What is Liver Transplant - How and Why it is done?
We would have all heard about organ transplants, but not completely aware of the reasons behind the transplant and life of the person after a transplant. I have pushed myself to writing this hub after a recent incident that happened with one of my friends' friend who has had a liver failure due to Liver Cirrhosis and for whom the doctors have advised a liver transplant.
Having undergone treatment for the past one year, he has not shown any signs of improvement and his health has been deteriorating. He's also been waiting for a long time for a donor liver with no success, and now his sister has come forward as a donor. Doctors will be removing 70% of the donor’s liver for transplantation.
Now this was something that I did not know before and I always thought that people who were alive could not donate their liver. I just got too curious and started reading about this and the information that I found was quite surprising. There is so much that one does not know.
I have discussed here what a liver transplant is, the types of liver transplants, who needs a liver transplant, why it is done, how it is done, how a person prepares him/herself for the process and the recovery process.
What is Liver?
All vertebrates(Animals having a bony or cartilaginous skeleton with a segmented spinal column and a large brain enclosed in a skull) have a liver.
Liver is considered to be the largest organ in the human body and weighs almost 3 pounds (4 pounds in men and 2.8 pounds in women). It is reddish brown in colour and is protected by the rib-cage. It is located below the diaphragm and to the upper right side of the stomach.
The liver has a right lobe and a left lobe and holds more than 1/10th of the body’s complete blood supply. Each lobe is made up of thousands of lobules that are connected to small ducts which connect to larger ducts to form the hepatic duct.
Liver cells are replaced by regeneration if they are lost, unless they are severely damaged, when they become irreparable.
Liver helps with digestion, producing proteins, producing bile, nutrients extraction, filtering blood off drugs and poisonous substances, controlling glucose levels (converts food into energy), fighting infections, balancing hormones, regulating fat metabolism, controlling blood clotting and many more.
What is liver transplant?
A liver transplant is a surgery or operation to remove a diseased or damaged liver and replace it with a healthy liver. The person from whom the liver is taken is called the donor (living or dead person who donates blood or other organs and body parts to a living person in need) and the person into whose body the liver is implanted is called the recipient.
The first liver transplants were performed in the 1960s and long-time survival of a patient after a liver transplant has improved in the recent years due to the discovery of immunosuppressants (prevent immune system from rejecting the transplanted liver).
With recent discovery of so many drugs and technologies, one need not be worried about the transplant process. Worrying worsens the health condition, so it is very important to be positive, and the transplant team will help you with the entire process.
When is liver transplant recommended?
A liver transplant is recommended to anyone whose liver is damaged to a point that it cannot perform its normal functions. Specialists from a variety of fields evaluate the patient, reviewing their medical history and performing different tests. Only after all these, it is decided whether a patient needs a liver transplant and if that is the only hope for long time survival for a person with liver failure.
What is liver damage/failure and how can it become damaged or fail?
Liver damage/failure occurs when the liver becomes damaged beyond repair. The liver will no longer be able to function as normal and is called End-Stage Liver Disease (ESLD). Liver damage/failure can be rapid/occur suddenly (acute liver failure) or gradual (chronic liver failure) over a few years due to a long term problem and it is life-threatening. It requires urgent medical attention.
The causes of gradual / chronic liver failure can be:
- Hepatitis B and C (due to blood borne virus)
- Alcoholic cirrhosis (Alcohol consumption over a long term)
- Primary Biliary Cirrhosis (PBC) (immune system attacks the bile ducts, liver gets damaged)
- Sclerosing cholangitis (backup of bile in liver due to narrowing of bile ducts)
- Hemochromatosis (body has too much iron – inherited disease)
- Alpha-1 antitrypsin deficiency (unnatural accumulation of Alpha-1 antitrypsin in liver)
- Acute hepatic necrosis (death of tissues in the liver)
- Biliary duct atresia (deformation of bile ducts or absence of bile ducts)
- Wilson’s disease (disease caused by abnormal levels of copper in the body and liver – inherited disease)
- Early stage Liver cancer (tumours that start in liver but have not yet spread outside the liver)
How to Recognize the Symptoms of Liver Disease
The causes of acute / rapid liver failure can be:
- Hepatitis A, B and C in children
- An overdose of Acetaminophen
- Ingestion of poisonous food
- Reactions to certain medicines
Symptoms of liver failure:
The early symptoms of liver failure can be mild and they are common symptoms like diarrhoea, loss of appetite, tiredness or weakness, feeling sick or vomiting, loss of weight, abdominal pain, pale stools etc., which is the reason why early diagnosis becomes difficult or ignored. These can also be confused with other health problems. Symptoms become prominent only when the damage is high and the liver is finding it difficult to function. As the situation becomes serious, the symptoms are serious like Jaundice, swelling in the abdomen due to enlarged liver, dizziness, coma, confusion, bleeding, dark urine, dark stools, high temperature, blood vomiting, etc.
