Liver Transplants

• What is a liver transplant?
• Who needs liver transplants?
• Acute liver disease
• Chronic liver disease
• Contraindications to liver transplantation
• How often are liver transplants performed?
• Before the operation
• During the operation
• After the operation
• Rejection
• Other problems
• Life after a liver transplant

What is a liver transplant?

A liver transplant is a surgical treatment for severe liver disease. It involves removal of the patient’s diseased liver and insertion of a donor liver. The replacement liver may be donated by a live donor (living donor transplantation), or from a person who has just died (cadaveric donation).

Who needs liver transplants?

Liver transplants are used in the treatment of patients with both acute and chronic liver disease. The most common reason for needing a liver transplant is liver cirrhosis (destruction of normal liver cells and replacement with scar tissue).

Acute liver disease

Patients with fulminant hepatic failure (liver failure) due to any cause may be considered for liver transplantation. Common causes of fulminant hepatic failure include viral hepatitis or paracetamol overdose.

Chronic liver disease

Patients with the following conditions should be considered for transplantation:

• Primary biliary cirrhosis
• Primary sclerosing cholangitis
• Chronic viral hepatitis (eg. hepatitis C)
• Autoimmune hepatitis
• Alcoholic liver disease: only in patients who meet strict criteria for abstinence
• Malignant disease: some patients with primary hepatocellular cancer (liver cancer)

In children, the most common indication for transplantation is biliary atresia (failure of the biliary tree to develop normally).

Contraindications to liver transplantation

Not everyone with liver disease is suitable for liver transplantation. Liver transplants are not possible where a patient has:

• A severe infection outside the liver
• Cancer outside the liver
• Metastatic cancer in the liver (eg. cancer spread to the liver from a primary bowel cancer)
• Active alcohol or substance abuse

Patients over the age of 70 years are also generally not considered candidates for liver transplants.

How often are liver transplants performed?

In Australia, approximately 160 liver transplants are performed each year. In the United States, this number is much higher, at about 4500 per year. The number of people waiting for a liver transplant in Australia is increasing each year.

Before the operation

Before a transplant can take place, the patient must undergo a number of tests and procedures to assess their suitability for the procedure. Tests may include:

• Tests to confirm the diagnosis (eg. a biopsy of the liver)
• Ultrasound or other imaging tests of the liver
• Imaging tests to assess the blood vessels that supply and drain the liver, and to look at the biliary tree (the system of ducts that collects bile from the liver and drains into the gall bladder)
• Tests to assess cardiovascular and respiratory function
• Tests to look at the function of the kidneys

In addition, because liver transplantation is a major operation, it is important that the patient receives psychosocial support. This may include counselling in some cases. When a patient has been identified as being a suitable candidate for a liver transplant, they are placed on a transplant waiting list. The amount of time they wait for a transplant depends on a number of factors, including how sick they are, their blood type, and body size. If the donor liver is to come from a living person (living donor transplantation), the donor must undergo extensive testing and counselling before the operation can proceed.

During the operation

Liver transplantation surgery usually takes about 8 hours. Firstly, the surgeon must remove the patient’s diseased liver. This involves disconnecting it from its blood supply and from its connections to the bile ducts. After this happens, blood which normally flows through the liver is either blocked or re-routed through a bypass system. The donor liver is then placed in the old liver site (‘orthotopic transplantation’). It is connected up to the blood supply and bile ducts. Blood will begin to flow through the new liver.

After the operation

Liver transplantation is major surgery. Patients who undergo transplantation are also commonly quite sick before the transplant can take place, and this places them at high risk of complications after surgery. However, 85% of patients who have successful transplants return completely to their normal activities. Potential problems with liver transplants include:

Rejection

Because the new liver comes from another person, the donor recipient’s immune system recognises the liver as ‘foreign’, and can attack it. This results in transplant rejection and destruction of the donated liver. To stop this happening, strong immunosuppressive drugs are used. These are essential to suppress the function of the immune system and reduce the likelihood of rejection taking place. However, they are also associated with a high risk of infection. This means patients who have received transplants must be very careful about protecting themselves from becoming ill.

Other problems

Depending on the cause for the transplant, it is possible that the original disease can return after a transplant has taken place. For example, patients with hepatitis A, B or C, there is a risk that the virus will infect the new liver. Patients with hepatocellular carcinoma (liver cancer) are also at risk of developing tumours in the new liver. Other problems include damage to or blockage of the blood vessels or bile ducts of the liver.

Life after a liver transplant

Liver transplantation is now a relatively safe procedure. Currently, 90% of those undergoing transplantation will be alive at one year, and about 75% will be alive at five years. Most patients who have liver transplants find they are able to go back to work and resume their normal activities. Patients who have liver transplants usually require life-long immunosuppressive therapy. It is very important to continue taking these medications to prevent transplant rejection from occurring. Eating a balanced diet and getting regular exercise can also help people to stay healthy after a liver transplant.

References

1. Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison’s Principles of Internal Medicine. 16th Edition. McGraw-Hill. 2005.
2. Keeffe, EB. Liver transplantation: current status and novel approaches to liver replacement. Gastroenterology 2001; 120:749.
3. Kumar P, Clark M. Clinical Medicine. 5th Ed. Edinburgh: W.B.Saunders; 2002.
4. Morris PJ, Wood WC (ed.). Oxford Textbook of Surgery (2nd ed). 2000, New York: Oxford University Press.