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Friday, February 8, 2008

All you need to know about Liver Transplant.

Your Physician may recommend a liver transplant when all other treatment options fail. The purpose is to replace your diseased liver with a healthy liver. Ideally, after a transplant you will be free from disease, and lead a fairly normal life as long as the transplant functions. Indications for liver transplant include:


  • Hepatitis B
  • Hepatitis C
  • Urea Cycle defects
  • Familial hypercholesterolemia
  • Alcohol induced cirrhosis
  • Glycogen Storage Disease
  • Autoimmune Hepatitis
  • Primary Hyperoxaluria type I
  • Cryptogenic cirrhosis
  • Crigler-Najjar syndrome type I
  • Congenital Hepatic Fibrosis
  • Neimann- Pick Disease
  • Primary Biliary Cirrhosis
  • Familial Amyloidosis
  • Biliary Atresia
  • Hepatocellular Carcinoma
  • Primary Sclerosing Cholangitis
  • Hepatoblastoma
  • Alagille Syndrome
  • Hemangioendothelioma
  • Familial Cholestasis
  • Non-Carciniod neuro-endocrine
  • Drug induced liver failure
  • Liver tumors
  • Acute/fulminant liver failure
  • Budd-Chiari syndrome
  • Alpha-1-antitrypsin deficiency
  • Wilson Disease
  • Hemochromatosis
  • Tyrosinemia
  • Protoporphyria
  • Cystic fibrosis
There are three options for liver transplantation: cadaver donor transplantation, living donor transplantation, and auxiliary transplantation.

Cadaver donor: The donor liver is obtained from a person who is diagnosed as brain dead whose family volunteers to donate the organ for transplantation. People who receive cadaver donors wait on the national computer list (UNOS Waiting List) until a suitable donor becomes available. The waiting times vary.

Living donor: A healthy family member, usually a parent, sibling, or child, or someone emotionally close to you, such as a spouse, volunteers to donate part of their liver for transplantation. The donor is carefully evaluated by the team to make sure no harm will come to the donor or recipient.

Auxiliary transplantation: Part of the liver of a healthy adult donor (living or cadaver) is transplanted into the recipient. The patient’s diseased liver remains intact until the auxiliary piece regenerates and assumes function. The diseased liver may then be removed.

The average success rate of a liver transplant at one and five years is 92 percent and 88 percent respectively. Once a Transplant Center determines that you are an appropriate candidate for transplantation, a suitable donor becomes available, and you have successfully completed the surgery, you have a good chance to lead a normal, healthy, active, life. However, to help insure successful outcomes, it is vital that you closely follow your physician’s recommendations. This will include taking immunosuppressive medications and monitoring your blood tests regularly.

The Transplant Evaluation

The Initial Consultation

During the consultation you will meet with members of the transplant team to review your past medical and social history to ascertain appropriate medical treatment.

You may meet various members of the Transplant Team:

Hepatobiliary Surgeons: trained in the field of transplantation

Hepatologists: Liver specialist that will take care of your medical needs during the transplant period.

Transplant Coordinators: registered nurses who assist in the evaluation, education and post-operative follow-up.

Transplant Social Worker: provides support for you and your family in dealing with stress and issues associated with chronic illness and transplantation

Blood Tests

You may be asked to have your blood drawn to confirm your blood type, evaluate serum chemistries, hematology, coagulation, hepatitis screens, and viral studies. If you are being evaluated for a liver transplant you must sign consent to be tested for HIV (AIDS). All transplant centers are required to test all potential transplant recipients. The results of these tests are confidential and will not be released without your permission.

Radiology

You may be required to have one or more of the following tests:

Chest X-ray, determines if your lungs and lower respiratory tract are healthy.

Ultrasound, examines your liver and other abdominal organs and blood vessels.

CAT Scan (Computerized Tomography), makes a computer image which shows the size and shape of your liver and major blood vessels. A contrast material may be injected into a vein to enhance the quality of the image.

MRI (Magnetic Resonance Imaging), makes a more detailed picture of your abdominal organs and their blood vessels.

Endoscopy, uses a scope to look at the esophagus and stomach and assess for ulcers, inflammation or varices. You will be sedated for this procedure.

