Liver transplantation
Liver Transplantation: Indications
Liver Transplantation is when a patient’s own liver is removed and replaced with a liver that has come from a deceased donor. There are a number of reasons why somebody may be considered for a liver transplant. The most common reasons are because your own liver is not working well (liver function deterioration) or because you have a cancer in your liver, e.g a primary liver cancer (hepatocellular carcinoma (HCC)) or a bile duct cancer (cholangiocarcinoma). There are also other less common reasons why you might need a liver transplant that your doctor can discuss with you.
Liver Function Deterioration
Liver transplant assessment is usually recommended when there is a progressive deterioration in liver function. Ideally patients with cirrhosis should be referred to the liver transplant team when they develop evidence of deteriorating liver function and/or experience their first major complication. Signs of liver deterioration include jaundice (yellowing of the skin), ascites (fluid in the tummy), hepatic encephalopathy (liver-related confusion), or bleeding varices (veins in the oesophagus or stomach). Medical treatment options may be limited and a liver transplant may a possible solution. One useful indicator of the severity of liver function deterioration is the MELD (Model for End Stage Liver Disease) score. It gives each person a “score” based on how sick they are, using a combination of important blood tests. It also indicates how urgently you need a liver transplant. The scale goes from 6 (less ill) to 40 (very ill).
Liver Cancers
Hepatocellular Carcinoma (HCC)
Hepatocellular Carcinoma (HCC) is the most common cancer that originates within the liver. Some patients may be at increased risk of developing HCC such as those with hepatitis B & C and haemochromatosis. Transplantation may be possible if the HCC is small and confined to the liver. If the HCC is large and/ or invading important blood vessels transplantation may not be possible. Diagnosis of HCC can be made by ultrasound, CT scan and MRI scan. Specific blood tests such as alpha-feto protein are measured every 6 months in those at risk. Some patients may require transarterial chemo embolisation (TACE) or Radiofrequency ablation (RFA). The Treatment of HCC is often complicated because patients also have advanced chronic liver disease. During assessment and while waiting for liver transplant you may receive treatment such as transarterial chemo embolisation (TACE) or Radiofrequency ablation (RFA). This treatment is aimed at controlling the size of the tumor and to reduce the risk of it spreading to a blood vessel or outside of the liver.
Cholangiocarcinoma (CCA)
Cholangiocarcinoma (CCA) is a rare carcinoma of the bile duct system. CCA can occur in diseases of the biliary system such as primary sclerosing cholangitis (PSC). Transplantation for CCA is only possible in specific cases, in conjunction with chemotherapy, radiotherapy, and brachytherapy. This combination of therapy is known as the ‘Mayo Protocol’. Biliary drainage and surgery are also required. If the CCA responds to this combination of therapy, then liver transplantation may be possible. If the CCA is not treated by ‘Mayo Protocol’, and/or has spread outside the bile duct, transplantation is not possible. Additional information can be discussed on an individual basis.
Phases of Liver Transplantation
Phase 1 - Assessment
The assessment phase involves having a variety of different tests carried out and meeting different members of the team. There are a number of reasons that the assessment period is vitally important. Firstly, and foremost, it is to ascertain the extent of your liver disease. Secondly, it is to ensure that there are no other medical treatment options available to you and transplantation is the best treatment option. It is vital to make sure that all avenues have been explored and that all medical treatments have been considered prior to transplantation. Thirdly it is important to ensure that you are fit to undergo transplant surgery and that there are no contra-indications. Both you and your family will be fully informed about your disease and all aspects of liver transplantation. This information will help you to make an informed decision about the treatment that is being offered to you.
Health professionals you will meet:
You will meet various members of the transplant team, including nursing staff, hepatologists, surgeons, dieticians and anaesthetists during your assessment. Depending on your current medical or surgical history, additional consultations may be necessary. The team have extensive knowledge, skill and experience in caring for patients with liver disease and those requiring liver transplantation and will decide whether you are fit for transplant surgery and ensure that there are no contraindications.
Investigations:
As part of your assessment, it is essential that a number of tests are carried out. The reasons for doing these are explained below. This is a general guide. Each person’s case is looked at individually so there may be one or two tests that are not mentioned here. Any individual tests will be explained to you in due course.
Blood Tests: Numerous blood tests are carried out to further assess your liver and kidney function. Tests are also done to detect any viruses you may have come in contact with, e.g. Chicken Pox, Shingles, C.M.V. A test for H.I.V. is routinely carried out on all patients being assessed for a transplant.
Chest X-Ray: This is performed to ensure that your chest is free from infection and to act as a baseline post transplant.
