|
History of
Liver Transplantation
The history of liver
transplantation began almost forty years ago. In the
late 1950s, Welch and others explored heterotopic
(other site) and orthotopic (same site) liver transplantation
in animals. A few years later in 1963 the first successful
orthotopic liver transplantation (OLT) in a human
being was performed by Thomas Starzl. The initial
enthusiasm generated by this new technique was dampened
considerably as investigators encountered a multitude
of intractable postoperative complications, most notably
graft rejection; after seven consecutive patient deaths
at three centers, all work on liver transplantation
was temporarily suspended. However, time and effort
brought important improvements and the number of OLTs
increased significantly after the introduction of
the potent antirejection drug cyclosporin-A in 1979.
Liver Transplantation
The liver is the
second most commonly transplanted major organ, after
the kidney, so it is clear that liver disease is a
common and serious problem. Liver transplant is surgery
to replace a diseased liver with a healthy liver from
a donor.
It is important
for liver transplant candidates and their families
to understand the basic process involved with liver
transplants, to appreciate some of the challenges
and complications that face liver transplant recipients
(people who receive livers), and to recognize symptoms
that should alert recipients to seek medical help.
A healthy liver is usually obtained from a donor who
has recently died, but has not suffered liver injury.
Many donors are victims of some sort of trauma and
have been declared brain dead. A donor with the right
blood type and similar body weight is sought to help
reduce the risk of rejection.
The donor liver
is transported in a cooled saline solution that preserves
the organ for up to 8 hours, thus permitting the necessary
tests for donor-recipient matching.
The diseased liver
is removed through an incision in the upper abdomen.
The donor liver is put in place and attached to the
patient's blood vessels and bile ducts. The operation
may take up to 12 hours and requires a large amount
of transfused blood.
In some cases,
a living donor may donate a section of liver for transplant
to someone else, often a family member or friend.
This poses some risk to the donor because of the nature
of the operation, but since the liver can regenerate
itself to some extent, both parties usually end up
with fully functioning livers after a successful transplant.
Need of Liver Transplant
The body needs
a healthy liver. The liver is an organ located in
the right side of the abdomen below the ribs. The
liver has many vital functions.
 It
is a powerhouse that produces varied substances in
the body, including
- glucose, a basic sugar and energy source
- proteins, the building blocks for growth
- blood-clotting factors, substances that aid in
healing wounds
- bile, a fluid stored in the gallbladder and necessary
for the absorption of fats and vitamins.
As
the largest solid organ in the body, the liver is
ideal for storing important substances like
vitamins and minerals. It also acts as a filter,
removing impurities from the blood. Finally, the liver
metabolizes and detoxifies substances ingested
by the body. Liver disease occurs when these
essential functions are disrupted. Liver transplants
are needed when damage to the liver severely
impairs a person's health and quality of life.
Hence, Liver transplants
are considered only when there is a high risk of death
from liver disease. Being told that a liver transplant
might be needed doesn't automatically mean that life
is in danger of dying right away. It usually takes
a long time to find a liver that is right for the
recipient.
Liver disease severe
enough to require a liver transplant can come from
many causes. Doctors have developed various systems
to determine the need for the surgery. Two commonly
used methods are by specific disease process or a
combination of laboratory abnormalities and clinical
conditions that arise from the liver disease.
In adults, chronic active hepatitis and cirrhosis
(from alcoholism, unknown cause, or biliary) are the
most common diseases requiring transplantation.
In children, and
in adolescents younger than 18 years, the most common
reason for liver transplantation is biliary atresia,
which is an incomplete development of the bile duct.
To summarize and
make it brief, Liver transplant is indicated for many
types of liver diseases. These diseases fall into
four categories.
Irreversible chronic liver disease can cause cirrhosis,
which develops over a long period of time
Fulminant liver failure, which develops very quickly,
can be caused by a virus or medication
Metabolic Diseases, including imbalances of iron,
cholesterol,copper, or enzymes
Liver Cancer, only if the cancer is small and has
not spread beyond the liver
Candidates
of Liver Transplant
Ultimately, the
transplantation team takes into account the type of
liver disease, the person's blood test results, and
the person's health problems in order to determine
who is a suitable candidate for transplantation.
A person who needs
a liver transplant may not qualify for one because
of the following reasons:
Active alcohol or substance abuse: Persons with active
alcohol or substance abuse problems may continue living
the unhealthy lifestyle that contributed to their
liver damage. Transplantation would only result in
failure of the newly transplanted liver.