ERCP, uses a scope similar to the endoscopy to take a closer look at your bile ducts. You will be sedated for this procedure.

Liver Angiogram, uses intravenous dye to take pictures of the liver and its anatomy.

Liver Biopsy, to diagnose the type of liver disease you have or evaluate the extent of damage it has caused.

Cardiac Evaluation

The Transplant Team may require you to undergo a cardiac workup to make sure your heart is strong enough to withstand treatment.

ECG, examines how well your heart is beating.

Echocardiogram, uses sound waves to look at your heart and the pressure in its vessels.

Stress Test, examines your heart’s response to exercise. There are a few different types of stress tests, some of which require you to walk on a treadmill and some of which give you medicine to make your heart think it’s exercising. The team will assess which one is appropriate for you.

Cardiac Angiogram, may be necessary if your stress test is abnormal. Dye is injected into your arteries to help identify any abnormalities or blockages in your heart vessels.

Pulmonary Evaluation

If you were a smoker or have a lung disease you may need some of the following tests:

PFT'S (pulmonary function tests), assess your lung capacity and function to determine your blood's ability to carry oxygen.

ABG (arterial blood gas), tests your carbon dioxide and oxygen level. For this test blood must be drawn from an artery.

In addition to the medical tests used to determine the extent of your liver disease, a transplant evaluation requires additional assessments. These may include the following:

Social Work/ Psychiatry

A social work/psychiatry consultation may be necessary to help you and your family with the many psychological and social issues involved with transplantation. It is vital that all potential transplant recipients have adequate support systems to help them through the process.

Alcohol/ Drug Screening

All potential transplant recipients may be randomly tested for alcohol and illicit drugs throughout the transplant process. Use of these substances will forfeit a patient's eligibility to be transplanted at our institution. You may be asked to sign a contract with our social worker regarding this matter.

Financing Transplantation

At the time of your initial consultation financial counselors may meet with you to verify your insurance coverage for transplantation. Many insurance companies require a letter from a Transplant Center confirming the medical necessity for you to undergo a transplant as well as the results of your transplant evaluation before they will approve a transplant.

It is very important that your pharmacy plan covers the transplant medications. As a potential candidate, you will be required to sign a pharmacy agreement stating that you will be responsible for all pharmacy expenses not covered by your insurance company.

Since the medications are very expensive, it is not uncommon for patients to have difficulty in affording them. If you do not have sufficient coverage, a finance counselor or transplant social worker will do their best to assist you in this matter.

Upon Completion of Your Evaluation

When your evaluation is completed, the transplant team will determine, based on the results, whether a transplant is necessary and if you are physically able to undergo the procedure.

Waiting for a Transplant

The waiting period varies depending on the type of transplant you require (cadaver, living, auxillary), your blood type, how sick your liver is, and your height and weight. You should ask the transplant team to estimate your approximate waiting time. During the waiting period, The Transplant Center will work with you closely to assist you in remaining as healthy as possible.

You will be followed by your primary referring physician who will confer with the transplant team when necessary. In addition, the Transplant Team will see you periodically.

Keeping Healthy

Stress Management

Waiting for a transplant can trigger many feeling, it is essential to stay in tune with your feelings. It is important to talk with someone and get the support you need. Some people cope better when sharing their feelings with others going through the same thing as you are. There are many organizations that provide support groups.

Eating Healthy

Fatigue, decreased appetite, nausea, vomiting, and food intolerances are sometimes associated with liver disease. Throughout the progression of the disease, development of ascites (increased fluid in the abdomen), hepatic encephalopathy (disorientation), increased diarrhea (from medications) and edema (fluid retention in the feet and legs) may leave you feeling further fatigued and depleted.

The goal of nutritional management of liver disease is to help you maintain or improve your nutritional status, achieve or maintain calories, and appropriate amounts of protein (without contributing to hepatic encephalopathy). It may be necessary to reduce your sodium and fluid intake. The nutritionist may provide you with a diet individually tailored to meet your nutritional needs and stay as healthy as possible while waiting for your transplant.

Keeping Active

The effects of a compromised liver such as malaise, decreased appetite, fatigue, and depression can take a toll on an individual’s ability to perform activities of daily living. This reduced activity can lead to a decrease in flexibility, and endurance, and eventually a decrease in cardiopulmonary performance resulting in an increased surgical risk.

