Liver transplantation is a surgical procedure whereby a failing liver is removed and replaced by a new liver from a donor.
Description
Liver transplantation is a process when, the surgeon removes the damaged liver of the patient and replaces it with a healthy one. This process encourages and promote the growth of new and healthy liver cells. This 2nd type of transplant is sometimes called a split-liver transplant.
The recovery time varies but generally takes around 3 months. Thereafter, most recipients can lead a normal and active life, though most will require drugs for the remainder of their life to prevent the body's immune system from rejecting the new liver.
- storing fuel for the body in the form of glycogen which is made from sugars such as glucose. When glucose is required by body cells, the liver breaks down glycogen, releasing glucose into the bloodstream.
- processing fats and proteins obtained from food.
- the production of clotting factors. These are proteins which enable blood to clot.
- the safe processing and removal of alcohol.
- the safe processing of many poisons and toxins from the body.
- the processing of many medicines.
- the production of bile which is used to aid fat digestion in the gut.
- the production of plasma proteins (mainly albumin) which are essential for fluid regulation within blood and the circulatory system.
- the storage of elements and vitamins such as Vitamins A, D, E, K and iron.
- the production of some antibodies to aid natural immunity.
A normal and healthy liver has a large reserve. It can recover and repair itself from many conditions such as infections, the effects of drugs, alcohol and other toxins and trauma. However, when this reserve is stretched too far from disease or exposure to toxins, the liver gradually starts to fail as normal liver cells are destroyed. The liver may go through stages of damage from a reversible fatty change, to hepatitis (inflammation of the liver), to cirrhosis (an irreversible scarring of the liver) to cancer.
At most stages of these liver changes, other treatments are available and will generally be considered before transplantation. Therefore, a liver transplant will only be considered if these treatments are no longer effective or if liver damage is too advanced or irreversible and is a risk to life. The exact timing and decision to undergo transplantation is a complex one, requiring the opinion of liver specialists and transplant surgeons. Some factors which may influence a decision include;
- the general health of the patient other than their liver disease,
- the age, shape and size of the patient,
- the patients mental and emotional state,
- the presence of cancer in other organs,
- the presence of infections, especially infections such as HIV,
- the availability of organs for transplant.
The assessment of the patient involves many tests such as blood tests, infection screens, x-rays, ultrasound scans, other types of scans such as CT or MRI and liver biopsies. This assessment will usually necessitate a hospital stay. In the UK and other EC countries, if a transplant is deemed necessary the patient is placed on a waiting list for a suitable donor. This wait may be as little as a few hours but may last several years. A suitable liver will be one which is matched to the recipient by blood grouping and by the shape and size of the donor. The recipient must be available to receive the donor liver within only a few hours since generally organs can be kept for approximately 20 hours after the removal from the donor.
The surgery itself is done under general anaesthetic. Once the patient is asleep 2 or 3 drainage tubes are inserted around the liver to drain excess blood and fluid during the operation. An incision along the patient's upper abdomen, just below the ribs, is made through which the diseased liver is removed. The new donor liver is then placed in the upper abdomen and "plumbed in" by connecting the arteries and veins that take blood to and from the liver. The bile ducts are also connected. The whole procedure takes approximately 6-10 hours. The recipient will then spend approximately 2 days in intensive care following surgery. Providing all is well the recipient will then be moved to a less intensive ward with a total stay in hospital of approximately 3 weeks. However, during this time the patient is closely monitored for signs of infection or rejection by the immune system.
The results of this procedure have been improving with time. Currently, there is a 90% one year survival rate. Most problems arise within the first 3 months of transplantation from either infection or rejection of the new liver by the body's immune system. Drugs called immunosuppressants are required for the rest of the patient's life to weaken the immune system and therefore to prevent possible rejection. However, as an effect of weakening the immune system the recipient is at higher risk of developing infections. It is possible to reduce the dose of these immunosuppressants over time.
Unfortunately, despite the use of immunosuppressant drugs chronic rejection of the liver may occur. In this instance other drugs may be required but often a second transplant is the only solution. Very occasionally the transplanted liver fails to function completely. A second transplant is again the only solution.
Liver transplantation for UK citizens only
For UK citizens a referral to a dedicated liver unit is usually made when a serious liver condition is diagnosed. A decision on transplantation is then taken in the way described above. If a transplant is deemed necessary the patient is entered into the liver transplant waiting list which is held by the National Health Service ("NHS") at certain centres in the UK. Although the actual transplantation procedure is therefore not done privately, the process of assessment may be done by the NHS or by the private sector. The actual surgery and recovery is as described above.
Liver transplantation for non-UK citizens
In the UK most whole livers from deceased donors are transplanted into those patients on the NHS waiting list. Therefore recipients are generally UK or EC citizens. However, if a donor liver becomes available but no suitable patient from the waiting list is found then it may be offered to non-UK or non-EC citizens.
In the case of donation by a living donor, the donor is usually a healthy family member who has the same blood group as the patient. The donor must be aged 21 years or more and should have no liver disease or any other chronic medical problems. The living donor has a portion of their healthy liver removed for transplantation to the recipient. Clearly this entails a surgical procedure for the donor also and the risks of this need to be discussed with the donor in person by the transplant team. The advantage of having a transplant from a living donor is that providing the donor is otherwise suitable, a date for surgery can be agreed at a time that is convenient to all parties. This is done in the UK in the private sector. Generally at the initial consultation as many results from any assessments done in the patient's home country as possible should be brought to the UK. Specifically, results of blood grouping tests for both donor and recipient should be available.
