Cleveland Clinic celebrated 30 years of liver transplantation in 2014 since completing its first adult liver transplant on November 8, 1984. As of December 31, 2011, 1,692 liver transplants have been performed at Cleveland Clinic, including the first lung-liver transplant in Ohio in 2007. The first pediatric liver transplant was performed on August 26, 1986.
Cleveland Clinic's liver transplant program is an essential component of a broad medical and surgical strategy to manage all patients with liver disease with the therapy most appropriate to that patient. Within the Liver Tumor Clinic, experts in all areas of liver disease participate in the evaluation, management, treatment and follow-up of liver transplant patients.
Cleveland Clinic's liver transplant program is a member of the Ohio Solid Organ Transplant Consortium (OSOTC) and the United Network for Organ Sharing (UNOS), meeting all their requirements for liver transplants.
The Centers for Medicare and Medicaid Services has certified CCF as a Medicare Center for liver transplantation, effective October 14, 1992. In addition, the OPTN/UNOS Board of Directors granted Cleveland Clinic full approval for live donor liver transplants on June 30, 2006, based on the recommendation of the Membership and Professional Standards Committee (MPSC).
If you or a loved one would like a second opinion from a top specialist at Cleveland Clinic, but may be disabled or find it too difficult to travel, we offer MyConsult. The MyConsult program is an online medical second opinion that connects you to our physician experts who will review your medical records and diagnostic tests to assess your suitability for transplant.
Welcome to the Liver Transplant Program. The Liver Transplant Team at Cleveland Clinic is here to help you regain your health.
Learn about the liver transplant process
We have designed an extensive teaching program to help you learn about the liver transplantation process, and your individual health needs and medical care before and after the transplant.
We know that learning about the liver transplantation process and how to care for your health may be overwhelming at first. But remember, you can learn a little each day. You'll also have this notebook as a reference while you wait for your transplant.
We understand that you are both excited and nervous about your transplant; these are normal reactions. Being prepared in advance by learning and understanding what to expect will help ease your fear of the unknown.
Always discuss your questions and expectations about the liver transplantation with your healthcare providers.
Be an active partner in your healthcare
We believe it is important for you to be an active participant in your health care. You will need to assume a lot of responsibility in your own care by doing whatever is necessary to build and maintain your strength for the liver transplantation.
Another important concern for your long-term health is for you to recognize and report any change in the way you feel; no one knows how you feel except you.
Since 2002, liver allocation for adults in the United States has been based on the Model for End-stage Liver Disease (MELD) score. The MELD formula, which is calculated on the basis of three objective variables (creatinine, bilirubin, and INR), predicts liver transplant survivability of patients waiting for liver transplantation, with higher MELD scores associated with higher mortality rates.
For patients with certain conditions (e.g., hepatocellular carcinoma), special scoring modifications are made.
The MELD score replaced the previous Status 2A, 2B and 3 categories. The most medically urgent category – Status 1, for patients with acute failure and a life expectancy of less than seven days without a transplant, as well as for transplant recipients with primary non-function of their graft – is still used to indicate the highest priority and has not been affected by MELD.
Time on the waiting list is only used to break ties between two or more patients with the same MELD score and the same blood type. The maximum MELD score is 40. Within a given organ procurement area, patients with a higher MELD score always rank ahead of those with lower scores, even if some patients with lower scores have waited longer.
For children under 18, livers are allocated according to the Pediatric End-stage Liver Disease score (PELD). PELD is similar to MELD, but also includes criteria related to pediatric growth issues (i.e., albumin level, growth failure, and age less than 12 months).
Each patient’s MELD or PELD score must be updated according to a schedule set by UNOS, ranging from weekly (for patients with higher MELD scores) to annually (for patients with MELD scores <10). MELD scores automatically revert to the previous lower score if the updated score is not registered with UNOS.
Download the MELD/PELD Calculator Documentation
- For further information and automated MELD calculations for liver transplant survivability go to www.unos.org.
Approval Process Listing
Patients whose liver transplant evaluations are complete are discussed at the weekly Liver Transplant Selection Committee meeting.
The committee comprises surgeons, hepatologists, a social worker, a chemical dependency specialist, a psychiatrist, a bioethicist, and an anesthesiologist. A decision regarding liver transplant is made by consensus, based on the information and opinions provided by team members who evaluated the potential liver transplantation patient.
