Pediatric Liver Transplant Frequently Asked Questions

What is a Pediatric liver transplantation?

A liver transplant is an operation performed to replace a diseased liver with a healthy one from another person. Children may need liver transplantation for a variety of liver diseases. An entire liver may be transplanted, or just a portion of the liver. The liver may come from a cadaver organ donor, or from a family member who is willing to donate a part of their liver.

When is liver transplant recommended for children?

A liver transplant is recommended for children who have serious liver dysfunction and will not be able to live without having the liver replaced. The most common liver disease in children for which transplants are done is biliary atresia. Other diseases may include Alagille's Syndrome, alpha-1-antitrypsin deficiency, Wilson's disease, hepatitis and hemochromatosis.

How many children in the world need liver transplants?

Precise numbers for India are not available, but according to the latest statistics from The United Network for Organ Sharing, 1030 children were waiting for a liver transplant in the United States on November 30, 2000, including:

• 474 in the newborn to 5 years age group.
• 216 in the 6 to 10 years age group.
• 340 in the 11 to 17 years age group.

Where do transplanted organs come from?

The majority of livers that are transplanted come from deceased organ donors. Organ donors are adults or children who have become critically ill (often due to an accidental injury) and will not live as a result of their illness or injury. An adult donor may have agreed to be an organ donor before becoming ill. Parents or spouses can also agree to donate a relative's organs. Donors can come from any part of the country. This type of transplant is called a cadaveric transplant.

A child receiving a transplant may either get a whole liver, or a segment of one. If an adult liver is available and is an appropriate match for two children on the waiting list, the donor liver can be divided into two segments and each part is transplanted.

Living family members may also be able to donate a section of their liver. This type of transplant is called a living-related transplant. Children receiving a partial liver seem to do as well as those who receive a whole liver.

Relatives who donate a portion of their liver can live healthy lives with the segment that remains.

How are transplanted organs allocated?

Criteria have been developed to ensure that all people on the waiting list are judged fairly as to the severity of their illness and the urgency of receiving a transplant. The people in most urgent need of a transplant are placed highest on the status list and are given first priority when a donor liver becomes available.

When a donor organ becomes available, a computer searches all the people on the waiting list for a liver and sets aside those who are not good matches for the available liver. The person at the top of the specialized list is considered for the transplant. If that person is not a good candidate, for whatever reason, the next person is considered, and so forth. Some reasons that people lower on the list might be considered before a person at the top include the size of the donor organ and the geographical distance between the donor and the recipient.

How is my child placed on the waiting list for a new liver?

An extensive evaluation must be completed before your child can be placed on the transplant list. Testing includes:

• Blood tests.
• Diagnostic tests.
• Psychological and social evaluation of the child (if old enough) and the family.
  

Tests are done to gather information that will help determine how urgent it is that your child is placed on the transplant list, as well as ensure the child receives a donor organ that is a good match. These tests include those to analyze the general health of the body, including the child's heart, lung and kidney function, the child's nutritional status and the presence of infection. Blood tests will help improve the chances that the donor organ will not be rejected. These tests may include:

Liver enzymes - Levels of liver enzymes can alert physicians to liver damage or injury, since the level of enzymes in the bloodstream increases under these circumstances.

Bilirubin - Bilirubin is produced by the liver and is excreted in the bile. Elevated levels of bilirubin often indicate an obstruction of bile flow or a defect in the processing of bile by the liver.

Albumin, total protein and globulin - Below-normal levels of proteins made by the liver are associated with many chronic liver disorders.

Clotting studies, such as prothrombin time (PT) and partial thromboplastin time (PTT) - Tests that measure the time it takes for blood to clot are often used prior to liver transplantation. Blood clotting requires vitamin K and proteins made by the liver. Liver cell damage and bile obstruction can both interfere with proper blood clotting.

Other blood tests will help improve the chances that the donor organ will not be rejected. They may include:

Your child's blood type - Each person has a specific blood type: type O, A, B, or AB. When receiving a transfusion, the blood received must be a compatible type with your child's type of blood, or an allergic reaction will occur. The same allergic reaction will occur if the blood contained within a donor organ enters your child's body during a transplant. Allergic reactions can be avoided by matching the blood types of your child and the donor.

Kidney, heart and other vital organ function tests - These tests determine whether the condition your child is suffering from can be cured with liver transplant. Some conditions may require multiorgan transplantation or may not be cured at all.

Viral studies - These tests determine if your child has antibodies to viruses that may increase the likelihood of complications while your child is receiving the immune system-suppressing medications to prevent rejection, such as cytomegalovirus (CMV) or Ebstein-Barr virus (EBV).

The diagnostic tests that are performed are extensive, but necessary to understand the complete medical status of your child. The following are some of the other tests that may be performed, although many of the tests are decided on an individual basis:

Abdominal ultrasound (Also called sonography.) - a diagnostic imaging technique which uses high-frequency sound waves and a computer to create images of blood vessels, tissues and organs. Ultrasounds are used to view internal organs as they function and to assess blood flow through various vessels.

Liver biopsy - a procedure in which tissue samples are removed (with a needle or during surgery) from the liver for examination under a microscope.

The transplant team will consider all information from interviews, your child's medical history, physical examination and diagnostic tests in determining whether your child can be a candidate for liver transplantation.

After the evaluation and your child has been accepted to have a liver transplant, your child will be placed on the waiting list.

The liver transplant team:

The group of specialists involved in the care of children ho are undergoing a transplant procedure is often referred to as the "transplant team." Each individual works together to provide the best chance for a successful transplant. The liver transplant team consists of:

Transplant surgeons - physicians who specialize in transplantation and who will be performing the surgery. The transplant surgeons coordinate all team members. They follow your child before the transplant and continue to follow your child after the transplant and after discharge from the hospital.

Hepatologist: are medical specialists in liver & digestive diseases.

Social workers - professionals who will provide support to your family and help your family deal with many issues that may arise including lodging and transportation, finances and legal issues. They can also help coordinate alternative means for school, so that your child does not get behind.

Dietitians - professionals who will help your child meet his/her nutritional needs before and after the transplant. They will work closely with you and your family.

Child psychologist - a psychologist who specializes in children will assist both the family and staff to cope with liver disease and transplant.

Other team members - several other team members will evaluate your child before transplantation and provide follow-up care, as needed. These include, but are not limited to, the following:

Pharmacists.

Anesthesiologists.

Respiratory therapists.

Cardiologists.

Hematologists.

Nephrologists.

Infectious disease specialists.

Physical therapists.

How long will it take to get a new liver?

There is no definite answer to this question. Sometimes, children wait only a few days or weeks before receiving a donor organ. If no living-related donor is available, it may takes months or years on the waiting list before a suitable donor organ is available. During this time, your child will have close follow-up with his/her physician and the transplant team. Our nurses & counselors will provide support & guidance during this waiting time.

How are we notified when a liver is available?

You will be notified by home phone or cell-phone that an organ is available. You will be told to come to the hospital immediately so your child can be prepared for the transplant.

What is involved in liver transplant surgery?

Once an organ becomes available to your child, you and your child will be immediately called to the hospital. This call can occur at any time, so you should always be prepared to go to the hospital, if needed. Once at the hospital, the child will have some more final blood work and tests to confirm the match of the organ.

The child will then go to the operating room. The transplant surgery may require several hours, but will vary greatly depending on each individual case. During the surgery, a member of the transplant team will keep you informed on the progress of the transplant.

Post-operative care for liver transplant:

After the surgery, your child will go to the intensive care unit (ICU) to be monitored closely. The length of time your child will spend in the ICU will vary based on your child's unique condition. After your child is stable, your child will be sent to the special unit in the hospital that cares for liver transplant patients. Your child will continue to be monitored closely. You will be educated on all aspects of caring for your child during this time. This will include information about medications, activity, follow-up, diet and any other specific instructions from your child's transplant team.

What is rejection?

Rejection is a normal reaction of the body to a foreign object. When a new liver is placed in a person's body, the body sees the transplanted organ as a threat and tries to attack it. The immune system makes antibodies to try to kill the new organ, not realizing that the transplanted liver is beneficial. To allow the organ to successfully live in a new body, medications must be given to trick the immune system into accepting the transplant and not thinking it is a foreign object.

What are the symptoms of rejection?

The following are the most common signs and symptoms of rejection. However, each child may experience symptoms differently. Symptoms may include:

Fever.

Jaundice (yellow skin or eyes).

Dark urine.

Itching.

Abdominal swelling or tenderness.

Fatigue.

Irritability.

Headache.

Your child's transplant team will instruct you on who to call immediately if any of these symptoms occur.

What is done to prevent rejection?

Medications must be given for the rest of the child's life to fight rejection. Each child is unique and each transplant team has preferences for different medications. Some of the anti-rejection medications most commonly used include the following:

• Tacrolimus.
• Cyclosporine
• Prednisone.

The doses of these medications may change frequently, depending upon your child's response. Because anti-rejection medications affect the immune system, children who receive a transplant will be at higher risk for infections. A balance must be maintained between preventing rejection and making your child very susceptible to infection. Blood tests to measure the amount of medication in the body are done periodically to make sure your child does not get too much or too little of the medications. White blood cells are also an important indicator of how much medication your child needs.

What about infection?

This risk of infection is especially great in the first few months because higher doses of anti-rejection medications are given during this time. Your child will most likely need to take medications to prevent other infections from occurring. Some of the infections your child will be especially susceptible to include oral yeast infection (thrush), herpes and respiratory viruses.

Long-term outlook for a child after a liver transplant:

Living with a transplant is a life-long process. Medications must be given that trick the immune system so it will not attack the transplanted organ. Other medications must be given to prevent side effects of the anti-rejection medications, such as infection. Frequent visits to and contact with the transplant team are essential. When the child becomes old enough, he will need to learn about anti-rejection medications, what they do, the signs of rejection and everything else the parents have learned so he can eventually care for himself independently.

Every child is unique and every transplant is different. Results continually improve as physicians and scientists learn more about how the body deals with transplanted organs and search for ways to improve transplantation

Why and how is the liver transplant done?

Q. Is there any alternative to liver transplant? Can the patient lead a normal life after the operation? What is the cost of the operation?

A. Once the liver is in terminal stages of damage (advanced cirrhosis), there is no alternative to liver transplantation. Patients undergoing successful transplant live a normal life, with normal life expectancy for age.

The procedure and relevant information about liver transplant in our Department is as follows.

At our centre here in Delhi, we do about 6-8 live donor liver transplants per month with 94% success rate for patients and 100% safety record for donors. A 94% success means that 94% of all patients are able to live a normal life, long-term. This makes us the most prolific and successful centre in South Asia. In November 2006, our centre became the first in South Asia to complete 100 liver transplants.

The liver donor must be from the patient�s family, aged between 18-55 years, weighing between 50-90kg (but not fat), and have the same blood group or blood group O. We take half the liver from the donor and this is very safe since the liver quickly regenerates, and the donor recovers completely. Once you identify such a person, the following screening tests should be done for the donor: CBC, LFT, Prothrombin time, creatinine, HCV-Ab, HBsAg, HIV-I,II, Ultrasound abdomen, ECG, Chest X ray.

The next step is to identify a donor in the family, get the screening tests done and send them to me along with the weight, height and blood group details of the patient and the donor.

Once you confirm the availability of a family donor, and your decision to come over for transplant, an appointment can be arranged with us directly call on +91-9811207735 or ring one of the Departmental secretaries on +91-11-42252222 or 42252200 (between 9.30am and 6pm local time) 2 days in advance.

The total expense of transplant and all related treatment for the patient and the donor is around Rs. 20 lacs (US$ 45000) and involves a total stay in Delhi of about 3 months (including pre transplant evaluation, transplant and post transplant follow up).

27 March 2007

Answered by
Dr. A. S. Soin
Liver Transplant Surgeon,
Sir Ganga Ram Hospital,
New Delhi

Via: http://www.doctorndtv.com

Alcoholism

Definition

Alcoholism is an illness marked by drinking alcoholic beverages at a level that interferes with physical health,mental health, and social, family, or occupational responsibilities.

Alcoholism is divided into 2 categories: dependence and abuse.

People with alcohol dependence, the most severe alcohol disorder, usually experience tolerance and withdrawal. Tolerance is a need for markedly increased amounts of alcohol to achieve intoxication or the desired effect. Withdrawal occurs when alcohol is discontinued or intake is decreased. Alcohol dependents spend a great deal of time drinking alcohol, and obtaining it.

Alcohol abusers may have legal problems such as drinking and driving. They may alsohave problems with binge drinking (drinking 6 or more drinks at one sitting).

People who are dependent on or abuse alcohol continue to drink itdespite evidence of physical or psychological problems. Those with dependence have more severe problems and a greater compulsion to drink.

Alternative Names

Alcohol dependence; Alcohol abuse

Causes

Alcoholism is a type of drug addiction. There is both physical and psychological dependence with this addiction. Physical dependence reveals itself by withdrawal symptoms when alcohol intake is interrupted, tolerance to the effects of alcohol, and evidence of alcohol-associated illnesses.

Alcohol affects the central nervous system as a depressant, resulting in a decrease of activity, anxiety, tension, and inhibitions. Even a few drinks can result in behavioral changes, a slowing in motor performance, and a decrease in the ability to think clearly. Concentration and judgment become impaired. In excessive amounts, intoxication may result.

Alcohol also affects other body systems. Irritation of the gastrointestinal tract can occur with erosion of the lining of the esophagus and stomach causing nausea and vomiting, and possibly bleeding. Vitamins are not absorbed properly, which can lead to nutritional deficiencies with the long-term use of alcohol. Liver disease, called alcoholic hepatitis, may also develop and can progress to cirrhosis. The heart muscle may be affected. Sexual dysfunction may also occur, causing problems with erections in men and cessation of menstruation in women.

Alcohol affects the nervous system and can result in nerve damage and severe memory loss. Chronic alcohol use also increases the risk of cancer of the larynx, esophagus, liver, and colon. Alcohol consumption during pregnancy can cause severe birth defects. The most serious is fetal alcohol syndrome, which may result in mental retardation and behavior problems. A milder form of the condition which can still cause lifelong impairment is called fetal alcohol affects.

The social consequences of problem drinking and alcohol dependence can be as serious as the medical problems. People who abuse or are dependent on alcohol have a higher incidence of unemployment, domestic violence, and problems with the law. About half of all traffic deaths are related to alcohol use.

The development of dependence on alcohol may occur over a period of years, following a relatively consistent pattern. At first, a tolerance of alcohol develops. This results in a person being able to consume a greater quantity of alcohol before its adverse effects are noticed. Memory lapses (black-outs) relating to drinking episodes may follow tolerance. Then, people may lose control over drinking and find it difficult or impossible to stop if they try. The most severe drinking behavior includes prolonged binges of drinking with associated mental or physical complications. Some people are able to gain control over their dependence in earlier phases before a total lack of control occurs. The problem is, no one knows which heavy drinkers will be able to regain control and which will not.

Withdrawal develops because the brain has physically adapted to the presence of alcohol and cannot function adequately in the absence of the drug. Symptoms of withdrawal may include elevated temperature, increased blood pressure, rapid heart rate, restlessness, anxiety, psychosis, seizures, and rarely even death.

There is no known common cause of alcoholism. However, several factors may play a role in its development. A person who has an alcoholic parent is more likely to become an alcoholic than a person without alcoholism in the immediate family. Research suggests that certain genes may increase the risk of alcoholism but which genes or how they exert their influence is controversial. Psychological factors may include a need for relief of anxiety, ongoing depression, unresolved conflict within relationships, or low self-esteem. Social factors include availability of alcohol, social acceptance of the use of alcohol, peer pressure, and stressful lifestyles.

The incidence of alcohol intake and related problems is increasing. Data from many sources indicate that about 15% of the population in the United States are problem drinkers, and approximately 5% to 10% of male drinkers and 3% to 5% of female drinkers could be diagnosed as alcohol dependent (12.5 million people).

Symptoms

Men who consume 15 or more drinks a week, women who consume 12 or more drinks a week, or anyone who consumes 5 or more drinks per occasion at least once a week are all at risk for developing alcoholism. (One drink is defined as a 12-ounce bottle of beer, a 5-ounce glass of wine, or a 1 1/2-ounce shot of liquor).

The following questions are used by the National Institute on Alcohol Abuse and Alcoholism to screen for alcohol abuse or dependence:

• Have you felt that you should cut down on your drinking?
• Do you ever drive when you have been drinking?
• Is someone in your family concerned about your drinking?
• Have you ever had any blackouts after drinking?
• Have you ever been absent from work or lost a job because of drinking?
• Do you have to drink more than before to achieve intoxication or the desired effect?

Some of the symptoms associated with alcoholism include:

• Drinking alone
• Making excuses to drink
• Need for daily or frequent use of alcohol for adequate function
• Lack of control over drinking, with inability to discontinue or reduce alcohol intake
• Episodes of violence associated with drinking
• Secretive behavior to hide alcohol related behavior
• Hostility when confronted about drinking
• Neglect of food intake
• Neglect of physical appearance
• Nausea and vomiting
• Shaking in the morning
• Abdominal pain
• Numbness and tingling
• Confusion

Alcohol withdrawal symptomsvary from mild to severe and may include:

• Rapid heart rate and sweating
• Restlessness or agitation
• Loss of appetite, nausea, or vomiting
• Confusion or hallucinations
• Tremors and seizures

Exams and Tests

All physicians should ask their patients about their drinking. A history may be obtained from family if the affected person is unwilling or unable to answer questions. A physical examination is performed to identify physical problems related to alcohol use.

• A toxicology screen or blood alcohol level confirms recent alcohol ingestion, which does not necessarily confirm alcoholism.
• Liver function tests can be elevated. GGPT (glutaryl transaminase) is often elevated more than other liver function tests.
• CBC (complete blood count) - MCV can be elevated (mean corpuscular volume or size of the red blood cells).
• Serum magnesium, uric acid, total protein, and folate tests may be abnormal.

Treatment

Many people with alcohol problems don't recognize when their drinking gets out of hand. In the past, treatment providers believed that alcoholics should be confronted about denial of their drinking problems, but now research has shown that compassionate and empathetic counseling is more effective.