Cancer: Cancers in locations other than just the liver
weigh against a transplant.
Advanced heart and lung disease: These conditions
prevent a transplanted liver from surviving.
Severe infection: Such infections are a threat to
a successful procedure.
Massive liver failure: This type of liver failure
accompanied by associated brain injury from increased
fluid in brain tissue rules against a liver transplant.
HIV infection
Pre
Liver Transplant tests
Pretransplant tests,
as well as giving a clear picture of the patient's
overall health status, help in identifying potential
problems before they occur. They also help in determining
whether transplantation is truly the best option.
This increases the likelihood of success.
The following procedures
help in evaluating a patient's health status:
Chest x-ray - Determines the health of the patient's
lungs and lower respiratory tract.
Electrocardiogram (EKG or ECG) - Determines how well
the patient's heart is working and may reveal heart
damage that was previously unsuspected.
Ultrasound with Doppler examination - Determines the
openness of the bile ducts and major vessels. It is
commonly done in all liver transplant recipients before
and after transplantation.
CT (CAT) scan - This computerized image will show
the size and shape of the patient's liver and major
blood vessels.
MRI (magnetic resonance imaging) - May be used in
place of CT scan or ultrasound to see inside the patient's
body.
Total-body bone scan - If the patient has a liver
tumor, ensures that it has not spread to his bones.
Blood tests - The patient's blood count, blood and
tissue type, blood chemistries, and immune system
function will all be checked. In addition, blood tests
for certain infectious diseases will be performed.
Pulmonary function test - The patient will be asked
to breathe into a tube attached to a measuring device,
which will reveal how well his lungs are working and
determine his blood's capacity to carry oxygen.
Hepatic angiograph - Dye injected into the patient's
arteries will enable the transplant physician to see
if there are any abnormalities or blockages in the
patient's blood vessels.
Cholangiogram - Reveals any obstructions or growths
in the patient's bile ducts.
Gallium, colloidal gold, or technetium scan - Gives
the transplant physician a view of the patient's liver,
gallbladder, and pancreas.
Peritoneoscopy - By inserting a flexible tube through
a tiny incision in the patient's abdomen, the transplant
physician will be able to see any structural changes
in the liver.
Upper gastrointestinal (GI) series - This will show
whether the patient's esophagus and stomach are disease
free.
Lower GI series - Ensures that the patient is free
of intestinal abnormalities.
Renal function studies - Urine may be collected from
the patient for 24 hours in order to determine if
the kidneys are working correctly. Blood tests such
as serum creatinine are also performed to measure
kidney function.
Liver Transplantation
- a Team work
The Transplant Team
consists of
Transplant Surgeon
Transplant Physician (Hepatologist)
Transplant Coordinator
Nurse Practitioner
Floor or Staff Nurse
Physical Therapist
Dietician
Psychologist / Psychiatrist
Social Worker
Pharmacist
Preparing
the Patient for Surgery
The patient may receive an enema to clean out his
intestines and prevent constipation after surgery.
His chest and abdomen will be shaved clean to prevent
infection, and an intravenous (IV) line will be inserted
in his arm or just under his collarbone to give medication
and keep him from getting dehydrated. The patient
will also be given a sedative to help him relax and
feel sleepy before going to the operating room.
Because transplantation is a major surgical procedure,
the patient may need a transfusion. Today, all blood
is screened very carefully; the likelihood of contracting
a disease is very small. Any concerns that the patient
has regarding the source of the blood should be relayed
to the transplant team during the waiting period,
before getting to the hospital. Most hospitals offer
the option of "autotransfusion" - this is
when the patient donates his own blood before surgery.
His/her own blood is stored and then used during transplantation.
Types of Liver Transplantation
Surgeries
Orthotopic liver transplantation(OLT) is the replacement
of a whole diseased liver with a healthy donor liver.
When an orthotopic transplantation is performed,
a segment of the inferior vena cava attached to the
liver is taken from the donor as well. The same parts
are removed from the recipient and replaced by connecting
the inferior vena cava, the hepatic artery, the portal
vein and the bile ducts.
The operation itself can be divided in two stages:
recipient hepatectomy and implantation of the graft.
The recipient's abdomen is opened through a transverse
incision which can be extended vertically in the midline
to the xiphoid process for better exposure ("Mercedes"
incision). The diseased liver is mobilised using diathermy.
