Health

How is a liver transplant performed ?

A liver transplant is a surgical procedure that removes a liver that no longer functions properly (liver failure) and replaces it with a healthy liver from a deceased donor or a portion of a healthy liver from a living donor.

Your liver is your largest internal organ and performs several critical functions, including:

• Processing nutrients, medications and hormones

• Producing bile, which helps the body absorb fats, cholesterol and fat-soluble vitamins

• Making proteins that help the blood clot

• Removing bacteria and toxins from the blood

• Preventing infection and regulating immune responses

Why it’s done

Liver transplant is a treatment option for people with liver failure whose condition can’t be controlled with other treatments and for some people with liver cancer.

Liver failure may happen quickly or over a long period of time. Liver failure that occurs quickly, in a matter of weeks, is called acute liver failure. Acute liver failure is an uncommon condition that is usually the result of complications from certain medications.

Although a liver transplant may treat acute liver failure, it is more often used to treat chronic liver failure. Chronic liver failure occurs slowly over months and years.

Chronic liver failure may be caused by a variety of conditions. The most common cause of chronic liver failure is scarring of the liver (cirrhosis). When cirrhosis occurs, scar tissue replaces normal liver tissue and causes the liver to not function properly. Cirrhosis is the most frequently reason for a liver transplant.

Major causes of cirrhosis leading to liver failure and liver transplant include:

• Hepatitis B and C.

• Alcoholic liver disease, which causes damage to the liver due to excessive alcohol consumption.

• Nonalcoholic fatty liver disease, a condition in which fat builds up in the liver, causing inflammation or liver cell damage.

• Genetic diseases affecting the liver, including hemochromatosis, which causes excessive iron buildup in the liver, and Wilson’s disease, which causes excessive copper buildup in the liver.

• Diseases that affect the bile ducts (the tubes that carry bile away from the liver), such as primary biliary cirrhosis, primary sclerosing cholangitis and biliary atresia. Biliary atresia is the most common reason for liver transplant among children.

Complications of the procedure

Liver transplant surgery carries a risk of significant complications. There are risks associated with the procedure itself as well as with the drugs necessary to prevent rejection of the donor liver after the transplant.

Risks associated with the procedure include:

• Bile duct complications, including bile duct leaks or shrinking of the bile ducts

• Bleeding

• Blood clots

• Failure of donated liver

• Infection

• Rejection of donated liver

• Mental confusion or seizures

Long-term complications may also include recurrence of liver disease in the transplanted liver.

Anti-rejection medication side effects

After a liver transplant, you’ll take medications for the rest of your life to help prevent your body from rejecting the donated liver. These anti-rejection medications can cause a variety of side effects, including:

• Bone thinning

• Diabetes

• Diarrhea

• Headaches

• High blood pressure

• High cholesterol

Because anti-rejection drugs work by suppressing the immune system, they also increase your risk of infection. Your doctor may give you medications to help you fight infections.

Before the procedure

Being placed on the waiting list

Doctors will use the results of your liver function tests and other factors to assess the severity of your illness, how urgently you need a transplant and your place on the liver transplant waiting list.

Your transplant waiting list priority is determined by two scoring systems called Model for End-Stage Liver Disease (MELD) for adults and Pediatric End-Stage Liver Disease (PELD) for children younger than age 12.

Your doctor will use a specific formula to determine your MELD scores, which can range from 6 to 40. The scores estimate the risk of death within 90 days without a transplant. A high MELD score indicates the urgent need of a transplant.

As deceased-donor organs become available, they are allocated according to MELD scores and classified by blood type. People with higher MELD scores are generally offered donated livers first. Time spent on the liver transplant waiting list is used to break ties among people with the same MELD scores and blood type.

Some liver conditions, such as liver cancer, may not result in a person getting a high MELD score. The transplant center can request additional MELD points for people with specific diseases if they meet defined exception criteria.

In addition, adults with acute liver failure are exempted from the MELD-based donor organ prioritization system and may be placed higher on the transplant waiting list according to the severity of their disease.

Waiting for a new liver

The wait for a donor liver can vary greatly. Some people wait days, while others wait months or may never receive a deceased-donor liver.

As you wait for a new liver, your doctor will treat the complications of your liver failure to make you as comfortable as possible.

Complications of end-stage liver failure are serious, and you may be frequently hospitalized. If your liver deteriorates, your MELD score is updated.

Living liver donors

Living-donor liver transplants using a small portion of a liver from a healthy, living person account for a small percentage of liver transplants each year. Living-donor liver transplants were initially used for children needing a liver transplant because suitable deceased-donor organs are scarce. Now, it is also an option for adults who have end-stage liver disease.

Living-donor liver transplants offer an alternative to waiting for a deceased-donor liver, and allow the organ recipient to avoid possible health complications of waiting for a transplant. The first step is to identify a living donor who is healthy and able to safely undergo a major surgical procedure. The donor’s age, blood type and organ size also are critical considerations in determining whether you and the donor are a match for living-donor liver transplant.