Three general steps are involved in treating the alcoholic once the disorder has been diagnosed: intervention, detoxification, and rehabilitation. Research finds that the traditional confrontational intervention - where the employer or family members surprise the alcoholic and threaten consequences if treatment is not begun - is NOT effective. Studies find that more people enter treatment if their family members or employers are honest with them about their concerns, and try to help them to see that drinking is preventing them from reaching their goals.

Once the problem has been recognized, total abstinence from alcohol is required for those who are dependent; for those who are problem drinkers, moderation may be successful. Since many alcoholics initially refuse to believe that their drinking is out of control, a trial of moderation can often be an effective way to deal with the problem. If it succeeds, the problem is solved. If not, the person is usually ready to try abstinence. Because alcoholism affects the people closely related to the alcoholic person, treatment for family members through counseling is often necessary.

Detoxification is the first phase of treatment. Withdrawal from alcohol is done in a controlled, supervised setting in which medications relieve symptoms. Detoxification usually takes 4 to 7 days. Examination for other medical problems is necessary. For example, liver and blood clotting problems are common. A balanced diet with vitamin supplements is important. Complications associated with the acute withdrawal of alcohol may occur, such as delirium tremens (DT's), which could be fatal. Depression or other underlying mood disorders should be evaluated and treated. Often, alcohol abuse develops from efforts to self-treat an illness.

Alcohol recovery or rehabilitation programs support the affected person after detoxification to maintain abstinence from alcohol. Counseling, psychological support, nursing, and medical care are usually available within these programs. Education about the disease of alcoholism and its effects is part of the therapy. Many of the professional staff involved in rehabilitation centers are recovering alcoholics who serve as role models. Programs can be either inpatient, with the patient residing in the facility during the treatment, or outpatient, with the patient attending the program while they live at home.

Medications are sometimes prescribed to prevent relapses.

• Naltrexone (Vivitrol) is an opioid antagonist that decreases alcohol cravings. In April 2006, the U.S. Food and Drug Administration approved an injected form of the drug.
• Disulfiram (Antabuse) works by producing very unpleasant side effects if even a small amount of alcohol is ingested within 2 weeks after taking the drug.
• Acomprosate is a new drug that has been shown to lower relapse rates in those who are alcohol dependent.

These medications are not given during pregnancy or if the person has certain medical conditions. Long-term treatment with counseling or support groups is often necessary. The effectiveness of medication and counseling varies.

Alcoholics Anonymous is a self-help group of recovering alcoholics that offers emotional support and an effective model of abstinence for people recovering from alcohol dependence. There are more than 1 million members worldwide, and local chapters are found throughout the United States.

For those who don't like the 12-step approach, there are several other support groups available. It is important that people dealing with alcohol problems know about these other groups because in the past, those who did not find AA helpful or were troubled by its requirement of submission to a "Higher Power" had no alternatives.

SMART recovery uses research-based cognitive techniques to help alcoholics recover. LifeRing recovery and SOS are two other secular programs. Women For Sobriety is a self-help group just for women - many female alcoholics have different concerns than men. Moderation Management is a program for problem drinkers seeking to moderate their drinking - it recommends abstinence for those who fail at such attempts.

Outlook (Prognosis)

Alcoholism is a major social, economic, and public health problem. Alcohol is involved in more than half of all accidental deaths and almost half of all traffic deaths. A high percentage of suicides involve the use of alcohol in combination with other substances. Additional deaths are related to the long-term medical complications associated with the disease. Only 15% of those with alcohol dependence seek treatment for this disease. Relapse after treatment is common, so it is important to maintain support systems in order to cope with any slips and ensure that they don't turn into complete reversals. Treatment programs have varying success rates, but many people with alcohol dependency have a full recovery.

Possible Complications

• Pancreatitis
• Heart muscle damage
• Nerve damage
• Esophageal bleeding
• Brain degeneration
• Cirrhosis of the liver
• Delirium tremens (DTs)
• Depression
• Erectile dysfunction
• Fetal alcohol syndrome in the offspring of alcoholic women
• High blood pressure
• Increased incidence of cancer
• Insomnia
• Nutritional deficiencies
• Suicide
• Wernicke-Korsakoff syndrome

When to Contact a Medical Professional

If severe confusion, seizures, bleeding, or other health problems develop in a person known or who is suspected to have alcohol dependence take the person to the emergency room or call the local emergency number such as 911.

Prevention

Educational programs and medical advice about alcohol abuse have been successful in decreasing alcohol abuse and its associated problems. Alcohol dependency requires more intensive management.

The National Institute on Alcohol Abuse and Alcoholism recommends that women have no more than 1 drink per day and men no more than 2 drinks per day. One drink is defined as a 12-ounce bottle of beer, a 5-ounce glass of wine, or a 1 1/2-ounce shot of liquor.

Liver Transplantation Frequently Asked Questions

Q. When does a liver transplant need to be done?

A. The liver has many jobs to do such as to helping to digest your food, clearing some wastes from your blood, making proteins that help your blood to clot, storing glycogen for energy, breaking down many poisons and medicines and many more tasks. When the liver is seriously damaged, there is no treatment that can help the liver do all of its jobs. Therefore, when a person reaches a certain stage of liver disease, a liver transplant may be the only way to prolong his or her life.

The most common reason for liver transplantation in adults is cirrhosis, a disease in which healthy liver cells are killed and replaced with scar tissue. The common causes of cirrhosis are alcohol abuse and Hepatitis due to B and C viruses. The most common reason for transplantation in children is biliary atresia, a disease in which the ducts that carry bile out of the liver are damaged. Liver transplant may also be done for some type of liver cancers.

Q. What are the signs of liver failure?

A. The liver only starts to fail when more than half of it is damaged. Once a person shows signs of liver failure, it means there is not much of the liver left for the body to rely on. Signs of liver failure may include the following:

• Yellow skin and eyes (jaundice)
  
• Forgetfulness, confusion, or even coma (encephalopathy)
  
• Feeling very tired (fatigue)
  
• Build-up of fluid in the stomach (ascites)
  
• Vomiting of blood from veins in the oesophagus and stomach (haemetemesis).
  