A normal and healthy liver has a large reserve. It can recover and repair itself from many conditions such as infections, the effects of drugs, alcohol and other toxins and trauma. However, when this reserve is stretched too far from disease or exposure to toxins, the liver gradually starts to fail as normal liver cells are destroyed. The liver may go through stages of damage from a reversible fatty change, to hepatitis (inflammation of the liver), to cirrhosis (an irreversible scarring of the liver) to cancer.
At most stages of these liver changes, other treatments are available and will generally be considered before transplantation. Therefore, a liver transplant will only be considered if these treatments are no longer effective or if liver damage is too advanced or irreversible and is a risk to life. The exact timing and decision to undergo transplantation is a complex one, requiring the opinion of liver specialists and transplant surgeons. Some factors which may influence a decision include;
- the general health of the patient other than their liver disease,
- the age, shape and size of the patient,
- the patients mental and emotional state,
- the presence of cancer in other organs,
- the presence of infections, especially infections such as HIV,
- the availability of organs for transplant.
The assessment of the patient involves many tests such as blood tests, infection screens, x-rays, ultrasound scans, other types of scans such as CT or MRI and liver biopsies. This assessment will usually necessitate a hospital stay. In the UK and other EC countries, if a transplant is deemed necessary the patient is placed on a waiting list for a suitable donor. This wait may be as little as a few hours but may last several years. A suitable liver will be one which is matched to the recipient by blood grouping and by the shape and size of the donor. The recipient must be available to receive the donor liver within only a few hours since generally organs can be kept for approximately 20 hours after the removal from the donor.
The surgery itself is done under general anaesthetic. Once the patient is asleep 2 or 3 drainage tubes are inserted around the liver to drain excess blood and fluid during the operation. An incision along the patient's upper abdomen, just below the ribs, is made through which the diseased liver is removed. The new donor liver is then placed in the upper abdomen and "plumbed in" by connecting the arteries and veins that take blood to and from the liver. The bile ducts are also connected. The whole procedure takes approximately 6-10 hours. The recipient will then spend approximately 2 days in intensive care following surgery. Providing all is well the recipient will then be moved to a less intensive ward with a total stay in hospital of approximately 3 weeks. However, during this time the patient is closely monitored for signs of infection or rejection by the immune system.
The results of this procedure have been improving with time. Currently, there is a 90% one year survival rate. Most problems arise within the first 3 months of transplantation from either infection or rejection of the new liver by the body's immune system. Drugs called immunosuppressants are required for the rest of the patient's life to weaken the immune system and therefore to prevent possible rejection. However, as an effect of weakening the immune system the recipient is at higher risk of developing infections. It is possible to reduce the dose of these immunosuppressants over time.
Unfortunately, despite the use of immunosuppressant drugs chronic rejection of the liver may occur. In this instance other drugs may be required but often a second transplant is the only solution. Very occasionally the transplanted liver fails to function completely. A second transplant is again the only solution.
Price Range for Liver Transplant in India ($): 63000 - 77000
Estimated UK Price for comparison ($): $450000
Percentage Saving India to UK: 84%
The Transplant Team
Having a liver transplant is a huge undertaking. It involves a large team of professionals who are involved from the outset. Liver patients will meet various members of the team at different times during the assessment period. The exact structure of the team will vary from centre to centre, as different hospitals and clinics organise things slightly differently. Some of the team members in a typical team are listed below:
1. TRANSPLANT CO-ORDINATOR
This individual is responsible for all aspects of organising the transplant, waiting lists and co-ordinating the process if a donor is found. This person is therefore your first point of contact for matters concerning the waiting list and transplant operation. The transplant co-ordinator will be responsible for making sure you have all the educational tools you need. He/she will also have a major role in caring for any living donors, arranging their assessments and will be their first point of call too. In short, this very important member of the team is responsible for supporting both recipient and donor throughout the whole transplant process.
2. TRANSPLANT SURGEON
Generally, it is the surgeon who heads the team and ultimately decides that a transplant is required; the timing of the operation (subject to waiting lists); is responsible for making sure all parties understand the operation, risks involved and complications that may arise and actually performs the operation. There are usually 2 transplant surgeons involved at any given operation. One removes the liver from either a live or deceased donor while the other transplants the liver into the recipient.
3. SPECIALIST PHYSICIAN (HEPATOLOGIST)
Most patients are initially cared for by doctors who specialise in diseases of the liver. The Hepatologist may suggest several treatments such as medicines and drugs. A transplant will only be considered if all other measures fail or if the patient has a rapidly progressing liver condition which will not respond to medical measures. Even after this stage, the Hepatologist will be important in deciding how the new liver is functioning and whether the patient and donor have any other medical needs.
4. ANAESTHETIST
This highly specialised doctor is responsible for your well-being throughout the operation. He/she will administer the local and general anaesthetic, monitor your vital signs through surgery and ensure that you wake up after the surgery is complete. Thereafter, it is generally anaesthetists who are in charge of ITU wards. They will ensure that your pain is controlled during this critical recovery period.
