Reasons for Liver Transplantation

The only reason to perform a liver transplant is that all other forms of treatment have been unsuccessful, and the patient's liver can no longer support life. This is called end stage liver disease.

There are several conditions that are more commonly treated with this procedure. They are frequently conditions that cause chronic or continuing liver inflammation. As the inflammation heals, fibrous tissue forms, much like a scar forms when a cut in the skin heals. Severe and advanced scarring of the liver is called cirrhosis. Cirrhosis is not reversible and leads to end stage liver disease. The following conditions are the most common causes of end stage liver disease:

Chronic viral hepatitis B and C
Alcohol related liver disease
Autoimmune hepatitis
Primary sclerosing cholangitis
Primary biliary cirrhosis
Steatohepatitis
Liver disorders inherited or present at birth
Drug induced liver damage

Primary biliary cirrhosis and primary sclerosing cholangitis have survival rates of over 90%.

Unfortunately, there are more patients who need a new liver than there are donors. Donor livers almost always come from individuals who have suffered fatal brain damage due to trauma, rather than disease. Consultants and patients are usually able to plan and perform a transplant before the patient reaches end stage liver disease. However, because of the lack of donor livers, the choice of who gets a new liver now depends on how critically ill the patient is.

Surgery
Liver transplantation is a complicated process. There are really three operations involved. The first is the removal of the liver from the donor. If the liver is donated at a different location, it must be transferred to the transplant centre under sterile refrigerated conditions within 8 to 20 hours. The second operation is the removal of the diseased liver from the patient, and the third is the operation to insert and connect the new liver. The operations on the recipient are so detailed they require a long time to complete. But, the team of surgeons, nurses, and support staff are now very experienced in the technique. The new liver is attached to the various blood vessels and bile ducts. When the surgery is completed, the patient goes to the recovery area.

Recovery
Recovery begins with several weeks in the hospital. Immediately after surgery, the patient is in intensive care. Continual monitoring for any infection, rejection, or poor functioning of the new liver takes place. Rejection occurs because the transplanted liver is recognised as foreign by the body. This is the body's normal reaction to any foreign substance. The body's rejection of the transplant would cause inflammation and damage to the new liver. Because of this, medications must be given to calm the rejection reaction in the body. Long-term treatment against rejection is always necessary.

There are three main medications used to prevent rejection. One is a cortisone drug, usually prednisone (trade names: Deltasone, Orasone). It is often used in a low dose. The side effects are fluid build-up and puffiness of the face. A more serious side effect is a change in the bones. Prednisone causes a loss of calcium that can lead to osteoporosis and damage to joints such as knees, hips, and shoulders. A second drug is called Sandimmune. Sandimmune is difficult to regulate and can produce high blood pressure, kidney damage, and occasionally growth of body hair. A third drug is Prograf. This drug has been dramatic in providing successful transplants with the lowest side effects. But even here, kidney damage can occur. It is easy to see why close follow-up is needed for patients on these drugs. Frequent blood tests are required to monitor the patient's progress and reduce side effects.

As recovery progresses, the patient is released to outpatient status, but must stay close to the transplant centre for daily visits and blood testing. Finally as things stabilise, the patient is sent home to the care of their consultant. Usually, follow-up is maintained with the patient's consultants at the transplant centre. Once patients have recovered, they can resume normal physical and sexual activities. Even vigorous exercise is possible after full recovery, but this should only be done after discussion with the consultant. There are few dietary restrictions. The patient is often advised to restrict salt (sodium) intake. A well-balanced diet with adequate protein is necessary. For reasons that are not clear, obesity frequently becomes a problem with liver transplant patients. To avoid this problem, patients should take control of their calorie intake early on.

As the body becomes familiar with the transplanted liver, the amount of medicine needed to control rejection can be adjusted and usually reduced. However, most liver transplant patients will always have to take at least some medication.

Liver Donation
It is very important that more livers become available for donation. All healthy people are encouraged to make arrangements to become liver donors if they are ever in a situation that would make this possible. Generally, there are no restrictions on age, sex, or race. The only matching requirements for livers are that the donor and recipient must be about the same size and have compatible blood types. Anyone wishing to become an organ donor should carry an organ donor card. It is important to discuss organ donation with family members, because they must always give consent when the circumstances take place.

Summary
Liver transplantation is an important move forward in the treatment of severe liver disease. It has opened a new world for patients who otherwise were destined to die from their liver disease. The operation is a major one, and there are still problems associated with medications used to prevent rejection. But overall, patients can usually expect a good outcome with return to normal activities.