Liver transplant patients may be approved for immediate placement on the United Network for Organ Sharing (UNOS), http://www.unos.org/, national liver transplant waiting list, or their placement on the list may be deferred pending completion of additional testing or a chemical dependency program (in patients with a history of substance abuse). Patients who are thought to be too well for OLT or in whom the risk of surgery outweighs the benefits will not be approved and are either deferred or rejected.
The final step in the liver transplantation review process includes approval by the Ohio Solid Organ Transplant Consortium (OSOTC) Liver Transplant Review Committee, comprised of representatives from other Ohio liver transplant programs and the lay public. OSOTC approval must be obtained for all patients. Potential liver transplant patients with MELD scores =25, or status 1 patients, can be listed with UNOS and the summary submitted to OSOTC within 24 business hours.
You will be notified by your transplant coordinator regarding the outcome of the selection committee meeting and when you are placed on the donor waiting list.
Management on OLT Waiting List
Once patients are placed on the transplant waiting list, care is coordinated between the local physician’s office and Cleveland Clinic hepatology. Follow-up appointments with the patient’s Cleveland Clinic hepatologist are generally scheduled every three to six months.
More frequent appointments can be scheduled depending on the patient’s MELD score or change in medical status. Components of the list management protocol are:
- Lab studies – are updated as directed by UNOS for MELD score calculation and prn.
- Echocardiograms and stress tests – are updated yearly and at the discretion of the anesthesiologist.
- Duplex ultrasonography – is done every six months to assess vasculature and for hepatoma screening.
- HCC – Bone scan, Chest CT, AFP Q three months
- Hepatitis B – If HBV-DNA or HBeAg positive, hepatology will begin antiviral therapy. HBV-DNA, HBeAg, HBeAb Q three to six months (with each follow-up visit)
- Primary Sclerosing Cholangitis – CA19-9, CEA Q three to six months (with each follow-up visit)
Liver transplantation patients are usually referred to the transplant center by their local physician or through case managers of insurance companies. The pre-transplant coordinator interviews the patient by phone, obtains the patient’s medical history, and schedules the patient for an evaluation for liver transplantation.
During the first phone call, the coordinator also explains the liver transplantation evaluation and selection process. Appointments for evaluation are generally scheduled as soon as possible, taking into account medical urgency.
The potential liver transplantation patient is asked to obtain outside medical records and imaging studies and bring these for review during the evaluation. An insurance review is conducted prior to the patient’s initial visit. Appointment schedules, maps, housing information, and education material are mailed to the patient.
The liver transplantation evaluation usually requires three full days of outpatient testing.
The informed consent process begins during the patient’s pre-transplant evaluation. Throughout the evaluation, patients are educated by the physicians and liver transplantation coordinator regarding the transplant procedure, postoperative care (including need for lifelong immunosuppression), and potential complications.
Patients with hepatitis B or C are informed of the need for HBIg infusions or interferon/ribavirin, respectively. The potential for use of donors with positive anti-HCV or HBcAb serology, other extended donors, or split livers is also reviewed with the patient during the evaluation, and the patient’s response is documented.
A thorough assessment of the patient’s support system, compliance history and motivation for liver transplantation is conducted by the social worker. Liver transplantation patients with a history of drug dependency undergo thorough evaluation by the chemical dependency counselor.
Time of Transplantation
When the organ transplantation coordinator calls to tell you that an organ has been located, you will be instructed to report to the admissions area. The transplant coordinator will tell you that you cannot have anything to eat or drink before you arrive at the hospital.
Donor livers are located through UNOS. Donors give their permission for organ donation before death or the donor’s family may give consent for organ donation at the time of death. An organ recipient and donor must have compatible blood types and similar body sizes.
At the time of death, the donor’s liver is removed, cooled, and stored in a special solution. Immediately after the donor’s liver is removed, it is transported to the recipient’s transplant center, where the transplant takes place as soon as possible.
Many people who are awaiting transplantation have mixed feelings because they are aware that someone must die before an organ becomes available. It helps to know that many donor families feel a sense of peace knowing that some good has come from a loved one’s death.
Locating a suitable donor for organ transplantation takes time. It is impossible to predict how long a wait there will be before a liver becomes available. Even when a donor is located, the surgery might not take place if there is a problem with the donor liver.