5. PSYCHIATRIST
This is a doctor who specialises in mental health. As having a transplant and even more so, donating a portion of your liver, are such emotive subjects and the process is so physically and psychologically demanding, it is the responsibility of the psychiatrist to ensure that the donor and recipient have the insight and knowledge required to make a sound and informed decision. The psychiatrist must also ensure that there is no coercion of either party in making a decision and finally that there are no mental health grounds for suspending the transplant process at any point. Only after this process is complete can a transplant proceed.
6. RADIOLOGIST AND OTHER SPECIALIST DOCTORS
As preparation for transplantation requires several different tests, scans and investigations for both recipient and donor, several other specialists may be involved in the assessment period. After the transplantation has taken place, further monitoring of the liver will of course be required. Chief among these specialists is the radiologist who will most likely be in charge of ultrasound scans, CT and MRI scans and X-rays as required.
7. NURSE
There will be many nurses responsible for many aspects of your care. These range from helping you with aspects of the many tests, investigations and scans that you will need in the assessment phase, to preparing you for the operation and looking after you after you return from theatre to the ward.
8. SOCIAL WORKER
The role of this team member is very varied and depends on place to place. In the UK for example the social worker will generally have many roles. They will discuss with donors the reasons for donating parts of their liver and will discuss the social and emotional issues surrounding donation and transplantation. In addition, they will be able to offer practical advice concerning financial matters, the claiming of benefits and other social issues.
9. PHYSIOTHERAPIST
This member of the team is responsible for many aspects of the rehabilitation process after surgery. Physiotherapy will help in early mobilisation and aid in reducing many potential post operative complications in both recipient and donor. This will hopefully reduce the recovery period and ensure early discharge from hospital.
10. OCCUPATIONAL THERAPIST
This member of the team along with the physiotherapist is responsible for the practical aspects of rehabilitation. Examples of this involve any activity related to self caring (activities of daily living).
11. DIETICIAN
Having undergone such major surgery both the recipient and donor will have specific dietary needs. This applies both in the immediate post operative recovery period and especially for the recipient will also apply over the longer term. This is because chronic liver disease causes many body wide problems. Symptoms such as abnormal weight loss are common. It is therefore not unusual for both recipient and donor to meet a dietician while in hospital.
12. INDEPENDENT ASSESSOR
This person or group of people are not members of the transplant team. In fact it is vital that they are free and independent from the team and have therefore no vested interest in the transplant process. However, legally in many countries a transplantation operation can not proceed without the consent of the independent assessor. The role of this person is to ensure that all procedures and protocols surrounding the recipient and donor are strictly adhered to. They will generally discuss the relevant issues with both parties to ensure that informed consent has been given, fairly, freely and without coercion.
Cadaveric Liver Transplantation
In a cadaveric liver transplantation, a whole liver is harvested from a cadaver (a deceased individual). This person may have been a victim of an accident or brain injury. His/her heart is kept beating and breathing is maintained artificially by a respirator but the donor is “brain dead”. This term applies to people who have total and permanent brain damage and who therefore cannot survive. They are therefore “legally dead”. But their other organs survive as oxygen is delivered to them through their own circulation using the respirator.
Providing the patient has previously applied to donor register (or has consented to organ donation in another way) or his/her family give consent, several organs and tissues such as liver, kidneys and others can be harvested and used for other sick patients. The donor is kept in ITU until he/she is taken to theatre for the organs to be collected.
When such organs become available, the donor blood is typed and hopefully, a suitable candidate for liver transplantation is found near the top of the waiting list locally. If a candidate is found further afield, the organ is transported by road or plane providing it can be received by a transplant centre near to the intended recipient. Livers can survive for around 20 hours before being transplanted. The selection criteria for recipients are discussed in detail on the page entitled “Liver Transplantation”. However, age, sex and race of either the donor or the recipient are not taken into account.
In the UK and many other countries, the identity and circumstances of death of the deceased donor are kept confidential.
For more than 30 years, cadaveric livers have been used successfully for transplants. Until 1989, this was the only way for a patient with liver failure to receive a donor liver. However, over the past few years, living donor liver transplantation has become increasingly successful and gets round the uncertainty of waiting times for a liver from a cadaver. Problems with cadaveric liver transplantation include;
limited supply of donor livers as someone else has to unfortunately die before a liver can be made available,
- uncertainty about timing of the transplant operation as there is no way to pre-empt or predict when a liver may become available,
- problems with transporting the donated liver to a transplant centre near to the intended recipient,
- getting the whole team together at short notice for the operation to occur. This however can be co-ordinated such that the organ is removed from the donor only when the receiving unit is ready to accept it.
- because of national waiting lists for transplants and the distances involved in international travel, cadaveric liver transplantation is generally unsuitable for patients looking to have surgery abroad.
- A fuller description of the operation, recovery and other details regarding the liver transplant itself can be found on the page entitled Liver Transplantation.
- Living Donor Liver Transplantation
- Living donor liver transplantation was first carried out in Japan in 1989. It was initially used for adult to child donations but over recent years, has been successfully used for adult to adult transplantations also. This procedure is also sometimes known as Split-Liver Transplantation.