Most living liver donors are close family members or friends of the liver transplant candidate. If you have a family member or friend who is willing to donate part of his or her liver to you, talk to your transplant team about this option.

Living-donor transplants have good results, just as transplants using livers from deceased donors. But finding a living donor may be difficult. Living liver donors go through extensive evaluation to ensure they are a match with the organ recipient and to assess their physical and mental health. The surgery also carries significant risks for the donor.

Your transplant team can discuss the benefits and risks with you and the potential donor.

Domino liver transplant

Another, less common, type of living-donor liver transplant is called a domino liver transplant. In a domino liver transplant, you receive a liver from a living donor who has a disease called familial amyloidosis. Familial amyloidosis is a very rare disorder in which an abnormal protein accumulates and eventually damages the body’s internal organs.

The donor with familial amyloidosis receives a liver transplant to treat his or her condition. Then, the donor can give his or her liver to you in a domino liver transplant because the liver still functions well. You may eventually develop symptoms of amyloidosis, but these symptoms usually take decades to develop.

Doctors usually select recipients who are 55 years old or older and who aren’t expected to develop symptoms before the end of their natural life expectancy. After your transplant, doctors will monitor you for signs of the condition.

Doctors will evaluate you to determine if you may be a candidate for a domino liver transplant or if another treatment option would be more appropriate for your condition.

Staying healthy

Whether you’re waiting for a donated liver or your transplant surgery is already scheduled, work to stay healthy. Being healthy and as active as you’re able can make it more likely you’ll be ready for the transplant surgery when the time comes. It may also help speed your recovery from surgery. Work to:

• Take your medications as prescribed

• Follow your diet and exercise guidelines

• Keep all appointments with your health care team

• Stay involved in healthy activities, including relaxing and spending time with family and friends

Stay in touch with your transplant team, and let them know of any significant changes in your health. If you’re waiting for a donated liver, make sure the transplant team knows how to reach you at all times. Keep your packed hospital bag handy, and make arrangements for transportation to the transplant center in advance.

During the procedure

Deceased-donor liver transplant

If you’re notified that a liver from a deceased donor is available, you’ll be asked to come to the hospital immediately. Your health care team will admit you to the hospital, and you’ll undergo an exam to make sure you’re healthy enough for the surgery.

Liver transplant surgery is done using general anesthesia, so you’ll be sedated during the procedure.

The transplant surgeon makes a long incision across your abdomen to access your liver. The location and size of your incision varies according to your surgeon’s approach and your own anatomy.

The surgeon removes the diseased liver and places the donor liver in your body. Then the surgeon connects your blood vessels and bile ducts to the donor liver. Surgery can take up to 12 hours, depending on your situation.

Once your new liver is in place, the surgeon uses stitches and staples to close the surgical incision. You’re then taken to the intensive care unit to begin recovery.

Living-donor liver transplant

If you’re receiving a liver transplant from a living donor, your surgery will be scheduled in advance.

Surgeons first operate on the donor, removing the portion of the liver for transplant. Then surgeons remove your diseased liver and place the donated liver portion in your body. They then connect your blood vessels and bile ducts to the new liver.

The transplanted liver portion in your body and the portion left behind in the donor’s body regenerate rapidly, reaching normal volume within a several weeks.

Diet and nutrition

After your liver transplant, it is especially important to eat a well-balanced diet to help you recover and keep your liver healthy.

Your transplant team includes a nutrition specialist (dietitian) who can discuss your nutrition and diet needs and answer any questions you have after your transplant.

In general, your diet after liver transplant should be low in salt, cholesterol, fat and sugar.

To prevent damaging your new liver, it’s important to avoid alcohol. Do not drink alcoholic beverages or use alcohol in cooking.

Your dietitian will also provide you with several healthy food options and ideas to use in your nutrition plan. Your dietitian’s recommendations may include:

• Eating at least five servings of fruits and vegetables each day

• Avoiding grapefruit and grapefruit juice because of their effect on a group of immunosuppression medications

• Having enough fiber in your daily diet

• Choosing whole-grain foods over processed ones

• Drinking low-fat or fat-free dairy products, which is important to maintain optimal calcium and phosphorus levels

• Eating lean meats, poultry and fish

• Following food safety guidelines

• Staying hydrated by drinking adequate water and other fluids each day

Exercise

Exercise and physical activity should be a regular part of your life after a liver transplant to continue improving your overall physical and mental health.

Soon after your transplant, you should walk as much as you can. Then, depending on your progress, you can start incorporating more physical activity into your daily life.

Walking, bicycling, swimming, low-impact strength training and other physical activities you enjoy can all be a part of a healthy, active lifestyle after transplant. But be sure to check in with your transplant team before starting or changing your post-transplant exercise routine.

References …

www.mayoclinic.org ( liver transplant)

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