Liver transplantation

Liver transplantation is a procedure during which the person’s own damaged liver is replaced by a healthy organ.

Overview

Gloves, blood sample and model of the liverLiver transplantation is a life-saving surgical procedure when the diseased liver, which fails to person’s life is replaced by a healthy organ. The liver is one of the most essential body organs which is the body’s chemical factory. Therefore, end-stage liver disorders may be life-threatening and are associated with severe complications. For individuals, at this point, the only possible option is liver transplantation.

The first liver transplantation was performed by Welch in dogs back in 1955, 8 years later Tomas Starzl managed to successfully transplant liver in man. Nowadays liver transplantation is the second most commonly performed organ transplantation.

Indications

Liver transplantation is performed for children and adults whose liver function is severely impaired, namely, they have an end-stage liver disease when any other treatment is not effective and life-threatening complications have developed or develop. Cirrhosis of different etiology is the most common indication for liver transplantation in adults. In children typically liver transplantation is performed due to biliary atresia – a condition characterized by the absence of the bile ducts.

The following disorders may be considered as indications for the liver transplantation.

  • Children
    1. Biliary atresia;
    2. Neonatal hepatitis;
    3. Congenital hepatic fibrosis;
    4. Crigler-Najjar disease type I;
    5. Inherited disorders of metabolism, including Wilson’s disease, hemophilia, familial hypercholesterolemia, tyrosinemia, etc.;
  • Adults
    1. Primary and secondary biliary cirrhosis;
    2. Primary sclerosing cholangitis;
    3. Autoimmune hepatitis;
    4. Caroli’s disease;
    5. Chronic hepatitis with cirrhosis;
    6. Hepatic vein thrombosis;
    7. Alcoholic cirrhosis;
    8. Fulminant hepatitis due to mushroom poisoning by Amanita phalloides or toxic influence of some medications such as acetaminophen;
    9. Chronic viral hepatitis;
    10. Liver cancer;
    11. Nonalcoholic steatohepatitis;

The liver plays one of the key roles in the body’s metabolism. When liver failure occurs the toxins and waste products accumulate in the blood, damaging the central nervous system and causing liver encephalopathy characterized by the cognitive and mental dysfunction. Increased levels of the blood bilirubin present with jaundice (a yellowish color of the skin and mucous membranes). The pressure in the portal vein increases and leads to portal hypertension, which may, in turn, cause bleeding from the varices in the esophagus. Fluid accumulates in the abdomen resulting in the ascites.

Contraindications

Liver transplantation is a complicated surgery and not all the individuals can go through the surgery and the postoperative recovery period. Some conditions and comorbid disorders may hinder the person’s ability to survive the surgery and recover successfully. If a person has mental health issues which may lead to poor therapy adherence and compliance liver transplantation cannot be performed.

  • Absolute
    1. Uncontrolled infectious disease, sepsis;
    2. Active substance or alcohol abuse;
    3. End-stage cardiovascular disease;
    4. AIDS;
    5. Any non-liver cancer;
    6. Severe systemic disease;
  • Relative
    1. Age over 70;
    2. Portal vein thrombosis;
    3. Renal failure not related to liver disease;
    4. Severe obesity;
    5. Severe malnutrition;
    6. Uncontrolled and untreated HIV infection;
    7. Uncontrolled psychiatric disorder;

Types of liver transplantation

Three types of liver transplantation procedure:

  • Orthotopic transplantation – a damaged liver is fully replaced with a healthy one;
  • Heterotrophic transplantation – a person’s liver is preserved, whereas the donor’s liver is placed at another site;
  • Reduced-size liver transplantation – a diseased liver is replaced with a part of a healthy liver;

Procedure

Brain-dead individuals are donors for transplantation. Sometimes for recipients with prior hepatitis B and C organs may be withdrawn from infected donors. For transplantation in children, one donor organ may be split between two recipients: the left segment will be transported to a small child and the right lobe – to an adult. After the liver is removed from the cadaver the surgery should be performed within 12 hours.

Living a healthy adult may also become a donor. Typically, the right lobe of the liver is transplanted in these cases. The living donor should:

  • be 18 -60 years old;
  • have a compatible blood type with  the  recipient;
  • have no chronic diseases or  major abdominal surgery in the past;
  • be related to the recipient;

Immunosuppressive treatment

Those who underwent organ transplantation should receive lifelong immunosuppressive therapy to prevent organ rejection. Usually, cyclosporine, tacrolimus, cellcept, and prednisone are prescribed in combination.

Complications

  • Acute rejection of the organ (becomes apparent within 1-2 days after the surgery);
  • Graft-versus-host disease (donors white blood cells attack the recipient’s body);
  • Renal dysfunction;
  • Portal vein thrombosis;
  • Hepatic artery thrombosis;
  • Intraabdominal bleeding;
  • Biliary obstruction;
  • Bile duct stenosis or leak;
  • Arrhythmias (irregular heartbeat);
  • Congestive heart failure due to fluid overload;
  • Pneumonia;
  • Posttransplantation lymphoproliferative disorders;
  • Viral infection;
  • Bacterial infection;
  • Fungi infection;

Outcomes

The outcomes depend on the person’s overall health, comorbid disorders and treatment compliance. The 5-year survival rate is over 60%.

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