Pulmonary Function Tests: These are non-invasive and are designed to look at the function of your lungs. This is to ensure that your body would be able to cope with the surgery and the early post operative period, at which time you will be on a ventilator and may be more susceptible to chest infections.
Electrocardiograph (ECG): This is not painful and involves attaching sticky pads to your chest with wires leading to a machine. This gives a tracing of the rhythm of your heart.
Cardiac ECHO: This is an ultrasound of the heart. Gel is placed on the chest and a study of the heart is carried out using sound waves. Depending on the results of this procedure, right heart studies may need to be carried out.
Ultrasound Scan: An ultrasound scan is a painless, non-invasive procedure carried out to look at the size and texture of your liver. It will also look at the blood vessels entering your liver to see if the blood is flowing through them normally.
Multi-slice liver CT: This is a specific type of x-ray (scan) that takes several pictures of your liver and abdominal cavity to provide additional information on the blood vessels supplying your liver. You will be required to drink a litre of water one hour prior to the procedure.
24 Hour Urine Collection: This looks at the function of your kidneys and involves collecting all your urine for 24 hours. A blood test is required on the day the collection finishes to calculate the result.
Oral Pantomogram (dental X-ray): This is an x-ray of your teeth and gums. It is needed to ensure that there are no areas in your teeth or gums that could be an infection risk after the surgery. In some cases you may need dental treatment carried out before the transplant operation.
What else will happen?
Depending on the results obtained from these tests and the complexity of your illness, further tests may be arranged in order to gather more information. For example you may need a consultation with the respiratory, kidney team, heart team or diabetic team.
How the decision is made?
At the end of your assessment phase, once all the tests have been completed and the results have been obtained, all the Health Professionals involved in your care will meet to plan your care. The multidisciplinary team meets on a Thursday morning to review your liver disease and symptoms. The results of your tests are reviewed to ensure that that you are fit enough to undergo a liver transplant operation. A decision is made at the meeting on the best management for your liver disease and if a transplant operation can be carried out. There are four possible outcomes from these discussions.
Transplantation is the best treatment - we will put you on the waiting list now.
Transplantation is indicated at some point in the future and we will continue to follow you closely at the transplant clinic.
There are more suitable treatments for you other than transplantation at present.
For either medical or technical reasons, transplantation is not possible.
If a decision is made to go ahead with transplantation, the next step is to go on the waiting list. If you are to be placed on the liver transplant waiting list, the transplant coordinator will make an appointment to meet with you and your partner/ carer or support person. Details of the surgery will be discussed with you and the documentation is completed to place you on the liver transplant waiting list. You will begin phase two of transplantation.
Phase 2 - Waiting for a suitable liver
How long do I have to wait?
Donor livers are matched with the recipient by, blood group, weight and MELD score. Waiting is probably the hardest phase for you because it is the time of least activity. The wait can range from weeks to months. Currently the average waiting time is 12-24 months.
What is the MELD score?
MELD is Model for End Stage Liver Disease. It gives each person a “score” based on how sick they are. It also indicates how urgently you need a liver transplant. The scale goes from 6 (less ill) to 40 (very ill)
Where will I wait?
It is hoped you will be well enough to wait at home. If you become unwell you may be admitted to hospital. If your condition deteriorated you may be in hospital until the time of the transplant.
How will I be contacted?
The Transplant Co-ordinator will contact you using the telephone numbers you and your family have provided.
What time of the day will the call come at?
Again, this is a difficult question to answer. You could be called at any time of the day or night, although it is more likely you will receive a call in the evening time. The transplant coordinator will have discussed transport arrangements with you prior to you being placed on the waiting list.
Will the transplant always go ahead?
In certain situations your operation may be cancelled after you have been called to the hospital. We term this a ‘false alarm’. If the donor liver was found to be unsuitable the transplant surgery would be cancelled. If this should happen you will be allowed to return home and you will remain on the waiting list.
What should I do if I am unwell?
If you are unwell, or put on antibiotics or other medication by your GP, or admitted to another hospital while you are on the waiting list please inform the transplant co-ordinators on 01 221 4131 or via the hospital switchboard 01 221 4000. You can e-mail liver.transplant@st-vincents.ie on work days.
Can I go on holiday whilst on the list?
Going abroad is not advisable while on the waiting list because it would not be possible to get you to the hospital on time for your transplant surgery. If there is a special occasion, you feel that you cannot miss, please discuss this with your transplant co-ordinator. You are free to travel within Ireland once you contact the transplant coordinator prior to your departure. The information they will require includes contact numbers, traveling time to the hospital and the dates you will be away. A minimum of 48hours notice is essential.