In this procedure, patients with liver failure receive a segment of liver from a spouse, blood relative or close friend. In some countries, even strangers may donate part of their liver, though the laws governing who can and who cannot donate vary in different countries. The living donor must be healthy and free from any diseases and infections before any consideration can be given to donate. As a result, the donor will go through a rigorous series of tests and evaluations including physical, psychological and psychiatric, well in advance of any surgery. At each stage, the process can only begin if the donor freely consents to the process. Naturally, the donor can withdraw his/her consent at any time, halting the process. The process can also be halted by any member of the transplant team, should they feel that there has been any undue coercion in obtaining the donor’s consent (this includes financial as payment for donations of organs is forbidden in most countries) or the donor has a medical problem which unacceptably increases their chances of a serious complication during or after surgery.
Nevertheless, donating any organ, especially a part of your own liver to help save a relative or friend is a major undertaking. Risks of such a complex operation should not be underestimated by the donor, his/her family or by the recipient. Further information regarding liver donation and other advice for potential donors can be found by reading the page entitled “Guidance for Liver Donors”.
THE HISTORY BEHIND LIVING DONOR LIVER TRANSPLANTATION
In the past, such living donations were always deemed too difficult medically as there was a fear of rejection of the transplanted organ from non-related individuals. It was also deemed to be unethical. However, over the past 10 or so years, this situation has changed considerably. In fact, there are now more living donations than cadaveric. The reasons for this are straightforward;
there are just not enough organ donors to meet the ever increasing demand for organs, especially livers. Living donors can be used to offset this shortage to some degree.
- more effective anti-rejection drugs are now used to prevent the recipient’s immune system attacking the donated liver. Livers which are not matched genetically can therefore be transplanted.
- the whole attitude to what is possible in transplant surgery has now changed. These days, more patients are traveling abroad for all types of surgery compared to even 5 years ago. This includes transplant surgery as it may be too expensive where you live or may not be available at all.
The shortage of livers for transplants is however set to increase. One of the key reasons for this is the rise in prevalence of the Hepatitis C virus. In a minority of cases, this will lead to liver failure. But across the world, this minority still numbers many tens of thousands of patients. Once the liver fails, it becomes increasing difficult to support the sick patient. Unlike patients of severe kidney disease who can be maintained indefinitely by kidney dialysis machines, no such options exist for liver disease victims. As their condition deteriorates, other organs start to fail also, thereby compounding the problem.
Unfortunately, many patients still die while on waiting lists around the world due to there being no suitable liver for them. If however a living donor can be found, who is willing to donate a portion of their liver and who can be matched to the patient, then the number of deaths of patients waiting on these lists can be decreased.
THE OPERATION
The details of the operation, recovery and the risks of transplantation are discussed in more detail on the page entitled “Liver Transplantation”. However, a few specific details about the operation for living donor liver transplantation are discussed here.
In cadaveric transplantations, recipients have their own failing liver removed completely at the beginning of the operation. A whole liver from a deceased individual is removed and implanted into the recipient. It is then connected to the blood circulation and the biliary system in exactly the same way as their own failed liver had been previously.
But in living donor liver transplantations, the old liver is completely removed and replaced with a portion of healthy liver from the donor. Approximately half of the liver from the living donor (usually the right lobe which is the larger of the two lobes) is removed and re-connected into the recipient. Remarkably, in both the donor and recipient, their “half” of the liver is able to fully regenerate into a full liver within only a period of 8-12 weeks. If all goes well, both donor and recipient can then live full and normal lives’.
2 separate surgical teams operate in adjoining or nearby theatres, so that once the lobe of liver has been removed, it can be re-connected into the recipient quickly. Thereafter, the process of recovery is similar for both and is summarised on the page entitled “Liver Transplantation”.
ADVANTAGES OF LIVING DONOR LIVER TRANSPLANTATION
Living donor liver transplantation has clear advantages over cadaveric liver transplantation.
1. Elective surgery: the fact that the donor is alive and well means that the transplant team can carefully plan the timing and location of the surgery. It is therefore not an emergency operation. As a result, the complication rate is reduced for the recipient. If on the day of surgery, the recipient or donor is unwell in any way, surgery can be postponed to another day.
2. Liver transplantation can be considered for many more people since the number of available livers increases as more living donors come forward to be considered for donation.
3. Patients can access transplantation from anywhere in the world. If transplantation surgery is not available locally, they and their living donor can travel to any other country where such services do exist.
4. Preservation time (the time the liver is without blood and therefore oxygen): this time is minimal for living donations and may be only a few minutes. In cadaveric donations, this can be many hours.
5. Quality of the liver: as the donor is screened extensively over a period of several weeks, it is safe to assume that the donor is fit and healthy. It can therefore be assumed that their liver will be in good shape. This level of insight is generally not possible with cadaveric donations as few tests can be done in the limited time available before organs are harvested.
The key disadvantage of living donor liver transplantation is clearly the effect it has on the donor. The donor of course endures a major operation, faces the prospects of possible complications and must take time away from their family and work in order to have the pre-operative evaluations, surgery and then go through the recovery period. Further information about the donor can be obtained by reading the page entitled A Guide For Living Donors.
Living With Your Liver Transplant
Once the recipient has had a liver transplant, it is imperative that he/she looks after this new liver. Advice on all aspects of lifestyle and living are therefore very important. These measures may ensure that their liver functions fully and properly and that as a result the recipient leads a healthy and full life.
Some of the most important aspects of daily living are discussed below:
1. DIET
By definition patients who have had a liver transplant have previously had severe liver failure. They will most likely have been unwell for a lengthy period of time preceding their transplant. Therefore there may be many nutritional problems that have built up over this time. Examples of this include deficiencies in vitamins, minerals and calories resulting in weight loss and other problems. It is therefore likely that the recipient will be advised by a dietician after the transplant.
Generally there are very few restrictions to dietary intake, though a healthy diet which is balanced and nutritious will be recommended. A healthy diet may entail a reduction in fat and sugar and should be high in fibre. The dietician may be able to help the recipient in creating a diet or meal plan.
It is recommended by some specialists that recipients should avoid eating food containing listeria for the first 3 months after transplantation. Listeria is a bacterial infection that may cause significant complications for recipients as they will be taking anti-rejection medication at this time. Typically foods containing listeria can include raw eggs, soft cheeses, seafood, mayonnaise, live yogurt, pate and unpasteurised milk.
It is thought that liver disease increases the likelihood of patients developing osteoporosis (thinning of the bones). This is caused by a decrease in absorption of Vitamin D. This essential vitamin is required for normal bone mass development. As a result, patients with liver disease may be at higher risk of developing bone fractures. To counteract this risk, recipients will be advised to increase their calcium and Vitamin D dietary intake. Examples of foods containing a good source of calcium include milk, cheese and canned sardines/salmon.
2. ALCOHOL
Drinking alcohol is not recommended for the first few months after transplantation. In those patients who have had alcohol related liver disease leading to liver transplantation, it is imperative that total abstinence from alcohol be advised. In short, these patients should not drink any alcohol. However, in other liver patients, over the longer term it is essential that they drink alcohol sensibly and in moderation. Binge drinking will always be discouraged. Many countries have national guidelines for alcohol intake and these should not be exceeded.
3. SMOKING
Most individuals are aware that smoking is detrimental to all aspects of health. This is especially so for patients who have received a liver transplant as they will be taking anti-rejection medication. These drugs reduce the efficiency of the immune system. Smoking is responsible for many infections, delayed recovery from infections and the development of cancers. Therefore transplant patients are particularly susceptible to the harmful effects of smoking.
In addition to the above points it is also thought that smoking delays wound healing. As liver transplantation is a major operation requiring a large incision, immediate post operative recovery can also be delayed.
Smoking will therefore always be discouraged and smoking cessation advice should be available from your doctor.
4. EXERCISE
Exercise is an important issue for everyone. This is especially so for victims of chronic liver disease. The likelihood is that after such an illness, the patient will be weak, will have lost weight and will have a degree of muscle wasting. It is therefore with a proper diet and a gradual resumption of exercise only that these changes can be reversed.
Exercise can also benefit the transplant patient in several other ways. It is known to reduce stress and anxiety symptoms, help achieve a normal sleep pattern, increase energy levels through the day and improve digestive function. Improved digestion will help liver transplant patients further by allowing a better dietary intake.
However, it must be remembered by all individuals who have not exercised recently, that their ability to exercise and general fitness levels will be much lower than they’re perhaps previously used to. Therefore, it is important that they start a gradual exercise plan, before slowly and carefully building up. This will reduce the likelihood of exercise induced injuries and strains.
As a rough guide, do not lift more than 6-7kg (15lbs) in weight or participate in sit-ups for 2 months. Avoid swimming for approximately 3 months.
5. DRIVING
It is generally recommended that recipients of liver transplantation wait 3 months before starting to drive again. However, this is a rough approximation as countries will have very different laws governing who can drive and when. In the UK for example, all aspects of licensing as regards driving are regulated by the DVLA. Drivers in the UK must notify the DVLA of their illness and operation. Insurance companies should also be notified.
6. RETURN TO WORK
The issues regarding work can vary greatly with the type of work you do, which country you live in and what type of benefits are available to you. As a generalisation, most recipients are advised to have around 6 months off work. Clearly it will be important to notify your employer regarding your health status and intended time off work.
Those will light duties or desk jobs may wish to return sooner whereas those with heavier or manual jobs may take longer.
7. SEX
There are no time constraints for sexual activity after transplantation. Most patients will resume sexual activity when they feel comfortable and confident enough. This may take a few weeks or several months and very much depends on the individual patient and also their partners. Other factors which may hinder sexual activity include the drugs that recipients will be taking such as anti-rejection medication. These can reduce sexual desire as well as sexual function.
However, if engaging in casual sex, it is strongly advised that adequate protection is used to prevent contraction of sexually transmitted infections. Examples include hepatitis B and C, HIV, syphilis, chlamydia and gonorrhoea.
It also strongly advised that all female recipients of child bearing age use adequate contraception for at least 1 year before conceiving.
8. SKIN CARE
As with many aspects of this page, this advice applies to everyone but is particularly relevant to transplant patients. It is vital that all recipients protect their skin from excessive sun exposure. The anti-rejection drugs that recipients take increases the risk of them developing skin or lip cancer compared to the general population. This is because taking these immunosuppressants interferes with the body’s ability to fight the development of abnormal cells which may lead to cancer. Recipients are therefore urged to heed the following advice;
avoid the midday sun (i.e. 10am-3pm) as the harmful ultraviolet radiation will be at it’s strongest then,
- cover up as much of your skin as possible by wearing long sleeved clothing and trousers, as well as a wide brimmed hat when outdoors.
