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UCSF Liver Transplant Program

Liver transplantation, first performed in 1963, provides an opportunity for a longer, more active life for people in the final stages, or end-stage, of liver disease. Advances in surgical techniques and new immunosuppressive medications that prevent the body from rejecting the transplanted organ have greatly improved success rates.

The Liver Transplant Program at UCSF Medical Center is one of the nation's leading liver transplant centers, designated a "Center of Excellence" by major insurance providers nationwide.

More than 300 patients, including adults and children, are referred to UCSF for liver transplant evaluation each year and 100 of these patients have transplants performed at here. The UCSF program has one of the lowest re-transplantation rates in the country and patient survival rates that are well above the national average.

The primary goal of the program is to return patients to a lifestyle as near to "normal" as possible. To accomplish this, UCSF emphasizes a comprehensive approach to address a full range of patient concerns, including physiological, psychological and nutritional issues.

Multispecialty Patient Care

The program's internationally recognized surgical team is supported by specialists in gastroenterology, infectious disease, anesthesiology, liver disease and pharmacology as well as by nurse coordinators, social workers, mental health professionals, a nutritionist and financial counselors.

Living Donor Transplants

This highly specialized procedure for adults and children involves removing a segment of the donor liver and transplanting it into the recipient. Living donor transplants are performed by a UCSF team that was among the first in the world to perform this surgery.

Renowned Research

UCSF is one of three national centers contributing to the National Institutes of Health (NIH) Liver Transplant Database, involving NIH-sponsored data collection and clinical trials. The immunogenetics laboratory at UCSF is involved in studies to prevent and treat rejection.

Introduction

This information covers liver function and the liver transplant process — from evaluation, surgery and post-transplantation.

Normal Liver Functions

The liver is the largest and heaviest organ in your body and performs many complicated functions. It is located in the upper right side of the abdomen, just below your diaphragm, and is in contact with the stomach and gallbladder as well as the small and large intestines. During surgery, your new liver will be placed in the same location as your own liver. The liver performs more than 400 functions every day to keep you healthy. These functions include:

• Bile Production — Liver cells generate bile, which is stored in your gallbladder, located near your liver. When your body needs bile to digest fats, it's released into your intestines. To prevent complications following transplant, your new liver will be transplanted without a gallbladder. Bile will be redirected naturally into your intestines.
• Glucose Maintenance — Your liver stores, releases and converts sugar from the blood. This process allows you to maintain a normal levels of blood glucose, or sugar, in your blood.
• Protein Metabolism — The liver produces large proteins that are important for cell growth, reproduction and repair.
• Filtration — Certain cells in the liver cleanse the body of bacteria and waste products such as ammonia.
• Blood Storage — Your liver regulates blood volume by storing and releasing blood when it's needed.

Liver Diseases

Many diseases can result in end-stage, or terminal, liver disease requiring a liver transplant. To understand your condition, you'll receive information about your specific illness at the time of your initial evaluation. Not everyone who is evaluated for a liver transplant actually needs one. Your initial appointment will help determine your treatment options.

Pre-Transplant Evaluation

Most liver transplant patients at UCSF are referred to the program by primary care doctors or by a specialist. When a referral is made, a transplant program coordinator will call you to schedule an appointment, typically on a Tuesday.

This preliminary Phase I Evaluation is the first step in helping you and the transplant team determine if a transplant is an appropriate option. It also enables the transplant team to assess the medical factors related to your liver failure.

The appointment will take a full day from about 8 a.m. to 4 p.m. and can be very tiring. The following tips will help you prepare for this first appointment:

• If possible, bring a family member or close friend to help you recall the large quantity of information you will receive about the transplant process.
• Because you will undergo many tests, please don’t eat or drink anything after midnight before your appointment. Bring a snack to eat after your tests.
• Please bring all your medications.
• Please bring your health insurance information.
• If you have copies of your medical records, please bring them.

As part of your evaluation, a series of tests will be conducted, including:

• Blood tests to help determine how well your liver is functioning and assess your kidney function.
• Ultrasound to view blood flow to and from your liver and locate any abnormal masses.
• Chest X-ray to help detect infection in your lungs and assess the status of your bones.
• Electrocardiogram (ECG)to help identify any changes in your heart rhythm..
• Pulmonary function tests to measure your lung capacity. You will be asked to breathe into a machine. Blood will be drawn to determine how well oxygen is being absorbed from your lungs.

During your visit, you will meet members of the transplant team, including surgeons, liver specialists or hepatologists, a social worker, a transplant coordinator and a financial counselor. We encourage you to ask questions.

