-home rehabilitation for liver transplantation is a gradual process and depends on the individual. The transplant team will give specific instructions. In general, walking is recommended to restore strength and prevent lung complications, but heavy lifting should be avoided for four to six weeks following transplant surgery. Other activities, such as driving may usually begin when the incision is free of pain. Sexual activity can resume when one is comfortable. A desire to become pregnant should be discussed ahead of time with the transplant team to determine if and when this is recommended.
Follow-up visits are required for check-ups. These begin soon after returning home. Initially, outpatient visits may occur weekly or even more often, and as time progresses the frequency of follow-up visits usually decreases.
Possible post-operative complications may arise following liver transplant surgery. They include:
- Bile duct problems
- Major bleeding
- Problems with blood vessels
Bile duct problems - Complications can arise with the connection between the donor and recipient bile duct or between the donor bile duct and intestine. If it does not heal properly, bile may leak out. Scar tissue can also block the bile duct causing bile the inability to flow.
Major bleeding - It is common for a liver transplant patient to experience bleeding after surgery. The new liver needs time to make blood-clotting proteins. Patients usually need blood transfusions, and an additional operation may be required within the first 24 to 48 hours after the transplant to resolve the problem.
Problems with blood vessels - Complications can arise with blood vessel connections between the donor liver and the recipient's blood vessels. A more serious complication is a clot in an artery or vein attached to the liver. If a clot occurs, the liver may fail.
Other problems include the long-term risks of immunosupression. These include complications related to too much or too little immunosuppression:
- Rejection
- Cancer
- Infection
Rejection - It is fairly common for a transplant patient to experience rejection episodes. The body identifies the new organ as foreign and may try to reject it. The immunosuppressive medications prevent rejection in 50 to 75% of cases. Changes may be made in the medications including an increase in dosage or the use of additional drugs to stop the rejection. Some episodes can cause permanent damage to the new liver. This may reduce longevity of the organ.
Cancer - Studies show that an estimated 6% to 8% of transplant patients will develop cancer over their lifetime with the transplant. This risk is higher than in the general population. Skin cancer is the most common, and is typically treated successfully. Some cancers result from the effects of the immunosuppressive medications and others are common cancers that occur at a higher rate in immunosuppressed individuals.
Infection - The immunosuppressant medications increase the risk of less serious and common infections such as urinary tract infection. In addition, they are associated with more serious infections like pneumonia. Finally, uncommon infections that do not affect non-immunosuppressed persons can occur.
Living donors are generally followed by the transplant team for a considerable period of time until recovery is complete.
Important! Nothing on this page is medical advice. If you need a transplant, please seek the advice and care of qualified transplant physicians. This is a general source of information and does not represent a medical opinion or recommendation.
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Section 3: Kidney Transplant