A: before, diseased liver; B: after, donor liver in place.(Click to Enlarge)
Orthotopic liver transplantation is the definitive treatment for end-stage liver disease and its complications. It is also used for:
During a liver transplant, your surgeon removes the diseased liver and replaces it with a healthy liver.
Liver Transplant: Types of Procedures
There are two types of liver transplant:
- Cadaver: Your surgeon harvests (takes) the liver from someone who died who was an organ tissue donor.
- Live donor: Your surgeon removes a portion of the liver from a healthy relative and places it in you. A healthy liver can regenerate to a normal size in a few months. A relative needs to undergo extensive workups before donating to make sure they are a suitable candidate.
Liver Transplant: Organ Allocation
In the United States, organs from cadavers are allocated by the United Network for Organ Sharing (UNOS). UNOS uses a scoring system called model for end-stage liver disease (MELD) to make the complex decision of where to place patients on the waiting list. MELD is a scoring system that rates the severity of liver disease.
You begin the transplant workup process when the MELD score reaches around 15, or if you develop a major complication of cirrhosis. MELD emphasizes the severity of the patient, not the amount of time spent on the waiting list.
Liver Transplant Candidates
Liver transplantation offers a definitive cure for many severe liver diseases when other forms of treatment like medication or surgery have failed.
You may need a liver transplant if:
You have acute liver failure due to toxic ingestions (often, toxicity due to acetaminophen, herbal supplements or acute hepatitis B).
You have end-stage liver disease from any number of causes, including cirrhosis. Cirrhosis is irreversible scarring of the liver, rendering the liver incapable of functioning. It can be caused by many conditions, including hepatitis B or hepatitis C, alcohol, nonalcoholic steatohepatitis (NASH) — fatty liver, primary sclerosing cholangitis, primary biliary cirrhosis, autoimmune liver disease or an overload of iron (hemochromatosis) or copper (Wilson’s disease).
You have hepatocellular carcinoma (liver cancer) and you meet certain criteria.
There is a lengthy waiting list for new livers and a shortage of donors. The surgery is also expensive and complex, and patients need to take antirejection medication after the transplant for the rest of their lives. Liver transplant is usually a last resort for these reasons.
Not every patient with end-stage liver disease is a candidate for a liver transplant. You will not be considered for a liver transplant if you:
- Actively abuse drugs and alcohol
- Suffer from a heart condition (which would make recovery too strenuous)
- Had previous major abdominal surgery
- Have certain malignancies (cancers)
You also may not be a suitable candidate because of:
- Chronic infections outside the liver
- Untreated human immunodeficiency virus (HIV) infection
- Extrahepatic cancer (cancer that occurred outside the liver)
- Extensive portal vein thrombosis
- Active psychiatric illness
Liver Transplant Workup
A liver transplant workup refers to the counseling and preparatory procedures you need to undergo before your liver transplant. The workup is performed by a trained, experienced team, including:
- Specialists based on your individual needs
You also will need to undergo several procedures. Once complete, your case is presented to the Liver Transplant Selection Committee, which decides if you will be placed on the waiting list.
You will meet with a transplant hepatologist (a liver transplant specialist) who identifies you as a liver transplant candidate. Then the workup is initiated in coordination with the liver transplant surgical team. During the consultation phase:
- The transplant social worker interviews you and your immediate family. If your social worker does not find evidence of psychosocial disorders, you continue to the next consultations.
- You will undergo a cardiac stress test and pulmonary (lung) function tests.
- If needed, you will need to be evaluated by a neurologist; renal, pulmonary and psychiatric consultations are also done on an as-needed basis.
- If you have hepatocellular carcinoma (liver cancer), you will probably need a consultation with an oncologist (cancer specialist) and an interventional radiology specialist.
After the consultation phase, you will need a radiological evaluation, also known as imaging scans. Imaging scans are noninvasive procedures that provide your doctor with detailed images of the inside of your body. Imaging scans for liver transplant workup include:
- Ultrasound and contrast computed tomography (CT) of your abdomen to check for liver cancer
- A specialized ultrasound called a Doppler to study your portal vein in some cases
- X-rays of the chest, sinuses and teeth
Your doctor will need to take a number of blood tests during the workup. Laboratory tests include:
- Viral hepatitis profile to check for evidence of viral hepatitis
- Cancer markers to check for evidence of cancer
- Complete blood count, complete metabolic panel, INR to calculate the MELD score
Other Procedures and Cancer Screening
Depending on your individual situation, you may require other tests as part of your workup. These may include:
- Esophagogastroduodenoscopy, a type of endoscopic procedure that looks for esophageal and gastric varices (varicose veins). This test also determines the extent of portal hypertensive gastropathy, the changes in the stomachs mucous lining due to portal hypertension.
- Colonoscopy: Patients with cirrhosis who are older than 40 years of age — younger if they are higher risk — need a screening colonoscopy. Your doctor can identify and remove polyps if necessary. Certain high-risk patients will need further screening colonoscopies every few years following the liver transplant.
- Endoscopic retrograde cholangiopancreatography (ERCP): Certain patients require this procedure to identify any strictures (narrowing) in the biliary system, which is the system for transporting bile.
- Mammogram and PAP smear for female patients.
- Cardiac ECHO and cardiac stress test. Coronary arteriogram may be needed if the cardiology consultant recommends it.
You will need certain vaccinations as part of your transplant workup. These include vaccinations for:
- Hepatitis A and B, unless you have prior immunity
- Pneumovax®, the vaccine for pneumonia, required every five years
- Skin test for tuberculosis
After the Workup
After the full preparation period, you will be evaluated by the liver transplant surgeon before being presented to the selection committee.
The selection committee includes physicians and liver transplant anesthesiologists, as well as social workers, pre- and post-liver transplant nurse practitioners and nurse coordinators, financial coordinators and a secretary to record the minutes.
Visit our Comprehensive Transplant Center at www.hopkinsmedicine.org/transplant .