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Liver Transplantation

Liver Transplantation

LIVER TRANSPLANTATION

Patient’s Information

INTRODUCTION

This information pack has been put together to try and help you through the process of assessment, transplantation and recovery. Comments or suggestions about the pack are welcomed and should be sent to our transplant coordinators. Their address can be found at the conclusion of this document.

THE LIVER

The liver is the largest solid organ in the body. It is located in the upper right-hand portion of the abdomen, protected by the ribs. It lies beneath the diaphragm and on top of the stomach, right kidney, and intestines (Figure 1). The liver is dark, reddish-brown and weighs approximately one and a half kilograms (3 pounds).

Figure 1. Location of the liver

The liver is divided naturally into two parts, the right and left lobes. It is held in position by its connections to major blood vessels and other organs, which lie close by. The blood vessels include the inferior vena cava, a large vein that takes blood from the lower part of the body, runs behind the liver and up through the diaphragm into the heart. Other blood vessels include the hepatic artery and portal vein and these are described a little later. The liver is attached to the diaphragm and other organs by ligaments (bands of tissue) (Figure 2).

The liver is the only organ in the body to have a double blood supply. Oxygenated blood flows in from the hepatic artery and a nutrient-rich blood flows through the portal vein from the gut. The blood drains from the liver through three hepatic veins (right, middle and left) directly into the inferior vena cava. The liver holds about 13 percent of the body’s blood supply at any given moment.

Figure 2. Anatomical division of the liver

The hepatic artery and portal vein divide inside the liver into eight segments (parts of the liver), which are numbered from 1-8 (Figure 3):

  • Segment 1(I): Caudate lobe
  • Segments 2 and 3 (II and III): Left lateral segment
  • Segments 1 to 4 (I to IV): Left lobe
  • Segments 5 to 8 (V to VIII): Right lobe

The liver tissue is made up of billions of liver cells (hepatocytes) and these are arranged in groups called lobules (Figure 4). These lobules connect to small tubes (ducts) that drain fluid (bile) produced by the liver cells. These small tubes connect with larger ducts, which come together to form the common bile duct, which drains into the gallbladder, which stores bile and sends it into the bowel (duodenum) during meals (Figure 5).

Figure 4. Structure of the hepatic lobule

Figure 5. The bile duct and gallbladder

The liver is the only organ in the body that can regrow after injury (regeneration). The liver is able to double its size in six – eight weeks after major liver surgery.

Functions of the liver

The liver can be considered to be “the factory or chemical laboratory” of the body. Blood flowing in from the portal vein carries all the substances absorbed by the stomach and bowel. The liver cells process this blood and breaks down the nutrients (food) and drugs into smaller building blocks, which the body can use more easily. The liver monitors and controls many of the chemicals in the blood, which are needed to live normally.

The liver is also responsible for breaking down chemicals, drugs and unwanted material. Some of the waste products generated during this process are eliminated through the bile, into the bowel and ultimately leave the body in the faeces. Other substances (bile acids) are also released into bile to help break down and absorb fat and meat in the bowel during digestion.

The liver has more than 2000 vital functions and some of these better-known ones include:

  • Production of bile
  • Production of cholesterol and special proteins to help carry fat through the body
  • Controls energy production (storing and breaking down sugars)
  • Stores important vitamins including Vitamin A, D, E and K
  • Controls the building and breaking down of protein in the body
  • Breaks down haemoglobin (blood) and stores iron
  • Changes ammonia (poisonous) to urea, which is excreted in the urine
  • Clearing the blood of drugs and other poisonous substances (excreted into the bile or blood)
  • Building proteins that help the blood to clot
  • Protects against infection by producing immune factors and removing bacteria from the blood stream

LIVER DISEASE

You are being assessed for transplant primarily because your liver is no longer functioning well. Liver failure can occur for several reasons. Occasionally, the liver stops working because of a severe, acute damage to the liver (hepatitis, drugs overdose) as is seen in patients with acute liver failure. More often, liver failure occurs due to chronic injury or insult to the liver. This is called chronic liver disease. The majority of patients undergoing liver transplant assessment at Shifa do so as a consequence of development of chronic liver disease and its complications.

Cirrhosis is the term given to scarring within the liver. Scarring occurs as a result of ongoing inflammation or liver damage. This may be related to viral infection in the form of chronic hepatitis B virus or hepatitis C virus infection or due to toxins such as alcohol. Occasionally, people develop cirrhosis through immune damage to the liver (autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis). There are also some genetic causes (inherited) for chronic liver disease, including iron deposition in the liver (haemochromatosis), copper overload (Wilson’s disease) and Alpha 1 Anti-trypsin deficiency. Sometimes, it is not possible to identify an exact cause of liver failure.

Symptoms of Chronic Liver Disease

As described previously, the liver behaves as a factory performing a number of functions. When these functions fail people develop significant problems.

These problems show themselves as:

  • ascites (fluid overload)
  • coagulopathy (easy bleeding and bruising)
  • encephalopathy or confusion
  • variceal bleeding
  • fatigue (tiredness)
  • jaundice (yellowing of the skin)

These symptoms and signs are very common in people in the final stages of liver disease (“end stage liver disease”) or cirrhosis

Ascites: Is fluid accumulation within the abdominal cavity and is a common symptom in people with cirrhosis and end stage liver disease. This occurs because of high pressure within the liver. The liver scarring and the increase in pressure cause fluid to accumulate in the abdomen causing ascites. Fluid in the abdomen is uncomfortable and can cause difficulty in breathing and restrict movement. Occasionally, this fluid can become infected (spontaneous bacterial peritonitis), and treatment with antibiotics may be required. This is a serious complication and can result in death for people with liver disease. Recurrent episodes of infection of this abdominal fluid are an indication for transplant.

While awaiting transplant, your doctor may treat you with water tablets (diuretics) to help the fluid to pass through your body. Alternatively your doctor may drain the fluid (paracentesis) with a needle. However, paracentesis or drainage is something that will only be performed if absolutely necessary since there are risks associated with the procedure including bleeding, introduction of infection and occasionally perforation of an organ within the abdomen. You can also help to control this abdominal fluid by restricting your fluid intake to 1litre a day and reducing the amount of salt you consume to less than 2g per day, if advised to do so by the medical team. Avoiding processed foods such as crisps, salted peanuts and other salted foods will help control fluid retention, but people find it difficult at times to cope with this treatment.

