What are indications of transplant surgery?
Basically, the conditions that require liver transplant can be divided into two groups: acute (sudden-onset) and chronic (long lasting) diseases:
Acute Liver Failure: This is the group of patients with highest priority for liver transplant. These patients can die quickly, if they cannot recover. As it is significantly hard to estimate the prognosis in these patients, they should be referred to organ transplantation centers where they can have liver transplant surgery, if required.
Chronic Liver Failure (Cirrhosis): Cirrhosis and associating clinical signs and symptoms, such as jaundice, bleeding varicose veins (gastric bleeding), ascites (fluid accumulation in abdomen), encephalopathy, cirrhosis-related renal diseases, infection and bleeding disorders, require transplant surgery.
How are evaluations done?
As is the case with any patient, evaluation of a patient presenting for liver transplant starts with medical history and physical examination. Later, it is continued with blood tests, radiology studies and relevant consultations. Tumor and infection markers are also screened, as immunosuppressive agents used after transplant surgery have the potential to worsen an existing cancer or infection.
The requirement for liver transplant is determined by a standardized scoring system that is globally used. This scoring system is called MELD (Model for End-stage Liver Disease) MELD is a system developed for patients with chronic liver disease to estimate severity of the disease and 3-month survival rate. For patients with cirrhosis, higher MELD scores point to advanced stage liver disease and therefore, 3-month mortality rate increases.
Patients with cirrhosis become transplant candidates when their MELD score is 15 points or higher. However, the patients with low MELD score can also be undergone liver transplant surgery, if clinical findings require doing so. A patient with a MELD score of 10 or higher should be seen as a transplant candidate and preparations should be started. Thus, pre-operative evaluations of the patient can be conducted in a more detailed manner. If these evaluations are performed before the brain is involved, success rate of the transplantation will be higher.
Conditions that are excluded from MELD scoring but require liver transplant:
- Liver Cancer
- Involvement of lungs
- Thrombosis of hepatic artery (if it occurs in the first 14 days after liver transplant.)
- Primary sclerosing cholangitis
- Refractory ascites
- Refractory hepatoencephalopathy
- Refractory varicose bleeding
- Gastropathy leading to chronic loss of blood
- Uncontrolled itching
Moreover, cancers that meet certain criteria can require liver transplant.
- Neuroendocrine tumor that spread to liver
- Epitheloid hemangioendothelioma
- Giant hepatic adenomas
Apart from these conditions, some metabolic diseases with hepatic origin are treated with liver transplant.
- Alpha1 Antitrypsin deficiency
- Wilson's disease
- Familial amyloid polyneuropathy
- Primary hyperoxaluria
- Cystic fibrosis
- Thyrosinemia
- Hemochromatosis
- Certain glycogen storage diseases (Type 1 and Type 4)
- Acute intermittent porphyria
How does transplant process performed?
There are two types of liver transplant surgery; deceased (cadaver) donor or living donor. For deceased donor transplants, a donor with a healthy liver, who is diagnosed with brain death, is needed and the operation is performed following preparations that are carried out under emergency circumstances.
On the other hand, for living donor transplants, both the donor and the recipient have detailed examinations and tests to minimize postoperative complications. Living donor liver transplant surgery is performed by removing right lobe of the donor liver for adult recipients and left lobe of the donor liver for pediatric recipients.
In the recipient surgery, the diseased liver is completely removed and the liver of deceased or living donor with appropriate volume is placed.
What will change in my life after transplant surgery?
First of all, the patient holds on to the life again after a successful liver transplant surgery. Outpatient follow-up visits are planned at weekly intervals for the first month after the patient is discharged, and next, these intervals are prolonged thereafter. Skin sutures are removed three weeks after the operation. Patient can drive one month later. In addition, the patient should take certain medications for the rest of life. Timely and appropriate use of these medications is important and essential for healthy functioning of the transplant liver. As long as the transplant liver functions properly, patients can continue living as usual; adults can resume working and children can return to school.
What will happen if my body rejects the new organ?
There two types of rejection following liver transplant surgery; acute and chronic. Acute rejection develops usually within 90 days. Rejection is manifested by various clinical symptoms, including but not limited to fever, tiredness, abdominal pain, dark yellow urine, light colored feces and ascites (fluid collection in abdomen), but none of these symptoms is specific to rejection. Moreover, certain parameters of blood tests that allows us evaluating liver functions elevate. If rejection is considered, the transplant liver is biopsied in order to both verify diagnosis of rejection pathologically and determine severity of rejection. The patient is hospitalized according to this result and the clinical condition of patient and relevant treatments are instituted.
Chronic rejects develops late and its incidence is around 1 percent. A new liver transplantation is usually required, although all treatment alternatives are started to manage the rejection.
