Liver Transplantation - All That You Wanted To Know About It!

The liver has many functions, including building proteins and other substances for the body to use, removal of waste products and toxins from the blood drug metabolism and energy storage. Liver disease causes these crucial functions to fail and when the failure is too severe to respond to medication liver transplantation may be an option.

Apollo Hospitals is among the few recognized transplantation centers in the country and has one of the largest transplantation registries. As liver transplantation is a major surgical procedure, the patients and family have quite a lot of concern areas. This broucher provides brief answer to frequently asked questions.

The information contain herein is of general nature and should not be construed as specific medical advice. Please consult your doctor for more details.

• Ascites : A build up of fluid in the abdomen.
• Autoimmune: A condition that results when the bile ducts inside and outside the liver don’t have normal openings. Bile becomes trapped in the liver causing jaundice and cirrhosis. If this condition is present from birth then without surgery it may cause death.
• Biopsy: Removing a small piece of tissue to view under a microscope.
• Cirrhosis: A chronic liver condition cause by scar tissue and damage to cells. Cirrhosis makes it hard for the liver to remove poisons (toxins) like alcohol and drugs from the blood. These toxins build up in the blood and may affect the brain.
• Cyclosporine: An immunosuppressant used after transplantation to prevent rejection.
• Immunosuppressant: Medicines that stop your immune system from attacking bacteria viruses and transplanted organs.
• Jaundice: A symptoms of many disorders. Jaundice causes the skin and white of eyes to turn yellow.
• Mycophenolate mofetill: An immunosuppressant used after transplantation to prevent rejection.
• Sirolimus: An immunosuppressant used after transplantation to prevent rejection.
• Steroids: A group of immunosuppressant used after transplantation to prevent rejection.
• Tacrolimus: An immunosuppressant used after transplantation to prevent rejection.

What are the donor organ options that are used for transplantation in children?

• Reduced size liver graft: a piece of a liver is taken from a brain-dead person(cadaver donor)

• Living donor transplant: A piece of a liver from an adult living donor and is used as a transplant for a child. Over the past 10 years, nearly 1000 of these transplants have been done throughout the world. They have been just as successful as transplants of whole organs. There are some risks of adult donation for transplant to a child. These risks seem to be much smaller than the risks of a living donor transplant to an adult.

Are there technical problems in doing a transplant on a child?

Yes. It is a little more difficult because the blood vessels are very small. Also, the care after surgery must be done in ICUs that can handle such small children.

Do children get the same anti-rejection drugs as adults?

In general, children get the same type of drugs that adults get. However, children may have different side effects. Therefore, only doctors who specialize in this field should handle the follow-up of children after transplants.

What makes a transplant successful?

First, you must have good medical care. Then, families and patients should make every effort to keep in touch with their medical terms. Children who get liver transplants will need to take drugs on schedule, see their doctor often and may need more procedures. All this will help to make transplants successful and will help to give long and healthy lives to the children. So make sure you stay in touch with your transplant team and follow their advice. Ask for counseling when you have any problems.

What does my liver do?

• It helps digest your food
• It clears some wastes from your blood
• It makes proteins that help your blood to clot
• It helps control the way your body, uses food and works with the body’s defense system
• It helps use and store vitamins
• It breaks down many drugs

What are the signs of liver problems?

Some signs of liver problems are:

• Feeling weak and sick in your stomach and losing appetite
• Muscle wasting(becoming skin and bones)
• Fluid build-up in the abdomen(ascites)
• Yellow skin and eyes(Jaundice)
• Forgetfulness, confusion or coma(encephalopathy)
• Swollen hands/ legs
• Itching
• Bruising, bleeding easily and nose bleeds
• Blood in vomitus, bloody/ black bowel movements

What is liver transplantation?

Liver transplantation is surgery to remove a diseased liver and replace it with a healthy one. This kind of surgery has been done for four decades. Across the world thousands of people have had liver transplants and now lead normal lives.

Being tired and losing your appetite can be signs of liver problems. Liver transplants can help adults and children.

PEDIATRIC LIVER TRANSPLANTATION

Liver transplantation is now one of the best treatments for fatal liver diseases in children. New drugs and ways of doing surgery have greatly improved patient survival rates. In the liver transplants for children, there are two main issues.