Evaluation and Recommendation

The goal of the initial evaluation is to gather information necessary to determine the severity of your liver disease and make preliminary recommendations regarding your care. After your test results are compiled, the transplant team will discuss your case during a weekly conference. This conference includes doctors, nurses, social workers and hospital administrators.

If preliminary findings indicate that the best treatment for you may be a liver transplant, you will be asked to begin a Phase II Evaluation. This is similar to the first evaluation, although the tests may be more invasive. These tests will help determine more precisely if a liver transplant can be done and what complications might occur.

Depending on the urgency of your case, the Phase II Evaluation may be scheduled shortly after your initial evaluation.

If it's determined that your case is not appropriate for transplantation, a transplant doctor and a coordinator will call and discuss this with you. The findings also will be discussed with the doctor who referred you to UCSF.

Activation

When all of your Phase 1 and Phase II tests are completed, the transplant team will discuss your case again. If the team determines that a liver transplant would benefit you, the coordinator will call you to review the results. At that time, your case will be activated. This means that you will be placed on a local and national list to receive a transplant.

Donor Availability

Once your case is activated, your transplant coordinator will explain how to obtain and use a pager. The pager is important because you'll need to come to the hospital immediately if a donor organ becomes available. Since donor availability can occur at any time of the day or night, you must carry a pager with you at all times and keep it turned on when you're not at home.

When a donor becomes available, careful testing is performed to ensure that the organs are not damaged in any way. Then, they are matched to a transplant candidate of compatible size and blood type.

At the Hospital

When you are paged for a transplant, go directly to the Admitting Office of UCSF on the first floor of the hospital at 505 Parnassus Ave. If you're interested in short-term lodging nearby, the transplant social workers can help you. Once you are admitted, you will have blood tests, a physical exam and other tests. It may be three to eight hours between the time of admission and your transplant surgery, depending on where the donor is located. Your family may stay with you until you are taken to the surgery suite.

Once the donor team determines that the donor organ is satisfactory, preparations for your surgery will be finalized and you will be taken to the operating room. Your family may wait in the Intensive Care Unit (ICU) waiting roomon the ninth floor of the hospital for adults. For children, the waiting room is on the sixth or seventh floor of the hospital.

In some cases, the team may conclude that the donor liver is not satisfactory. If this occurs, the transplant will be canceled. If a cancellation occurs, remember that it is in your best interest.

Surgery

Your surgery may last from four to 12 hours depending on your condition. Patients who have had previous surgeries may be in surgery longer because of scar tissue.

During surgery, your old liver and gallbladder will be removed and replaced with the new donor liver. Your gallbladder is no longer required.

After surgery, you will go directly to the intensive care unit (ICU), usually for one or two days. Immediately after surgery, a breathing tube will be inserted to help you breathe. In most cases the tube can be removed within 24 hours after surgery. Equipment to monitor your condition also will be attached until you are more stable. When you leave the ICU, you will be cared for on either the 14th floor for adults or the sixth and seventh floor for children.

Everyone recuperates from liver transplantation differently. Depending on your condition, you will be hospitalized from two to eight weeks following the transplant.

During your stay, you will learn many things, including when and how to take your medication, signs and symptoms of rejection and other important aspects of post-transplant care. We encourage others — family members or friends — to learn about your care such as medication and laboratory tests because you may need help when you return home.

Post-Transplant

After leave the hospital, you'll be seen in the liver transplant clinic at least once a week for the first month. As you improve, you'll be seen less frequently. Eventually, you'll be seen once a year. If you're not from the San Francisco area, you may need to stay close by for the first month after discharge. After that, your doctor or a specialist near your home will provide follow-up care.

Blood tests are obtained twice a week following the transplant. The frequency of blood tests is gradually reduced. You'll be asked to call in test results to the transplant office and will be notified about any adjustments in your medications.

Complications

Complications can occur with any surgery. Patients undergoing organ transplants may face additional complications. The life-threatening disease that created the need for your transplant may affect the functioning of other body systems. Other risks, such as rejection, also may occur. Some possible transplant complications and medication side effects include:

