Liver Transplant

Where is the liver?

Your liver is located underneath the right ribcage, immediately below your diaphragm.  You can feel your liver by pressing firmly below the ribs whilst breathing in.  It is a solid organ measuring about 14cm across, but can be larger in some diseases of the liver (hepatomegaly – large liver). With cirrhosis of the liver, the liver can shrink.

Basic organ function

Some functions of the liver include:

  • Cleansing and metabolising nutrients that have been absorbed from the intestine.
  • Production of bile to assist in the digestion of foods and in particular in the breakdown of fatty foods. One of the major items that the liver breaks down is alcohol, using a specific enzyme to break alcohol down to acetaldehyde. Acetaldehyde is further slowly broken down by other liver enzymes, but this all takes time.  A build-up of acetaldehyde in the bloodstream results in a ‘hangover’.
  • Production of blood clotting factors
  • Storing of sugar as glycogen and then restoring it back to glucose when the body needs energy
  • Detoxification of chemical and metabolising of drugs

Effects of a non-functioning organ

Liver failure occurs when parts of the liver become damaged beyond repair and the liver is no longer able to function. Liver failure has a number of consequences. If you have liver failure initially you will have:

  • Nausea
  • Loss of appetite
  • Fatigue
  • Diarrhea

As the liver failure progresses, the build up of bile in your body will cause the following

  • Yellowing of your eyes and skin.
  • Itchy skin
  • Weight loss
  • Sleepiness and mental disorientation
  • Swollen abdomen
non functioning liver effects

Diseases resulting in liver failure

Many conditions can occur as a result of a non-functioning liver.  Here are a few:

  • Fatty liver (Cholesterol or triglycerides can accumulate in the liver).
  • Cirrhosis of the liver (Scarring of the liver).
  • Oesophageal varices (protruding blood vessels as a result of liver failure).
  • Alpha-one anti-trypsin deficiency (a birth defect with a missing enzyme).
  • Primary biliary atresia (bile ducts don’t form properly).
  • Alcoholic liver disease and other drug-induced conditions.
  • Hepatitis (A, B, C and others) may affect liver cell functioning.
  • Wilson’s disease (disorder of copper metabolism).
  • Ascites (fluid build-up in the belly).

Treatments for a non-functioning liver

Treatments for liver failure may depend on the conditions or disease that led to liver damage and or may not be reversible. In many occasions there is a treatable cause and the liver may recover after treatment and resume its normal functions.  e.g. If the liver failure was due to a virus, the liver often recovers with supportive care once the virus has run its course.

One of the most common causes of liver disease  is alcohol abuse. Alcohol is directly harmful to the liver and can cause inflammation of the liver  (hepatitis). The first course of action in alcohol related liver disease should be to stop causing injury to the liver by ceasing consumption of alcohol.

In case of diseases like  Wilson’s disease the management is in reducing copper consumption in food and water. Additional medications may assist in this effort.

In other cases of liver failure, it may be necessary to be considered for a liver transplant.  A referral to a liver transplant unit is required for an assessment to take place in order to determine suitability.  Many people are not suitable for a variety of reasons.

Donation

Organ donation of a liver ideally is matched as closely as possible to both blood type, as well as to the size of the potential recipient to the donor. However in emergency situations, blood group incompatible Liver transplants are performed and wide differences in size are accepted, if there is no alternative. Liver transplantation requires that the recipients’ diseased liver is removed and the donor’s liver is put in the same place as the diseased liver.  This is known as orthotopic transplantation.  In some instances, larger livers can be cut down to reduce their size, and the cut down portion may be transplanted into a child or small adult.

Source and number of donors. Most liver donors come from deceased (cadaveric) organ donors.  In rare instances, a living liver donor can donate a lobe of their liver to a relative or friend, however, the risks to the “healthy” donor are considerable, and thus this option is not taken lightly by the medical staff of the transplant unit.

Donor operation

Deceased Donor operation. After death of the donor, the liver retrieval team goes to the donor hospital, while blood tests are being performed, and potential recipients identified. Along with other retrieval teams for other organ types, the organs are removed in a careful and precise order to maintain as many blood vessels and bile duct structures as possible

Transplant recipient selection & recipient preparation for transplant

Transplant recipient selection

If you are waiting for a liver transplant,  you will be evaluated according to a rigorous protocol and placed on a waiting list by your transplant unit. Your eligibility to receive a transplant will be based on factors including urgency, blood type, size, ability to receive an organ.   If a hospital in the same state as the donor cannot appropriately match a potential waiting recipient, the organ is offered interstate.

Recipient preparation for transplant

Once you have been identified as a potential match for a donor, you will be contacted and asked to come to the hospital.  Often two potential recipients are called in case the first choice has an issue that makes them unsuitable to proceed to transplant e.g. in infection.  It will often be many hours between receiving the call and being prepared to go to surgery.

