Liver Transplantation
Fortunately, most people with chronic liver disease will never need a liver transplant. So why read this section? Well, all people who have chronic liver disease are at risk (which varies depending upon a multitude of factors) for the complications associated with chronic liver disease. These include cirrhosis, liver failure, liver cancer, and intolerable symptoms, such as severe itching and fatigue. If one or more of these complications occur, a person may become a candidate for a liver transplant. Therefore, all people with chronic liver disease and their family members can benefit by reading this chapter to increase their understanding of liver transplantation. Furthermore, it is important for people to be aware that liver transplantation is an accepted standard treatment option for those with liver failure and that it is a life-saving operation with a high success rate.
Only people who have the greatest likelihood of survival should undergo a liver transplant; therefore, this chapter will differentiate the good candidates for transplantation from the poor candidates. This chapter also discusses the evaluation process that leads to a person becoming listed for a liver transplant. Both general and specific (based on individual liver disorders) indications for transplantation will be reviewed. The biggest problem in the field of liver transplantation is that there is an ever increasing scarcity of available livers for donation. This issue, as well as some potential solutions to this problem, will be discussed in this chapter. This chapter will conclude with a review of post-transplant medications, post-transplant complications and what to expect after a liver transplant.
THE HISTORY AND SUCCESS RATE OF LIVER TRANSPLANTS
The first successful human-to-human liver transplant was performed by Dr. Thomas Starzl in 1968. (The first attempt at liver transplantation occurred in 1963 but was unsuccessful.) Liver transplantation is now a routinely successful operation. The high success rate is due to the many advances that have occurred since the early days of transplantation, when less than 30 percent of transplant recipients survived beyond one year. Currently, approximately 85 to 90 percent of people will survive at least one year, and approximately 75 to 85 percent of people will survive at least five years after receiving a new liver. Not only can people live a long life after a liver transplant (one person has been living with a transplanted liver for over thirty-two years!), but the quality of life is typically excellent. Most people can return to their regular jobs and daily routines without limitations.
There are approximately 125 transplant centers in the United States and more than 5000 liver transplants are performed in this country each year. As of August 29 2003, 17,696 people were on the liver transplant waiting list.
DETERMINING WHO NEEDS A LIVER TRANSPLANT
Having chronic liver disease or even cirrhosis does not automatically give rise to a need for a liver transplant. Nor does it qualify a person for a liver transplant. Yet, in cases where a transplant is warranted, a person does not want to wait until it is too late to be evaluated for a transplant. On the other hand, it is not necessary that everybody with chronic liver disease be evaluated for a liver transplant as soon as a liver problem is discovered. So, is there some kind of special gauge hidden on the body that only an experienced liver specialist can see that tells her when it is time to send her patient for a transplant evaluation? Well, not exactly. However, there are some specific criteria that are used to make this decision. Indications for a transplant that are specific to the cause of liver disease will be addressed on page 316. The following section is a discussion of some general indications for liver transplant independent of the type of liver disease.
GENERAL INDICATIONS FOR LIVER TRANSPLANT
A person is referred for a liver transplant when it is estimated that she will not live more than two years without a new liver. Accordingly, evidence of decompensated cirrhosis (such as ascites, variceal bleeding, or encephalopathy) is an indication for liver transplantation. Any manifestation of liver failure, whether due to acute or chronic liver disease (such as persistent jaundice or coagulopathy) is an indication for liver transplantation. People who have developed liver cancer due to chronic liver disease should also be evaluated for a transplant. Liver disease patients with symptoms such as relentless fatigue or intractable itching, so intolerable that they significantly diminish the quality of life, may also be candidates for a liver transplant evaluation. Finally, a person who had liver transplant in which the newly transplanted liver is not functioning may be a candidate for transplantation. While it is essential that a patient be evaluated by a liver transplant center once one of the above-mentioned conditions has developed, medical treatment should be the first line of therapy and should be undertaken so as to stabilize the patient until a new liver is available.