• What caused the liver failure in the first place?
• What is the severity of disease process and how soon does the child need a liver transplant.

Why do children need a liver transplant?

• Billiary artesia: This is a disease in which a child is born with no bile ducts. It is the most common reason for liver transplants in children
• Problems in digesting and using food: ‘Inborn errors of metabolism’ including the following conditions:
• Alpha-I-antitrypsin deficiency tyrosinemia and wilson’s disease.
• Lipid storage(Gaucher’s disease, Niemann-pick disease, Wolman’s disease, cholesterol ester storage disease)
• Carbohydrate storage diseases (galactoserria and glycogen storage diseases)
• Liver Cancers: Some liver cancers are found only in children
• Sudden liver failure: This is a sudden liver failure that can cause death. It can have many causes. Mostly it comes from too much paracetamol or other drugs. In this kind of liver failure, a liver transplant can cure the problem if done early.

What is involved in the donor-evaluation process?

Donors undergo a thorough check-up that includes:

1. Blood tests: Determine donor’s blood type, to see that it matches that of the person in need of the transplant. Blood tests are done to test the donor’s liver, kidney, and thyroid. Other tests are done to check for viruses such as hepatitis and HIV(the virus that causes AIDS)
2. Physical Examination: If donor and recipient blood types are a close match the donor will get physical examination.
3. Ultrasound: An ultrasound is done for the liver, other organs and the blood vessels
4. Other Tests: Such as MRI, and CT Scans, help to give a complete view of the donor’s organs
5. Tests of the lungs and heart may also be done. It takes 2 to 4 days for a donor to go through these tests. In an emergency situation, it can be done in as little as 48 hours

For how long does the donor remain hospitalized?

Donors stay in the hospital for up to 7 days after surgery. They may spend their first night after surgery in the ICU. The next day they often go to the general surgical floor where the nurses have experience in caring for liver donors. Donors are encouraged to get out of bed and walk as soon as they are able.

How long before the liver donor is fully recovered?

For the most part, it takes about 4 weeks to recover from surgery. In the month after leaving hospital donors return to the hospital regularly to be checked. Donors often get back to work within 3 to 6 weeks. The medical staff will let you know when it is safe to return to normal life.

What are the donor’s health care costs?

The health insurance of the person who gets the transplant covers the donor’s health care costs. This includes the costs of the check up, doctor’s fees, hospital costs, and follow-up visits after surgery.

What are the reasons for needing a liver transplant?

In adults, the most common reason for liver transplantation is Liver cirrhosis. Cirrhosis is caused by many different types of liver injuries that destroy healthy liver cells and replace them with scar tissue. Cirrhosis can be caused by viruses such as hepatitis B and C, alcohol, autoimmune liver disease, build-up of fat in the liver and hereditary liver diseases. Sometimes the cause of liver cirrhosis is not known.

In children, the most common reason for liver transplantation is billiary atresia. Bile ducts, which are tubes that carry bile out of the liver, are missing or damaged in this disease and obstructed bile causes cirrhosis. Bile helps digest food.

Other reason for needing liver transplantation is certain liver cancers, benign liver tumors, and hereditary diseases.

Sudden or rapidly developing liver failure may sometimes affect children and adults. The common causes of certain viral illness and reaction to some medicines like excess does of pain killers and even certain herbal/ traditional medicines. A liver transplant can save life if undertaken at the right time.

How will I know whether I need a liver transplant?

Based on your sickness and liver disease status, your doctor may recommend you to the liver transplant unit for further evaluation. You will meet the liver transplant team. The team is usually led by a liver transplant surgeon and includes liver specialists (hepatologists), nurses, and other health care professionals. The transplant team will arrange blood tests, x rays, and other tests to help make the decision about whether you need a transplant and whether a transplant can be carried out safely.

Other aspects of your health like the condition of your heart, lungs, kidneys, immune system, and mental health will also be checked to be sure you’re strong enough for surgery.

Can anyone with liver problems get transplant?

You cannot have transplant if you have

• Cancer in another part of your body
• Serious heart, lung or nerve disease
• Active alcohol or illegal drug abuse
• An active severe infection
• Inability to follow your doctor’s instructions

How did living-donor liver transplantation begin and how common is it?