2011 Cleveland Clinic liver transplant facts and figures
For information on key data for the liver transplantation program please visit, www.ustransplant.org. This third party resource evaluates all solid organ transplant programs in the United States. You will be able to find liver transplantation outcome information including; number of transplants performed, survival rates, wait list times and other vital statistics. In addition, you will be able to research OPOs across the country and compare programs regionally and nationally.
In general, liver transplantation is indicated in children and adults suffering from irreversible liver dysfunction or the effects of liver dysfunction after alternative medical and surgical treatments have been utilized and where the benefits of transplantation out weight risk of alternative modalities.
Specific indications can include:
- Acute hepatic fulminant failure
- Extrahepatic biliary atresia or hypoplasia
- Inborn errors of metabolism including:
- Alpha-I antitrypsin
- Crigler-Najjar disease, Type I
- Byler's disease
- Glycogen storage disease, Type I
- Wilson's disease
- Wolman's disease
- Familial amyloidotic polyneuropathy
- Primary hyperoxaluria type 1
- Sclerosing cholangitis
- Hepatic vein thrombosis (Budd-Chiari)
- Hepatocellular Carcinoma (HCC), Stage I or II, or: single lesion </=6.5 cm, or multiple lesions (</=3) with largest </=4.5 cm total maximum tumor diameter </=8 cm ) UCSF criteria)
- Cirrhosis including:
- Alcohol cirrhosis (see Alcohol or Substance Dependence Addendum)
- Biliary cirrhosis (primary or secondary): Caroli, choledochal cyst, congenital cholestasis (PFIC), iatrongenic biliary tree injury/damage, trauma
- Chronic active hepatitis (A, B, C, non A, non B, autoimmune)
- Congenital biliary cirrhosis
- Cryptogenic cirrhosis
- Alpha I Antitrypsin Deficiency
- Viral cirrhosis
The Liver Transplant Team at Cleveland Clinic is comprised of surgeons, liver transplant physicians, coordinators, nurses, social workers and a vast network of people and resources to make the liver transplant process as smooth as possible.
Liver Transplant Center Leadership:
Liver Transplant Surgeons:
Liver Transplant Hepatology:
- Robert O'Shea, MD, MSCE
- Kadakkal Radhakrishnan, MD
- Carlos Romero-Marrero, MD
- Jamile Wakim-Fleming, MD
- Claudia Zein, MD, MSc
- Nizar Zein, MD
- Saul Kane, MD
- Emily Carey, DO
- Ibrahim Hanouneh, MD
Liver Transplant Coordinators:
Clinical Nurse Manager:
- Mary Kay Quinn, RN, MSN, CCTC
- Patricia Chapek, RN, MSN, CNOR
- Amy Daneri, RN, BSN
- Donna Ferchill, RN
- Peggy George, RN, BSN, CCTC, CLNC
- Katey Hellickson, RN, BSN, CCTC
- Nancy Luciano, RN
- Barb Mastroianni RN, MSN
- Julie Plescia, RN, BSN, CCTC
- Lori Pulice, RN, BSN, CCTC
- Mary Kay Quinn, RN, MSN, CCTC
- Elizabeth Wirick, RN, BSN
Post Liver Transplant Coordinators:
- Rich Adams, RN
- James Filisky, RN
- Molly Nikolic, RN
- Deb Plavney, RN, BSN, CCTC
- Lori Pulice, RN, BSN, CCTC
- Tracey Stinnett, RN
- Christine Panko, RN, BSN, CCTC
- Gretchen Garibaldi, RN, BSN
Living Donor and Pediatrics:
Living Liver Donor:
- Amy Daneri RN, BSN
- Donna Ferchill, RN
- Mary Kay Quinn, RN, MSN, CCTC
Living Liver Donor FC:
- Peggy George, RN, BSN, CCTC, CLNC
Liver Transplant Social Work:
Liver Transplant Financial Counselor:
Liver Transplant Program Assistants:
- Jacqui LeMaster, Department Supervisor
- Jennifer Mocsiran
- Maged Argalious, MD (Anesthesiology)
- Kathy Coffman, MD (Psychiatry and Psychology)
- Jacek Cywinksi, MD (Anesthesiology)
- Steven Gordon, MD (Transplant Infectious Disease)
- Robert Helfand, MD (Anesthesiology)
- Samuel Irefin, MD (Anesthesiology)
- John Jerabek, DO (Anesthesiology)
- Leia Johnson, MD (Transplant Infectious Disease)
- Lucileia Teixeira Johnson, MD (Infectious Disease)
- Saraswathi Karri, MD
- Allen Keebler, MD (Anesthesiology)
- Kamel Maheshwari, MD (Anesthesiology)
- Theodore Marks, MD, PhD (Anesthesiology)
- Sherif Mossad, MD (Transplant Infectious Disease)
- Brian Parker, MD (Anesthesiology)
- Maurico Perilla, MD(Anesthesiology)
- Mangalakaraipudur Ramachandran, MD (Anesthesiology)
- Rabin Shrestha, MD (Transplant Infectious Disease)
- Martin Smith, STD. (Bioethics)
- Alan Taege, MD (Transplant Infectious Disease)