Coagulation: As discussed previously, the liver produces factors that help the blood to clot. When the liver is not working well, these factors are not produced and increase the risk of bleeding and bruising. This is measured when you come to clinic. Occasionally, Vitamin K may be prescribed to help improve the clotting function.

Bleeding: When high blood pressure (portal hypertension) develops within the veins going to the liver, other veins may open up within the abdomen to help relieve this pressure. These opened veins develop into varices (varicose veins) in the lining of the oesophagus or gullet and stomach. If the pressure becomes very high, these veins can rupture and bleed. This is a serious complication and if you vomit blood or notice a change in the colour of your stools towards black, you must go immediately to your local hospital. Black stools could be a sign of bleeding. If you do have variceal bleeding, it can usually be controlled with drugs and endoscopic therapy. This is discussed later in this booklet.

To help prevent bleeding you may be prescribed another drug called Propranolol (Inderal). This treatment may cause your blood pressure to fall so it is important you report any dizziness to your doctor.

Encephalopathy: Since the liver processes all of the substances which come into the body, if it is not working well, the broken-down products of proteins cannot be processed as efficiently as before. This results in a build up of ammonia within the blood and when ammonia goes to the brain it can cause confusion. This is called encephalopathy and can be as mild as a feeling of sleepiness during the day or as severe as a coma.

Encephalopathy usually manifests itself through changes in behaviour; either increased aggression or increased fatigue and sleepiness. Occasionally, a build up of ammonia can be detected by a sweet smell from the breath. If you are at risk of developing encephalopathy, you may be prescribed lactulose. This helps keep the gut clear of excess bacteria and causes loose stools – you should then have two – three loose stools per day. This usually prevents encephalopathy or keeps it under control.

Jaundice: Occurs when bilirubin, a pigment normally eliminated through the bile, accumulates within the blood stream. This is frequently the case when the liver is failing. This may result in yellow discolouration to the skin and the eyes and in itching, which can be very difficult to control.

Sexual Function: Both men and women with end stage liver disease and cirrhosis often report problems with sexual function. For men, this can mean reduction in libido or desire, difficulty in obtaining or sustaining erections. This coupled with fatigue and a number of other symptoms, makes life difficult for many patients.  For women, these problems manifest themselves as irregularity or absence of periods or difficulty in becoming pregnant. These symptoms are common for many women with end stage liver disease or cirrhosis. In many women cirrhosis also results in a reduced libido or desire.

Development of Liver Cancer: If you have chronic liver disease and cirrhosis you have an increased risk of developing liver cancer (hepatocellular carcinoma). Liver cancer in itself is a good reason to perform transplantation. However, experience has shown that only people with cancers within a certain size range benefit from a liver transplant. In general, transplant is offered to people with either one area of cancer within the liver of no more than 5cm in size or to people with three areas of cancer, the total volume of which is no greater than 7cm. When people go beyond this level of cancer or have blockage of the veins of the liver, the outcome from transplant is not good, and in that situation, transplant is not an option.

People with cirrhosis, particularly that related to viral hepatitis (HBV, HCV), or alcohol should have ultrasound scans taken of the liver every 6 or 12 months to screen for hepatocellular carcinoma.

If you have liver cancer, you will undergo scanning whilst on the waiting list and you may be offered some form of treatment for your cancer in an attempt to prevent it from growing.

ASSESSMENT

THE LIVER TRANSPLANT ASSESSMENT PROCESS

This leaflet is designed to explain how we assess people with liver disease and whether or not liver transplantation is the right treatment for you. It should answer common questions you may have and explain what happens during the assessment and the possible outcomes.

You are here because your doctors feel that this is the right time to assess how severe your liver disease is and whether treatments other than transplantation may help. The main question to be answered is whether or not a liver transplant is the best treatment for you.

We also have to identify any medical problems, which may complicate or even prevent a transplant being possible.

During the assessment you will undergo lots of tests. Some will assess your liver disease but others are to examine your fitness for major surgery. These tests look at the function of your lungs, heart and kidneys. The number and complexity of these tests will vary from person to person.

You will meet many members of the transplant team during your assessment, including hepatologists, transplant surgeons, anaesthetists, dieticians, social workers and transplant co-ordinators. Each member of the team will be evaluating you from his or her own viewpoint. Other specialists in the hospital may be asked for an opinion.

“Having all these tests does not necessarily mean that a liver transplant offers you the best treatment option”

The entire liver transplant team meets to discuss the suitability of individual patients for transplantation. After your case has been discussed, one of the team will talk to you about what happened at this meeting. A summary of your assessment will be sent to the doctors who normally look after you.

If you have any questions, please do not hesitate to ask any member of the transplant team.

TRANSPLANT EVALUATION

 

Your assessment for liver transplantation may take place either as an outpatient or as an inpatient. Your pre-transplant evaluation consists of a number of medical tests designed to give a clear picture of your general health. These tests are performed because the Transplant Team wants to do everything in its power to help ensure that you have a successful transplant. To do this, your general health will be assessed in a systematic fashion. As a consequence, the transplant evaluation may reveal some conditions, which need to be corrected, before your transplant surgery. Occasionally the test may reveal a problem, which makes transplant more difficult or indeed impossible to perform. If such a situation arises, the reasons for these difficulties will be discussed with you and your doctor will attempt to create another possible treatment plan for you.

Positive Attitude

The Transplant Team will be concerned if you are ambivalent or not really committed to either the assessment or surgery. The transplant evaluation is difficult, and in many respects is a test of how you will be able to cope with some of the uncertainties, which can arise during your care. It is important that you take an active role in your own well-being.

The transplant assessment can take up to 5 days and occasionally longer to complete and may at times being very boring and frustrating. Your doctors and nurses understand that being sick is difficult and that it is a struggle at times to cope with the stresses imposed by certain conditions.

While you are with us, you will see patients who are at different levels of ill health. Some people will be undergoing transplant assessment because they are very sick, while others may be undergoing transplant assessment as a consequence of poor quality of life.

A positive mental attitude cannot be measured in blood tests or by other measures; however, it can help a great deal in getting through the transplant evaluation process and can also help your recovery following transplantation.

The Transplant Assessment Work-up

The work-up involves interviews and examinations with various members of the transplant team. This will include interviews with a transplant co-ordinator, social worker, transplant surgeon and other doctors or services that may be necessary for you to undergo a successful transplant.

Sometimes, these interviews will seem repetitive and boring, but it is important that you engage with all of the members of the team so that they can get a clear picture of your specific needs. Following this, you will undergo a number of tests including blood tests. You should also be aware that not all people who undergo transplant evaluation would have the same tests. For example, it may be necessary for older people to have more tests than younger people as it is likely that other organs have suffered from damage over time or as a consequence of the liver disease.

The Assessment Process

It is a stepwise assessment of the recipient and the donor. The purpose of stepwise assessment is to avoid un-necessary investigations. Assessment starts from recipient once he/ she has clear indications of liver transplantation. The timing of transplant is crucial; so objective assessment process is mandated.

 

Objectives of liver transplant assessment:

  1. Right recipient selection
  2. Right donor selection
  3. Better outcome

Stepwise Recipient Assessment:

Patients are examined by hepatologists and liver transplant surgeons. After initial assessment if a patient is a candidate for liver transplant, detailed briefings are given to the patient and their family regarding the risks and benefits of the transplant operation.

Patients are given time to think and plan transplantation. They are also provided with educational material. Once the patient and family has made final decision for liver transplantation, the detailed assessment process is started that includes following:

Radiological assessment 

  1. Ultrasound of the abdomen
  2. Liver dynamic CT abdomen, and Chest CT to rule out/stage HCC, determine extent of liver disease
  3. MRI and CT brain in selected cases

Cardiac Assessment:

  1. ECG
  2. Echocardiogram/stress echo including PA pressure
  3. Coronary angiogram (selected cases )
  4. Cardiologist comments

Pulmonology assessment

  1. CXR
  2. Pulmonary function tests
  3. Pulmonologist evaluation

Nephrology assessment

  1. Renal function tests
  2. Routine urine analysis
  3. Urine culture
  4. Nephrologists evaluation

Psychiatry assessment

  1. Consultation & Evaluation

 

 

Recipient Exclusion Criteria (contraindications to transplant):

  • Severe, irreversible, medical illness that limits short term life expectancy
  • Severe Pulmonary Hypertension (Mean PA pressure > 50mmHg)
  • Sepsis or uncontrollable infection
  • Severe, uncontrolled Psychiatric illness
  • Uncorrectable congenital abnormalities which are severe and life threatening

Relative Exclusion Criteria:

  • Advanced malnutrition
  • Active Infection
  • Inability to comply with medications and conform to follow up regimens

 

 

Stepwise donor evaluation:

Once it is assured that patient is fulfilling the liver transplant criteria and is fit enough to undergo major surgery, the donor workup starts. We accept donors from within the family (close blood relatives and non-close blood relatives) according to the following criteria:

Living Donor selection criteria:

  • A blood related person or a spouse who shares compatible blood group with the patient.
  • Donors must be healthy individuals with no major health problem.
  • Must be in good physical and mental health
  • Must be between the ages of 18 and 50 years
  • Voluntarily, altruistic donation
  • Have a body mass index (BMI) less than 35
  • Must have a compatible blood type with the recipient
  • Must be free from the following:
    • Significant organ diseases (i.e., Heart, Lung & Kidney disease, etc.)
    • Ongoing malignancy (cancer)
    • HIV/AIDS
    • Hepatitis
    • Active or chronic infections
    • Active substance abuse

Laboratory work-up the living donor:

The purpose of the stepwise evaluation of the donor is to avoid un-necessary investigations. If the donor is found to be unsuitable at any step, the other investigations should be abandoned. Before starting the investigations of the donor, detailed history and physical examination including height, weight, BMI is recorded. Steps of donor evaluation are as follows:

Special Considerations and/or Issues in Donor Evaluation:

Donor Advocate:

Usually a physician outside of the transplant team, who will help the donor understand the process, procedure, risks and benefits of live organ donation.  The donor advocate will protect and promote the interests and well-being of the donor. Donors can opt to withdraw at any time during the assessment process.  The reasons for withdrawal will be kept confidential.

Liver Biopsy:

Our program may perform liver biopsy on potential donors based on clinical findings that suggest some degree of concern regarding histological status of the liver, i.e., elevated AST/ALT, presence of steatosis on imaging studies and so on.

Cost of Donor Evaluation:

Financial considerations of the donor evaluation and hepatectomy are important to consider because the process is complex and expensive and some of donors has “failed donor evaluations,” i.e., potential donors who undergo testing and are rejected for donation. Living donation is not possible for all the donors due to medical and technical reasons.

After complete assessment of the recipient and the donor, the case is presented in Transplant Multidisciplinary Meeting (MDM).

Transplant Multidisciplinary Meeting (MDM) Guidelines:

  1. a) Objective: Discussion of all patients under consideration for transplantation.

Attendees:

  1. Consultant Hepatologist
  2. Consultant Liver Transplant Surgeon(s)
  3. Consultant Liver Transplant Anesthetist(s)
  4. Consultant Intensivist(s)
  5. Transplant Coordinator Team (including MDT Co-ordinator). The Co-ordinator will also act as a social worker
  6. Physicians in training
  7. Nurses responsible for care of patient

  1. b) Agenda in brief: For each patient:
    1. Short/salient summary of each patient based on evaluation proforma and listing meeting outcome.
    2. Discuss suitability for transplantation
    3. Discuss necessity/appropriateness of further investigations
    4. Define action plan (outcome) – listing/ time-frame – record outcome – Database

 

  1. c) Presentation at MDM: List of all patients for discussion to be circulated to attendees 24hrs prior to meeting (responsibility of MDT Co-ordinator). All names are forwarded 24 hours before the meeting.

Give short summary of patient’s history: indications for transplantation, presentation, referral source, suspected/confirmed diagnoses, and investigations +/- treatments to date.  Summarise all available relevant transplant assessment related investigations.