Should I follow a special diet after transplantation?
A special diet is not required following a successful liver transplantation, provided the patient is healthy. Dietary instructions may be required, if the patient has co-existing diseases, such as hypertension and diabetes mellitus.
When can I engage in routine activities of daily life after the operation?
Most patients start engaging in usual activities of daily life within 2 months in average after a successful liver transplantation.
Deceased Donor
What does deceased donor liver transplant mean?
The liver of deceased donor with medically declared brain death is surgically removed, after consent of the family is obtained for deceased organ donation, and it is supplied to most appropriate patient, who is registered in organ waiting list, according to the rules supervised by Ministry of Health. Candidate recipient is urgently called and prepared for surgery under emergency circumstances and the deceased donor liver is transferred to the recipient as soon as possible.
How is deceased donor transplant surgery performed?
If a transplant candidate with no living donor scores ≥15 in MELD scoring test in the light of the blood tests and the disease that leads to liver failure, the candidate is registered in the deceased donor list. When a match deceased donor is found and presented to our Organ Transplantation Center over the system of Ministry of Health, surgical removal of the deceased donor liver is started. Relevant team goes to the hospital, wherein the deceased donor is present, and the liver and other appropriate organs are removed and placed in cold storage containers. Meanwhile, candidate recipients, who are registered in our center, are listed again over the system of Ministry of Health. Candidate recipients are called, starting with the first patient in the list. Second candidate is contacted if the first one declares inability to present for surgery. The patient who declares to present for surgery is admitted, preoperative examinations and investigations are urgently completed and the patient is undergone surgery, if no contraindication is detected.
How is my care maintained in waiting period?
Patients, who are registered in the deceased donor transplant list, should visit our Organ Transplantation Center for relevant follow-up examinations at regular intervals. This allows them to be as much prepared as possible in case a deceased donor is found for liver transplant surgery in an unexpected time. Unfortunately, it is not possible to estimate this interval. Related medication treatments and medical examinations should be maintained at gastroenterology outpatient clinic in the waiting period.
What will happen when I am admitted for organ transplant?
The patient who gives positive response to our call should present to our Organ Transplant Center as soon as possible. Patients should not eat or drink (at least for 6 hours) before the surgery since they will be operated on. Various consultations and examinations are performed for the patient depending on the date of last follow-up visit. The patient with no contraindication for surgery is informed and the patient is transferred to the operating theater after the consent is obtained before two witnesses.
Living Donor
Who can be a donor?
It is necessary to be older than 18 and cognitive functions should be intact according to the legislation in our country. Moreover, consent of the donor and the spouse, if any, is obtained for kinships up to 4th degree, but approval of Ethics committee is required for kinship beyond 4th degree.
1st degree relative: Father and mother.
2nd degree relative: Sibling, grandmothers and grandfathers
3rd degree relative: Maternal uncle, paternal uncle, maternal aunt, paternal aunt, niece
4th degree relative: Children of maternal uncle, paternal uncle, maternal aunt, paternal aunt and niece
What are advantages of having a living donor?
It is possible to minimize perioperative complications for recipient candidates of the liver transplant, as detailed tests, examinations and preparations are carried out in elective (non-emergent) circumstances.
Moreover, it is required to store liver of cadaver donor in a cold storage container for many hours until it is transferred to the recipient, while this interval can be decreased to minutes in living donor transplants and thus, complications of this necessity can be prevented.
What should my donor expect in transplant surgery?
The volunteer living organ donor is evaluated in detail to determine whether s/he is appropriate for liver donor surgery. All organ systems are reviewed and relevant blood tests, radiology studies and consultations are performed to determine whether the donor has a known disease or not. If a contraindication for surgery is detected in detailed examinations, the process is stopped and the donor is refused.
Donor candidate with favorable test results is informed about the risks of surgery and the consent is obtained, including the consent letter of the spouse, before two witnesses.
Date of operation is scheduled and the donor is hospitalized in organ transplantation unit one day before the operation and relevant preparations are initiated. In the surgery, right lobe of the liver is removed if the recipient is an adult or the left lobe is removed if the recipient is a child. The patient is transferred to the intensive care unit after the surgery, and after the patient is stabilized here for 1 to 2 days in average, they are transferred to the room in organ transplantation clinic.
If all parameters are stable in inpatient follow-up, donors are discharged in 5 to 7 days in average. Patient is asked to present for outpatient follow-up visits after the discharge and skin stitches are removed 10 days after the operation. They can start driving one month later and resume activities of daily life and work in 2 months in average.
The space that forms after the liver is removed is covered in approximately 1 month by the rest of liver that grows gradually.