THOSE WHO ARE POOR CANDIDATES FOR LIVER TRANSPLANTATION
A liver transplant is a very serious undertaking for everyone involved—the transplant surgeon and transplant team, the patient, and the patient’s loved ones. It is of utmost importance that the decision to go ahead with a liver transplant takes into account the likelihood of a successful outcome. There is a shortage of donor livers available for transplantation, and this is a problem that continues to worsen. It stems, in large part, from the improved success rate of liver transplantation – the number of transplants being undertaken keeps increasing thus, the need for more livers. Because each donor liver is so valuable and scarce, the transplant team will necessarily make a careful assessment of whether the proposed recipient is a good candidate for the operation.
Certain conditions disqualify a person from undergoing a liver transplant because a successful outcome is unlikely. These conditions are known as absolute contraindications. They include the following:
• AIDS (acquired immunodeficiency disease)
• Cancer presently existing in an organ other than the liver.
- Metastatic cancer of the liver (advanced liver cancer that has spread to another organ)
- Alcoholic liver disease coupled with failure to abstain from alcohol for the last six months
• Severe active infection.
• Active substance abuse (for example, alcohol or heroin).
• Irreversible brain dysfunction.
• Advanced heart or lung disease.
Many other conditions are less than optimal for a liver transplant, but do not rule out the possibility. These conditions are known as relative contraindications. They include:
• Age (approximately 65 years old or older).
• Previous cancer in an organ other than the liver. (A two-year or longer waiting period is required between completion of cancer treatment and the time of liver transplantation. This is because there is a high likelihood of cancer recurrence if a person is treated with transplant immunosuppression drugs within this two-year period.)
• Kidney failure.
• HIV positivity (typically as part of a research protocol).
• Morbid obesity.
• Malnutrition.
• Prior portosystemic shunts (see page xx).
• A blood clot in the portal vein - known as portal vein thrombosis.
• Psychosocial assessment indicating an inability to adhere to post-liver transplant medication regimen and instructions.
- Lack of social support
EVALUATING A PATIENT FOR A LIVER TRANSPLANT
Once the doctor has determined that a patient should be evaluated for a liver transplant, many diagnostic tests will need to be performed. First, the patient must meet with, and be evaluated by, the entire liver transplantation team. This team generally consists of a transplant surgeon, liver specialist, psychiatrist, and social worker. Other specialists, such as a cardiologist (heart doctor) or pulmonologist (lung doctor) may need to be consulted as well. The opinions of each of these people are factored into the final decision as to the patient’s suitability for a liver transplant. And the extent of additional testing required will hinge upon the evaluation of these healthcare professionals. Such testing may include special imaging studies of the liver such as magnetic resonance imaging (MRI), heart exams such as an echocardiogram and a stress test, a chest X-ray and pulmonary function tests, a purified protein derivative (PPD) skin test to test for tuberculosis exposure, a colonoscopy if over 50 years old, an upper endoscopy to evaluate for esophageal varices, a dental evaluation, and further blood tests. Finally, financial issues are considered.
Since the evaluation process can seem scary and overwhelming, it’s always a good idea for the patient to bring a family member, loved one, or close friend along to the appointment. Not only will this person serve as emotional support, but she will assist in recalling and sorting through all the details of the day and can help arrange future testing.
Once the transplant team determines that a person is a candidate for a liver transplant, she is placed on a waiting list. Prior to 2002, transplant candidates were wait-listed based on the United Network for Organ Sharing (UNOS) status-ranking system (see Table 22.1 on page xx). Rankings were based on the points accumulated when assessed for severity of liver disease based on the Child-Turcotte-Pugh (CTP) scoring system, which appears in Table 22.2 on page xx. The more points accumulated, the higher the status on the transplant list. Patients are also listed according to time spent on the list, their blood type and donor size requirements—height, weight, chest circumference, and liver volume. In 1998, the Department of Health and Human Services decreed that organs should be allocated on the basis of medical urgency, and that the amount of time spent on the liver transplant waiting list should no longer be a factor in determining who should get a liver. The new scoring system eliminated transplant list waiting time and hospital status as factors for determining who should get a liver. As of 2002, liver allocation is based on the MELD score. The MELD scoring system is discussed in detail under the heading MELD.
All contents of this article are Copyright © Melissa Palmer, MD
Melissa Palmer, MD is the author of " Dr. Melissa Palmer's Guide of Hepatitis and Liver Disease". (Published 2004. Penguin Putnam).
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