liver transplant – House Medicine

The Transplant Process

In order to undergo liver transplantation, a number of steps and procedures must be followed to ensure a successful transplant process. These steps include:

Patients are usually referred to us by their hepatologist or oncologist. We do accept self-referrals! Patients are encouraged to seek transplant evaluation as soon as diagnosed with moderate hepatic insufficiency. This is to establish records, perform the appropriate workup, and proceed with transplant listing.

The Work up Process

After successfully completing your initial pre-transplant evaluation, your transplant coordinator will begin scheduling appointments for testing and procedures needed prior to transplant. Some of these tests or procedures will need to be updated annually. Your transplant coordinator will notify you when a test or procedure needs to be updated. It is important to keep up with your tests and procedures so that you can be transplanted when you get the call.

Required Testing

Simple blood tests including blood typing
EKG
Chest x-ray
Dental exam
Abdominal Ultrasound
Coronary Angiogram (for all patients over 45, diabetic, or risk factors/history of heart disease)
Cardiology consult (if you have risk factors, are diabetic or over age 45)
Colonoscopy (for all patients over the age of 50)
Mammogram and Pap smear for all women over the age of 40
Recent Prostate Specific Antigen (PSA) for all men over the age of 40

All patients will be presented at the Patient Selection Committee Meeting (PSC) after they have completed all their testing and have been seen by the multidisciplinary transplant team.

The purpose of the PSC is to review the results of testing, discuss visits with the multidisciplinary team, and to determine if they qualify for placement on the transplant wait list.

The results of the PSC discussion will be conveyed to the patient and referring physician within 10 days.

If you are approved and cleared by the multidisciplinary team in PSC, you will be added to the National Waiting List for pancreas transplant. You will be placed on the waiting list based on your blood type and antibody test.

The national organ waiting list is managed by an organization called the United Network for Organ Sharing (UNOS), a private, nonprofit agency that works with the federal government. UNOS keeps track of all the people in the United States who need pancreas transplants, and matches them with donors.

If you are not approved for listing at the time of PSC, your transplant coordinator will explain any additional testing or requirements to get you listed for transplant. On some occasions, you may not qualify for transplant. Your coordinator will explain in detail as well as send a letter to your primary doctor explaining the reasons you cannot be transplanted at this time.

Organ Offers

When a suitable donor is found, the surgeon and coordinator will first review donor history and testing results. If the offer is suitable for you, the surgeon will give the OK to admit you for your transplant. In some cases, the surgeon or transplant coordinator may call and discuss the organ offer with you.

Getting the Call

Once you have received a call from the coordinator and you have accepted the organ offer, you will then be instructed to arrive at St Vincent as soon as possible. Please drive to St Vincent with as many important members of your family as necessary.

Your coordinator will ask you the following questions:

What time did you last eat or drink anything?
When was your last dialysis session?
Have you had any recent admissions to the hospital or new health problems?
Have there been any changes to your life situation (ie, support, financial, or emotional states that may impact your post-transplant care

Once these questions have been answered, you coordinator will instruct you not to eat or drink anything and come to the hospital. If you are diabetic, please inform the coordinators so that instruction about medication dosing can be given. You should bring all current medications and a bag with a set of clothes and other essentials for hospital admission.

Arrival to the Hospital

We strive to proceed with transplant ASAP, however we realize there may be need for further evaluation and or need for . You will be directed to Admissions and then the floor for nursing assessment, have some additional testing done including blood work, EKG, and chest xray, and any other testing that needs to be updated since your last clinic visit. You may require dialysis prior to your transplant. The transplant surgeon will order dialysis if needed.

On arrival to the hospital, you will be greeted by your surgeon. He will prefer to speak to you and your family members about the details of the process, including risks and benefits.

The Transplant Operation

The process of anesthesia, prior to the actual surgery starting, can take 1-2 hrs. The anesthesia portion involves sedation, paralysis, intubation (insertion of a breathing tube), IV lines (arterial, central venous, cardiac monitoring), and occasionally transesophageal echocardiography.