- use high factor sun block lotions and lip balm when outdoors. Always remember to re-apply regularly, especially if swimming.
- 9. HAIR CARE
- The condition of your hair can also be affected both by liver disease and by medication such as steroid drugs. Hair may become brittle and fragile. Scalp hair loss also becomes more likely. Hair dyes, bleaches and other hair chemicals can increase the damage to hair at this time. It is therefore recommended that recipients wait until they are on lower doses of steroids or until they manage to stop the steroids completely before using these hair products. Good hair care is therefore strongly advised by for example using conditioners.
- Conversely, transplant patients may find that they begin to develop excess facial and body hair. This again can be as a result of medication. Hair removal creams may be useful but further advice can be sought from your doctor. Patients must never reduce or stop their medication without consulting a doctor.
- 10. EYE CARE
- Regular 6 monthly eye tests are recommended for liver transplant patients. This should involve screening for cataracts and glaucoma as these conditions can occur with medication. Visual acuity can also change during the first 6 months after transplantation surgery.
- 11. DENTAL CARE
- Recipients are usually advised to inform their dentist about their liver disease and especially about transplantation. It is also advisable for recipients to have a 6 monthly dental assessment. Antibiotics are routinely given to transplant patients before and during any dental surgery such as tooth extractions.
- 12. SLEEP PATTERN
- Recipients of liver transplants frequent have some degree of sleep disturbance. This may be an inability to drift off to sleep (initial insomnia) or they may wake up regularly through the night. The causes for this may include being in hospital on a noisy hospital ward and the stresses and anxieties which inevitably are present with transplant surgery. However, once patients go home, a normal and regular sleep cycle tends to return within a few weeks. Sleeping tablets are usually not required.
- 13. ANXIETY AND DEPRESSION
- The complexities and seriousness of both liver failure and transplantation surgery are discussed elsewhere in this guide. But not surprisingly, emotional and psychological symptoms can develop as a result. Patients may worry about their health, finding a liver donor, the surgery itself, the lengthy recovery process, the possibility of complications and death, the impact on their families and financial prospects.
- Anxiety and depressive symptoms are therefore common amongst this group of individuals. They are advised to discuss any of these issues with their doctor, transplant co-ordinator or counsellor.
- 14. PREGNANCY
- Women who have liver transplantation can go on to have children. But they are usually advised to wait at least 1 year after surgery before they start trying to conceive. Adequate contraception must therefore be used. However, the combined oral contraceptive pill is usually not advised in this instance. For further information regarding this, women are advised to discuss this with their hepatologist or obstetrician.
- 15. OTHER WOMEN’S HEALTH ISSUES
- Immunosuppressant medication can increase the risk of developing cancer. This occurs as these drugs reduce the efficiency of the immune system, thereby allowing abnormal cells which otherwise may have been destroyed, the chance to develop into cancers. Women are therefore asked to have regular cervical smears (Pap smears) and carry out regular breast self-examination. Any masses or other symptoms must be reported immediately to a doctor.
- 16. VACCINATIONS
- Vaccines are given to people of all ages from birth to old age. Some are part of national immunisation schedules whilst others are given for travel or occupational reasons. However, after liver transplantation, live vaccines should not be given or accepted by patients. Attenuated (or killed) vaccines are permitted. The following are some examples of those vaccines which are and are not permitted.
- Permitted (attenuated/killed) vaccines
- Inactivated polio (Salk)
- Influenza (flu vacc)
- Polysaccharide Typhoid (Typhum Vi)
- Pneumococcal
- Tetanus
Not permitted (Live) vaccines
- BCG
- MMR
- Oral typhoid
- Polio (Sabin)
- Smallpox
- Yellow fever
- 17. TRAVEL
- Before traveling to a malaria zone, transplant patients will need to discuss anti-malaria drugs with their hepatologist. Malaria can be a very serious infection if contracted by immunocompromised patients. Every effort should therefore be taken by recipients to avoid catching this infection.
Similarly, common sense must be exercised in trying to avoid contracting other infections such as Hepatitis A from contaminated food and water in certain countries. The risk of sexually acquired infections is also greater in certain countries.
Please also read the section on skin care and vaccinations if considering going abroad. Finally, before traveling, it is vital that liver transplant patients arrange adequate travel insurance in case of emergencies.
A Guide for Living Donors
The fact that you are even considering donating half of your liver to another is a remarkable thing. Whatever your reasons are, you may ensure that someone else lives when otherwise that person will most likely die. But, it is vital that you embark on this process for your own reasons and that you have not been coerced in any way into making a decision that you are uncomfortable with. This is important for reasons of safety as well as peace of mind for you. However, you must also bear in mind that despite your and the transplant teams best efforts, the recipient may still suffer a complication from surgery and may still die. Alternatively, patients who have hepatitis C or liver cancer can have a recurrence of liver damage after successful transplantation and may then succumb to these conditions.
In most countries, it is illegal for the donor to claim or receive a fee or be financially recompensed in any way other than for travel, accommodation and medical expenses.
WHO CAN BECOME A DONOR?
This varies from country to country as the rules that apply can be very different. But generally, certain criteria are used in deciding the suitability of a prospective donor.