This stage of the operation may be difficult due to
the presence of dense vascular adhesions and portal
hypertension particularly after previous surgery.
The porta hepatis is dissected to ligate and divide
the common bile duct and the common hepatic artery.
The portal vein is skeletonised and the vena cava
is identified and isolated.
When veno-venous bypass is required, both the femoral
and the axillary veins are dissected and cannulated.
Finally, vascular clamps are placed on the portal
vein and inferior vena cava above and below the liver,
veno-venous bypass is started and the diseased liver
is then excised. The donor liver is then implanted
by suturing the supra-hepatic and then the infra-hepatic
vena cava. Any residual UW solution is then flushed
from the graft. The portal vein is anastomosed and
the liver is reperfused. After haemostasis, the gallbladder
is removed. The donor hepatic artery is then anastomosed
to the recipient common hepatic artery. If the native
artery does not provide an adequate arterial inflow,
an infrarenal donor iliac artery conduit may be used
to rearterialise the graft. Biliary drainage is established
either by primary end-to-end anastomosis of the bile
duct or by using a Roux-en-Y hepatico-jejunostomy.
Complete haemostasis is secured before abdominal closure.
Heterotopic transplantation is the addition of a donor
liver at another site, while the diseased liver is
left intact.
When there is a possibility that the afflicted liver
may recover, a heterotopic tranplantation is performed.
The donor liver is placed in a different site, but
it still has to have the same connections. It is usually
attached very near the original liver, and if the
original liver recovers, the donor shrivels away.
If the original liver does not recover, it will shrivel,
leaving the donor in place.
Reduced-size liver transplantation is the replacement
of a whole diseased liver with a portion of a healthy
donor liver. Reduced-size liver transplants are most
often performed on children.
Reduced-size liver transplantation tranplants part
of a donor liver into a patient. It is possible to
divide the liver into eight pieces, each supplied
by a different set of blood vessels. Two of these
pieces have been enough to save a patient in liver
failure, especially if the patient is a child. It
is therefore possible to transplant one liver into
at least two patients and to transplant part of a
liver from a living donor and have both donor and
recipient survive. Liver tissue grows to accommodate
its job so long as there is initially enough of the
organ to use. Patients have survived with only 15-20%
of their original liver, provided that 15-20% was
healthy.
Split Liver Transplantation is the technique of splitting
a whole liver into two grafts, the left lateral segment
for a child and the residual right lobe for an adult
became established in the mid-1990's overcoming early
problems of patient selection and technical complications.
Liver Transplantation
Surgery
Liver transplants usually take from six hours to
12 hours. During the operation, surgeons will remove
the liver and will replace it with the donor liver.
Because a transplant operation is a major procedure,
surgeons will need to place several tubes in the patient’s
body. These tubes are necessary to help the patient’s
body carry out certain functions during the operation
and for a few days afterward.
During the operation, a tube will be placed through
the patient’s mouth into his/her windpipe (trachea)
to help him/her breathe during the operation and for
the first day or two following the operation. The
tube is attached to a ventilator that will expand
the patient’s lungs mechanically. A nasogastric
tube will be inserted through the patient’s
nose into his/her stomach. The N/G tube will drain
secretions from the patient’s stomach, and it
will remain in place for a few days until his/her
bowel function returns to normal. A tube called a
catheter will be placed in the patient’s bladder
to drain urine. This will be removed a few days after
the operation. Three tubes will be placed in the patient’s
abdomen to drain blood and fluid from around the liver.
These will remain in place for about one week.
In most cases, the surgeon will place a special
tube, called a T-tube, in the patient’s bile
duct. The T-tube will drain bile into a small pouch
outside of his/her body so it can be measured several
times daily. Only certain transplant patients receive
a T-tube, which remains in place for five months.
The tube causes no discomfort and does not interfere
with daily activities.
Recovery from Liver
transplantation
Initially in the intensive care unit there is very
careful monitoring of all body functions including
the liver. Once the patient is transferred to the
ward, the frequency of blood testing, etc. is decreased,
eating is allowed and physiotherapy is used to regain
muscle strength. The drug or drugs to prevent rejection
are initially given by vein, but later by mouth. During
the transplantation, frequent tests are done to monitor
liver function and detect any evidence of rejection.
Tips !
- Care for the T-tube. Make sure that it is draining
and does not look infected. Swab the insertion site
with betadine at least daily.