• Muscle wasting
  
• Poor clotting of the blood

Q. How is the decision made whether I need a liver transplant or not?

A. If the doctors believe that a patient with liver failure is not likely to live for one more year, he or she would become a candidate for liver transplantation. This is, however, a very complex issue and must be answered on a case by case basis. You must first undergo a variety of laboratory tests, x-rays and consultations. You will need to be admitted to the hospital for approximately one week to carry out these tests. Once they are completed, your test results are reviewed at the Liver Transplant Committee meeting made up of doctors, nurses, transplant coordinators, psychologists and social workers. This is to help us decide whether a liver transplant is the best choice for you. If you are found to be appropriate for a transplant, you will be placed on the waiting list for a liver transplant. Once in a while, patients are found to be too healthy for a transplant. These patients may then be followed closely for signs of more liver failure. As their liver gets worse, they will be re-tested and if suitable may be placed on the liver transplant list at that time. Other patients may be too ill to survive the transplant. In these cases, the committee will not approve a liver transplant.

Q. What are my chances with a liver transplant?

A. The survival rate after liver transplant is more than 80% at one year, and 70% at five years. This implies that if 20 patients undergo liver transplantation, within one year 4 will die due to the complications of the operation or its medications. Within 5 years four more out of these 20 are likely to die due to a variety of problems.
If you compare this with the results of operation for most cancers, this is an exceptionally good end result. It is particularly so, given that without a liver transplant most patients would have died within a year.

Q. How long will a new liver last?

A. No one knows how long a transplanted liver can last. The longest reported survivor is 25 years. Ten year survival is common. Hopefully, improvements in techniques and medications that are continually occurring will allow most patients receiving liver transplants today to have long productive lives.

Q. I have liver disease due to alcohol. Can I have a transplant?

A. Yes. However you must have completely stopped taking alcohol for a minimum period of one year. You will be assessed by a psychologist and a psychiatrist to establish whether your mental, social and family environment may drive you to alcohol following a successful transplant. Even small amounts of alcohol after a liver transplant can seriously damage the new liver.

Q. Will hepatitis C or Hepatitis B be cured by a liver transplant?

A. No. Hepatitis C and B viruses can live in cells other than in the liver. Once the old liver is removed and the new one is connected the hepatitis virus spreads back into the liver within the first weeks to months after the transplant. It is almost certain to occur with Hepatitis C. This is the bad news: at present we have no way to make the Hepatitis C virus go away completely. The good news is that overall results with Hepatitis C after liver transplantation is good because although the disease comes back it does not seem to greatly damage the liver in the majority of cases. Occasionally, it is possible for the hepatitis to return so severely that the new liver fails very soon, but this is uncommon. Fortunately Hepatitis B can be treated more effectively, however it is very expensive.

Q. Where do donated livers come from?

A. There are two types of donors:

• Cadaver Donor: In this case, the donor liver is obtained from a person who is diagnosed as "brain dead" and whose family volunteers to donate the organ for transplantation. Cadaveric organ donation from brain-dead patients remains the principal form of donation in most parts of the world. "Brain death" usually result from head injury, stroke, brain haemorrhage etc. . Such donors are on a ventilator in a hospital intensive care unit. Although their heart continues to beat and keep their blood circulation going, they are clinically dead. Because the ventilator provides oxygen which keeps the heart beating after death, they are called heart-beating brain-dead donors. If their breathing support machines were stopped, the heart would stop immediately. Even on a ventilator, they are unlikely to survive more than a week. In these circumstances death is confirmed by brain stem death tests, which are recognized all over the world and by the Indian parliament (Transplantation of the Human Organs Act, 1994). Whilst their heart is beating on the ventilator, their organs can be removed for transplantation into a recipient.
  
• Living Donor: Recently, living-donor liver transplants have become more common, particularly in Asian countries such as Japan, Korea, Taiwan, Singapore etc. where for various reasons, cadaveric donors are very few in number. A healthy family member, usually a parent, sibling, child or spouse may volunteer to donate part of their liver for transplantation. For an adult who needs a liver, the right half of a liver is removed from the donor and used for the transplant. For a child who needs a liver, a smaller part of the liver (part of left side) is removed from a living donor for the transplant. The donor is carefully evaluated by the team to make sure no harm will come to the donor or recipient. (See Living Donor FAQ.)
  

Q. What happens when I am placed on the waiting list for a transplant?

A. Once a suitable donor is found, you will be contacted instantly and you will need to reach the hospital at the earliest. We will therefore need a list of the names and telephone numbers of people who will know where to reach you.
There are many problems that may come up during the waiting period. You may need to be seen by our doctor regularly. You should have your blood tested and your medicines changed as necessary to keep you in the best possible shape for a transplant. It is very important that you keep all your appointments.

Q. How long will I be in hospital after the transplant operation?

A. Liver transplant is a major operation taking about 6 to 12 hours to perform. Following the surgery you will be in the transplant intensive care unit for about 2 to 3 weeks. There will be intensive monitoring of your liver, kidney, heart function etc. during this period. Subsequently you may go to the ward till your discharge. Generally you are expected to be in hospital for about 4 to 6 weeks after the operation.

Q. What are the most common complications following a liver transplant?

A. The two most common complications following your liver transplant are Rejection and Infection. These complications are most common in the first year following your transplant.

• Rejection: Your body's immune system is designed to destroy foreign cells such as bacteria and viruses, which are harmful to you. Your immune system attacks the cells of the new liver because they're not like your body's own cells. This attack is called "rejection," the most serious problem that can happen after a transplant. To prevent rejection of the new liver, you need to take anti-rejection medicines called "immunosuppressants". Examples are tacrolimus, cyclosporine, azathioprine, mycophenolate, prednisolone etc.
  Approximately 50% of liver transplant recipients experience at least one episode of rejection. Usually this rejection episode resolves completely with treatment. If you do not take your medication properly as instructed, your chances for rejection are higher.
  
• Infection: Micro organisms called bacteria, viruses, protozoa and fungi cause infections. Because you will be taking immunosuppressive medications that suppress your immune system, you will be at risk of acquiring infections from these micro organisms. Some of these organisms live normally in the body and do not produce illness before your transplant. Once you are transplanted and the immune system is suppressed, these organisms could trigger infections. Hence monitoring for infection is extremely important for the newly transplanted patient.