These include;
in some countries, only people genetically related to the patient such as a parent, child or sibling can be considered. In addition, close personal relatives such as a spouse or friends may be considered,
- in some countries, strangers will also be considered,
- an age limit may apply for some centres. Typically, this means donors are between 18 and 55 years of age. In other countries, no such age limits apply,
- donors must not be overweight,
- donors must not have any major medical problems themselves,
- donors must not have any major psychological or psychiatric problems themselves,
- donors must be in a position to fully understand the implications of their decisions and be able to participate in the consenting process,
- donors must have a compatible blood group to the recipient,
- the reasons for your donation must be altruistic and voluntary. Donors must never feel coerced into making any decisions.
- preferably, donors should have the backing and support of their own family.
- THE ASSESSMENT
- The initial assessment will try to ensure that most of the criteria listed above are fulfilled. For example, a member of the transplant team will ensure that the you do not have any obvious medical or surgical reason for declining the donation. The same is true for psychological and psychiatric conditions. The initial assessment will also aim to provide you and your family with all the information required to either continue with the assessment phase or pull out from the whole process. It will, in addition, ensure that the transplant team is convinced that the decision to donate is being made voluntarily and freely and that you fully understand the implications of your decisions. At each stage of the assessment phase, you will be asked for your consent again. You can decline to consent and therefore stop the process of donation at any time.
- The actual process of assessment varies from centre to centre but most involve the following stages;
- 1. Stage 1
- blood tests for blood grouping,
- blood tests for infection screening for hepatitis B, C and HIV amongst others,
- the completion of a health questionnaire to identify any factors which may prevent transplantation,
- Chest X-ray,
- ECG,
- lung function tests,
- a psychiatric evaluation,
- after these tests results have been deemed normal and safe for donation purposes, you will meet other members of the team such as the anaesthetist.
- 2. Stage 2
- This stage usually involves an overnight hospital stay in order to establish the size, shape and condition of your liver. This is done by;
- ultrasound scan,
- CT or MRI scan,
- liver biopsy,
- echocardiogram.
This will further decide your suitability as a liver donor for your intended recipient.
3. Stage 3
You and your family will meet the surgeons to confirm that all is well. The transplant team must satisfy themselves that you still freely consent to the process and it is medically safe to continue. The risks to you should once again be highlighted and discussed. At this stage in many countries, the information obtained so far is sent to an independent panel or assessor. It is their duty to ensure that all procedures and protocols have been followed and it is safe to continue with the donation. Once approval is given, a date for the operation can be set.
This whole process may take as long as 3 months. It is encouraged throughout the whole assessment process that your family or next of kin accompany you to these clinic appointments so that they are also fully aware of the risks involved.
THE CONSENTING PROCESS
The key issues in consent have already been discussed above, namely, that you are fully informed and aware at each stage of the assessment and that you have not been forced into taking such measures. The process can be halted at any time by;
you, the donor,
- the transplant team,
- the recipient,
- the independent assessor or pane
- BEFORE THE OPERATION
- It is useful for you to know the following before the operation;
1. alcohol intake: you should stop drinking alcohol for 2 weeks before the operation date,
2. smoking: you will be strongly encouraged to quit smoking well before the operation. This will greatly reduce the chances of complications, especially chest infections and delayed wound healing,
3. contraception: female donors who take the oral contraceptive pill will be asked to stop taking this from 1 month before the operation. This will decrease your risk of developing a blood clot such as a DVT following surgery. Therefore, alternative contraceptive methods must be used to prevent pregnancies.
Donors are usually admitted to hospital 1-2 days before the date of transplantation. You will then usually be screened for infections again by blood and urine tests and chest X-ray. A repeat ECG may also be taken to ensure that the heart is still functioning normally. You will have regular checks of your temperature, pulse and blood pressure. If at any time, there is a suggestion of infection, the operation will be cancelled and re-scheduled for another day. The recipient undergoes the same process.
These checks are of course repeated again each time the operation is re-scheduled.
Once the donor and recipient have been cleared for the operation to proceed, the following will apply to both donor and recipient;
- from midnight before the operation, you will be “nil by mouth”, i.e. you will not be allowed to eat or drink anything,
- on the morning of surgery, you will be asked to shower and change into a theatre gown,
- you will be given surgical support stockings for your legs to help prevent blood clot formation,
- you will be asked to remove all jewellery,
- dentures and glasses will be removed in theatre,
- you will be given medication through a line in your arm or hand to help you relax,
- you may have an epidural inserted into the back. This is a tube through which local anaesthetic is given and used for pain control for approximately 2 days after the operation,
- general anaesthetic is then given and you will fall asleep for the duration of the operation,
- a tube will be inserted through the mouth and into the windpipe. This intubation tube gives the anaesthetist free access to your airways so that a ventilator can be attached,
- a small tube called a nasogastric tube is inserted through the nose and into the stomach. This tube is used to drain the stomach of all fluids and reduces the chances of vomiting,
- a catheter is inserted into the urinary bladder to drain urine,
- a line is placed into your neck or upper chest to give easy access to your circulation. This is used to administer fluids and medication,
- after the operation, you will have approximately 2 drainage tubes in your abdomen. These will drain fluids such as blood and bile from inside the abdomen into bags.
- These drainage tubes remain in place for 4-5 days before being removed.
- after the operation, you will be closely monitored for 2-3 days in an intensive care ward.
- THE OPERATION
- This is discussed in detail on the page entitled “Living Donor Liver Transplantation”.