- Patient should evaluate himself daily for signs
of rejection and/or infection.
- Take post-transplant medications exactly as ordered.
Do not skip a dose, crush your pills or double your
dosage.
- Make sure that the transplant coordinator's phone
number is known to the patient and his /her family
as well.
- Avoid salt and alcohol, as ordered by the doctor.
Salt encourages fluid retention in the body, and
alcohol is harmful to your liver, especially in
combination with certain liver-transplant drugs.
- Patient should move legs around when lying in
bed, to help prevent blood clots from forming.
- Take pain relievers as seldom as possible. An
analgesic would be needed for the first four to
seven days, but after that, pain would not be experienced
to an extent where a great deal of pain medication
is required.
- Avoid vigorous exercise for the first six weeks.
Patient can resume to daily activities as soon as
they feel up to it. But use common sense - don't
lift heavy objects, don't strain your incision,
don't dive off the high dive.
Warnings !
Call the doctor if signs of rejection, infection,
swelling, fluid retention or vomiting are experienced.
Avoid handling soil and animal waste. Do not clean
cages, fish tanks or cat litter boxes.
Care post Liver
Transplantation
Medical care of the liver transplant patient is
exactly that: monitoring and maintaining health of
organ recipients and donors, pre, during and post-operatively.
Transplant recipients directly contribute to the
success of their transplant. Failure to comply with
the immunosuppression medical regimen is the number
one cause of organ failure. Close follow-up with your
transplant team and primary-care physician can help
ensure a good outcome. Careful attention to medication
schedules, lifestyle changes, infection-avoidance
techniques are all important ways to prolong one's
life after transplantation.
In sum, the longest known liver transplant survivor
is living a normal life over 30 years after the operation.
If all goes well, a liver transplant can last as long
as the patient.
Post-transplant care is typically categorized into
four general time periods. The following table outlines
possible complications and common infections in each
time period.
| Time Period |
Complication |
Common Infections |
| 0-1 months |
Regimen-related toxicityGraft
failureDrug reactions |
Most bacteriaCandida, AspergillusHerpes
simplex |
| |
|
|
| 1-3 months |
Acute GVHD Acute GVHD Graft-Versus-Host
Disease |
Candida, other fungiPneumocystis
cariniiCytomegalovirus |
| |
|
|
| 3-12 months |
Chronic GVHDRelapse |
P.cariniiVaricella-Zoster
virusesCytomegalovirus
Encapsulated bacteria |
| |
|
|
| 12 months |
Chronic GVHDRelapse |
P.cariniiVaricella-Zoster virusesCytomegalovirus
Encapsulated bacteria |
| |
|
|
Medications prescribed after
Liver Transplant
Cyclosporine
| Therapeutic action:
|
This medication is
given to prevent rejection of the transplanted
liver. |
| Dosage: |
The initial oral
dose of Cyclosporine can be given 4-12 hours
prior to transplantation as a single dose of
15 mg/kg.
It must be taken every 12 hours. The prescribed
dosage maybe changed frequently to maintain
an appropriate blood level.
The initial single daily dose can be continued
postoperatively for 1-2 weeks and then tapered
by 5% per week to a maintenance dose of 5-10
mg/kg/day. Some centers have successfully tapered
the maintenance dose to as low as 3 mg/kg/day
in selected renal transplant patients without
an apparent rise in rejection rate.
Cyclosporine is dosed according to blood levels
and renal function. The dose is highly individualized
because of variable absorption, elimination,
and effect on renal function. The drug is initiated
at 1-2 mg/kg/d in 2 divided doses and advanced
as tolerated, but maintenance dose ranges widely
from 1-10 mg/kg/d. |
| |
|
| Adverse / side effects:
|
- high blood pressure (May require medication)
- hand tremors
- headache
- tingling of hands and feet· runny
nose with nasal congestion· decreased
kidney function (Kidney function is monitored
by blood tests and should be checked as directed
by the transplant team)
- increased hair growth· swollen gums
- night sweats
- increased sex drive
- depression or other mental symptoms
|
| |
|
| Remark: |
The principal toxic effect of cyclosporine
is nephrotoxicity, manifested acutely by elevations
in BUN and creatinine. This effect usually is
reversible with reductions in dosage. However,
an irreversible form is associated with histologic
changes in the kidney. Other toxic effects include
hyperkalemia and hepatotoxicity. |
| |
|
Tacrolimus
| Therapeutic action:
|
The
mainstay of immunosuppressive drug for you after
liver transplantation. Tacrolimus lowers the
activity of the immune system and in turn keeps
the body from rejecting the new liver |
| Dosage: |
Patient
Population
|
Recommended
Initial Oral Dose*
|
Typical
Whole Blood Trough Concentrations
|
| Adult liver transplant patients
|
0.10-0.15 mg/kg/day |
month 1-12 : 5-20 ng/mL |
| Pediatric liver transplant patients
|
0.15-0.20 mg/kg/day |
month 1-12 : 5-20 ng/mL |
| |
|
| *Note: two divided
doses, q12h |
| Adverse / side effects:
|
- Nausea, vomiting, diarrhea, constipation
- Tremor, headaches
- Alopecia
- Hypertension
- Nephrotoxicity
- Increased blood sugar levels
|
| |
|
| Remark: |
- Tacrolimus is best given on an empty stomach,
so it is ideal to give it before meals or
2-3 hours after meals.