Q. What are the side effects of the anti rejection medicines?

A. Soon after a liver transplant, typically you will be given three anti-rejection pills, as they work better in combination. Later it maybe reduced to two or even one. These medicines weaken your immunity just enough so your body accepts the new liver. They are very strong medicines but without them you will lose your new liver.
As explained above, the main side effect of these medicines is infection. You will therefore be given drugs to prevent acquiring viral, fungal and protozoal infections. Any bacterial infections will be treated accordingly as recommended by the transplant team.
The other side effects are:

• Transplant medicines can make you more likely to get some type of cancers like cancer of lymph glands and skin. The doctors will try to adjust the dose of the medicines so that you do not get infections or cancers. Furthermore, you will be regularly checked for the development of cancers. Most of these cancers are easily treated, if detected early. Nevertheless 1% of transplant recipients die of cancer.
  
• Diabetes, high blood pressure, weight gain, high cholesterol, weak bones, hair thinning etc. are other relatively minor side effects. These can be detected early and appropriate treatment started to prevent any major issues.

Q. What happens after my discharge?

A. You will need to attend the out patient department regularly for check-up by the doctor and for testing your blood. Initially you will have to visit 2- 3 times a week; later once a week and then less often. The better you look after your new liver, the longer it will last for you and the lesser the side effects of medications.

What Are the Myths Vs. Facts About Alcohol and the Liver? True or False?

True or False?

• Many victims of liver disease are not alcoholics.
  
  
• Even moderate social drinkers may risk liver damage.
  
  
• People who never drink alcoholic beverages may still get serious liver problems.
  

Answer: All statements are true. How many did you get right?
If you were surprised by the answers, don't be discouraged. You are not alone. Most people are confused about the relationship between alcohol and the liver. The American Liver Foundation has found that there is much misunderstanding on this subject. Because myths can be harmful, here are straight answers to some of the most common questions about alcohol and the liver.

Does alcohol cause liver disease?
Yes, but it is only one of the many causes, and the risk depends on how much you drink and over how long a period. There are more than 100 liver diseases. Known causes include viruses, hereditary defects, and reactions to drugs and chemicals. Scientists are still investigating the causes for the most serious liver diseases.

How much alcohol can I safely drink?
Because some people are much more sensitive to alcohol than others, there is no single right answer that will fit everyone. Based on current dietary guidelines, moderate drinking for women is defined as an average of 1 drink or less per day. Moderate drinking for men is defined as an average of 2 drinks or less per day (USDA, 2000). A standard drink is one 12-ounce beer, one 5-ounce glass of wine, or one 1.5-ounce shot of distilled spirits. Each of these drinks contains about half an ounce of alcohol.

Are there dangers from alcohol besides the amount that is consumed?
Yes. Even moderate amounts of alcohol can have toxic effects when taken with over-the-counter drugs containing acetaminophen. If you are taking over-the-counter drugs, be especially careful about drinking and don't use an alcoholic beverage to take your medication. Ask your doctor about precautions for prescription drugs.

Can "social drinkers" get alcoholic hepatitis?
Yes. Alcoholic hepatitis is frequently discovered in alcoholics, but it also occurs in people who are not alcoholics. People vary greatly in the way their liver reacts to alcohol.

What kinds of liver diseases are caused by too much alcohol?
Alcoholic hepatitis is an inflammation of the liver. Symptoms include loss of appetite, nausea, vomiting, abdominal pain and tenderness, fever, and jaundice. It is believed to lead to alcoholic cirrhosis over a period of years. Cirrhosis involves permanent damage to the liver cells. "Fatty liver" is the earliest stage of alcoholic liver disease. If the patient stops drinking at this point, the liver can heal itself.

How can alcoholic hepatitis be diagnosed?
Alcoholic hepatitis is not easy to diagnose. Sometimes symptoms are worse for a time after drinking has stopped than they were during the drinking episode. While the disease usually comes on after a period of fairly heavy drinking, it may also be seen in people who are moderate drinkers. Blood tests may help in diagnosis. Proof is established best by liver biopsy. This involves taking a tiny specimen of liver tissue with a needle and examining it under a microscope. The biopsy is usually done under local anesthesia.

Are men or women more likely to get alcoholic hepatitis?
Women appear to be more likely to suffer liver damage from alcohol a woman's body handles alcohol differently than a man's body.

Do all alcoholics get alcoholic hepatitis and eventually cirrhosis? No. Some alcoholics may suffer seriously from the many physical and psychological symptoms of alcoholism but escape serious liver damage. Alcoholic cirrhosis is found among alcoholics about 10-25 % of the time.

Is alcoholic hepatitis different from "fatty liver?"Yes. Anyone who drinks alcohol heavily, even for a few days, may develop a condition in which liver cells are swollen with fat globules and water. This condition is called "fatty liver." It may also result from diabetes, obesity, certain drugs, or severe protein malnutrition. Fatty liver caused by alcohol is reversible when drinking of alcohol is stopped.

Does alcoholic hepatitis always lead to cirrhosis?
No. It usually takes many years for alcoholic hepatitis to produce enough liver damage to result in cirrhosis. If alcoholic hepatitis is detected and treated early, cirrhosis can be prevented.

Is alcoholic hepatitis dangerous?
Yes. It may be fatal, especially if the patient has had previous liver damage. Those who have had nutritional deficiencies because of heavy drinking may have other ailments. These medical complications may affect almost every system in the body. It is important to recognize and treat alcoholic cirrhosis early, so that these life-threatening consequences are prevented.

How can alcoholic hepatitis be prevented?
The best treatment is to stop drinking. Treatment may also include prescribed medication, good nutrition, and rest. The patient may be instructed to avoid various drugs and chemicals. Since the liver has considerable ability to heal and regenerate, the prognosis for a patient with alcoholic hepatitis is very hopeful - if he or she totally abstains from drinking alcohol.

Is cirrhosis different from alcoholic hepatitis?
Yes. Hepatitis is an inflammation of the liver. In cirrhosis, normal liver cells are damaged and replaced by scar tissue. This scarring keeps the liver from performing many of its vital functions.