• Hemorrhage — One function of the liver is to manufacture clotting factors. When a liver fails, the ability to produce clotting factors is impaired. To correct this problem, you'll receive blood products before and after surgery. It is expected that your new liver will start working very quickly to help prevent any excessive bleeding, but you may be returned to surgery to control bleeding, particularly if it occurs within the first 48 hours after transplant.
• Thrombosis — A blood clot in a vessel leading to or from your liver may injure your new liver. You will receive special anticoagulation medication to prevent this. This is a serious complication which may require a second transplant.
• Rejection — Your body's immune system protects you from invading organisms. Unfortunately, it also views your new liver as foreign and will try to destroy it to protect you. This is known as rejection. To prevent this, you will take special immunosuppressive medication for the rest of your life. Rejection can be diagnosed early by performing weekly liver biopsies during the first few weeks after liver transplant. Although rejection is common, with early diagnosis and treatment the situation can be controlled in more than 95 percent of cases.
• Infection — Medications you take for rejection also impair your body's ability to fight off infections. You'll take medication to help prevent infections but you'll need to use caution and avoid contact with people with infections, especially during the first three to six months after transplant. Contact the transplant office if you're exposed to someone with a contagious disease. You also must call the office if you develop a fever of 100 degrees or more or if you feel sick. Good hand washing is an important way to prevent contracting infections after transplantation.
• Medication Side Effects — Immunosuppressive medications help prevent and treat rejection. These drugs decrease your body’s resistance to foreign bodies, such as your new liver. You must take these medications for the rest of your life or you'll reject your liver. Immediately after surgery, the dosage will be high since the chance of rejection is greatest at this time. The dose will be lowered quickly to smaller amounts if there are no signs of rejection.
  
  Medications have side effects that usually are dose-related. Most people experience the highest level of side effects in the beginning when dosages are high. As the dose is lowered, the effects will probably lessen. Side effects may occur in some patients and not in others. Medications include:
  
  Prednisone is a steroid that prevents inflammation. Possible side effects include:
  
  
  • Physical Appearance — Puffiness or roundness in cheeks, abdomen and shoulders. Acne may appear or increase, for which medication can be prescribed.
  • Increased Appetite — Although initially you may lose weight after your transplant, you'll must watch your diet when you're home. Large weight gain can be detrimental to your transplant. A well-balanced diet and exercise will help prevent this.
  • Stomach Irritation — Prednisone can put you at risk for developing ulcers. Never take this medication on an empty stomach.
  • Mood Swings — Intense feelings of sadness or happiness after the transplant are common. In some cases, this may be a side effect of prednisone.
  • Prolonged Healing — Prednisone may slow your body's healing capability. It may take longer for cuts and bruises to heal or for you to recover from viral infections. You also will be more susceptible to viruses nd infections.
  • Sun Sensitivity — Avoid exposure to the sun for more than two hours. Always apply a number 20 sunscreen and cover your face and body if outside for an extended period.
  Neoral or Gengraf (cyclosporine) and Prograf — This medication suppresses cells specifically responsible for rejection. Possible side effects include:
  
  • Temporary Kidney Dysfunction — This is dose-related and will lessen with a decrease in dosage.
  • Body and Facial Hair — You may experience an Increase in body and facial hair when taking neoral or gengraf. Prograf may result in thinning of the hair.
  • Hand tremors — This medication may cause hand tremors.
  • Blood Pressure — These medications may cause high blood pressure.
  .

Expenses

Most insurance plans cover the costs associated with liver transplantation. During your evaluation, you will meet with a financial counselor who will discuss the approximate cost of the transplant and of follow-up care as well as the resources available to you. When you come for your evaluation, please bring your insurance information with you.

Support Groups

Every Tuesday, a liver transplant support group meets in the solarium on the 14th floor of the UCSF Medial Center at 505 Parnassus Ave. This group includes patients who have had a transplant as well as those who are waiting for one, and their families. We encourage patients and families to attend. It can be helpful to hear the transplant experience from another patient's perspective. It also can help prepare you physically and emotionally to cope with changes you'll face before and after a transplant.

Most of our patients and their families feel overwhelmed with the possibility of a liver transplant. A transplant — from the evaluation phase through recovery — requires physical and emotional stamina. Emotional support and practical assistance provided by family members is crucial.

Prolonged illness and serious surgery affect family members and loved ones as well as the patient. Advanced liver disease can result in extreme fatigue, which may come and go unpredictably. The ability to work may be impaired and income may be reduced. Family activities may be disrupted and family members and friends may need to help with basic needs. Advanced liver disease also may cause irritability, moodiness and social withdrawal.

Beginning with the first evaluation, the UCSF transplant team will help you and your family and friends understand your condition and what a transplant will mean for you. Discussing your feelings about a transplant with your family and friends is very important.

Feel free to ask questions during your appointments, regardless of how trivial they may seem. Write your questions or concerns as they come to mind and bring them to your appointments.

Remember, you're not alone! Many people are available to help you and your family. A bond often develops among fellow patients and their families, bringing support and encouragement from those who have "been there." Involving your loved ones will help you and them through the process.

This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.