- Tacrolimus needs to be given approximately
12 hours apart so that a constant level is
in the blood stream to prevent organ rejection.
Before breakfast and after dinner are ideal
times.
- The dosage of Tacrolimus is different for
each individual patient. Only the doctor can
adjust the dosage in accordance with the blood
FK506 level.
- Post-liver transplantation patients must
have regular follow-ups and blood-taking after
discharge
|
| |
Mycophenolic
Acid
| Therapeutic action:
|
It
is indicated for the prophylaxis against acute
rejection. |
| Dosage: |
If necessary, the
dose should be increased gradually (over a few
days) to improve tolerability and avoid GI problems.
Thrice daily dosing may be more effective than
twice daily dosing.
Children: 600 mg /m2 per dose
given po twice a day (q12h) or 400 mg /m2 per
dose given po three times daily (q8h).
Adults: Increase gradually
from 500 mg bid to 750 mg tid (maximum = 3 g
per day) Reduce dose in the presence of severe
renal impairment (CLcr<20 mL/min).
Reduce dose or discontinue therapy in the presence
of diarrhea or neutropenia
The drug should be taken on empty stomach.
Avoid antacids and cholestyramine. |
| |
|
| Adverse / side effects:
|
- Diarrhea
- Lower the white cell count and increase
the risk of bacterial or viral infection
|
| Remark: |
- Contraindication to known hypersensitivity
to mycophenolate sodium, mycophenolic acid
and MMF.
- Precaution in pregnancy and breast-feeding
women.
- Mycophenolic acid tablets should not be
crushed and should be swallowed whole
|
Mycophenolate
Mofetil (Mmf)
| Therapeutic
action: |
Mycophenolate
mofetil is used for the prevention of rejection.
It could be used in conjunction with other immunosuppressants. |
| Dosage: |
250 mg per capsule
and 500 mg per capsule is available.
The dosage needs to be adjusted in accordance
with your white cell count.
Take this medication as directed usually twice
daily on an empty stomach one hour before or
two hours after meals. Swallow this medication
whole. Do not crush, chew or open it. |
| |
|
| Adverse / side effects:
|
- Nausea, vomiting, diarrhea
- Lower the white cell count and increase
the risk of bacterial
- or viral infection
|
| Remark: |
Contraindication are known hypersensitivity
to MMF and breast-feeding women. |
Prednisolone
| Therapeutic
action: |
Prednisolone is in a class of drugs called
steroids. Prednisolone reduces swelling and
decreases the body's immune response.
Prednisolone is given with other drugs to
prevent acute rejection. Prednisolone is a
corticosteroid that can be used for life long
immunosuppression to prevent organ rejection,
or in higher doses, for the treatment of rejection.
Corticosteroids are manufactured naturally
in the body in a 24-hour rhythm. You should
take your corticosteroid medication first
thing in the morning so that you can copy
your body's natural rhythm.
|
| |
| Dosage: |
5 mg per tablet.