What causes cirrhosis?
There are many causes for cirrhosis. Long-term alcohol abuse is one. Chronic hepatitis is another major cause. In children, the most frequent causes are biliary atresia, a disease that damages the bile ducts, and neonatal hepatitis. Children with these diseases often receive liver transplants.

Many adult patients who require liver transplants suffer from primary biliary cirrhosis. We do not yet know what causes this illness, but it is not in any way related to alcohol consumption.

Cirrhosis can also be caused by hereditary defects in iron or copper metabolism or prolonged exposure to toxins.

Should alcoholics receive a liver transplant?
Some medical centers will not perform liver transplants on alcoholics because they believe a substantial percentage of these patients will return to drinking. Other centers require abstinence from drinking at least six months before and after surgery, plus enrollment in a counseling program
Via: American Liver Foundation

What I need to know about Liver.

Transplantation

On this page:
What does my liver do?
What are the signs of liver problems?
What is liver transplantation?
How long does it take to get a new liver?
Where do the livers for transplants come from?
What happens in the hospital?
What is rejection?
What are the other problems that can damage the liver transplant?
How do I take care of my liver after I leave the hospital?
Can I go back to my daily activities?
For More Information
Glossary

What does my liver do?

Your liver helps fight infections and cleans your blood. It also helps digest food and stores energy for when you need it.

What are the signs of liver problems?

• Some signs of liver problems are
• feeling tired or weak
• losing your appetite
• feeling sick to your stomach
• losing weight
• bruising or bleeding easily, such as nosebleeds
• bloating due to fluid buildup in the abdomen (ascites*)
• declining mental functions

Also, liver problems often make the skin and the whites of the eyes turn yellow, a condition called jaundice, and may cause swelling in the legs and the abdomen.
You cannot live without a liver that works. If your liver fails, your doctor may put you on a waiting list for a liver transplant.

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 more than 38 years. Many people have had liver transplants and now lead normal lives.Being tired and losing your appetite can be signs of liver problems.

What are the reasons for needing a liver transplant?

In adults, the most common reason for liver transplantation is 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 diseases, buildup of fat in the liver, and hereditary liver diseases.

In children, the most common reason for liver transplantation is biliary 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 reasons for transplantation are liver cancer, benign liver tumors, and hereditary diseases. Sometimes the cause of liver disease is not known.

Liver transplants can help adults and children.

How will I know whether I need a liver transplant?

Your doctor will decide whether you need to go to a hospital that does liver transplants. You will meet the liver transplant team. The team is usually led by a liver transplant surgeon and includes liver specialists, 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 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 a transplant?

• You cannot have a 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 long does it take to get a new liver?

If you need a transplant, your name will be placed on a national waiting list. Your blood type, body size, and how sick you are all play a role in when you will receive a liver. Currently, the sickest people are at the top of the list, so you may have to wait a long time.

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

Where do the livers for transplants come from?

Whole livers come from people who have just died. This type of donor is called a cadaveric donor. Sometimes a healthy person will donate part of his or her liver for a particular patient. This kind of donor is called a living donor.

All 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 it has the best chance of working in your body.

Health Insurance
You should check your health insurance policy to be sure it covers liver transplantation and prescription medicines. You will need many prescription medicines after the surgery and for the rest of your life.

What happens in the hospital?

When a liver is available, you will be prepared for the surgery. If your new liver is from a living donor, both 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 starts when the new liver arrives at the hospital.

During Surgery
The surgery can take from 4 to 14 hours. While the surgeon removes your diseased liver, other doctors 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 of 1 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 slowly start eating again. You will start with clear liquids, then switch to solid food as your new liver starts to work.

After surgery you will learn how to take care of your new liver.

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 take medicines. These drugs, such as steroids, cyclosporine, tacrolimus, sirolimus, and mycophenolate mofetil, are called immunosuppressants. 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 damage your kidneys. 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 may treat you for complications.

What are the signs of rejection?

Doctors will check your blood for liver enzymes, the first sign of rejection. Often rejection does not make you feel ill. Sometimes rejection can cause

• nausea
• pain
• fever
• jaundice

Often, a liver biopsy is needed to be sure that the transplanted liver is being rejected. For a biopsy, the doctor takes a small piece of the liver to view under a microscope.
Blood tests will show if the new liver is being rejected.

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

Return of the problem that made the transplant necessary in the first place is the most common problem for patients with liver transplants. Also, hepatitis C virus may damage a transplant if the patient was infected before the operation took place.

Other 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?

Liver transplants usually work. About 80 to 90 percent of transplanted livers are still working after 1 year. 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 possible.

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 or bile ducts. You will need to avoid sick people and report any illnesses to your doctor. You will need to eat a healthy diet, exercise, and not drink alcohol, especially if alcohol was the cause of damage to your own liver. You should use medicines, including ones you can buy without a prescription, only if your doctor says they are safe for you. It is important to do what your doctor says to take care of your new liver.

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

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, though, depending on how sick you were before the transplant. You will need to check with your doctor on how long your recovery period should be. Social workers and support groups will help you adjust to life with a new liver.

Work. After recovery, most people are able to go back to work.

Diet. Most people can go back to eating as they did before. Some medicines may cause you to gain weight, and others may cause diabetes or a rise in your cholesterol. Meal planning and a balanced low-fat diet can help you remain healthy.

Exercise. Most people can engage in physical activity after a successful liver transplant.

Sex. Most people return to a normal sex life after liver transplantation. It is important for women 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 want to check with your doctor before starting any activity.

Glossary
Ascites (uh-SY-teez): A buildup of fluid in the abdomen.

Autoimmune (AW-toh-im-YOON): A term that refers to a person's immune system attacking his or her own body.

Biliary atresia (BILL-ee-air-ee uh-TREEZ-ya): A condition that results when the bile ducts inside or outside the liver don't have normal openings. Bile becomes trapped in the liver, causing jaundice and cirrhosis. This condition is present from birth and without surgery may cause death.

Biopsy (BYE-op-see): Removing a small piece of tissue to view under a microscope.

Cirrhosis (sir-ROH-sis): A chronic liver condition caused 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 (sy-klo-SPOR-in): An immunosuppressant used after transplantation to prevent rejection.

Immunosuppressants (im-you-no-suh-PRESS-unts): Medicines that stop your immune system from attacking bacteria, viruses, and transplanted organs.

