liver transplantation


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Liver Transplantation

 

Definition

Liver transplantation is a surgery that removes a diseased liver and replace it with a healthy donor liver.

Purpose

The liver is the body's principle chemical factory. It receives all nutrients, drugs, and toxins absorbed from the intestines and performs the final stages of digestion, converting food into energy and replacement parts for the body. The liver also filters the blood of all waste products, removes and detoxifies poisons and excretes many of these into the bile. It processes other chemicals for excretion by the kidneys. The liver is also an energy storage organ, changing food energy to a chemical called glycogen that can be rapidly converted to fuel.
As the liver fails, all of its functions diminish. Nutrition suffers, toxins build up, and waste products accumulate. Scar tissue builds up on the liver if disease is of long duration. As the liver scars, blood flow is progressively restricted in the portal vein, which carries blood from the stomach and abdominal organs to the liver. The resulting high blood pressure (hypertension) causes swelling of and bleeding from the blood vessels of the esophagus. Severe jaundice, fluid accumulation in the abdomen (ascites), and deterioration of mental function, due to the build-up of toxins in the blood (liver encephalopathy), eventually occur, leading to death.
Among the many causes of liver failure that bring patients to transplant surgery are:
  • Progressive hepatitis (mostly due to virus infection) accounts for more than a third.
  • Alcohol damage brings in about 20%
  • Scarring or abnormality of the biliary system accounts for roughly another 20%.
  • The remainder comes from selected cancers, other uncommon diseases, and a situation called fulminant liver failure.
National Transplant Waiting List By Organ Type (June 2000)
Organ Needed Number Waiting
Kidney 48,349
Liver 15,987
Heart 4,139
Lung 3,695
Kidney-Pancreas 2,437
Pancreas 942
Heart-Lung 212
Intestine 137
Fulminant liver failure most commonly happens during acute viral hepatitis, but it is also the result of mushroom poisoning by Amanita phalloides and toxic reactions to some medicines, like an overdose of acetaminophen. This is a special category of candidates for liver transplant because of the speed of their disease and the immediate need of treatment.
The first human liver transplant was performed in 1963, and since then, thousands of liver transplants are done every year. Since the introduction of of cyclosporine (a drug that suppresses the immune response that rejects the donor organ), success rates for liver transplantation have reached 85%.

Precautions

Patients with advanced heart and lung disease, who are HIV positive, and who abuse drugs and alcohol are poor candidates for liver tranplantation. Their ability to survive the surgery and the difficult recovery period, as well as their longterm prognosis, is hindered by their conditions.

Description

There are three types of liver transplantation methods. They include:
  • Orthotopic transplantation is the replacement of a whole diseased liver with a healthy donor liver.
  • Heterotopic transplantation is the addition of a donor liver at another site, while the diseased liver is left intact.
  • Reduced-size liver transplantation is the replacement of a whole diseased liver with a portion of a healthy donor liver. Reduced-size liver transplants are most often performed on children.
When an orthotopic transplantation is performed, a segment of the inferior vena cava attached to the liver is taken from the donor as well. The same parts are removed from the recipient and replaced by connecting the inferior vena cava, the hepatic artery, the portal vein and the bile ducts.
When there is a possibility that the afflicted liver may recover, a heterotopic tranplantation is performed. The donor liver is placed in a different site, but it still has to have the same connections. It is usually attached very near the original liver, and if the original liver recovers, the donor shrivels away. If the original liver does not recover, it will shrivel, leaving the donor in place.
Reduced-size liver transplantation tranplants part of a donor liver into a patient. It is possible to divide the liver into eight pieces, each supplied by a different set of blood vessels. Two of these pieces have been enough to save a patient in liver failure, especially if the patient is a child. It is therefore possible to transplant one liver into at least two patients and to transplant part of a liver from a living donor and have both donor and recipient survive. Liver tissue grows to accommodate its job so long as there is initially enough of the organ to use. Patients have survived with only 15-20% of their original liver, provided that 15-20% was healthy.
Availability of organs for transplant is a current crisis in the transplantation business. In October 1997, a national distribution system was established that gives priority to the sickest patients closest in location to the donor liver, but makes livers available nationally. It is now possible to preserve a liver out of the body for 10-20 hours by flushing it with cooled solutions of special chemicals and nutrients, so it can be transported across the country.

Preparation

Before transplantation takes place, the patient is first determined to be a good candidate for transplantation by going through rigorous medical examination. A suitable candidate boosts their nutritional intake in order to ensure that they are as healthy as possible before surgery. Drugs are administered that will decrease rejection after surgery. Consultation with the patient, as well as any family, is conducted to explain the surgery and its complications. Psychological counciling is recommended.

Aftercare

In order to prevent organ rejection, immunosuppressive drugs will be taken. Hospitalization ranges from four weeks to five months, depending on the rate of recovery.
Successfully receiving a transplanted liver is only the beginning of a life-long process. Patients with transplanted livers have to stay on immunosuppressant drugs for the rest of their lives to prevent organ rejection. Although many can reduce the dosage after the initial few months, virtually none can discontinue drugs altogether. Prednisone, azathioprine, and tacrolimus are often combined with cyclosporine for better results. Newer immunosuppressive agents are coming that promise even better results. In spite of immunosuppressants, rejection occurs most of the time and requires additional medication. In some cases it cannot be reversed, and retransplantation becomes necessary.