Ultrasound images of Chronic Liver Disease
Diagnosis of liver failure:
Liver problems and liver failures can be diagnosed with a number of different tests.
- LFT (Liver function tests) – This tests help to find the enzyme levels in your liver. Damaged livers release a large amount of these enzymes into the blood and hence the enzyme level will be high in the blood if the liver is damaged. Also the speed at which the blood clots will help determine the functionality of the liver.
- Blood tests – These tests are done to find out the blood type, the time it takes to clot, the biochemical status of blood
- Autoantibody tests – Antibodies help to fight infections in the body. Sometimes the immune system attacks the cells and tissues in the body and this is called autoimmunity. If this is the case, then presence of these antibodies in the blood will help diagnose autoimmune liver diseases.
- Virology – This test is conducted to check viruses in the blood stream for example hepatitis virus and for AIDS testing. The test conducted to check the amount of virus in the blood is called virology.
- Ultrasound scan – This scan is used to look at the liver and often used to check the conditions of bile ducts and gall bladder. It will also help to see if the liver is enlarged.
- CT (Computed Tomography) scans – These tests are conducted to get a clearer image of the liver and can help with biopsies. This uses x-ray equipment.
- Echocardiograms – This test is done to evaluate the functionality of the heart
- Pulmonary function studies – These tests are performed to study the performance of the lungs.
- MRI (Magnetic Resonance Imaging) – This is a more powerful scan than the CT scan and helps in investigating tumours. This scan uses a tube scanner.
- Liver biopsy – While all the above tests are done externally and will not give complete information about the disease, the liver biopsy is a method where a tiny piece of the liver is taken for diagnosis. In this method, a fine needle is sent into the body, into the liver and a tiny piece is withdrawn. This sample is then examined under a microscope to study the condition of the liver.
Treatment of liver failure:
Liver failure can be treated with proper medication, if the failure is due to overdose or due to a virus attack. In some cases where part of the liver is functioning, treatments can be taken to save the part that is functioning. In cases where the deterioration of the liver has been long term, and no other treatments work, then a liver transplant will have to be done.
Types of liver transplant:
Liver transplants can be done in cases where the donor is a living donor or a deceased donor. There are three types of liver transplant.
Living donor liver transplant (LDLT) - A liver segment is removed from a healthy living donor and implanted into the recipient after extensive medical and psychological evaluations. Both the donor and the recipient have to be in stable health to undergo transplantation and for it to be successful. This option is used for patients who have an end stage liver disease. The livers of both the donor and the recipient grow to normal size in a few weeks’ time. This method is widespread these days, as the liver regenerates quickly and there is a shortage for deceased donors. The first living donor liver transplant was performed in November 1989 at the University of Chicago Medical Centre.
Deceased donor liver transplant – In this case the deceased donor maybe a victim of an accident, whose brain has stopped working permanently but the heart is still beating or a person who died just recently. The liver from this donor is taken and transplanted to the recipient provided all the tests are successful.
Split donation – This is similar to deceased donor organ donation, where the liver from the deceased donor (recently died) is removed and split into two pieces (one large and one small). Each piece is implanted into two different people and they grow into a normal size in a few weeks.
Criteria for liver donation:
- Good health
- Matching blood type
- Desire to donate
- Be between 18 and 60 years old
- Donor and recipient have to be of similar size or donor bigger than the recipient
- Pass all the liver tests and scans
Preparation for Liver transplantation:
Hospital and specialists will evaluate the patients for liver disease and the cause for liver disease. Donors will be tested for infections, hepatitis, AIDS and other problems. The recipients and donors are checked to see if their blood type and body size match. The team that will work on the transplantation will do a pre-transplant evaluation. The patient will be contacted once a donor becomes available and the transplant will happen if the liver is compatible.
For detailed information on how a patient gets prepared for a liver transplant, and what information they are provided with, please follow the link below.
How liver transplant is done?
The liver transplant operation is a major operation and takes from six to twelve hours and can be sometimes even more up to eighteen hours depending on individual cases. Anaesthesia is given and all the necessary tubes are inserted. A long incision is made across the abdomen and the location and size of the incision depends on the anatomy of the patient’s body and the surgeon’s approach towards the surgery. The native liver is removed by disconnecting the blood supply and bile ducts in the liver and the donor liver is placed in the same location anatomically connecting the blood vessels and bile ducts. The incision is then stitched / stapled to close the incision and the patient is taken to the Intensive care unit for recovery.
