Treatment Options

 

What is a liver transplant?

 

A liver transplant is the replacement of a sick liver with a donated, healthy liver. Liver transplants require that the blood type and body size of the donor match the person receiving the transplant.

 

Why do I need a liver transplant?

 

A liver transplant is necessary when your liver is failing and a doctor recommends you be evaluated for a transplant. Many diseases can cause liver failure, including primary liver cancers and for some who have neuroendocrine cancer. Other common reasons for liver transplants are:

 

Chronic hepatitis B and chronic hepatitis C

Bile duct diseases

Cirrhosis

Genetic diseases

Autoimmune liver diseases

Primary liver cancer

Alcoholic liver disease

Fatty liver disease

 

If primary liver cancer is involved and you are a candidate or if you have liver damage that is severe enough from liver disease, transplantation may be necessary. A transplant provides you with a liver that can keep up with the demands of a full, active life.

 

Am I eligible for a transplant?

 

After being referred by a doctor to a transplant center, the transplant team evaluates your overall physical and mental health, plan to pay for transplant related medical expenses, and emotional support family and friends will provide. Based on the findings, the team decides if you are eligible for a liver transplant.

 

The following procedures help in evaluating your health status:

 

Chest x-ray - Determines the health of your lungs and lower respiratory tract.

 

Electrocardiogram (EKG or ECG) - Determines how well your heart is working and may reveal heart damage that was previously unsuspected.

 

Ultrasound with Doppler examination - Determines the openness of the bile ducts and major vessels. It is commonly done in all liver transplant recipients before and after transplantation.

 

CT (CAT) scan - This computerized image will show the size and shape of the patient's liver and major blood vessels.

 

MRI (magnetic resonance imaging) - May be used in place of CT scan or ultrasound to see inside the patient's body.

 

Total-body bone scan - If the patient has a liver tumor, ensures that it has not spread to any other part of the body.

 

Blood tests - The patient's blood count, blood and tissue type, blood chemistries, and immune system function will all be checked. In addition, blood tests for certain infectious diseases will be performed.

 

Pulmonary function test - You will be asked to breathe into a tube attached to a measuring device, which will reveal how well your lungs are working and determine his blood's capacity to carry oxygen.

 

Hepatic angiograph - Dye injected into your arteries will enable the transplant physician to see if there are any abnormalities or blockages in your blood vessels.

 

Cholangiogram - Reveals any obstructions or growths in your bile ducts.

 

Gallium, colloidal gold, or technetium scan - Gives the transplant physician a view of your liver, gallbladder, and pancreas.

 

Peritoneoscopy - By inserting a flexible tube through a tiny incision in your abdomen, the transplant physician will be able to see any structural changes in the liver.

 

Upper gastrointestinal (GI) series - This will show whether your esophagus and stomach are disease free.

 

Lower GI series - Ensures that you are free of intestinal abnormalities.

 

Renal function studies - Urine may be collected from you for 24 hours in order to determine if the kidneys are working correctly. Blood tests such as serum creatinine are also performed to measure kidney function.

 

If you are eligible, the center will add you to the national transplant waiting list. The waiting list is prioritized so the sickest people are at the top of the list.

 

Who is on the transplant team?

 

YOU

Your support team

Transplant Surgeon

Transplant Physician (Hepatologist)

Transplant Coordinator

Nurse Practitioner

Floor or Staff Nurse

Physical Therapist

Dietician

Psychologist / Psychiatrist

Social Worker

Pharmacist

 

How long will I have to wait for a liver transplant?

 

The waiting time for a liver transplant varies from person to person. The time you have to spend on the waiting list depends on your blood type, body size, stage of liver disease, overall health, and the availability of a matching liver. Days and weeks may pass while the transplant team waits for UNOS to locate the right liver for you. The anxiety and hope for the telephone to ring often becomes intense; the telephone a life preserver always at hand.  Use this time to prepare for the hospital stay, get your support team organized, and arrange for help after surgery.

 

When the important call comes

 

When the life-changing call comes, you should bring the following to the hospital:

 

Your medications

A list of your drug allergies

Your health insurance information

 

IMPORTANT: As soon as a liver is available, you should stop all eating and drinking immediately. Your stomach must be empty when you are taken into the operating room.

 

What should I expect when I arrive for my new liver?

 

After admission, you will undergo a thorough physical examination, including more blood work, a chest x-ray, and EKG, and, possibly, other tests. Unfortunately, surgery may be postponed in some cases. You will be sent home if:

 

You have an infection

You have any other medical problem that would interfere with surgery or recovery

The donor liver shows signs of deterioration or poor function

 

If surgery is postponed, the transplant team can help you through the disappointment. This is only a temporary setback, and the search for a new liver will go on.

 

What happens before my transplant?

 

You may receive an enema to clean out your intestines and prevent constipation after surgery. Your chest and abdomen will be shaved clean to prevent infection, and an intravenous (IV) line will be inserted in your arm or just under your collarbone to give medication and keep you from getting dehydrated. You will also be given a sedative to help you relax and feel sleepy before going to the operating room.

 

What happens during the transplant?

 

You will be under general anesthesia throughout the surgery. Once asleep, the transplant surgeon will make an incision shaped like a boomerang on the upper part of the abdomen. The surgical team will then remove your old liver, leaving portions of your major blood vessels in place. The new liver will then be inserted and attached to these blood vessels and to your bile ducts. To help with bile drainage, a tube will also be inserted in the bile duct during surgery.  Your transplant will take between four and twelve hours.

 

Will I have to have drains and tubes?

 

During liver-transplant surgery, the surgeon may find it necessary to place a small tube, called a T-tube, into your bile duct. The T-tube allows bile to drain out of your body into a small pouch, known as a bile bag. The amount of bile, which varies in color from deep gold to dark green, can then be measured. If a T-tube is put in place, it may remain attached to a bile bag for a week or possibly longer. When the bile bag is removed the T-tube will be tied or capped. It will remain in place for several months so that it can be used for special testing.