Risks

Early failure of the transplant occurs once in four surgeries and has to be repeated. Some transplants never work, some succumb to infection, and some suffer immune rejection. Primary failure is apparent within one or two days. Infections happen in half the patients and often appear during the first week. Rejection usually starts at the end of the first week. The surgery itself may need revision because of narrowing, leaking, or blood clots at the connections.
There are potential social and economic problems, psychological problems, and a vast array of possible medical and surgical complications. Close medical surveillance must continue for the rest of the patient's life. Infections are a constant risk while on immunosuppressive agents, because the immune system is supposed to prevent them. A way has not yet been devised to control rejection without hampering immune defenses against infections. Not only do ordinary infections pose a threat, but because of the impaired immunity, transplant patients are susceptible to the same "opportunistic" infections that threaten AIDS patients—pneumocystis pneumonia, herpes and cytomegalovirus infections, fungi, and a host of bacteria.
Immunosuppression also hinders the body's ability to resist cancer. All the drugs used to prevent rejection increase the risk of leukemias and lymphomas.
There is also a risk of the original disease returning. Hepatitis virus still inhabits the patient, as does the urge to drink alcohol. Newer antiviral drugs hold out promise for dealing with hepatitis, and Alcoholics Anonymous (AA) is the most effective treatment known for alcoholism.
Drug reactions are also a continuing threat. Every drug used to suppress the immune system has potential problems.

Resources

Organizations

American Liver Foundation. 1425 Pompton Ave., Cedar Grove, NJ 07009. (800) 223-0179. http://www.liverfoundation.org.

Key terms

Acetaminophen — A common pain reliever (Tylenol).
Antigen — Any chemical that provokes an immune response.
Bile ducts — Tubes carrying bile from the liver to the intestines.
Biliary system — The tree of tubes that carries bile.
Hepatic artery — The blood vessel supplying arterial blood to the liver.
Inferior vena cava — The biggest vein in the body, returning blood to the heart from the lower half of the body.
Leukemia — A cancer of the white blood cells.
Lymphoma — A cancer of lymphatic tissue.
Portal vein — The blood vessel carrying venous blood from the abdominal organs to the liver.

liver transplantation

a treatment for end-stage hepatic dysfunction in which a donor liver is matched in size and blood group to the recipient. The transplanted organ may be introduced as an auxiliary liver or as a total replacement. The procedure requires five anastomoses and many units of blood. Because of a shortage of child-size livers, pediatric transplants often are performed with a segment of an adult liver. Common postoperative complications include acute graft rejection, infection, hepatic complications (bile leakage, abscess formation, hepatic thrombosis), acute renal failure, giant emphysematous blebs, and fungal infections.

liver transplantation

Surgical implantation of a donor liver into a patient with end-stage liver disease. The disease may be caused by alcoholic cirrhosis, chronic cholestatic diseases, chronic or fulminant hepatitis, or toxic liver destruction. Immunosuppressive drugs (such as cyclosporine) must be taken after the procedure to prevent rejection of the grafted organ. With optimal care, about 75% of grafted livers remain functional after 1 yr. Patients with HIV or uncontrolled systemic infections, metastatic cancer, active alcoholism, or other severe cardiac, pulmonary, or neurological illnesses are not candidates for the procedure. In the U.S. about 4000 liver transplants are performed annually.
See also: transplantation

Patient discussion about liver transplantation

Q. I would like to know what it takes to get on a liver transplant list.. I have been diagnosed with cirrhosis of the liver. I have been clean and sober now over 2 years... I have also been hospitalized more times than i don't like talking about but I have been admitted for high amounts of ammonia levels, low blood pressure, and dehydration

A. Thank you for your answer. At my next GI appointment, the doctors told me that to have someone else that i'd like to be there at which time he will explain it all to me and either my brother or sister because i've have been admitted so many times because of ammonia levels, my brain has hardly no memory left. Let's all with this disease stick together.

More discussions about liver transplantation
References in periodicals archive ?
Vascular complications after orthoptic liver transplantation.
The National Institutes of Health is funding a multi-center study on the safety and efficacy of kidney and liver transplantation in HIV-positive people.
Furthermore, a 1996 NIH workshop on OLT for patients with ALD concluded that liver transplantation provides a good outcome in alcoholic patients and that relapse rates after OLT were lower if the patients had successfully completed conventional alcohol rehabilitation programs prior to OLT (Hoofnagle et al.
18) However, as Perri et al (26) pointed out, a novel approach is needed because the current treatment efforts have yielded such poor results after reviewing all the GVHD cases after liver transplantation.
Transjugular intrahepatic portosystemic stent-shunt (TIPSS) insertion as a prelude to orthotopic liver transplantation in patients with severe portal hypertension.
Results published in a recent issue of Liver Transplantation, a journal of the American Association for the Study of Liver Diseases (AASLD), suggest that the antioxidant N-acetylcysteine (NAC), when injected prior to harvesting of the liver, significantly improves graft survival and complication rates following transplantation even when a suboptimal organ is used.
In addition, researchers found that continued alcohol abuse following liver transplantation decreases the survival graft survival, further highlighting the importance of preventing alcohol relapse.
Kristian Enestvedt, MD, FACS; and their team observed that obese patients experienced the same risk of dying after liver transplantation as normal weight patients.
CONCLUSION : THE NEW TECHNOLOGY CAN BE RECOMMENDED AS A "BRIDGE" THERAPY PRIOR TO LIVER TRANSPLANTATION.
Becker, a specialist in Liver Transplantation Surgery was signed here on Wednesday to start Liver Transplantation Surgery at GIMS within two months.
Bishkek hosted discussions on May 13 on possibility of carrying out liver transplantation surgeries in the Kyrgyz Republic with the participation of doctors from India.
This new centre will have capacity of 30 patients and will provide the facility of liver transplantation of two patients at a time.