Several tubes are placed in the body that aid to carry out certain functions during and few days after the operation.
- A tube through the mouth into the lungs to help with breathing, controlled by a ventilator (stays for one or two days following operation)
- Intravenous lines will be started in the arms and hands
- A tube through the nose into the stomach to drain secretions from the stomach (stays in place for a few days after operation)
- A catheter (tube) in the bladder to drain urine (stays for a few days after operation)
- Additional catheters can be introduced in the neck and wrist to monitor the heart, blood pressure and to take blood samples.
- Three tubes in the abdomen to drain blood and fluid from around the liver (stay for a few days after operation)
- A tube in the bile duct (T tube) to drain bile outside into a small pouch (stays for a few months after operation). Not all patients have this tube fitted.
The patient stays in the hospital for one to two weeks after the transplant and some patients may stay longer depending on the complications if any. The patient will be well aware of rejection and infection symptoms and also about how to check blood pressure and pulse by the time they are discharged to go home.
Complications after liver transplant:
Liver transplant is a major operation and is a complicated one. After the operation there can be two common complications associated with the transplant.
Rejection – Our body works in such a way that the immune system destroys any foreign objects that enter our body. So, the immune system may attempt to attack the new liver and destroy it and this happens in almost 70% of the cases. Anti-rejection medicines called immunosuppressants are given to stop this attack and these have to be taken according to prescription for the rest of the patient’s life.
There can be side effects from these anti-rejection medicines like headaches, high cholesterol, high blood pressure, diabetes, diarrhoea, brittle bones, kidney damage, skin cancer, etc.
Rejection symptoms can be fever, headache, nausea, dark urine, jaundice, abdominal swelling etc. In some cases of rejection medicines are adjusted and in serious cases and second transplant will have to be done. There are 3 types of rejections
- Hyperacute rejection – caused by preformed anti-donor antibodies, happens within minutes to hours after the transplant
- Acute rejection – Happens within days or weeks after the transplant and is the most common type.
- Chronic rejection – This is rejection that happens after a year of the transplant
Infection – The anti-rejection medicines stop the immune system from attacking the liver and hence there is high risk of infections for these patients. This does not happen with all the patients and these infections can be treated.
Apart from the above, the patients who have undergone a transplant are at high risk of cardiovascular diseases and coronary heart diseases after the transplant. Mild exercises and proper diet can reduce these risks. There can also be other complications like bile duct complications (leaks, blockage or shrinks), bleeding, failure of the new liver, blood clots, memory problems, blockage of blood vessels etc. Also any diseases associated with the old liver are likely to recur in the new one, depending on the type of disease. So care has to be taken all the time and the health monitored life-long.
Patients who have had a liver transplant have regular check-ups with their transplant surgeon and the transplant coordinator (who will be a nurse). The first check-up is scheduled one or two weeks after discharge. All patients have a check-up after five months and any patient who had a T tube inserted will have it removed by the transplant surgeon. Then there is a visit one year after the transplant and every year, that is annually thereafter there will be a visit.
How to take good care of our liver
While all these are procedures followed before, during and after the liver transplant, with some care, failure of the liver can be prevented.
Prevention of liver failure:
There are so many ways in which liver failure can be prevented.
- Always make sure you eat fresh and healthy food, avoiding processed food and also have a proper balanced diet
- Wash your hands well after you use the bathrooms and before having food because germs are spread by hands.
- Do not share razors, toothbrushes and any other toiletries
- Always use disposable needles and make sure that the needle is disposed immediately after use.
- Avoid alcohol, and if you drink, drink in control.
- Get vaccines for hepatitis
Liver kept alive outside human body for first time
Liver transplant has become advanced. Earlier, the donor liver was placed in ice till they were ready to be transplanted and during this period, many livers get damaged and go out of use.
Surgeons in London have carried out a liver transplant surgery, where the donor liver was kept alive at body temperature. The patient who underwent the liver transplant surgery is a 62-year-old Ian Christie from Devon and he is doing well after the surgery.
Please see the video to the right that shows how the machine works.
Organ Donation - A Recipient's Story
There are so many deaths every year all over the world due to liver diseases and the death rates remain high because there are less numbers of donors. The only way we can help to reduce death from liver disease is to join the Organ donation register in your respective countries so that someone benefits from a transplant (it can also help with other organ donations).
The contents of this hub are for general information only and should not be used as an alternative or substitute for medical advice from your own doctor or other health care professionals. Always consult your GP or health professional if you are concerned about your health in any way.
Thank you for reading and please do correct me if there are any mistakes or errors in the information provided here.
This hub is written to create awareness in people regarding health care and organ donation and is in no way written to create worries or anxieties in anyone.