Liver Transplant
Preparation
Successful liver transplants can lead to a longer, more active life for people with end-stage liver disease.
The liver, the largest organ in your body, is located behind your rib cage on the right side. It has many functions including processing proteins, fats and carbohydrates, and breaking down toxic substances such as drugs and alcohol. The liver makes the chemical components that help your blood clot. If the liver fails, you lose the ability to clot blood and process nutrients needed for life.
The liver also excretes a yellow digestive juice called bile, which may accumulate if your liver is not functioning properly. Your eyes may become "jaundiced" or yellow or your skin may itch from the accumulated bile. Some medications help treat the symptoms of liver failure, but there are no drugs that "cure" liver failure.
If your liver begins to fail, you may be eligible for a liver transplant. A liver transplant may not be recommended if you have an infection outside the liver, a medical condition that poses a problem or if you are an active substance abuser. Additional information is available by request on the medical center's policy regarding liver transplantation for patients with alcoholic liver disease.
People who have certain cancers -- such as metastatic carcinoma and cancer of the bile ducts called cholangiocarcinoma -- or have certain heart or lung conditions are not considered candidates for liver transplant.
End-Stage Liver Damage
Because the liver has so many functions, a number of different diseases and conditions can result in liver failure.
Congenital Liver Damage or Cirrhosis
Congenital or acquired end-stage liver damage, called cirrhosis, can be due to various factors such as nutritional deficiencies, poisons including alcohol or previous inflammation. These causes of liver damage include:
Liver-based disorders due to physical and chemical or metabolic changes in the body include:
Other Conditions
Transplant Preparation
The preliminary evaluation, called a Phase I Evaluation, is the first step in helping you and the transplant team determine if transplantation is an appropriate treatment 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, have family members or close friends accompany you to help understand the significant amount of information you will receive about the transplant process.
Because you will undergo many tests, do not eat or drink anything after midnight of the day before your appointment.
Plan to bring a snack. Please bring any medications you are taking, your health insurance information and your medical records if you have them.
Tests
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 to assess your kidney function.
Ultrasound scan to view the blood flow to and from your liver, and locate any abnormal masses in the liver. A probe will be moved over your liver so that its image can be reflected and reviewed on a screen.
Chest X-ray to help detect infection in your lungs and assess the status of your bones.
Electrocardiogram to help identify any changes in your heart rhythm.
Pulmonary function test to measure your lung capacity. You will be asked to breathe into a machine and blood will be drawn to determine how well oxygen is being absorbed from your lungs.
Every patient also is evaluated by a liver specialist, called a hepatologist, and a surgeon. The hepatologist will do a full exam, review your health history and discuss what it means to be on the transplant waiting list. The wait for a new liver can be up to three years and tests may need to be repeated prior to the transplant. You can discuss your test results with the hepatologist and surgeon and both will answer any questions.
Many patients find it helpful to write down questions before the appointment. You will meet with the financial counselor to review your insurance information. Patients with a history of drug or alcohol dependency are required to remain drug and alcohol free for six months prior to transplant and agree to random screening.
The Waiting List
Once the evaluation is complete, the transplant team meets to discuss each case and to decide whether to add you to the waiting list. Once on the waiting list, you will be notified and undergo further testing at your local doctor's office. Patients on the cadaveric waiting list will receive instructions about getting a pager and informing the team about changing health conditions.
If a liver transplant isn't in your best interest, a transplant team member will call to discuss other options. Before your operation, a social worker will talk to you to about your adjustment after the surgery. Weekly support groups led by social workers for current and former transplant recipients and their families address a broad range of issues. Individual counseling also is available during your hospital stay. If necessary, a social worker can arrange follow-up services and answer questions about disability.
Liver transplantation can be done with a cadaveric donor from someone who has died or by a living donor. To receive a cadaveric donor, you are put on a national waiting list until a donor becomes available. This can occur at any time, day or night. The wait is generally two to three years.