This drug will be withdrawn gradually during
the first post-transplantation year. |
| |
| Adverse / side effects:
|
- Fluid retention
- High blood pressure· Gastric ulcer·
Weight gain due to increased appetite
- Night sweating
- Moon face
- Muscle weakness, joint pain, osteoporosis
- High blood sugar level· Increased
risk of infection
- Bruising
- Impaired vision
|
| |
| Remark: |
Prednisolone is best given with
milk and food.Inform doctor if there are signs
and symptoms of infection.Regular body weight
check up. |
Lamivudine
| Therapeutic
action: |
Lamivudine inhibits the replication of hepatitis
B virus.
|
| |
| Dosage: |
100 mg per tablet |
| |
| Adverse / side effects:
|
- Nausea, vomiting, diarrhea, abdominal discomfort
- Malaise, musculoskeletal pain
- Lactic acidosis
|
| |
|
| Remark: |
Contraindicated in breast-feeding
women.Lamivudine is used in patients with hepatitis
B infection after liver transplantation. Close
monitoring is necessary to check for recurrence
of hepatitis B virus. |
Ursodeoxycholic
Acid
| Therapeutic
action: |
Ursodeoxycholic acid increases the secretion
of bile and decreases the risk of gallstone
formation.
|
| |
|
| Dosage: |
250 mg per capsule,
500 - 1250 mg daily |
| |
|
| Adverse / side effects:
|
Rare |
| |
|
| Remark: |
Contraindicated in pregnant and
breast-feeding women. |
Nystatin
| Therapeutic
action: |
An anti-fungal drug for prevention and treatment
of candidiasis and oral infection
|
| |
|
| Dosage: |
Oral suspension
5 ml each time and 4 times daily; it is effective
by rinsing the mouth for a few minutes before
swallowing. Do not eat and drink within 30 minutes
after taking the drug. |
| |
|
| Adverse / side effects:
|
Nausea, vomiting, diarrhea |
| |
|
| Remark: |
Contraindicated in pregnant and
breast-feeding women. |
Acyclovir
| Therapeutic
action: |
An anti-viral drug for prevention and treatment
of viral infection such as herpes.
|
| |
| Dosage: |
400 mg per tablet
and 3 times daily; duration of therapy is about
3 months. |
| |
| Adverse / side effects:
|
Nausea, vomiting, diarrhea, abdominal
pain |
| |
| Remark: |
Not suitable for patients with
known Acyclovir hypersensitivity and impaired
renal function. |
Fluconazole
| Therapeutic
action: |
An anti-fungal drug for prevention and treatment
of candidal and cryptococcal infection
|
| |
| Dosage: |
It has syrup and
capsule preparation. 50 - 400 mg daily adjusted
according to severity of infection; duration
of therapy is about 3 months.
Dosage will be adjusted according to your condition. |
| |
| Adverse / side effects:
|
- Nausea, vomiting, diarrhea, abdominal pain
- Headache
- Skin rash
- Hypokalemia
|
| |
| Remark: |
It is well absorbed by oral administration.
Rinse mouth for a few minutes before swallowing.
Do not eat and drink within 30 minutes after taking
the drug. |
Complications
that can arise after Liver Transplantation
Common
complications are:
Bleeding
There is a small
risk of bleeding at the anastomosis, the place where
the blood vessels from donor and recipient were sewn
together. This is minimized by monitoring clotting
factors in the blood after surgery and measuring output
from the drains placed during the operation.
Hepatic Artery Thrombosis
If a clot forms
in the hepatic artery it can cause the liver to malfunction.
Abdominal ultrasound is performed the day after your
surgery to look for this condition and will monitor
the aptient throughout postoperative recovery. If
found, medications or surgical repair can minimize
permanent damage and avoid the need for re-transplantation.
Bile Duct
Leaks
The ducts that
drain from the new liver are attached to a bile duct
or portion of intestine in the recipient. This connection
can leak and bile can drain into the abdominal cavity,
causing infection. If a bile leak occurs, a catheter
may be inserted into the abdomen to allow external
drainage. This is temporary and can usually be managed
without surgery.
Rejection
Rejection is a
normal reaction of the body to a foreign object. When
a new liver is placed in a person's body, the body
sees the transplanted organ as a threat and tries
to attack it. The immune system makes antibodies to
try to kill the new organ, not realizing that the
transplanted liver is beneficial. To allow the organ
to successfully live in a new body, medications must
be given to trick the immune system into accepting
the transplant and not thinking it is a foreign object.
The first rejection commonly occurs within three months
after the operation. Patients are monitored closely
during this time so the warning signs of rejection
can be spotted early and steps taken to control it.
A biopsy of the liver is usually necessary to diagnose
the extent of the rejection taking place, and to rule
out any other problems. Biopsy results will help determine
which anti-rejection therapy would be best for you.
Infection
Because the immune
system is suppressed by medications after transplantation,
you are at higher risk for developing certain infections.
