What does the liver do and why would a transplant be needed?
The liver is the body's largest internal organ (approximately three pounds in adults). It’s located below the diaphragm on the right side of the abdomen.
The liver performs many complex functions in the body, including the following:
- Produces most proteins needed by the body.
- Metabolizes (breaks down) nutrients from food to produce energy, when needed.
- Prevents shortages of nutrients by storing certain vitamins, minerals and sugar.
- Produces bile, a compound needed to digest fat and to absorb vitamins A, D, E and K.
- Produces most of the substances that regulate blood clotting.
- Helps your body fight infection by removing bacteria from the blood.
- Removes potentially toxic byproducts of certain medications.
When is a liver transplant needed?
Liver transplantation is considered when the liver no longer functions adequately (liver failure). Two possible causes of liver failure are an acute (sudden) failure from infection or complications from certain medications.
Long-term liver failure is more common and can be a result of the following conditions:
- Chronic (long-term) hepatitis for a variety of reasons, including autoimmune liver disease (inflammation and scarring of the liver tissue) and primary sclerosing cholangitis (scarring and narrowing of the bile ducts inside and outside of the liver). This causes backup of bile in the liver and liver failure.
- Biliary atresia (abnormal inflammation and scarring of the bile ducts). This is a common reason for liver transplant in children.
- Metabolic liver disorders, including for example, urea cycle defects.
- Acute liver failure, including Wilson's disease (a rare inherited disease in which copper is deposited abnormally throughout the body, including the liver).
- Liver cancer, including hepatoblastoma in young children, and even rarer, hepatocellular carcinoma in older children and adolescents.
In advanced liver disease, some or all of the following signs might begin to appear:
- Jaundice (yellow coloring of the skin and eyes).
- Nausea, vomiting and/or loss of appetite.
- Poor weight gain.
- Tendency to bruise and bleed easily.
- Ascites (fluid in the abdomen).
- Swelling in the legs and feet due to fluid accumulation.
- Fatigue and decreased energy.
- Clay-colored stools.
- Dark, tea-colored urine.
- Mental confusion, possibly progressing to coma.
- Vomiting blood or passing blood in the stool.
The type of liver disease determines which liver functions are impaired. Your child’s symptoms might be different from other patients undergoing evaluation for liver transplants.
How are candidates for liver transplant determined?
Candidates for liver transplant are evaluated by specialists from several fields. The evaluation includes a review of the patient’s medical, surgical and psycho-social history, and a variety of tests.
Many healthcare facilities offer an interdisciplinary approach to evaluate and select candidates for liver transplantation. This interdisciplinary healthcare team may include the following:
- Liver specialist (hepatologist).
- Transplant surgeons.
- Transplant coordinator, usually a registered nurse who specializes in the care of liver transplant patients. This person will be your main contact with the transplant team.
- Social worker, to discuss your support network of family and friends, employment history and financial needs.
- Psychiatrist, to help you deal with issues such as anxiety and depression that may go along with the liver transplantation experience.
- Anesthesiologist, to discuss potential anesthesia risks.
- Chemical dependency specialist, to aid those with a history of alcohol or drug abuse.
- Patient Financial Advocate, to act as a liaison between you and your insurance companies.
- Nutritionist, to help evaluate your current nutritional status.
- Pharmacist, to review your medications for potential drug interactions
What tests are required before getting a liver transplant?
Your healthcare provider will want to review all of your medical records, X-rays, liver biopsy slides, operative reports and a list of medications at your initial evaluation. To complement and update previous tests, some or all of the following studies are usually performed during your evaluation:
- Computed tomography (CT scan), which uses X-rays and a computer to create pictures showing liver size and shape, blood supply and any liver lesions. A chest CT scan may also be needed.
- Doppler ultrasound to determine if the blood vessels to and from your liver are open.
- Echocardiogram and, for adults, stress testing to help evaluate your heart.
- Pulmonary function studies to determine your lungs' ability to exchange oxygen and carbon dioxide.
- Blood tests to determine blood type, clotting ability and biochemical status of blood, and to measure liver function. Serology screening (a blood test that looks for antibodies) is also included.
If these tests reveal specific problems, the medical team may order additional tests.
How does the liver transplant waiting list work?
If you become an active liver transplant candidate, your name will be placed on a national waiting list. Patients are listed according to blood type, body size and the model of end-stage liver disease/pediatric end-stage liver disease (MELD/PELD) score.
The MELD/PELD score is calculated by simple blood tests (creatinine, bilirubin and INR for MELD and bilirubin, INR and albumin and growth parameters in infants, for PELD). Patients with the highest scores are assigned organs first.
Your transplant team will determine if a particular donor organ is a suitable match for you. As patients become more ill, their scores may increase and their priority for transplant increases, allowing for the sickest patients to be transplanted first. A small group of patients who are critically ill from acute liver disease have the highest priority on the waiting list.
It’s impossible to predict how long a patient will wait for a liver to become available. Your transplant coordinator is always available to discuss where you are on the waiting list.
Where does a liver for a transplant come from?
There are two types of liver transplantation options: living donor and cadaveric.
Living donor liver transplants are an option for some patients with end-stage liver disease. In this procedure, a segment of liver is removed from a healthy living donor and implanted into a recipient. Both the donor and recipient liver segments will grow to an adequate size in a few weeks.
The donor, who may be a blood relative, spouse, friend, or in some cases an entirely anonymous altruistic individual, will have extensive medical and psychological evaluations to make sure there is as little risk as possible. Blood type and body size are important factors in determining who is an appropriate donor.