  1. d) Discussion:
  • Rationalisation for transplantation and absolute/relative contraindications:
  • Exploration of other treatment options/further investigations
  • Recommendation of treatment(s) (e.g. abstinence programs etc)

 

  1. e) Define action plan:
  • If accepted for listing, discuss priority/type of graft/immunosuppressant regimen.
  • If not listed, define reasons/future candidacy/ follow up plan.
  • If patient to be re-discussed, define issues for re-discussion
  • Record outcome – with review date if appropriate

 

  1. f) Updates: Updates will only be discussed on the basis that they require a new decision from the Transplant MDM.

 

  1. g) Acute Liver Failure: Patients with acute liver failure approaching or meeting listing criteria for urgent transplantation can be discussed ad-hoc and listed upon agreement between Intensivist/Hepatologist/consultant transplant surgeons. We follow King’s College criteria for liver transplant in acute liver failure.

 

  1. e) MDM- Responsibilities of Transplant Co-ordinator:
  • Preparation of MDM
  • Circulate list to all attendees 24hrs prior to the meeting
  • Record attendance and generate quarterly report for “Chair”
  • Ensure outcomes are recorded – check database & written record
  • Contribute to MDM discussion – additional information including influential factors e.g. social issues, previous experience of patient

After approval from transplant MDM both the donor and the recipient are presented to the hospital Evaluation Committee for final approval. Hospital evaluation committee is a legal requirement of Human Organs and Tissues Act, 2009 (No.F.9 (1)/2009-Legis).

 

  1. g) The Hospital Evaluation Committee:
  2. Ensures that no organ or tissue is retrieved from non-related living donors without the prior approval of the Evaluation Committee
  3. Determine propriety of removal of a human organ from any living person using brain death protocol to be formulated; and
  • Determine fitness or otherwise for transplantation of a human organ into any other body.

 

The hospital Evaluation Committee either approves the case (for close blood relatives) or forwards it to Human Organ Tissue Authority (for non-close blood relatives).

Documentary evidence of relation is established by relevant national identity card, birth certificate and marriage certificate.

In case of non-close blood relatives the evaluation committee evaluate for the following:

  1. There is no commercial transaction between the recipient and the donor. No payment of money or money’s worth as referred to in HOTA act, has been made to the donor or promised to be made to the donor or any other person. In this connection, the Evaluation Committee shall take into consideration:
  1. An explanation of the link between recipient and donor and the circumstances which led to the offer being made.
  2. Documentary evidence of the link e.g. proof of relationship (NADRA Family Relationship Certificate-FRC).
  3. Reason why the donor wishes to donate.
  4. There is no middleman / tout involved.
  • The donor is not a drug addict or active substance abuse
  1. The next of kin of the proposed donor gives permission on stamp paper in case of non-close blood relatives.

 

SURGICAL PLANNING

After assessment of the recipient and the donor the surgical team designs surgical plan

For the living donor liver transplantation.

After this process is complete, both the recipient and the donor are informed about the process of liver transplantation in detail and informed consent is obtained separately from the donor and the recipient and the date of surgery is decided and following plan is given all the risks and benefits of the transplant to the donor and to the recipient are explained in detail. Recipient, donor and the family is provided with the opportunity to enquire any other information regarding the whole process.

 

The recipient operation will take 6-8 hours. The recipient will stay 4-6 days in the ICU followed by another 2 weeks in the hospital. The recipient average hospital stay should be around 12-15 days. Donor’s total hospital stay should be 7-8 days. The recipient will be given prophylactic antibiotics, analgesia, low molecular weight heparin for DVT prophylaxis and immunosuppressive drugs (including Tacrolimus, Mycophenolate Mofetil and steroids), anti-fungal medication and Omeprazole.

Liver transplant co-coordinator will accompany the patient and their family throughout the process to facilitate them at each and every step.

Waiting period for liver transplantation

During the waiting time we ask that you take good care of yourself. You should:

  • Eat healthy foods (our dietician can provide you with advice and an eating plan).

 

  • Take regular physical activity such as walking.

 

  • Stop smoking, as this will improve your chances of avoiding serious chest infections and survival after transplantation. In the long term it will significantly reduce the risk of cancer of the mouth and lungs. If you are a heavy smoker then you may not be considered a suitable candidate for transplantation.

 

  • Not drink alcohol, as this will cause further damage to your liver. If your transplant is being performed for alcohol-related liver disease, failure to abstain from alcohol will be considered as failing to comply with treatment and will result in you being withdrawn from the waiting list.

 

FOLLOW UP DURING WAITING TIME

After you have gone onto the liver transplant waiting list you will have a follow-up appointment with a consultant transplant surgeon. Remember it is your responsibility to keep the transplant co-ordinator up to date with changes in your condition or contact details.

VACCINATION BEFORE LIVER TRANSPLANTATION

Please note advice regarding vaccination is continually being updated.  Please ask us for the most up to date information.

  • Vaccines may consist of either a live attenuated form of the virus (“live”), or an inactivated form of the virus/viral exotoxins (“killed”).
  • For certain groups of patients live vaccines should not be given.  These include:
  • Patients on immunosuppressant therapy (This will apply after your liver transplant – please see vaccination and travel advice post transplant. However some patients may be on immunosuppressants before their transplant)
  • Patients receiving chemotherapy/radiotherapy (or within 6 months of treatment)
  • Patients receiving high doses of prednisolone
  • Patients who are HIV positive

Please note this is not a full list of patients who cannot have live vaccines.  We will be able to advise you on an individual basis. Your immunisation history should be checked before transplant to ensure that you have received the normal childhood immunisations and appropriate boosters.

  • Where there is uncertainty, titres should be checked and boosters given where necessary.  We can advise you on which boosters are necessary and how these are given as appropriate.
  • In addition to your normal childhood immunisations all patients with chronic liver disease are advised to receive the vaccines detailed below.
Vaccine When Comments
Influenza vaccine

Annually, in autumn

This can be given by your GP
Pneumococcal vaccine Adults: single dose (Pneumovax IIÒ).  Given as an intramuscular injection or deep subcutaneous injection.

