Treatments

Liver disease, severe enough to require a liver transplant can occur from many causes. Doctors have developed various systems to determine the need for the surgery. Two commonly used methods are by specific disease process or a combination of laboratory abnormalities and clinical conditions that arise from the liver disease. Ultimately, the transplantation team takes into account the type of liver disease, the person’s blood test results, and the person’s health problems in order to determine who is a suitable candidate for transplantation.

A liver transplant may be recommended for people who have end-stage liver disease (ESLD), a serious, life-threatening liver dysfunction. ESLD may result from various conditions of the liver.

The most common liver disease for which transplants are done is cirrhosis. Cirrhosis is a long-term disease of the liver in which a fiber-like tissue covers the organ and prevents toxins and poisonous substances from being removed. Other diseases that may progress to ESLD include, but are not limited to, the following:

• Acute hepatic necrosis: This is the death of tissue in the liver.
• Biliary atresia: A condition in which the bile ducts are absent or have developed abnormally.
• Metabolic disease: Conditions that affect the chemical activity in cells that are affected by the liver.
• Liver cancers: These are primary tumours (that start in the liver) that have not spread outside the liver.
• Autoimmune hepatitis: A chronic inflammation of the liver, resulting in liver cell damage and destruction.

In adults, chronic active hepatitis and cirrhosis (from alcoholism, unknown cause, or biliary) are the most common diseases requiring transplantation. In children, and in adolescents younger than 18 years, the most common reason for liver transplantation is biliary atresia, which is an incomplete development of the bile duct.

Laboratory test values and clinical or health problems are used to determine a person’s eligibility for a liver transplant.
For certain clinical reasons, doctors may decide that a person needs a liver transplant.

• These reasons may be health problems that the person reports, or they may be signs that the doctor notices while examining the potential recipient. These signs usually occur when the liver becomes severely damaged and forms scar tissue, a condition known as cirrhosis.
• The most common clinical and quality-of-life indication for a liver transplant is ascites, or fluid in the belly due to liver failure. In the early stage of this problem, ascites may be controlled with medicines (diuretics) to increase urine output and with dietary modifications (limiting salt intake).
• Another serious consequence of liver disease is hepatic encephalopathy. This is mental confusion, drowsiness, and inappropriate behaviour due to liver damage.
• Both ascites and encephalopathy are used in the current classification system to determine the severity of liver disease.
• Infection in the abdomen, known as bacterial peritonitis, is a life-threatening problem. It occurs when bacteria or other organisms grow in the ascites fluid.
• Liver disease causes scarring, which makes blood flow through the liver difficult and may increase the blood pressure in one of the major blood vessels that supply it. This process may result in serious bleeding.
• Blood may also back up into the spleen and cause it to increase in size and to destroy blood cells.
• Blood may also go to the stomach and oesophagus (swallowing tube). The veins in those areas may grow and are known as varices. Sometimes, the veins bleed and may require a gastroenterologist to pass a scope down a person’s throat to evaluate them and to stop them from bleeding.

These problems may become very difficult to control with medicines and can be a serious threat to life. A liver transplant may be the next step recommended by the doctor.

Symptoms of Liver Disease

People who have liver disease may have many of the following problems:

• Jaundice – Yellowing of the skin or eyes
• Itching
• Dark, tea-coloured urine
• Grey or clay-coloured bowel movements
• Ascites – An abnormal build-up of fluid in the abdomen
• Vomiting of blood
• Tendency to bleed
• Mental confusion, forgetfulness

Exams & Tests

Extensive testing must be done before an individual can undergo a liver transplant. Because of the wide range of information necessary to determine eligibility for transplant, the evaluation process is carried out by a transplant team. The team includes a transplant surgeon, a transplant hepatologist (doctor specializing in the treatment of the liver), one or more transplant nurses, a social worker, and a psychiatrist or psychologist. Additional team members may include a dietician and anaesthesiologist.

Components of the transplant evaluation process include, but are not limited to, the following:

Psychological and social evaluation: Psychological and social issues involved in organ transplantation, such as stress, financial issues, and support by family and/or significant others are assessed. These issues can significantly impact the outcome of a transplant.