Recipients for the living donor transplantation must be active on the transplant waiting list. Their health must also be stable enough to undergo transplantation with excellent chances of success.
In cadaveric liver transplantation, the donor may be a victim of a cerebral vascular accident or head injury, such as spontaneous bleeding into the head. There are two types of cadaveric donors, both involving patients who have suffered irreversible brain injury:
- In a donation after cardiac death, the brain injury is very extensive but the patient doesn’t meet brain death criteria. The family has agreed to withdraw support, and it is done in a controlled setting. After the heart has stopped, the donor is declared dead and organs can be removed.
- In brain dead donors, there is no longer any brain activity but the heart has continued to beat.
The identity of a cadaveric donor and circumstances surrounding the person's death are kept confidential. It is considered an anonymous “gift.”
Hospitals will evaluate all potential donors for evidence of liver disease, alcohol or drug abuse, cancer or infection. Donors will also have serology testing and testing for other infections. If this screening doesn’t reveal problems with the liver, donors and recipients are matched according to blood type and body size. Age, race and sex are not considered.
The transplant team will discuss your transplantation options with you at the time of your pre-transplant evaluation, or you can contact the transplant team for more information.
What happens when a matching organ is found?
When an organ has been identified for you, a transplant coordinator will call you. Do not eat or drink anything once you have been called to the hospital. The transplant coordinator will let you know of any additional instructions.
When you arrive at the hospital, you will have additional blood tests, an electrocardiogram and a chest X-ray before the operation. You also may meet with the anesthesiologist and a surgical resident. If the donor liver is found to be acceptable, you will proceed with the transplant. If not, you will be sent home to continue waiting.
What happens during the liver transplant operation?
Liver transplants usually take six to 12 hours. During the operation, surgeons will remove your liver and replace it with the donor liver.
Because a transplant operation is a major procedure, surgeons will need to place several tubes in your body. These tubes will help your body carry out certain functions during the operation and for a few days afterward.
- A tube will be placed through your mouth into your trachea (windpipe) to help you breathe during the operation and for the first day or two after. The tube is attached to a ventilator that will expand your lungs mechanically.
- A nasogastric tube will be inserted through your nose into your stomach to drain secretions from your stomach. It will remain in place for a few days until your bowel function returns to normal.
- A tube called a catheter will be placed in your bladder to drain urine. This will be removed a few days after the operation.
- Tubes will be placed in your abdomen to drain blood and fluid from around the liver. These will remain in place for about a week.
Risks / Benefits
What are the possible complications after liver transplantation?
Two of the most common complications after liver transplantation are rejection and infection:
- Rejection: Your immune system works to destroy foreign substances that invade your body. The immune system, however, cannot tell the difference between your transplanted liver and unwanted invaders, such as viruses and bacteria, so it attempts to attack and destroy your new liver. This is called a rejection episode. About 30% of all liver transplant patients have some degree of organ rejection in the first year. Patients take anti-rejection medications to ward off the immune system attack.
- Infection: Because anti-rejection drugs suppress the immune system, liver transplant patients are at an increased risk for infections. This problem lessens over time. Not all patients have problems with infections, and most infections can be treated successfully as they occur.
Recovery and Outlook
What anti-rejection medications are taken after liver transplant?
After the transplant, you will take anti-rejection medications called immunosuppressants. These medications slow or suppress your immune system to prevent it from rejecting your new liver. They may include:
- Azathioprine (Imuran®).
- Myophenolate mofetil (Cellcept®).
- Prednisone (Deltasone®, Kedral®, Medrol®, Orasone®, Prelone®, Sterapred DS®).
- Cyclosporine (Neoral®).
- Tacrolimus, AKA FK506 (Prograf ®).
- Sirolimus (Rapamune®).
You must take one or a combination of these drugs exactly as prescribed for the rest of your life.
When will I be able to go home after the liver transplant?
The average hospital stay after liver transplantation is 10 to 14 days. Some patients may be discharged in less than one week, while others may be in the hospital much longer, depending on complications that may arise. You need to be prepared for both possibilities.
To provide a smooth transition from hospital to home, the nursing staff and your transplant coordinator will begin to prepare you for discharge shortly after you are transferred from the intensive care unit to the regular nursing floor. You will be given a discharge manual, which reviews much of what you will need to know before you go home.
You will be an important participant in your healthcare. Before your discharge, you will learn:
- How to take your new medications.
- How to check your own blood pressure and pulse.
- The signs of rejection and infection.
- When it is important to contact the transplant team.
Readmission to the hospital after discharge is not uncommon, especially within the first year after transplantation. The admission is usually for treatment of a rejection episode, infection or other complication.
What follow-up is necessary after a liver transplant?
Your first return appointment will generally be scheduled about one to two weeks after you’re discharged from the hospital. During this visit, you’ll see your transplant hepatologist, transplant surgeon and transplant coordinator. If needed, a social worker or a member of the psychiatric team can also be available.
Additional appointments are scheduled for every two to four weeks until three months after the transplant (as directed by the transplant physicians). Generally, patients are then scheduled to return for follow-up at six and nine months.
All patients are scheduled to return to the transplant clinic on the first anniversary of their transplant, and then every year after that.
Your primary care healthcare physician should be notified when you receive your transplant and when you are discharged. Though most problems related to the transplant will need to be taken care of at the transplant hospital, your primary care healthcare provider will remain an important part of your medical care.
Where can I learn more about living liver donation?
Learn more about the Living Liver Donor program from Cleveland Clinic's Transplant Center.