Jaundice (JAWN-dus): A symptom of many disorders. Jaundice causes the skin and the whites of the eyes to turn yellow.

Mycophenolate mofetil (MY-co-PHEN-olate MOF-i-til): An immunosuppressant used after transplantation to prevent rejection.

Sirolimus (si-RAW-lih-mus): An immunosuppressant used after transplantation to prevent rejection.

Steroids (STAIR-oids): A group of immunosuppressants used after transplantation to prevent rejection.

Tacrolimus (ta-CRAW-lih-mus): An immunosuppressant used after transplantation to prevent rejection.

Life After Transplant

Q: How long will my liver transplant last?

A: Liver transplant can have excellent outcomes. Recipients have been known to a normal life over 30 years after the operation. According to the most recent year computed international average one-year graft survival at 83%, and patient survival at 87% for patients receiving a deceased donor liver and 92% for those transplanted with an organ from a living donor. Five-year graft and patient survivals are 67% (deceased/2000) 62% (living/2000) and 76% (deceased/2000) 81% (living/2000), respectively. During 2006 at one-year graft and patient survival rates are 82% and 88%.

It is important to remember that many factors come into play with these statistics. They represent ALL patients transplanted, including the very old and the very young, those who were critically ill and those with less severe liver problems at the time of transplant.

Transplant recipients directly contribute to the success of their transplant. Failure to comply with the immunosuppression medical regimen is the number one cause of organ failure. Close follow-up with your transplant team and primary-care physician can help ensure a good outcome. Careful attention to medication schedules, lifestyle changes, infection-avoidance techniques are all important ways to prolong one's life after transplantation.Q: What can I expect my quality of life to be after liver transplantation?A: The first three months following transplantation are the most difficult. The body is adjusting to the "new" liver and all the medications needed to maintain its health. By the time of discharge from the hospital patients are able to care for themselves, with some minor restrictions. The transplant team carefully prepares each patient for discharge. Most patients can return to work within 3 to 6 months after a transplant. Playing sports and getting healthy exercise, socializing, and traveling for business and pleasure are all possible. The Center's expectation is that people who undergo liver transplantation can and do go on to lead "normal" lives.

Q: Will my liver disease come back after a transplant?
A: Certain liver diseases can reappear in the new liver. One example is hepatitis C. The transplant team can advise you on the incidence of recurrence of specific liver ailments. In cases where there is a risk of recurrence the transplant team will monitor you very closely to help prevent recurrence.

Q: How much pain is typical after the surgery?

A: There is pain after liver transplant surgery, however it is generally not as severe as with other abdominal surgeries. This is because nerves are severed during the initial abdominal incision causing numbness of the skin around the abdomen. These nerves regenerate over the following six months and sensation returns. More common post-transplant discomfort is back pain associated with the length of time on the operating table. The team prescribes the appropriate pain medicine for each patient.

Q: How large is the scar?

A: The standard incision used for the liver transplant is called a "chevron incision." It starts at the right side of the midsection just under the ribs and extends to the left edge of the abdomen. There is also a short incision starting under the sternum (breastbone) which extends to meet the horizontal incision.

Q: How long is the recuperation period?

A: Most patients are hospitalized for 2-3 weeks after liver transplant. Afterwards, they generally recuperate at home and typically return to work or school after about 3 months.

Q: Will I need to take medications after my liver transplant?

A: Patients must take many medications after a liver transplant: some to prevent rejection (immunosuppressants), some to fight infection, and others to treat the side effects of the immunosuppressants. Patients returning home after transplantation will be taking approximately 7 to 10 different type of medicines. As the patient heals and recovers health with the help of their new liver, dosages and number of medications are reduced over time. By six months, it is common to be down to 1 or 2 medications. However, patients will be taking immunosuppression medications for the rest of their lives in virtually all cases. It is vital that these medications are taken as prescribed, in the proper amounts and at the specified times. Missing medication doses or discontinuing them on one's own can lead to rejection and organ failure.

Q: What side effects can be expected from the medications prescribed after transplant?

A: Is usually not granted for more than six months after a liver transplant, because the disabling disease has been treated. From the start of the transplant process, patients should consider their long-term employment goals so that they can rejoin the workforce in a timely manner and avoid lapses.

Q: Can I drink alcoholic beverages after my transplant?

A: No. Not only is alcohol toxic to the liver, it can also interfere with the metabolization of certain medications. Be aware that many "non-alcoholic" beers do contain some alcohol.

Q: Can I have sex after my liver transplant?

A: Yes. Sexual activity can resume early after discharge from the hospital. Because of illness, many patients experience impotence or lack of desire prior to the transplant. This usually reverses itself after transplant, but a patient's libido tends to return slowly. Immunosuppressed individuals are at greater risk of contracting sexually transmitted diseases, therefore protective barriers such as condoms should be used (unless in a long-term monogamous relationship).
Because of their chronic illness, many people are unable to conceive prior to transplant, but this may not be the case afterwards. Birth-control methods should be discussed with your transplant team and implemented when sexual activity resumes.

Q: Will I be able to have children after my transplant?

A: Many couples are able to have children after liver transplantation with minimal risk to the mother and baby. Women are advised to wait at least one year following transplantation before trying to conceive. It is important to discuss such plans with the transplant team. They will need to carefully evaluate the health and medication regimen of women seeking to become pregnant. Often, changes in medications are recommended. Women becoming pregnant will need to be closely followed by their obstetrician and the transplant team. It is common to require monthly lab testing for pregnant transplant recipients. Babies born to immunosuppressed mothers tend to have lower birth weights than average, but are generally healthy. Planning the pregnancy and receiving close follow-up care throughout are key.

Q: How can I get in touch with the family of my donor? (Relevant in case you received a cadaver organ)

A: Transplant recipients often want to thank the donor's family for the liver they received. This can only be done anonymously through the organ procurement agency. To communicate with the donor's family, write a letter without signing it and give it to the team's social worker at the Liver center. They send it to the organ procurement agency who in turn forwards it to the donor's family. Often the donor's family will respond via another anonymous letter. However, not everyone receives a response, but this does not mean your gratitude wasn't appreciated by the donor's family.