Blood tests: Blood tests are performed to help determine a good donor match, to assess the patient’s priority on the donor list, and to help improve the chances that the donor organ will not be rejected.

Diagnostic tests: Diagnostic tests may be performed to assess the liver as well as the patient’s overall health status. These tests may include X-rays, ultrasound procedures, liver biopsy, and dental examinations. Women may need a Pap test, gynaecology evaluation, and a mammogram.
The transplant team will consider all information from interviews, medical history, physical examination, and diagnostic tests in determining the patient’s eligibility for liver transplantation. Once eligibility is confirmed, the hunt for the donor begins.
If the patient is to receive a section of liver from a living family member (living-related transplant), the transplant may be performed at a planned time. The potential donor must have a compatible blood type and be in good health. A psychological test will be conducted to ensure the donor is comfortable with the decision.

Pre-transplant Medications

The following pre-transplantation medications are usually prescribed:

Lactulose: It is important to continue taking this medication because it helps clear the toxins that cannot be cleared when the liver isn’t working well. With the doctor’s approval, the patient can adjust the lactulose dose to produce 2-3 soft bowel movements per day

Diuretics: These medications promote removal of excess fluid from various parts of the body, such as the abdomen and legs. The excess fluid is lost through urination, and the patient may do this frequently. Daily monitoring of weight is helpful in determining the ideal dose. Routine monitoring of blood test results is an important part of diuretic therapy because important substances are also removed in the urine and may need to be replenished.

Anti-ulcer medications: These medications are routinely given both before and after liver transplantation to prevent ulcers from forming in the stomach or bowels.

Beta-blockers: These medications reduce the chance of bleeding from the gastrointestinal (feeding) tract. They also lower blood pressure and heart rate. They sometimes make the patient feel tired.

Antibiotics: People with liver disease can be more susceptible to infections. The doctor may put the patient on long-term antibiotics if the patient gets repeated infections. The patient should call the doctor if feeling unwell or if he or she has symptoms of infection.

Before the Surgery

• The doctor will explain the procedure to the patient/family and offer the opportunity to ask any questions about the procedure.
• The patient will be asked to sign a consent form that gives permission to do the surgery. The patient/family must read the form carefully and ask questions if something is not clear.
• For a planned living transplant, the patient should fast for eight hours before the operation, generally after midnight. In the case of a cadaver organ transplant, the patient should begin to fast once he/she is notified that a liver has become available.
• The patient will be asked to wear a hospital gown.
• The patient may be given a sedative prior to the procedure to help him/her relax.
• Based on medical condition of the patient, the doctor may request other specific preparation.

Liver transplantation requires a stay in a hospital. Procedures may vary depending on the patient’s condition.

During the Surgery

• An intravenous (IV) line will be started in the arm or hand of the patient. Additional catheters will be inserted in the neck and wrist to monitor the status of the heart and blood pressure, as well as for obtaining blood samples. Alternate sites for the additional catheters include the subclavian (under the collarbone) area and the groin.
• The patient will be positioned on the operating table, lying on his/her back.
• If there is excessive hair at the surgical site, it may be clipped off.
• A catheter will be inserted into the bladder to drain urine.
• After the patient is sedated, the anaesthesiologist will insert a tube into the lungs so that breathing can be controlled with a ventilator. The anaesthesiologist will continuously monitor the patient’s heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
• The skin over the surgical site will be cleansed with an antiseptic solution.
• The doctor will make a slanting incision just under the ribs on both sides of the abdomen. The incision will extend straight up for a short distance over the breast bone.
• The doctor will carefully separate the diseased liver from the surrounding organs and structures.
• The attached arteries and veins will be clamped to stop blood flow into the diseased liver.
• Depending on several factors, including the type of transplant being performed (whole liver versus a portion of liver), different surgical techniques may be used to remove the diseased liver and implant the donor liver or portion of the liver.
• The diseased liver will be removed after it has been cut off from the blood vessels.
• The doctor will visually inspect the donor liver or portion of liver prior to implanting it.
• The donor liver will be attached to the blood vessels. Blood flow to the new liver will be established and then checked for bleeding at the suture lines.
• The new liver will be connected to the bile ducts.
• The incision will be closed with stitches or surgical staples.
• A drain may be placed in the incision site to reduce swelling.
• A sterile bandage or dressing will be applied.