In addition, prior to surgery a catheter will be placed into your bladder to drain urine and tube in our stomach via your nose (nasogastric tube). These catheters are generally removed on post op day 3-4. On rare occasion depending on your condition – the catheters may stay longer.

In some instances, surgery starts by proceeding with incisions made in your upper chest and grown for placing large IV lines to allow for blood “bypass”. Once this is completed an incision on your abdomen.

Your old liver is removed and your new one is replaced.

The two veins, one artery, and bile duct of the new liver all require surgical reconstruction. These are major blood vessels in the body and extreme care is taken during the re-sewing of these vessels.

Surgery time varies from 6 hours to as long as 14 hours. More or less time does not mean better or worse results. Every patient is different and unique in their own way that can affect surgery time.

On rare occasions there is a planned scenario to bring the patient back to the operating room during the course of the next 1-3 days. This is often not related to complications but more so related to anticipated staging steps of the operation for certain people. You are then awakened and transported to the recovery room or directly to the intensive care unit (ICU). While in the ICU your blood pressure, heart rate and lung oxygen exchange will be closely monitored. The ICU is a busy location with critical patients and thus family visits and intervals are limited. Once your doctors consider your condition stable they will then transfer you to the transplant floor outside the ICU.

After successfully receiving a transplant, our job is not done. A transplanted organ requires periodic maintenance and follow-up care to make sure both the organ and the patient continue to thrive!

Hospital Recovery

Once surgery is complete, you are then awakened and transported to the recovery room or directly to the , which is located on the 4th floor.

Your surgeon will have spoken to your family and they should be able to visit you within 1-2 hours of arriving at the ICU, Once your doctors consider your condition stable they will then transfer you to the 5th or 7th floor.

In general by now you will be free from most IV lines and allowed to eat and ambulate. During surgery a catheter will be placed into your bladder to drain urine. This catheter is removed on post op day 3-4. On rare occasion depending on your condition- the catheter may stay longer or you may even be sent home with a catheter to have a voiding trial later at the clinic.

By post-op day 4-5 you are ready for discharge. Instructions include:

Avoiding excess water intake.
Avoiding any food products with high potassium.
Resuming diabetic diet and care if diabetic.
Appropriate precautions for infection control.

Possible complications following kidney/pancreas transplant include:

Clot in the pancreas or kidney: Usually noted within the first 24-48 hours post-op, and can present with sudden abdominal pain and an acute rise in your blood sugars. The treatment for this condition is unfortunately removal of the pancreas or kidney, and we are not able to salvage an organ under these circumstances. You may in the future qualify for a second transplant.
A break in the suture line of the bowel or bladder: This suture line break down leads to leakage of stool in the case of bowel drainage or urine and pancreatic juice. Both complications require urgent repair, which may or may not be successful, and may lead to multiple surgeries and/or eventual pancreas removal.
Delayed Graft function: Sometimes the transplanted kidney may not function immediately, and occurs in approximately 30-50 percent of deceased donor kidneys and less than 10% of live related or non-related kidneys. During this delay, the kidney is either making little urine or no urine at all, and you may need dialysis. Sometimes you may be discharged home on dialysis as we monitor improvement in your kidney function over time.
Post-op pain
Post-op bleeding requiring blood transfusion
Infections that may include large abscesses which require wash out procedures and placement of drains.
Urine leakage from the bladder suture line, for which you will be taken back to surgery for an attempt at correction.
Hernia formation requiring surgical intervention.

We advise all patients interested in pancreas transplant there may be up to 30% chance of a second surgical procedure to repair or possibly remove the kidney and/or pancreas. The rate of pancreas clot nationally is 1-5% and we are proud to have better than expected pancreas results at St. Vincent.

Discharge from Hospital

Going Home from Transplant

During your admission to the hospital for pancreas transplant, the transplant coordinator will meet with you and your designated caregivers to discuss and educate you about how to take care of your new organ. A log book and manual will be given during your first teaching session.