Doctors will prescribe other medications to prevent
the more common post-transplant infections. Patients
would need to routinely monitor their temperature
at home, and make certain adjustments in their daily
living to avoid contracting harmful infections.
Hepatitis
Recurrence
If the patient
is suffering from Hepatitis B or C prior to receiving
the new liver, it is possible to experience a recurrence
of the virus after transplantation. To help identify
and control any recurrence, patient will be screened
with blood tests and liver biopsies at regular intervals.
If recurrence is detected, medications will be prescribed.
Graft-Versus-Host
Disease
By definition, acute GVHD occurs before day 100 post-transplant
and chronic GVHD occurs beyond day 100. Recent advances
have reduced the incidence and severity of this post-transplant
complication, but GVHD, directly or indirectly, still
accounts for approximately 15% of deaths in BMT patients.
Acute GVHD should be treated by the BMT team at
the transplant center where the patient was transplanted.
Chronic GVHD can develop months or even years post-transplant,
and so physicians assuming the care of transplant
patients need to be aware of its symptoms. Table 2
outlines the major symptoms of chronic GVHD. This
table explains Organ involvement indicators for chronic
GVHD:
| Organ/Tissue |
|
| |
| Skin/Hair |
Rash, scleroderma,
lichenoid skin changes, dyspigmentation, alopecia |
| |
| Eyes |
Dryness, abnormal Schirmer's Test,
corneal erosions, conjunctivitis |
| |
| Mouth |
Atrophic changes, lichenoid changes,
mucositis, ulcers, xerostomia, dental caries |
| |
|
| Lungs |
Bronchiolitis obliterans |
| |
|
| GI tract |
Esophageal involvement, chronic
nausea/vomiting, chronic diarrhea, malabsorption,
fibrosis, abdominal pain/cramps |
| |
|
| Liver |
Abnormal LFTs, biopsy abnormalities |
| |
|
| Genitourinary |
Vaginitis, strictures, stenosis,
cystitis |
| |
|
| Musculoskeletal |
Arthritis, contractures, myositis,
myasthenia, fascities |
| |
|
| Hematologic |
Thrombocytopenia, eosinophilia,
autoantibodies |
Cyclosporine A and
methotrexate are indicated for chronic GVHD, but these
should only be administered by physicians familiar
with using these drugs to treat chronic GVHD.
Patients must take
many medications after a liver transplant: some to
prevent rejection (immunosuppressants), some to fight
infection, and others to treat the side effects of
the immunosuppressants. Patients return home after
transplantation having been started on approximately
7 to 10 different type of medicines. As the transplant
patient heals and recovers health with the help of
their new liver, the dosages and number of medications
are reduced over time. By six months, it is common
to be down to 1 or 2 medications. However, transplant
patients will be on life-long immunosuppression in
virtually all cases. It is vital that these medications
are taken as prescribed, in the proper amounts and
at the specified times. Missing medication doses or
discontinuing them on one's own can lead to rejection
and organ failure.
Diet
and Nutrition post Liver Transplant
It is important
that during the first three months after a transplant
patient should avoid eating foods that may contain
‘listeria’. This is a bacteria that can
cause problems whilst the patients are taking higher
doses of anti rejection drugs.
Foods that may
contain listeria include the following:
Unpasturised
cheese
Live
yoghurt / curds
Foods
containing raw eggs eg. Mayonnaise
Regular diet should comprise
of:
Fruits
Vegetables
Whole-grain
cereals and breads
Low
-fat milk and dairy products or other sources of calcium
Lean
meats, fish, poultry, or other sources of protein
Caring for your bones
Liver disease decreases the ability to absorb vitamin
D which plays a part in maintaining the strength of
the bones. Research has shown that transplant patients
are at higher risk of developing bone fracture as
a result of ‘thin’ bones (known as osteoporosis)
To lower the fracture risk, patients should make
sure that they are getting enough calcium and vitamin
D in their diet. The following foods are a good dietary
source of calcium.
Canned
Sardines / salmon
Calcium
fortified orange juice
Milk
- including skimmed and low-fat
Cheese
from pasturised milk
Avoid:
Avoid
sugary snacks such as cakes and biscuits between meals.
While on steroids, try to restrict your salt intake.
Do not eat cheese made from unpasteurised milk and
avoid cheeses with mould.
Alcoholic beverages are not recommended.
Stop smoking!
|