 

Revaccination is usually avoided due to severe reactions occurring with the second dose.  If it is decided necessary (low titres) then an interval of 5-6 years should be left before re-administering the vaccine.
Hepatitis A Booster doses may be required after 10 years

 

DIETARY ADVICE for PEOPLE WITH Liver Disease

 

Introducing you to your diet

What you eat is important to your overall health and medical treatment. Your diet will play a major role in the clinical management of your liver disease. It is important to know what dietary restrictions are required.

The liver plays a central role in many essential body functions, including the breaking down of food, so people with liver disease may have impaired nutritional function; the degree of nutritional impairment is related to the severity and duration of the liver disease. Your recovery from any liver-related surgery will also be affected by your nutritional status too.

The dietician will advise you on balancing your diet for your particular needs. Everyone is different and diet will change before and after liver transplantation. Your nutritional status will be assessed initially and regular evaluations made to monitor the effects of nutritional advice, ensuring that deficiencies do not arise.

Get to Know Your Nutrients

Protein: Protein has many functions in the body. It is important for health and repair of the immune system, muscle, skin and other tissues. Protein-rich foods include meat, fish, eggs, lentils, yoghurt, cheese and milk.

 

Carbohydrates: These are the main sources of starch, fibre and also provide us with a good variety of vitamins and minerals in our diet.

 

Fat: Fat is a useful source of energy in the diet, especially if you have a poor appetite.  However in certain cases, fat intake may need to be restricted or alternatives used.

 

Salt (sodium): Healthy eating guidelines include advice to reduce salt intake. Some aspects of liver disease may require a more severe salt restriction.

Fibre: Fibre helps prevent constipation and related problems. It can also help control the levels of cholesterol and sugar in your blood. Good sources of fibre are wholemeal cereals, bread, pasta, lentils, fruit and vegetables.

Fluid: It is important to maintain an adequate amount of fluid intake but in some cases of liver disease, your doctor may ask you to restrict the total amount of fluid you drink each day.

You may find that you have lost your appetite or eat less than you normally would. It is very important that you don’t lose weight (fat and muscle) unnecessarily. If you find that you are having these problems, please ask to see the dietician during your stay at the hospital or ask to be booked into the dietician outpatient clinic.

Meanwhile:

Try eating small amounts at mealtimes and have a snack between each meal. (for example plain biscuits or cake, toast or crumpets). Avoid filling yourself up with bulky, low-energy foods such as soup, fruit and too many vegetables. Try to avoid drinking lots of fluids with meals as they also fill you up very quickly. Remember that if your body is retaining extra fluid  (symptoms are swollen legs or ankles) this will make your body weight increase and make it difficult for you to notice that you are actually losing flesh (fat or muscle) weight.

If you are concerned about your diet and nutrition in relation to your liver disease, ask to see a dietician either during your hospital stay or ask your doctor, nurse or transplant co-ordinator to refer you to the dietician’s clinic. They can then review your dietary intake and advise you and your family about your nutritional needs.

PRE TRANSPLANT DIETARY ADVICE

During your hospital stay you may experience:

  • Loss of appetite
  • Reduced food intake
  • Unintentional weight loss
  • Increased nutritional requirements, due to your illness

Your doctor may have advised you to follow a high protein and high calorie diet and requested review by a dietitian. Apart from the meals provided by the hospital you can request extra snacks from your nurse and/or ward hostess. The table below shows what is suitable for you.

 

 

Patients with
NO-SALT RESTRICTION
Patients with

SALT RESTRICTION

Fresh milk Yes Yes
Full fat yoghurts Yes Yes
Sandwiches Yes No cheese and  beef
Cheese & biscuits Yes No
Soup Yes No
Cakes Yes Yes
Sweet biscuits Yes Yes

 

  • Food supplements, such as build up milk drinks, are available on recommendation by a dietitian.
  • There are also shops and cafes within the hospital where you can buy food during your stay.
  • Good high protein/high energy foods can be brought in by your family but at your own risk.
  • The ward does not have a microwave oven, and can only provide very limited fridge space.
  • Please only bring small quantities of food products.

 

Patients with
NO-SALT RESTRICTION
Patients with

SALT RESTRICTION

Potted desserts – mousses/trifle Yes Yes
Ice cream (no storage on ward). Yes Yes
Yoghurts & milk drinks Yes Yes
Sandwiches Yes N0 beef  or cheese, sausage
Cheese –based meals Yes No
Cooked meals/snacks (no storage – eat on day) Yes Cooked without added salt
Cakes, scones, biscuits Yes Yes

 

If you have been advised by your doctor to reduce your salt intake, a dietician will give detailed advice early on in your admission.

Please ask to see a dietician if you have not been seen.

Please let you nurse / dietician knows if you have any other dietary restrictions or food allergies.

SOCIAL SUPPORT

 

The experience of liver transplantation may be overwhelming and confusing for you and your family.  The Liver Unit recognizes that all patients need to be treated differently and that there may be some people who find the whole process more difficult to cope with than others. It is sometimes easier to talk to a professional about your feelings and fears because you may not want to upset your loved ones.  If you feel that you need some emotional support, practical advice or just clarification of procedures or an objective listening ear, you can talk through your concerns with a Liver Unit team members.

As a parent or the family breadwinner you may be worried about the effect this prolonged period of treatment may have on your financial situation.  A long-term illness usually means a change in financial resources due to the excessive travelling involved and increased fuel and telephone bills.  Our social worker is available to discuss these concerns and to advice.

If you have any comments or suggestions about this booklet they would be welcomed and should be sent to the transplant coordinators .

 

LIVER TRANSPLANTATION

(TRANSPLANT SAVE LIFES)

PART-II: THE TRANSPLANT

LIVER TRANSPLANTATION

Risks and Benefits of Liver Transplantation

 

The benefits that you will notice from a successful transplant will depend on the problems that your liver is causing you. The most common problems are vomiting of blood or passing blood in your motions (melaena), abdominal swelling due to fluid accumulation (ascites) and episodes of confusion (encephalopathy). If your transplant is successful, these problems should be cured.