- Claudene Vlah, MD (Anesthesiology)
- Sivan Wexler, MD (Anesthesiology)
- Eliyahu Zisman, MD (Anesthesiology)
- Sekar Bhavani, MD (Anesthesiology)
- John Seif, MD (Anesthesiology)
- Steven Mawhorter, MD (Infectious Disease)
- Eric Cober, MD (Infectious Disease)
- Kyle Brizendine, MD (Infectious Disease)
- Christine Koval, MD (Infectious Disease)
- Cyndee Miranda, MD (Infectious Disease
- Karam Obeid, MD (Infectious Disease)
Options for Transplant
Standard organ transplant is a procedure in which your liver is removed and replaced with the entire donor organ.
National Waiting List Organ Donation
We cannot predict how long you will be on the national waiting list to receive a liver. It could be days, a few weeks or even several years. Placement on the waiting list does not guarantee that you will get an organ.
When and if there is an organ that becomes available for you, your transplant coordinator will notify you. Have a plan in place so that you can leave your home on short notice. There is always a possibility that the donor liver is not functioning properly or the donor may become too unstable to continue with transplant. The surgeon will inform you of this event as soon as they are aware of the situation. This is called a "Dry Run" before the operation. Please do not be too disappointed if this happens. We always have your best interest uppermost in our minds.
You must be approved and placed on the donor waiting list to qualify for a living donation. Interested donors may call 216.445.8473. Advantages of having a living donor include knowing the scheduled date of your surgery and avoiding prolonged waiting periods on the national donor list.
You have the right to refuse an organ transplant procedure. Your transplant surgeon and physician will discuss other treatment options with you.
How long you stay in the hospital will depend on how quickly you recover. You will remain in the hospital as long as your doctor feels it is necessary. The time can vary, depending on how sick you were before the transplant, and/or if there are any problems after the surgery.
All liver transplantation patients will be contacted within 48 hours of discharge by the transplant coordinator to review medications obtained at patient’s local pharmacy and to reiterate points of discharge instruction.
Staples and sutures will be removed between day 14 and 21 after the liver transplant. Additional appointments for drain or T-tube removal are scheduled as needed after your liver transplantation.
Lab studies will be obtained bi-weekly for the first two weeks, followed by weekly lab studies for the next eight weeks, every two weeks for two months and then once per month if lab studies are stable. Lab work for liver transplantations is done at CCF or at the patient’s local lab. For outside lab work, a letter stating needed blood tests and instructions for mailing blood samples for immunosuppression monitoring will be given to the patient.
Outpatient lab work is reviewed by the post-transplant coordinator, abnormal values are then reviewed with the liver transplantation physician. Liver transplantation patients will remain under the care of the surgeons for the first three months and then post-OLT care will be transferred to the hepatology service in most cases.
Twice annually, we will send you a current issue of Hepatic Times, our newsletter for patients who have undergone a liver transplant.
Read the latest Hepatic Times newsletter.
For More Information
Call Jacqui LeMaster in the Transplant Office at 216.445.8473
Some of the first recipients of liver transplants were children. Advances in surgical techniques and anti-rejection medicines have greatly increased the chances of a successful outcome for this treatment option in children. We perform transplantation in both living related donors and shared liver surgeries.
Whenever an infant, child or teen develops liver disease, our Pediatric Liver Transplant team works with referring pediatricians to increase their chances for long-term survival. We pledge to do everything in our power to make a transplant a reality - we will work expeditiously for our patients.
For more information on Cleveland Clinic’s pediatric transplant program, please call 216.444.6123.