A daily program consisting of regular exercise and normal activity can reduce complications and maximize your strength, flexibility, mobility, endurance, and breathing.

The Surgery

At the time of transplant, you will be admitted into the hospital and prepared for surgery.

Cadaver Transplantation: When an organ becomes available, you will be notified by a physician from the team to come into the hospital. If you have a cold or flu or some other infection, your transplant may need to be postponed. If the decision is to proceed with the transplant you must come into the hospital and be prepared for the operating room. While you are being prepared for surgery, a team of surgeons will be working to remove the organs from the donor. On rare occasion, the surgeons may find something that makes the organ unsuitable for transplant. In this case your surgery will be postponed until a suitable donor is found. We realize that this is very disappointing, however, we would do more damage to you if we gave you an organ that was less than perfect. In most instances the organ is found to be suitable and the transplant proceeds as scheduled.

Living Donor Transplantation: This is a planned operation, therefore, the donor and recipient will be required to undergo presurgical testing the week before the transplant. This includes blood tests, EKG, chest x-rays and a meeting with the anesthesiologist. Both parties will be admitted the morning of the surgery. The donor will be hospitalized for 4-6 days after surgery.

Regardless of the type of donor you have, an average donor operation lasts about 3.5 hour and an average transplant takes about 4.5 hours. The surgeon will notify your family when the procedure is completed. Immediate family may then see you for a few minutes after the surgery. It is important that those who are ill postpone visiting until they are well. Initially, you will be in the Intensive Care Unit where you can be watched very closely. You may be attached to a cardiac monitor, intravenous lines, tubes and drains. When your condition stabilizes, you will be transferred to a regular room where you will complete your recuperation process and learn how to care for yourself at home.

The average length of stay for liver transplantation is 7 to 12 days.

The Medications

After a liver transplant you will be required to take many medications. You will be put on a combination of the following drugs; Sandimmune, Neoral, Prograf prednisone, Imuran, Cellcept, Zenapax, or Simulect. The purpose of these medications. is to prevent rejection of your transplanted liver. These medications have many side effects. They may include high blood pressure, excessive hair growth or loss, hand tremors, mood swings, weight gain, bone loss, and diabetes. Many side effects are temporary and some will continue as long as you are taking the medications. We do our best to minimize side effects and reduce dosages as quickly as possible to avoid complications.

Complications

As with any other surgical procedure, complications may arise after liver transplantation.

Bleeding: There is a small risk of bleeding from the place where the donor and recipient blood vessels were sewn together (anastomosis site). This is minimized by monitoring clotting factors in the blood after surgery and by measuring the output in the drains placed at the time of surgery.

Hepatic Artery Thrombosis: A clot can form in the hepatic artery that can cause the liver to malfunction. We perform an ultrasound the day after surgery to look for this complication and monitor you throughout your postoperative course. If it is found, medications or surgical repair can minimize permanent damage and avoid retransplantation

Bile Duct Leaks: The bile ducts from the new liver are sewn to a bile duct of the recipient or a piece of intestine. This connection can leak and drain into the abdomen and cause an infection. If a bile leak occurs a catheter may be inserted into the abdomen to allow the bile to drain externally. This is temporary and can usually be managed without surgery.

Rejection: Your body will recognize your new organ as foreign and immune cells (lymphocytes) can attack the transplanted organ. Most patients experience some degree of rejection, but it is usually easily reversed with medications. The first rejection usually occurs during the first three month. You will be monitored closely during that time so early signs of rejection can be identified and treated. A biopsy of the liver may be necessary to diagnose the extent of the rejection and rule out any other problems. Results will determine which treatment is best for you.

Infection: You immune system is suppressed after a transplant making you more at risk for certain infections. We will prescribe medications to prevent the more common post transplant infections. You will need to monitor your temperature at home and make certain adjustments in your daily life to avoid harmful infections.

Life after a Liver Transplant

There are many new things a person will experience after a liver transplant. You will be instructed on how to care for yourself before you leave the hospital. Most patients recuperate fully within the first three months, return to work and have active lives. The goal is to provide excellent care and follow up in concurrence with your primary physicians in order to make the length and quality of life appreciable better than before.

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