Other problems that you might have noticed are severe tiredness, itching and yellow skin and eyes (jaundice). These symptoms improve after a successful transplant. By treating these symptoms, we would hope that your quality of life would be better after the transplant. The main benefit of a liver transplant is that we would expect you to live longer than you would have done without it.

All operations have risks. A liver transplant, because it is such a big operation, has many risks, or complications. Some of the complications are easily treated, but others are more serious and can lead to death.

To put these risks in perspective, for every 100 patients that have transplant for chronic liver disease, 90 are alive a year after the transplant, and most of these will be enjoying a better quality of life than before their transplant. Five years after the transplant at least 70 of these 100 recipients will be alive. These figures apply to patients who are living at home at the time that they are called in for their transplant. The risks are higher for patients who are in hospital whilst waiting for transplantation.

Complications can be separated by time after transplant into three groups:

  • Immediate complications, which occur within the first 48 hours after surgery
  • Early complications, occurring within three months of the operation
  • Late complications, occurring after three months.

Many of the late complications are caused by the medication given following the transplant to prevent the liver from being rejected. These complications are described in subsequent sections of this pack.

When you arrive on the ward you will be seen by a doctor who will go through your medical history, examine you and take blood. You will also have a chest x-ray and ECG. After this you will have a wash with an antiseptic soap and shampoo.

A member of the surgical team will briefly check that you are happy with the consent form that you will have previously signed.

ANAESTHESIA FOR LIVER TRANSPLANTATION

An anaesthetist will have already seen you when you were being assessed for surgery. They will be kept up to date with any changes in your health since you went on the waiting list. The next time you meet them will be on the ward shortly before the operation.

Usually, you will receive a “pre med” injection (a sedative) on the ward just before going to theatre to make you feel less anxious. Your relative(s) will be invited to accompany you as far as the operating theatre, but will be taken back to the ward before you are given your anaesthetic.

When you get to theatre the anaesthetist will measure your blood pressure, oxygen levels and heart rhythm. You will be asked to breathe some oxygen before you go off to sleep, but because of the pre-medication you may not remember this.

After you go to sleep, a special tube is placed into your wind-pipe (Figure 6). This allows us to breathe for you whilst you are asleep; this will not be removed until you are awake on the intensive care unit after your transplant.

Figure 6. Tracheal intubation

The anaesthetists spend time inserting drips and ‘lines’ before your surgery starts (Figure 7). These are designed to allow us to give you fluids, monitor your blood pressure, monitor pressures in your heart and sometimes measure how hard your heart is working. This allows the anaesthetists to decide which fluid and drugs you may need during the operation. The amount of monitoring will depend on how severe your disease is and any other medical problems that you may have.

During your anaesthesia you will need to have:

  • A tube which passes into the windpipe from the mouth – this is attached to a ventilator to assist your breathing. It remains in place until you wake up and are able to breathe on your own in the Intensive Care Unit.
  • A tube that passes into the stomach via the nose – this is to prevent your stomach becoming distended or bloated during the operation. It remains in place until you are ready to drink fluid.
  • Several drips are placed in the veins of the neck and forearms. These are used to give fluid and drugs and to monitor your condition. They remain in place until your condition is stable and you are able to drink fluid on your own.
  • ECG electrodes, which are placed on your chest to monitor your heart rate during the operation.
  • A catheter (tube) inserted into your bladder, which drains urine until you are, awake enough to go to the toilet unaided.

Figure 7. Anaesthetic preparation

While you are unconscious and unaware your anaesthetist will be in the operating theatre looking after you and will remain with you at all times. He or she monitors your condition and administers the right amount of anaesthetic drugs to maintain you in the correct level of unconsciousness during your surgery. Your anaesthetist is constantly aware of your condition and trained to respond. Your anaesthetist will be monitoring such factors as heart rate, blood pressure, heart rhythm, body temperature and breathing. He or she will also constantly watch your need for fluid or blood replacement. If you have any other medical conditions, your anaesthetist will know of these from your pre-operative assessment and be able to treat them during surgery.

Pain relief

Good pain relief is important. It prevents suffering and helps you recover more quickly. Your anaesthetist will probably discuss different pain-relief methods with you before your surgery so you can make an informed decision about which you would prefer.

  • Some people need more pain relief than others. Worry increases the pain people feel.
  • Pain relief can be increased, given more often, or given in different combinations.
  • Occasionally, pain is a warning sign that all is not well, so please tell the nursing.
  • Good pain relief helps prevent complications
  • If you can breathe deeply and cough easily after your operation, you are less likely to develop a chest infection.
  • If you can move around freely, you are less likely to get blood clots (deep-vein thrombosis or DVT).

It is much easier to relieve pain if it is dealt with before it gets bad. So, you should ask for help as soon as you feel pain and continue the treatment regularly.

Opiates

These are the drugs often used for severe pain. They include morphine, diamorphine, codeine and pethidine. They may be given as tablets, injections or patient-controlled analgesia. They may also be added to a spinal or epidural to give longer and better pain relief.

Some people experience side effects from these drugs – the most common include feeling sick, vomiting, constipation, and drowsiness.  Larger doses can produce breathing problems and low blood pressure (hypotension). The nursing staff will watch you closely for any signs of these and give you other drugs to treat these side effects.

Your reaction to opiates will affect you considerably. One in three people find opiates unpleasant. If they make you very sick, controlling your pain may be more difficult. Constipation can be a problem. If it is something you are concerned about, ask the nurses who will be able to help.

Blood transfusion and blood products

Improvements in surgical technique and anaesthesia have resulted in large reductions in the amounts of blood loss during surgery, and the average requirement for transfusion is now four units of blood.

We will make a considerable effort to minimise the use of blood provided by our hospital blood bank; as we routinely use a ‘cell-saver’; a machine, which can wash your own blood lost during the operation so that it can be given back to you. However in some circumstances, blood loss can be significant and you may require large amounts of blood and clotting products.

As the diseased liver is removed, it can no longer make or release clotting products, this may require infusion of plasma from the blood bank, which contains clotting products.