The T-tube is attached to the skin with a stitch. The dressing around the tube should be changed at least once daily, and more often if it becomes moist. The transplant nurse will show you how to change the dressing without pulling out the T-tube.

 

Other drains may be placed in your abdomen during the postoperative period. A common name for these drains is Jackson-Pratt (JP). They are used to drain fluid from around the liver. Generally, these drains are removed before you go home.

 

How will I feel after surgery?

 

You will wake up in the intensive care unit after the anesthesia wears off.  You will have some pain and/or discomfort but will be given medication to help give you relief. You will have a tube inserted through your nose which runs down your throat and into your stomach. This will keep your stomach empty and help to prevent nausea and vomiting.  You may also have a tube inserted in your throat to help you get enough oxygen. It will be connected to a breathing machine called a ventilator. You should try to relax and let the machine breathe for you. You will not be able to talk with this tube in place, but will only need it for a few days. Nurses will do everything they can to help you patient communicate. Afterwards, your throat may feel sore or scratchy for a few days.

 

You will be asked to cough periodically to keep your lungs clear. If it hurts to cough, you should ask for someone to support your abdomen or hold a small pillow close.  You will have an IV line in your arm or neck under the collarbone, which will be used to give fluids and medication for the first few days after surgery.

 

For several days after surgery, you will have a catheter in your bladder to drain urine. You may feel uncomfortable, and may feel that you have to urinate constantly, but it is only temporary.  During surgery, several drains will be placed in or near the incision. These drains will be removed 5 to 10 days after surgery.

 

The length of a hospital stay will depend on your progress. You will be encouraged to talk to someone on your transplant team if you are uneasy or apprehensive about going home.

 

When will I follow up?

 

After leaving the hospital, you will receive a schedule of follow-up clinic visits for lab tests and checkups. The purpose is to track your progress and detect potential complications as early as possible.  On days when you are scheduled for follow-up visits, you should bring your medication list and your surgery handbook. You will be given specific instructions for routine lab work or special tests that you

 

Do I need to watch for anything?

 

While primary concerns involve infection and rejection, many other problems, such as colds or flu, adjustment of other medications, and minor infections can be handled by a local physician. You need to take precautions and learn to watch for signs of infection and rejection that necessitate notifying a local physician or transplant team immediately. These include:

 

a fever that continues for more than 2 days

shortness of breath

a cough that produces a yellowish or greenish substance

a dry cough that continues for more than 1 week

prolonged nausea, vomiting, or diarrhea

an inability to take prescribed medication

bleeding, bruising, black stools, red or rusty-brown urine

a rash or other skin changes

pain, discharge, or swelling at the T-tube site

vaginal discharge or itching

burning discomfort with urination

exposure to mumps, measles, chicken pox, or shingles

unusual weakness or light-headedness

emergency-room treatment or hospitalization

 

United Network of Organ Sharing (UNOS)

Every patient waiting for an organ transplant in the United States is registered in the UNOS computerized data network. All have equal access to donated organs. The 68 organ recovery organizations across the country are members of UNOS.

When an organ procurement organization coordinator contacts UNOS, the UNOS technician inputs the organ donor's medical history, physical measurements, and blood type, and prints a computerized list of likely transplant recipients. The list is printed in order of matching priority, which includes medical criteria, length of time waiting, blood type, body weight, size of recipient diseased organ, and severity of illness. Kidney and pancreas recipients are also matched by tissue (genetic) typing.

 

If the first potential recipient does not match medically with the available organ, the OPO coordinator maintains the computer search in an assigned region or elsewhere in the nation for a potential recipient who most nearly matches the donor. Likewise, organ recovery organizations throughout the United States will notify each other when an organ becomes available for waiting recipients in their respective areas.

 

Matching donor organs with recipients is critical. Transplant waiting times may vary from a few months to several years because of matching difficulties.

 

What are the risks of a liver transplant?

 

The most common risks associated with liver transplants are rejection. Rejection occurs when your body’s immune system attacks an object it does not recognize. To prevent rejection, you will be given medicines to weaken the immune system. Modern medications have made rejection less of a concern in liver transplant patients.

 

Rejection medications may have side effects of increased blood pressure, headaches, diarrhea, and nausea. Also, because rejection medications weaken the immune system, it can be hard for you to fight infections. However, most infections can be treated with medications.

 

What is my prognosis after a liver transplant?

 

Most patients return to a regular lifestyle six months to a year after a successful liver transplant. Eating a healthy diet, exercising regularly, and taking recommended medications are important factors to staying healthy.

 

Nearly 75% of liver transplant patients are alive five years after their transplants. In some patients, the liver disease they had before the transplant comes back and they may need treatment or another transplant.

 

Helpful Resources

 

Liver Transplant Sources

American Liver Foundation

1425 Pompton Avenue

Cedar Grove, NJ 07009

(201) 256-2550

(800) 223-0179

 

International Transplant Nurses Society

Foster Plaza 5, Suite 300

651 Holiday Drive

Pittsburgh, PA 15220

(412) 928-3667

 

Transplant Recipients International Organ (TRIO)

1735 I Street NW, Suite 917

Washington, DC 20006

(202) 293-0980

(800) 874-6386

 

United Network for Organ Sharing (UNOS)

The National Organ Procurement and Transplantation Network

1100 Boulders Parkway, Suite 500

P.O. Box 13770

Richmond, VA 23225-8770

(804) 330-8500

What can people do to help those who need a liver transplant?

 

People can help by registering to be an organ donor. To obtain an organ donor card, please visit: www.organdonor.gov.