Living donor transplants were first done in children because of the long waiting period for cadaver organs and increasing death rate on the list. It was done in children in the 1980s and is now being done in adults for the last 8 years. In India because of relative lack of cadaveric organs, the majority of transplants are done using living donor organs.

Who can become a donor?

People who want to be liver donor are carefully checked to ensure that they can safely give a part of their liver and that their liver is healthy. The first concern is the safety of the donor as well as being sure that the graft will work for the person in need. The risks to the donor are real. Discuss this with your doctor. In general liver donors must:

• Be good in health
• Have a blood type that is a close match to the blood of the person in need.
• Not have a selfish motive for donating

There should be no pressure of any kind on a person to donate part of his liver nor should there be any money given or received.

What are the major risks in donating?

As with any major surgery, there will be pain from the incision, which will get better with time. Other risks to the donor include bleeding, infection, and temporary bile leaks. Fatalities in transplantation have been reported from certain transplant centers in the world but it is rare. Most have full recoveries and are healthy. Discuss regarding risk to the donors with your transplant surgeon.

What happens during donor surgery?

The incision is the shape of mirror image of ‘L’. The gallbladder is always removed. The donor’s liver is split into two parts. One part is removed for the transplantation. The surgeon then closes the wound with sutures and staples. There are later removed at a follow-up visit to the surgeon’s office. The liver begins to heal and grow new tissue. It takes about 8-21 weeks for the liver to grow back to its normal size.

LIVING DONOR TRANSPLANTATION

What is a living donor liver transplant?

A living-donor transplant is when someone who is alive gives a part of his or her liver to a person who needs a transplant. Family members such as parents, sisters, brothers, adult children or someone close, such as a spouse, may offer to give part of his or her healthy liver. This can be done because a healthy liver can grow new tissues. After the transplant, the liver parts of both the donor and person in need will grow and form complete organs.

What are the benefits of living donor liver transplantation?

The best reason for living donor transplant is that it shortens the waiting time for a liver. The timing of the surgery can be planned. The chance for as successful transplant is increased. Today, thousands of patients await liver transplantation but only handful cadaveric organs become available every year. A living-donor transplant gives those in need an early transplant before their liver failure gets worse and their livers are in danger.

How long does it take to get a new liver?

If the transplant team recommends that you need a transplant, you will be counseled regarding your options of living donor liver transplant or cadaver liver transplant.

If you have a living donor in your family your waiting time could be as short as one week. The living donors and donated livers are tested before transplant surgery. The testing makes sure the liver is healthy, matches your blood type and is the right size so that it has the best chance of working in your body.

In case you do not have a living donor, your name will be placed on a waiting list with your consent. Your blood type, body size and how sick you are, plays a role in deciding your place on the list. Currently the sickest people are at the top of the list, so you may have to wait your turn.

While you wait for a new liver you and your doctor should talk about what you can do to stron for the surgery. You will also start learning about taking care of a new liver.

Where do the livers for transplantation come from?

Whole livers come from people who are brain dead (heart beat still present). These people are on breathing machines in various hospital ICUs. This type of donor is called “cadaveric donor”. Alternatively a healthy person in the family can donate a part of his or her liver for the patient with liver failure. This kind of donor is called a ‘living donor’. More information on living donor liver transplantation is included in the latter part of this booklet.

Financial resources/ Health Insurance

You should check to be sure that you will be able to cover the cost of liver transplantation and prescription medicines. You will need certain medicines after the surgery and some for the rest of your life. Check with your employer, health insurance policy or aid organizations if they can support you in part or full.

What happens in the hospital?

When liver is available, you will be prepared for the surgery. If your new liver is from a living donor, both of you and the donor will be in surgery at the same time. If your new liver is from a person who has recently died, your surgery will start when the new liver arrives at the hospital.

Can I go back to my daily activities?

Yes. After a successful liver transplant, most people can go back to their normal daily activities. Getting your strength back will take some time, depending on how sick you were before the transplant.

You will need to check with your doctor on how long your recovery period will be

• After recovery, most people are able to go back to work
• Most people can go back to eating as they eat before. Some medicines may cause you to gain weight others may cause diabetes or rise in your cholesterol. Meal planning and a balanced low-fat diet can help you remain healthy.
• Most people can engage in physical activity after a successful liver transplant
• Most people returned to normal sex life after liver transplantation. It is important for a woman to avoid becoming pregnant in the first year after transplantation.