The anaesthetist will be constantly checking blood results as well as how well your blood is clotting during the transplant to make sure that you get the right products to try and limit bleeding. Sometimes drugs are given in addition to try and improve clotting (Aprotinin or Tranexamic acid), these are usually only given when we expect there to be a high blood loss or where clotting is extremely abnormal before the start of the operation.

Transfer to Intensive Care Unit (ITU)

After your transplant operation, you will be transferred to ICU. You will be kept sedated during this period and won’t remember anything. Once you arrive in the ICU, the anaesthetists will hand over care to the intensive care doctors and nurses, informing them of what has happened during the transplant as well as other important information relevant to your care.

During your transplant operation, the transplant coordinators will keep your relative(s) updated on progress on a regular basis

Benefits and risks of anaesthesia

Safety in anaesthesia

Anaesthesia is necessary to allow surgery to be carried out safely and in comfort.

The benefit of anaesthesia is that it will remove pain and sensation. This benefit needs to be weighed against the risks of the anaesthetic procedure and the drugs used.  This will vary from person to person.

It is difficult to separate these risks from those of your operation or procedure and your general health.

The risk to you as an individual will depend on:

  • Whether you have any other illness
  • Personal factors, such as whether you smoke or are overweight
  • Whether the surgery, is complicated, long or done in an emergency.
  • Side effects and complications of anaesthesia

Side effects and complications

Side effects and complications after general anaesthesia are variable and to understand them we provide the following table showing an index of side effects and complications. As people also vary in how they interpret words and numbers we have also provided a scale of risk to relate it to the index (For example: the risk of something happening to one in 10 people means that, on average, it will not happen to nine out of 10 people).

Very common and common side effects and complications

Feeling sick and vomiting after surgery
Some operations and anaesthetic and pain-relieving drugs are more likely to cause sickness (nausea) than others. Sickness can be treated with anti-vomiting drugs (anti-emetics), but it may last from a few hours to several days.
Sore throat
If you have had a tube in your airway to help you breathe, it may give you a sore throat. The discomfort or pain lasts from a few hours to days and can be treated with pain-relieving lozenges.
Dizziness, blurred vision
Your anaesthetic or loss of fluids may lower your blood pressure and make you feel faint. Fluids or drugs (or both) will be given into your drip to treat this.
Shivering
This may be due to you getting cold during the surgery, to some drugs, or to stress. You can be warmed very efficiently using a hot-air blanket.
Headache
This may be due to the effects of the anaesthetic, to the surgery, to lack of fluids, or to anxiety.
Itching
This is a side effect of opiates (such as morphine) but can also happen as an allergic reaction (for example, to drugs, sterilising fluids or stitches (sutures).  If you have itchiness, it can be treated with other drugs.
Aches, pains and backache
During your operation you may lie in the same position on a firm operating table for a long time. Great care is taken to position you, but some people still feel uncomfortable afterwards.
Pain during injection of drugs
Drugs used may cause some pain or discomfort when they are injected.
Bruising and soreness 
This may be caused around injection and drip sites by a thin vein bursting, movement of a nearby joint, or infection. It normally settles without treatment, but if the area becomes uncomfortable, the position of the drip can be changed.
Confusion or memory loss
This is common among older people who have had an operation under general anaesthetic. It may be due to several causes. It is usually temporary, but may last a few days or weeks.
Chest infection
A chest infection is more likely to happen to people who smoke, and may lead to breathing difficulties. This is why it is very important to give up smoking for as long as possible before your anaesthetic.
Bladder problems
After certain types of operation and regional anaesthesia (particularly with a spinal or epidural), men may find it difficult to pass urine, and women tend to leak. To prevent problems, a urinary catheter may be inserted at a suitable time.
Muscle pains       
These sometimes happen if you have received a drug called suxamethonium. This is a muscle relaxant, which is given for emergency surgery when your stomach may not be empty.
Slow breathing (depressed respiration)
Some pain-relieving drugs can cause slow breathing or drowsiness after the surgery.  If muscle relaxants are still having an effect (have not been fully reversed), the breathing muscles may be weak. These effects can treated with other drugs.
Damage to teeth, lips or tongue
Damage can be caused to your teeth by clenching them as you recover from the anaesthetic. If your anaesthetist finds it difficult to get the breathing tube in the right place, your teeth may also be damaged. It will be more likely if you have limited mouth opening (for example, if you have arthritis of the jaw), a small jaw or a stiff neck.
An existing medical condition getting worse
Your anaesthetist will always make sure that you are as fit as possible before your surgery. However, if you have had a heart attack or stroke, it is possible that it may happen again – as it might even without the surgery. Other conditions such as diabetes or high blood pressure will also need to be closely monitored and treated.
Awareness
Your risk of becoming conscious during your operation will depend on your general health and the type of operation you are having. For example, if you are very ill, the anaesthetist may use a combination of muscle relaxants and a lighter general anaesthetic to reduce the risks to you. However, the risk of your being aware of what is going on is increased. Monitors are used during the operation to record how much anaesthetic is in your body and how your body is responding to it. These normally allow your anaesthetist to prevent your anaesthetic from becoming too light. If you think you may have been conscious during your operation, your anaesthetist should be told about it as soon as possible. He or she will want to know, to help both you and future patients.

 

Uncommon side effects and complications

Rare or very rare complications

Damage to the eyes      
Anaesthetists take great care to protect your eyes. Your eyelids are held closed with adhesive tape, which is removed before you wake up. However, sterilising fluids can leak past the tapes or you could brush your eyes as you wake up after the tapes have been removed. These may cause damage to the surface of your eye, which is usually temporary and responds to eye drops.

 

Serious allergy to drugs
Allergic reactions will be noticed and treated very quickly. Very rarely, these reactions lead to death even in healthy people. Your anaesthetist will want to know about any allergies that you or your family have.
Nerve damage
Nerve damage (paralysis or numbness) may be due to damage by the needle when performing a regional block, or it can be caused by pressure on a nerve during an operation. Most nerve damage is temporary and recovers within two to three months.
Death          
Deaths caused by anaesthesia are very rare, and are usually caused by a combination of four or five complications arising together. There are probably about five deaths for every million anaesthetics given in the UK.
Equipment failure
Vital equipment that could fail includes the anaesthetic gas supply or the ventilator. Monitors are now used which give an immediate warning of problems, and these failures rarely have serious effects.

To understand a risk, you must know:

  • How likely it is to happen
  • How serious it could be
  • How it can be treated.

The anaesthetist may use many drugs or combinations of drugs.  The more complicated the anaesthesia and surgery are, the more chance there is of complications and side effects.

It is the responsibility of the anaesthetist to advise you on what anaesthetic techniques will give you greatest benefit and reduce as far as possible these risks. Making these decisions is difficult but your anaesthetist will want to help you, so that you can make the choices that are right for you.

TRANSPLANT SURGERY

Orthotopic liver transplantation

This is the “standard” type of liver transplantation. It requires the retrieval of the liver from an organ donor and the implantation of the liver graft in the recipient patient.

The recipient operation itself can be divided in two stages: taking the old liver out (recipient hepatectomy) and implanting the new liver.

The operation starts with the abdominal incision (cut). An incision is made across the upper abdomen but this may be extended upwards towards the breastplate if the operating space is cramped (“Mercedes” incision). The diseased liver is freed from all of its attachments.

This stage of the operation may be difficult due to the presence of scarring and portal hypertension, particularly after previous surgery. The blood supply to the liver and the bile duct are prepared to receive the new liver (Figure 10). The next step is to remove the old liver completely.

The new liver is placed in the space left by removing the diseased liver (Figure 12). The liver is attached by stitching the blood vessels back together again and blood flow is restored and the liver immediately changes colour and starts to work (Figure 13).

Some liver diseases cause damage to the bile duct and are not suitable for joining up to the new liver. In these cases a loop of small bowel will be attached directly to the new bile duct (a Roux loop) (Figure 16). This procedure is most commonly performed in children and in about 20% of adult liver transplants.

After this the surgical team will spend some time stopping any bleeding. Just before closing the wound, one or two tubes (drains) will be positioned by the side of the liver to drain any fluid that may collect and release it to the outside. These drains will be removed between three and seven days after your surgery.

The muscle of the wound is stitched together using nylon stitches. The skin is closed with dissolvable stitches (do not have to be removed) that are hidden. Occasionally the wound cannot be closed in this way and stitches, which do have to be removed, are used. The surgical team will inform you after the surgery as to the reasons why the wound was closed in a different way.  After surgery you will remain asleep on the ventilator and transferred to the Intensive Care Unit.

 

“Piggy-back” operation

This is a modification of the standard operation and avoids the use of veno-venous bypass. The diseased liver is removed leaving the vena cava intact to maintain blood flow from the legs and kidneys back to the heart (Figure 17).

To do so, the liver has to be freed from the vena cava by dividing small connecting veins. A vascular clamp is placed over the three hepatic veins and the liver is removed. The donor liver is then attached by stitching the donor vena cava to the hepatic veins. Preservation fluid is flushed from the liver. The lower vena cava is tied off (Figure 18) and the portal veins joined together. Blood is then let into the new liver. This technique is quicker and avoids potential complications of veno-venous bypass.

Figure 18. Lower donor vena cava tied off

Living related liver transplantation

Living related liver transplantation was started in the early 1990’s to overcome a shortage of livers for children. Due to scarcity of cadaveric organs in Asian countries, living donor liver transplant is the main stay of treatment for patients with end stage liver disease.  In this procedure, part of a parent or relatives liver, is surgically removed and transplanted into the recipient. It has now become possible to donate the right or left lobe to an adult. The risks of this procedure are greater and the results are comparable to whole liver transplantation.

Living related liver transplantation is at present the main source of liver transplantation in Pakistan, both in children and adults.

As living donation is not risk-free, a thorough medical, psychological and social assessment of the potential donor is performed to ensure that the medical risks are as low as possible (see information leaflet on living donors).

The recipient operation in children is the same as for a cadaveric left lateral segment graft and in adults as right lobe split liver transplantation. Immunosuppressive regime is also similar.

Auxiliary liver transplantation

In some cases of acute damage to the liver, it is possible to perform an auxiliary liver transplantation as an alternative to the standard procedure.

This operation involves:

  • The removal of part of the diseased liver, leaving the remainder intact and with potential for recovery (native liver)
  • The implantation of a donor liver, which will provide effective function and allow the survival of the patient

Over the longer term it appears that the majority (80%) of survivors have recovered their own liver and approximately two thirds of patients will be able to wean completely from their immunosuppression by two years post transplant.

Auxiliary liver transplantation provides the prospects of long term survival without the need for immunosuppression and our current results are comparable to those obtained by whole liver replacement.

Domino liver transplantation

Some patients with a rare hereditary disease called “amyloidosis” need a liver transplant to stabilise their condition. The livers from these patients are perfectly normal except that they produce an abnormal protein (amyloid) that causes their disease.

It takes between 30 to 40 years for the amyloid damage of nerves and organs occur. Therefore, we consider these livers for transplantation in selected patients in need of urgent or high risk transplantation.

(GIFT OF LIFE FOR YOU ….and…. THE LIFE GOES ON)

LIVER TRANSPLANTATION: PART-III: THE POST TRANSPLANT CARE

Early POST-TRANSPLANT PERIOD

intensive care Unit STAY
All adult patients return to the Intensive Care Unit immediately after their liver transplant. The majority of people who receive a liver transplant will stay in the ITU for 72-96 hours.
Immediate Postoperative Phase
At the end of the operation, you will be transferred to the Intensive Care Unit (ITU). At this point you will be asleep and sedated and will be unaware of this process. In the first few hours after transplant, we will be assessing you to make sure that there is no serious bleeding and that your new liver is functioning well. You will be attached to a breathing machine (ventilator) and we will continue to monitor your heart rate and rhythm, blood pressure, urine output and the levels of oxygen and acid in your blood. All of the drips and tubes that were inserted whilst you were in the operating theatre will still be present. Using this information we can decide which fluids and drugs that you need. During this period you will be examined by the doctors responsible for the ITU and also receive one-to-one nursing care.
As soon as you return from the operating theatre, we will perform more blood tests, to check liver function and clotting, and also a chest x-ray and ECG. We will try to allow your immediate relatives to visit during this period after surgery.

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