You will be taught to monitor for:

Signs and symptoms of rejection or infection
How to record your weight, urine output, blood pressure, heart rate, and temperature
The education sessions take place immediately after transplant, throughout your hospital stay, and upon discharge.

Medications

A transplant Pharmacist will review all of your new life-long medications to prevent rejection. All other medications you are taking will also be reviewed with you before discharge.

24-Hour Nursing Care

A nurse is available 24 hours a day, 7 days per week including weekends and holidays. They can be reached at (213) 484-5551. The nurse can answer any questions you have related to transplant and call your doctors with any urgent needs.

The first 90 days

After leaving the hospital, you will follow up in the transplant clinic closely, as frequently as daily until you are stabilized. Labs are done every clinic visit in the morning before you take your medications. The transplant team will monitor your lab results, urinary output, vital signs, and incision closely to assure no complications arise.

What to bring to your clinic visit

Your log book (tracks urine output, vital signs, and blood sugar if necessary)
Medication list
All your medication bottles
Snacks, comfort items (pillow, blanket, books, etc) while you are waiting

At the end of your clinic visit, your transplant coordinator will review any medication changes and provide a new medication list, prescriptions and lab orders for the next visit. It may be necessary to call you at home with lab results. Keep your medication list with you and be prepared to write down any changes to your medications.

The First 5 years

Once you are more stable, you will be seen less frequently in the transplant clinic. You will need to follow up with your primary doctor 90 days after transplant and regularly after that. Your primary doctor will manage any related health issues such as high blood pressure and diabetes, and your regular annual health exam and cancer screenings. You will also need to follow up with any specialist physicians regularly such as Endocrinology and Cardiology.

What to bring to clinic

Medication list
Any new medications or changes prescribed by another doctor
Any requests or orders from your primary or other doctor(s)

A needle biopsy may be needed to find the reasons for ongoing problems with the pancreas transplant. Possible treatments for chronic rejection include different types of immunosuppression, steroids, or other medications.

Understanding Your Liver

The liver is an important organ located in the right upper abdomen. It is responsible for more than 500 different tasks in your body! Some of the important ones include:

Conversion of food to energy
Detoxification of drugs and poisons
Metabolism of medications
Production of bile for digestion
Production of blood clotting factors

Conversion of food to energy, detoxification of drugs and poisons, metabolism of medications, production of bile for digestion, production of blood clotting factors

Problems With Your Liver

The liver has an amazing ability to regenerate when damaged. However, there are certain conditions which permanently effect the liver and require medical intervention. Some of these include:

Hepatitis

Hepatitis is a viral infection that affects the liver. The first sign of hepatitis may be flu-like symptoms or yellowing of the skin and eyes (jaundice). In some cases no symptoms might be noted.

Hepatitis is a viral infection that affects the liver. There are different types, but the two most common are and . The virus is spread through contact or contamination of blood.

If the disease has been left untreated for many years, hepatitis may lead to cirrhosis, cancer, or end-stage liver disease requiring liver transplant.

The first sign of hepatitis may be flu-like symptoms or yellowing of the skin and eyes (jaundice). In some cases no symptoms might be noted.

If a patient has risk factors for infection, hepatitis can be diagnosed with blood tests.

Sometimes patients may require further specialized imaging or liver biopsies to determine the extent of damage to the liver.

There are a number of FDA approved medications for hepatitis B and C. Newer medications are all-oral and have low side effects. After taking these medications, more than 95% of people are cured for life. Patients who develop liver cancer or cirrhosis may require or transplant.

Fatty Liver Disease

Fatty liver occurs when the liver begins to store fat at levels that are not normal. This usually occurs when a patient is at least 20 pounds overweight.