You should talk to your transplant team about sex and reproduction after transplantation.

If you have any questions, you may check with your doctor before starting any activity.

Eating a healthy diet and taking the medications are part of taking care of your new liver.

What are the other problems that can damage the liver transplant?

Return of the problem that made the transplant necessary in the first place in less than 10% of patients with liver transplants. Also, hepatitis C virus may damage a transplant if the patient was infected before the operation took place.

Rarely occurring problems include:

• Blockage of the blood vessels going into or out of the liver

• Damage to the tubes that carry bile into the intestine

What if the transplant doesn’t work?

About 90% transplanted livers are still working after 1 year and about 75% livers are working at 5 years after transplant. If the new liver does not work or if your body rejects it, your doctor and the transplant team will decide whether another transplant is necessary.

How do I take care of my liver after I leave the hospital?

After you leave the transplant center at the hospital, you will see your doctor often to be sure your new liver is working well. You will have regular blood tests to check that your new liver is not being damaged by rejection, infections or problems with blood vessels and bile ducts. You will need to avoid sick people and report any illness to your doctor. You will need to eat a healthy diet, exercise and not drink alcohol. You should only use medicines, including ones you can buy without a prescription, after counseling your doctor. It is important to do what your doctor says to take care of your new liver.

During Surgery

The surgery can take from 6 to 14 hours. While the surgeon removes your diseased liver, other doctors will prepare the new liver.

The surgeon will disconnect your diseased liver from your bile ducts and blood vessels before removing it. The blood that flows into your liver will be blocked or sent through a machine to return to the rest of your body. The surgeon will put the healthy liver in place and reconnect it to your bile ducts and blood vessels. Your blood will then flow into your new liver.

After Surgery

You will stay in the hospital for an average 2 to 3 weeks to be sure your new liver is working. You will take medicines to prevent rejection of your new liver and to prevent infections. Your doctor will check for bleeding, infections and rejection. During this time you will start to learn how to take care of yourself and use your medicines to protect your new liver after you go home.

In the hospital, you will start eating again. You will start with clear liquids, then switch to solid food as your new liver starts to work.

What are the likely complications following a liver transplant?

Minor wound infection and discharge of liquefied fat is seen in about 10% of people. This will settle with little or no intervention. Major wound infection needing another surgery is extremely rare.

By now you are aware that liver transplantation involves making a lot of connections. There is an extremely small chance that these connections can become too tight or too loose. We have a very highly trained team of doctors who are able to treat them with minimally invasive techniques without resorting to another surgery.

Hepatic Artery Thrombosis (HAT) / Clotting of the hepatic artery is a rare complication seen in less than 4% of the patients and portal vein thrombosis is even rarer and is seen in less than 1% of the patients. When identified, the clot will have to be removed and it will involve another surgery. In spite of all this, if we are not successful, re-transplantation will be necessary.

What is rejection?

Rejection occurs when your body’s natural defenses, called the immune system, damage the new liver. Your immune system keeps you healthy by fighting against things that don’t belong in your body, such as bacteria and viruses. After a transplant, it is common for your immune system to fight against the liver and try to destroy it.

How is rejection prevented?

To keep your body from rejecting the new liver, you will have to take medicines. These drugs such as tacrolimus, cyclosporine, steroids, sirolimus and mycophenolate mofetil are called immunosuppressant. Immunosuppressants weaken your immune system’s ability to reject your new liver.

Do immunosuppressants have any side effects?

Yes. You can get infections more easily because these drugs weaken your immune system. You will need to stay away from people who are sick. These drugs may also increase your blood pressure, cause your cholesterol to rise, cause diabetes, weaken your bones and may damage your kidneys in the long run. Steroid drugs may also cause changes in how you look by causing weight gain. Your doctor and the transplant team will monitor these effects and treat you for any complications that may occur.

What are the signs of rejection?

Doctors will check your blood for liver enzymes at the first sign of rejection. Often rejection does not make you feel ill. Sometimes rejections can cause- pain, fever, jaundice, and changes in liver function tests.

Often a liver biopsy is needed to diagnose rejection. For a biopsy, the doctor takes a small piece of the liver to examine under a microscope. Blood tests will show if the new liver is being rejected.