Living Donors
A living donor is usually someone in the family or a close friend. Living-donor liver transplantation in adults is a relatively new technique that evolved from the successes of living-donor liver transplantation in children and adult split-liver cadaveric transplantation.
A healthy liver has two lobes, one is about 60 percent of the total liver and the other is 40 percent. Either lobe can be transplanted and grow into a full healthy liver for the recipient. A liver donated from a person who has died can be split and used for two recipients. A living person can donate a portion of liver and still maintain liver health.
Living-donor liver transplantation allows doctors to do the transplantation without the sometimes lengthy wait for a cadaveric liver. Both donor and recipient livers grow to full size after the transplant.
During a transplant evaluation, live donation will be discussed. Donor safety is a primary concern. Donors must be in good health, be of a compatible blood type to the recipient and be motivated to donate from altruistic reasons. If this is a feasible option for you, a donor evaluation will be started after all the recipient testing is completed. If after testing the donor the transplant team determines the donation would work, a surgery date is scheduled for both you and the donor. This process usually takes up to four to six months.
Procedure
Your surgery may last from four to 12 hours depending on your condition. Most patients who have had previous surgeries remain in surgery longer because of scar tissue accumulation. During surgery, your damaged liver and gallbladder will be removed and replaced with the donor liver. Your gallbladder is not required and won't be replaced.
If you are in or approaching end-stage liver disease and would like to learn more about whether a liver transplant is a good option for you, please call the UCSF Liver Transplant Program at (415) 353-1888.
Patients who live outside San Francisco may be evaluated in our clinics located in Fort Bragg, Fresno, Las Vegas, Modesto, San Jose and Santa Rosa. Initial appointments for these clinics are arranged through the Liver Transplant Program.
Recovery
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. Many monitoring lines also will be attached; these, too, will be removed as you become more stable. When you are ready to leave the ICU, you will be cared for on the 14th floor of the hospital if you're an adult. Children are cared for on the sixth or seventh floor. Everyone recuperates from liver transplantation differently. Depending on your condition, you will be hospitalized for two to eight weeks following the transplant.
After the Hospital
After you are discharged from the hospital, you will be seen in the liver transplant clinic at least once a week for the first month. As you improve, you will be seen less often; eventually, you will be seen once a year.
If you are not from the San Francisco area, you probably will 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. Laboratory blood tests are obtained twice a week following transplantation. Gradually, the frequency of blood tests will be reduced. You will be asked to call in test results to the transplant office.
You will be notified about any adjustments in your medications. Complications can occur with any surgery. Patients undergoing organ transplantation 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 will 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 it is possible that you may be returned to surgery to control the bleeding, particularly if it occurs within the first 48 hours after transplant.
Thrombosis -- This is a serious complication that may require a second transplant. If a blood clot forms in a vessel leading to or from your liver, this may injure your new liver. You will receive special anticoagulation medication to prevent thrombosis.
Rejection -- Your body's defense system, the immune system, protects you from invading organisms. Unfortunately, it also views your new liver as foreign and will try to destroy it in an attempt to protect you. This is known as rejection. To prevent this from occurring, you will be given special immunosuppressive medication that must be taken 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.
Preventing Rejection
Immunosuppressive medications help to prevent and treat rejection. These drugs decrease your body's resistance to foreign bodies, such as your new liver. You will need to take these medications for the rest of your life or you will reject your liver. Immediately after surgery, the dosages will be high since the probability of rejection is greatest at this time. Dosages will be lowered quickly to smaller amounts if there are no signs of rejection.
The medications have side effects, which are usually dose-related. Most people experience the highest level of side effects in the beginning when medication dosages are high. As the dosage is lowered, these effects will probably lessen. Side effects may occur in some patients and not in others.
The medications you will take for rejection also impair your body's ability to fight off infections. You will be given medication to help prevent infections but you also will need to use caution and avoid contact with people with infections, especially during the first three to six months after transplant.
Copyright © 2002 - 2008 The Regents of the University of California