After the Surgery

After the surgery the patient may be taken to the recovery room before being taken to the intensive care unit (ICU) to be closely monitored for several days. Alternately, the patient may be taken directly to the ICU from the operating room. The patient will be connected to monitors that will constantly display ECG tracing, blood pressure, other pressure readings, breathing rate, and oxygen level. Liver transplant surgery requires an in-hospital stay of seven to 14 days, or longer.

The patient will most likely have a tube in the throat so that breathing can be assisted with a ventilator until he/she is stable enough to breathe on their own. The breathing tube may remain in place for a few hours up to several days, depending on the patient’s situation.

The patient may also have a thin plastic tube inserted through the nose into the stomach to remove air that the patient may swallow. The tube will be removed when bowels resume normal function. The patient will not be able to eat or drink until the tube is removed.

Blood samples will be taken frequently to monitor the status of the new liver, as well as other body functions, such as the kidneys, lungs, and blood system.

The patient may be put on special IV drips to help maintain blood pressure and heart function and to control any problems with bleeding. As the patient’s condition stabilizes, these drips will be gradually weaned down and turned off as tolerated.

Once the breathing and stomach tubes have been removed and the patient’s condition has stabilized, the patient may be given liquids to drink. The patient’s diet may be gradually advanced to more solid foods as tolerated.

Immunosuppression (anti-rejection) medications will be closely monitored to make sure the patient is receiving the optimum dose and the best combination of medications.

When the team of doctors feels the patient is ready, he/she will be moved from the ICU to a room on a regular nursing unit or transplant unit. The patient’s recovery will continue to progress here. Physical activity will be gradually increased as the patient gets out of bed and walks around for longer periods of time. Diet will be advanced to solid foods as tolerated.

Nurses, pharmacists, dieticians, physical therapists, and other members of the transplant team will teach the patient/family how to take care of the patient once discharged from the hospital.

Rehabilitation

Once at home, it will be important to keep the surgical area clean and dry. The doctor will give specific bathing instructions. The stitches or surgical staples will be removed during a follow-up visit, if they were not removed before leaving the hospital. The patient should not drive until the doctor says so. Other activity restrictions may apply.
Notify the doctor to report any of the following:

• Fever: This may be a sign of rejection or infection.
• Redness, swelling, or bleeding or other drainage from the incision site
• Increase in pain around the incision site: This may be a sign of infection or rejection.
• Vomiting and/or diarrhoea

The doctor may give additional or alternate instructions after the procedure, depending on the patient’s particular situation. To allow the transplanted liver to survive in a new body, the patient will be given medications for the rest of his/her life to fight rejection. Each person may react differently to medications, and each transplant team has preferences for different medications. New anti-rejection medications are continually being developed and approved. Doctors tailor medication regimes to meet the needs of each individual patient. Usually several antirejection medications are given initially. The doses of these medications may change frequently, depending on the patient’s response. Because anti-rejection medications affect the immune system, people who receive a transplant will be at higher risk for infections. A balance must be maintained between preventing rejection and making the patient very susceptible to infection.

Some of the infections that transplant patients will be especially susceptible to include oral yeast infection (thrush), herpes, and respiratory viruses. The patient should avoid contact with crowds and anyone who has an infection for the first few months after your surgery.

The following are the most common symptoms of rejection. However, each individual may experience symptoms differently. Symptoms may include, but are not limited to, the following:

• Fever
• Jaundice: A yellowing of the skin and eyes due to bile pigments in the blood.
• Dark urine
• Itching
• Abdominal swelling or tenderness
• Fatigue or irritability
• Headache
• Nausea

The symptoms of rejection may resemble other medical conditions or problems. The patient/family must consult the transplant team with any concerns they have. Frequent visits to and contact with the transplant team are essential.