- POSSIBLE COMPLICATIONS OF THE DONOR OPERATION
- It is vital for you and preferably your family and next of kin to fully understand and appreciate the very real risks that such major surgery inherently brings. Although serious complications are uncommon, they still occur. It is thought that around 20% of all donors will experience some complication of surgery though thankfully, the majority of these problems are minor. However, the following complications can occur;
- 1. Risks during the operation itself, including;
- heart attack,
- stroke,
- haemorrhage (bleeding)
- death – this is estimated to occur in around 0.5-1% of cases.
- 2. Risks immediately after the operation, including;
- haemorrhage: bleeding may occur as the liver has a rich blood supply.
- bile leakage: bile may leak from the cut surfaces of the liver although this usually settles by itself.
- infection: these can occur at the wound site. Chest infections or pneumonia can also occur.
- thrombosis: clots can develop in the deep veins of the leg (DVT’s). These can fragment and travel through the circulation to the lungs where serious complications can occur. This is called a Pulmonary Embolism and is potentially a fatal condition.
- liver failure: it is possible that the remainder of the donors liver fails to function properly. In this instance, the donor may also find themselves in a situation where they need a transplant to survive.
- THE RECOVERY PERIOD
- As donating half your liver is a major undertaking, your recovery will take some time. Most donors will have some pain as would be expected after any type of major operation. Transplant centres have different methods for helping patients control their pain from the use of epidurals (see above) to Patient Controlled Analgesia (PCA). PCA’s are used by some centres as a means of letting the patient control (within pre-set limits, programmed by the anaesthetist) the amount of pain killers that patient gets. This is done by connecting a pump full of pain killers which is controlled by a hand held unit. Every time the patient presses a button, a fixed dose of pain relief is administered through an intravenous line.
- It is imperative that the donor starts to mobilise as quickly as possible after the immediate post-operative phase. Physiotherapy can then begin which will help donors to mobilise further and recover quicker from the operation. Early mobilisation alone with physiotherapy, deep breathing exercises and an effective cough are also vital to help prevent a build up of secretions in the lungs. This helps to reduce the chances of developing chest complications such as pneumonia.
It may take 1-2 days for the bowels to start working again. During this time, donors are given fluids intravenously. Thereafter, bowel function begins to return slowly. At this stage, donors start drinking sips of fluids only. Gradually, as bowel function returns further, donors are allowed to eat a light diet. This process continues for a few days after surgery until a normal diet can be resumed.
The incision required to remove a portion of the liver is similar to that used to transplant the liver into the recipient. Therefore, both recipient and donor have the same large wound, located just below the rib cage in the upper abdomen. This is sometimes called a “Mercedes Incision”. Initially after surgery, the wound will have a dressing applied over the top to protect it. How the incision is closed depends on the surgeon. Some will use stitches whereas others will use staples. The wound which will be obvious at first will fade with time.
A total hospital stay of 6-10 days is expected after the operation for most donors. But clearly, this greatly depends on the speed of your recovery and on any complications that may arise. If at this time you have recovered sufficiently, you will be discharged from the hospital.
FOLLOW-UP ARRANGEMENTS
The transplant team will need to ensure that the appropriate follow-up arrangements are in place after the donor has left the hospital. The exact arrangements for follow up differ from centre to centre but a typical schedule of follow-up looks like this;
1. 1-2 weeks following discharge: you will be appointed to return to the hospital clinic. The surgeon will examine the wound and some blood tests will be taken to ensure that the liver and other organs are functioning properly.
2. 3 months following discharge: further blood tests and a scan of your liver are done. The scan is able to determine whether your remaining liver (the left lobe) has grown back and to what degree.
3. 1 year after donation: a general check up is done to assess how you are and how the donation has affected you.
4. Thereafter, many transplant centres will offer an assessment on an annual basis.
For patients and donors traveling abroad, follow up arrangements may be made either with the transplant centre (this will of course entail further journeys to get to the centre) or local specialist clinics if these are possible.
How long you remain off work depends on the nature of your work. Heavy lifting is not advised for at least 6 weeks following surgery. But clearly, this time period may be longer if you suffer from complications. In generally, you will be advised to refrain from work for around 8-12 weeks. This may of course have financial implications. You are therefore asked to take this into account before deciding on liver donation.
SOME OTHER QUESTIONS AFTER LIVER DONATION
When can the contraceptive pill be restarted?
Women are usually advised to restart the oral contraceptive pill after at least 3 months post-surgery. Adequate alternative contraceptive methods must be used during this time.
When can sexual activity restart?
There are no time limits for this. Donors can resume sexual activity whenever they feel comfortable. However, it may take several months before all sexual activities can be comfortably performed.
When can donors drive again?
Driving laws vary in different countries. It is therefore not possible to determine here how these laws will apply to each donor. To some extent, you should enquire about any restrictions that may apply locally. In the UK for examples, driving licenses and restrictions are overseen by the DVLA. Other countries will have their own equivalents. Insurance companies should also be informed.
But in general, donors will probably feel comfortable enough to drive at 6 weeks after surgery.
Can donors drink alcohol?
Donors can drink alcohol after discharge from hospital. Clearly, common sense must be exercised and all patients as well as donors must drink in moderation. There are nationally agreed guidelines on alcohol intake in the UK but not all countries will have such guidance.