The surgical operation

The surgical operation

Liver transplant surgery requires opening up the belly from the navel to the sternum and also to the side.  The surgeons will remove the diseased liver maintaining as many blood vessels and bile duct lengths as possible.  Once completed, the bile duct should already be producing bile before closing up the abdominal wound.

Immediate recovery from the operation

After the operation, you will be sore!!  However, the liver should be working, and almost immediately the yellow in your skin and eyes will start to fade.  Apart from checking for infections and the like, the week or so after the operation is spent adjusting the medication dosage so they are right for you.  The time spent in hospital after the operation can range from a week to several weeks and depends on how quickly you can regain strength and how rapidly the liver function blood tests become stable.

Immune suppression and other medications

You will be on immunosuppression medication for the rest of your life, to prevent rejection.  Many such medicines also have additional side-effects, for which other medication may be given. To reduce the amount of immune-suppression medication you need to take, additional medications, such as prednisone are prescribed.  Approximately 10% of all transplant recipients become diabetic after transplant.  Blood pressure, as well as kidney function, is also monitored closely.

Organ functioning after transplant

After the transplant, your organ will probably function perfectly, but maintaining that for the long term require that you look after your transplanted organ.  Ensure you keep taking your medication on time and regain physical activity (slowly).  Being immune suppressed means that you are now more susceptible than ever to infections and to cancers such as skin cancer.

Discharge from hospital

Hospital discharge is an important step, but please remember that many nurses and doctors and other hospital staff have put a lot of effort in your regaining a lifestyle in the community. Ensure that you say “thank you” to everyone you can.  They will appreciate it.

Recovering at home

For at least a few weeks afterward, do not over-do things.  But also do not lounge around all day.  You should be able to return to a normal lifestyle within a couple of months. Spend the time appreciating those around you and what this generous donation has done to improve your quality and quantity of life.

Doctors monitoring

You will be required to visit your doctor on a regular basis.  Initially, this may be quite regular, but in time will extend to several months. If seeing multiple doctors for different things, please ensure that all doctors know what medications you are taking.  Some medicines do interact with other medications and must be taken with care.

Blood tests

Blood tests are used to monitor your liver and kidney function as well as other blood variables. Blood tests should ideally be done the day or so before your doctor’s appointment so that they have the latest information.

Stages of returning to activity, including work

Return to work or other activities only if you feel up to it.  It is recommended you start slowly in the first instance.  This also includes sexual activity. If in doubt, ask your doctor.  Don’t be shy – they have heard it all before.

Healthy eating

This is a no-brainer. Do eat healthy food. Everything and anything in moderation.  It is highly recommended that you do not eat raw meats (including fish etc) until you are completely stable.

What to avoid

Because you are immune suppressed, always check with your Hepatologist if another doctor suggests you should receive any immunisations.  The Mantoux test for tuberculosis and immunisations for yellow fever, for example, are forbidden as are any other immunisations using live or weakened bacteria or viruses.  However influenza vaccinations or immunoglobulins are okay. Avoid coming into close contact with children or people with chicken pox or measles etc.

Driving after Transplant Surgery

You may wish to resume driving as soon as possible after your surgery. You must check with your doctor to clarify when it is safe to drive. You can resume driving after four to six weeks post-transplant depending on the type of surgery you have had and the size of the wound. Before driving, ensure that your wound is healing well, that you are alert and not fatigued, no longer experiencing significant pain or taking medications that can cause drowsiness.

For information on assessing fitness to drive, please visit the website www.austroads.com.au . The guidelines on this website outline the responsibility drivers, health professionals and the licensing authorities. The rules for driving are very clear and are set out to protect you, the transplant doctors and the general public.

Respect your new organ

It is highly recommended that you do not drink alcohol after receiving a liver transplant.  If you transplant was due to alcoholism, then this is imperative.  Respect your new organ as it will be rapidly damaged by alcohol and you will not be eligible for a further transplant.

Enjoy life

In most cases, liver transplant recipients have received their new organ after the donor died.  You should live your life to the fullest in order to give thanks to your donor’s gift.  Think about writing to your donor family anonymously through DonateLife or your transplant unit making sure that you keep your comments anonymous and do not identify yourself.

Finally, ensure that you ‘make the most of life’.

Acknowledgements

This information is intended for educational purposes only. Transplant Australia acknowledges that each patient experience is different and does not provide this information as a substitute for medical advice. Please contact your transplant unit or doctor if you need medical advice.

Transplant Australia gratefully acknowledges the contribution of Dr Henry Pleass (Professor of Surgery at Westmead Clinical School, University of Sydney) in developing and reviewing this material.