Fatty liver occurs when the liver begins to store fat at levels that are not normal. This usually occurs when a patient is at least 20 pounds overweight. In some individuals, the liver becomes fatty but no damage is done, this is called non-alcoholic fatty liver disease or NAFLD. In other people, the fat in the liver causes damage, and this is known as non-alcoholic steatohepatitis (NASH). NASH is the form of fatty liver that is very dangerous to your health.

NASH occurs when there is inflammation of the liver because of fat. This often occurs in people who are overweight, pre-diabetics/diabetics, those who have high cholesterol, or people who take certain medicines. Because of the damage being done to the liver, the “enzymes” become elevated, which is another way of saying your liver cells are dying faster than expected. As your liver cells die, they are replaced with scar tissue (fibrosis).

Fatty liver may not cause any symptoms in some people, others may complain of pain on their right side where the liver is. The liver actually does not have nerves to sense pain, but it has a capsule or skin around it that does have nerves. As the capsule stretches because of the fat, patients may experience a constant dull pain. If a patient’s weight increases 10% above the ideal amount, then probably fatty liver is present.

Blood Tests

If fat is harming the patient would be to check a blood test, specifically measuring liver enzymes. If the AST and ALT are high, this may be a sign that the patient has NASH.

Imaging

Fatty liver disease can be diagnosed by a ultrasound, MRI, CT or fibroscan, which can also tell your doctor if there is serious scar tissue present.

Liver Biopsy

A liver biopsy can tell us what stage you are at and confirm the diagnosis of NASH.

Currently, the best treatment for fatty liver is diet and exercise, along with good control of other medical condition like diabetes and high cholesterol. Losing just 20 pounds brings most patients back to health. Vitamin E may help but increases risk of heart disease and prostate cancer, so we don’t recommend it.

What is the best diet for me?

Please avoid animal fat and refined sugars. Red meat, fried food and sweets are especially harmful. This may be because of a genetic difference between you and other people.
Diets rich in vegetables, fruits, nuts, olive oil and lean meats like salmon is a good option, this diet is commonly known as the Mediterranean diet.
A registered dietician is the best person to go through this with you. We will help you find one.

What can I eat?

Breakfast

Fruits: Papaya, berries (raspberries, strawberries, blueberries), peaches, apricots, apples, pears, kiwi and melons.
Non-fat yogurt is the only dairy you are permitted to eat.
High fiber cereals.
No bacon or ham.
Don’t use butter.
No milk, eggs, or cheese. If you plan on eating eggs, only eat egg whites.
Vitamin D and calcium pills can replace your dairy intake.
Lots of water. Coffee is good.

Lunch

Soup is best. Should be a clear broth with vegetables.
Chicken is “OK”.
No excessive pasta. Small amounts may be ok.
Avoid canned food since it often has a lot of salt.
Salads should never contain anything white. No cream or cheese.
Avoid sodas.
Drink water or green tea.

Dinner

Vegetables and fish. Fish should not be bigger than your palm and salmon is preferred.
No bread/tortillas, no rice, no potatoes.
Absolutely no RED meat. No pork.
Fish or organic chicken that has not been fried is acceptable.
No sugary desert. Artificially sweetened or fruit may be the best replacement.

What can’t I eat?

Avoid anything from a cow or a pig.
Nothing fried.
Reduce the amount of milk and cheese significantly.
Avoid butter.
No white bread or tortillas.

Cirrhosis

Cirrhosis occurs when the liver becomes “scarred,” oftentimes due to chronic alcohol use or infection with hepatitis virus.

Cirrhosis is inflammation and scarring of the liver. It can be a consequence of fatty liver disease, hepatitis, or heavy alcohol abuse. Both women and men who drink too much can have this condition. Some information suggests that genetics and problems with alcohol metabolism can make this condition worse. Cirrhosis can also occur at any age, but usually takes many years to develop.

Cirrhosis can be diagnosed by clinical exam. Patients with cirrhosis oftentimes can develop:

Jaundice
Swelling in the belly and legs
Confusion
Severe fatigue
Bruising and easy bleeding
Coma

Cirrhosis can also be diagnosed by: