All About Liver Transplantation

Liver and its functions:

The liver is the largest solid organ in the body. It is located in the upper right part of your abdominal region.

Functions:

1) Builds special proteins to prevent bleeding.
2) Filters blood and helps fight infection.
3) Makes bile to break down fat in the food you eat.
4) Removes toxic substances from everything you eat, breathe and drink.
5) Builds sugar, stores sugar and releases sugar for energy when required by the body.
6) Stores a few types of vitamins.
7) Stores minerals.
8) Helps to break down proteins in food you eat.
9) Sends special ‘messengers’, called hormones, to other organs in the body.

Signs and Symptoms of liver disease:

a) Ascites (water in the abdomen)
b) Fatigue
c) Confusion
d) Change in sleep patterns
e) Itching
f) Jaundice (yellow colour of skin or in the white part of the eyes)
g) ‘Spiders’ (broken blood vessels found on your face, arms & chest)
h) Easy bruising
I) Nausea
j) Change in bowel movements (pale stools/black stools or fatty stools)
l) Swollen ankles
m) Dark urine
n) Fever and infections
o) Pain in area of the liver
p) Internal bleeding

Liver Transplant:

Liver transplantation or hepatic transplantation is the replacement of a diseased liver with some or all of a healthy liver from another person (allograft).
The liver is made up of many cells. When these cells are destroyed, your liver loses much of its function. The liver is able to grow again, but, if too much of your liver is destroyed by disease, you will need a new liver.

Liver transplantation may be done for all of these types of liver disease.

Transplant team:

The Liver Transplant Team is a group of highly skilled professionals who work together to help you have a successful transplant and recovery.

The members of the liver transplant team include:

a) Hepatologist: Is a physician who is highly skilled in the diagnosis and treatment of liver disease. This doctor will care for you throughout the entire transplant process and will follow you even after your transplant.

b) Liver Transplant surgeon: the liver transplant surgeon is involved in patient evaluation and selection. The surgeon performs the transplant operation and manages your post operative recovery.

c) Transplant Coordinator: the transplant coordinator is a registered nurse who arranges your clinics and tests after the transplant. Transplant coordinator can always put you in touch ith the right people and the right savvies to meet your particular needs.

d) Social Worker: the Social Worker meets with all transplant patient and their families to review each individual’s situation and family supports. He / she will work with you and your support persons to plan for transplant, keeping your unique needs in mind. He / she will be able to advise you about financial and medication issues. In addition, your social worker will provide supportive counselling for you and your family.

e) Psychiatrist and /or Psychiatric Nurse: the Psychiatrist and / or Psychiatric Nurse will see you during your transplant evaluation. These professionals specialize in helping patients cope with chronic illness and the anxiety, depression, and tests that may go along with it.

f) Physiotherapist: the Physiotherapist will work with you throughout the post – operative transplant process to help you gain and maintain optimum strength and flexibility.

g) Nurse: nurse will help coordinate the activities of your other health care team members , as well as caring for your needs during your hospital stay.

Pre-Transplant Evaluation:

Pre-transplant evaluation consists of a variety of medical tests and interviews with members of the transplant team. You will be sent information about all the tests and appointments you will be having. The purpose of this evaluation is to make certain that there is nothing else wrong with any of your other organ systems that would increase the risk of liver transplant, sometimes the assessment will uncover a problem that makes transplantation a poor option for you or identifies a problem that may need correction prior to the transplant.

Your doctor has referred you to a liver specialist because you have signs and symptoms of liver disease. This liver specialist is a Hepatologist or a Transplant Surgeon. During your appointment with your liver specialist you can expect the following:

• You will be examined by the liver doctor
• You will be asked questions about your health
• You may meet other members of the liver transplant team.
• You may have blood work drawn

Your liver doctor will discuss the treatment for your liver disease with you. If liver transplantation is discussed at this time, then the next step will be to do more tests. You will receive information about your assessment from the liver specialist and the transplant assessment coordinator.

You will also meet with the Anaesthesiologist – the doctor who will put you to sleep at the time of your transplant operation. The anaesthesiologist will ask you about previous anaesthetics and operations. He / she will explain the risks associated with general anaesthesia.

During your assessment you will also see a Social Worker, a Dietician and a Transplant Coordinator who will provide you with further education and assistance before your transplant.

Types of Liver Transplants:

Livers for transplant can come from two possible sources: cadaveric (brain dead) donors, or a living donor. In Indian,transplantation is governed by the law on organ transplantation – Human Organ Transplantation Act 1994. You need to enrol with the ZCCK (Zonal Coordination Committee for Organ Transplantation in Karnataka for undergoing Cadaveric organ transplantation.)

Cadaver Donors: Most liver transplants are done from a cadaver donor. Cadaver donors are individuals who have recently died from severe injury (such as head injury from a motor vehicle accident, gunshot wounds to the head or bleeding in the brain). Transplantation is scheduled as soon as possible after brain death has been declared. Donor livers can also be split between two patients waiting for transplant). ZCCK maintains a list of patient requiring liver transplant and allocates the available organ as per the list. Race and sex of the donor have no bearing on the match. You will not develop any of the physical characteristics of your donor- with the exception of a healthy liver. Donors must be approximately thesame height and weight as the recipient, with no history of heart disease, infection, or abdominal trauma.

Living Donation: A blood relative or spouse can also give part of their liver to the patient. If the relative / spouse is blood group compatible, approximately the same size, and in good health, this type of transplant has every chance of success. A donor is evaluated carefully by a series of blood tests, x-rays, ultrasounds and interviews before being considered acceptable.

If you have a family member who would like to donate, please discuss it will them and your hepatologist or transplant
coordinator.

Times lines:

1. Liver Transplant surgery: On an average takes 4-6 hours.
2. Hospital stay post liver transplant: 10 to 15 days.
3. Follow up required post liver transplant: Life time. Weekly
4. follow up for one year post transplant. Monthly follow up during the second year and one in three months thereafter.

LIVER TRANSPLANT SURGERY:

The operation consists of

• The removal of your diseased liver
• The sewing in of your new liver

Your gall bladder will also be removed. Your new liver is sewn into place in five areas. These reconnected areas are referred to as anastomoses.

Four of the areas are blood vessels:

1. Suprahepatic vena cava ( above liver )
2. Infrahepatic vena cava ( below liver )
3. Portal liver
4. Hepatic artery
5. The fifth area is: The bile duct

Your transplant surgery will take about 4-6 hours. You may need 4 to 6 units of blood (on average) during the operation. There is a 10-15% chance that during the surgery, you will be on bypass to keep your blood pressure stable. For bypass, two extra incisions are needed. One is in the left groin and the other is in the left armpit.

When the surgery is completed you will be taken to the Medical / surgical Intensive Care Unit where you will be for 2-3 days. You will have a large incision on your abdomen that will be held together with staples. There will be three drains that help remove fluids from around your liver.

Post Transplant care:

For the first two weeks following transplant, the main focus will be:

a) Monitoring for rejection – through blood test and biopsies.

b) Adjusting the immunosuppressive therapy: which prevents your body from rejecting your new liver.

c) Education and teaching – on how to take care of yourself and your new liver.

d) Rehabilitation – Physiotherapist will help you gentle increase your activity level day by day to aid your healing process.

e) Reassurance – the transplant team will be able to answer your questions and address fears and concerns as they arise.

Possible complications of liver transplantation:

• Infection: As your immune system is being altered to prevent the possible rejection of of new liver by your body. Signs of infection are fever, sore throat, shortness of breath, persistent cough, change in colour sputum, increased production of sputum, cold sores around lips and mouth, pain or burning on urination, redness/swelling/drainage/pain from the incision, flu like symptoms.
• Rejection – Your transplanted liver is viewed as an invader, just like a virus, and comes under attack by your own immune system. This process is known as rejection, which can be mild, moderate or severe. This is a normal response of your body. However, in order to prevent it from interfering with normal function of your new liver, it is important to detect rejection early and to treat it promptly. Immunosuppressive agents are used to prevent rejection. Signs of possible rejection are – fever, fatigue, shortness of breath and sudden weight gain.
• Diabetes: Some patients can develop diabetes after surgery. This is a result of side effects of some anti-rejection /immunosuppressant drugs.
• Osteoporosis: Osteoporosis is a disease whereby the structure and strength of bones become weekend. This may increase your risk of fractures. Transplant patients have an added risk of osteoporosis because one of the side effects of prednisolone (a commonly used immune-suppressive) is an increased risk of osteoporosis.
• Increased risk of cancer: Research has shown an increased risk of cancers like lymphoma, skin cancer, bowel cancer or cancer of cervix in women among patients on anti-rejection drugs.
• Hypertension (high blood pressure): It is a possible side effect of anti-rejection drugs like cyclosporine and prograf. Therefore, never stop or change blood pressure drugs on your own.
• High cholesterol: This may be a side effect of prednisolone and cyclosporine.