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FEATURE: LIVER TRANSPLANT QUESTIONS AND ANSWERS


Approximately 6,000 liver transplants are performed in the U.S. each year. But more than 17,000 Americans are still waiting for donated livers to become available for transplants. Recipients and those awaiting transplants have a myriad of questions about the transplant process and long-term outcomes. ALF sits down with Dr. Fredric Gordon to answer the most frequently asked questions. Dr. Gordon is the medical director of liver transplantation and hepatology at Lahey Hospital and Medical Center and an associate professor of medicine at Tufts Medical School.

Q. Assuming no complications, how long can a liver last? Will transplant patients ultimately need another transplant?

When doctors perform liver transplants, they expect it to last indefinitely. The liver, even a transplanted one, has the ability to regenerate so it does not have an expiration date. Some patients may develop a recurrence of their disease, which can harm their new livers. We would most often see this in patients with hepatitis C. However, the good news is that there are excellent new treatments for hepatitis C so we expect to see far fewer patients who require another transplant.

Q. What happens during a liver transplant surgery?

During the procedure, the entire damaged liver is removed and a new liver is put in its place. The operation generally takes three to seven hours. The surgeons spend the first one to two hours disconnecting the blood vessels and bile ducts of the damaged liver and then remove the entire liver. The next two to five hours are spent first connecting the veins of the new liver to the recipient followed by the artery and then the bile duct. Usually the new liver starts to make healthy bile before the operation is over. The surgeon then closes the wound and the patient is taken to the recovery room.

Q. Can a transplant patient live a normal life?

Transplant recipients can live a normal life, although it may not be considered "normal" to take medication every day to prevent organ rejection and to see the transplant team every 3-12 months for life. But day-to-day, most patients should be able to follow a normal routine.

Q. Is there a special diet that transplant recipients must follow?

There are no special diets for transplant recipients, although patients may have other dietary restrictions. But whether for an organ recipient or any other person, a healthy and balanced diet is beneficial.

Transplant recipients require normal amounts of protein in their diet. This usually means 1.2-1.5 grams of protein for every kilogram of body weight. One kilogram is equal to 2.2 pounds so a rough estimate of daily protein intake is to multiply your body weight by 0.75.

Q. Are there a lot of medications to be taken to prevent rejection of the new liver? What are the side effects?

There are a variety of medication options and combinations to prevent rejection. Typically liver transplant recipients are on high doses of two to three medications for the first several months and then it tapers down to one to two medications indefinitely. Side effects will vary and patients should discuss them with their doctors.

Q. How is the decision made as to who receives a new liver?

This is a complex decision that is addressed by each transplant programs’ screening committee. There are no universal rules so each program can make their own decisions. Every patient is evaluated by a health care team, which includes a surgeon, hepatologist, infectious disease specialist, psychiatrist, pharmacist, social worker and nutritionist. Each specialist determines if there are reasons why a patient is not a candidate for transplantation or issues that are concerning and need to be addressed before a transplant can take place. Once the patient is accepted and added to the transplant list, they are ranked for transplantation by their MELD score.

The MELD score is a calculation that utilizes three blood tests: the total bilirubin, the INR (International Normalized Ratio), and the creatinine. The first two are liver tests and the third is a kidney test. MELD calculators can be found on the Internet. The range is from six to 40. A MELD score of six means that the liver is healthy and not in need of transplantation. A MELD score of 40 indicates that the patient is very ill and requires urgent transplantation.

So when a liver becomes available in the region it will go to the person with the highest MELD score.

Q. What causes liver damage that is so severe that it warrants a transplant?

There can be many reasons why a liver becomes severely damaged and it can start early in life. For example, some babies are born with a debilitating liver condition called biliary atresia and may end up needing liver transplantation. Other diseases, when not treated early, can promote liver damage, including hepatitis C, hepatitis B, fatty liver disease, alcoholic liver disease, alpha-1 antitrypsin deficiency, primary sclerosing cholangitis, certain inherited diseases and hundreds of others.

These conditions can lead to progressive scarring – also known as fibrosis – which causes scar tissue to form in the liver, impeding blood flow. This can result in cirrhosis and failure of the liver to function properly.

Q. Are patients with liver cancer eligible for new livers? If a person needs to take anti-rejection drugs, wouldn’t it affect their ability to fight their disease?

Some patients with liver cancer are eligible for liver transplantation. In order for patients to be considered a candidate, the tumor has to be within the Milan criteria, which specifies that if there is a single tumor it needs to be less than or equal to five cm in size with no evidence of spread outside the liver. If there are two or three tumors then all of them need to be less than or equal to three cm in size with no evidence of spread outside the liver. If the patient is within the Milan criteria then they are, in fact, given “exception points" to put them in contention for a liver transplant before their liver fails. If the tumor is outside of the Milan criteria then there is a very high rate for recurrence of cancer after liver transplantation because of the immune system’s inability to prevent the cancer from returning.

Q. What is a live liver transplant? What is involved for the donor?

Live donor liver transplantation may be an option for patients who require a liver transplant but are not sick enough to have a high MELD score (i.e., not in contention for a new liver soon). In this case, a healthy live donor, usually someone who is emotionally connected to the recipient, offers one of their liver lobes for the recipient. For small recipients, the smaller left lobe of a donor liver may be enough. For larger recipients, the right lobe of the donor would be required. The recipient’s entire liver is removed and replaced with the partial organ. Both the donor and recipient will have nearly normal sized livers by one month after transplantation/donation.

The donor goes through an extensive evaluation, which includes independent internists, psychiatrists, and social workers. The patient undergoes a variety of blood tests and scans of the abdomen (CT scan or MRI). The donor must have an acceptable blood type match and be willing to donate of “their own free will without coercion or financial reward.” Live donor liver transplantation is rarely undertaken in an emergency situation.

Read about two exceptional young men whose friendship culminated in the greatest gift.

Q. How can a person find out more about becoming an organ donor?

The easiest way to become a donor is to enroll with your state’s organ donor registry. You can find it online at Donate Life.

Return to the main menu of the April 2014 Liver Lowdown by visiting here.

Page updated: April 10th, 2014