Facts on Liver Transplant
- 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 in this country.
- 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.
- Some basics are as follows:
- The liver donor is the person who gives, or donates, all or part of his or her liver to the waiting patient who needs it. Donors are usually people who have died and wish to donate their organs. Some people, however, donate part of their liver to another person (often a relative) while living.
- Orthotopic liver transplantation refers to a procedure in which a failed liver is removed from the patient's body and a healthy donor liver is transplanted into the same location. This procedure is the most common method used to transplant livers.
- With a living donor transplant, a healthy person donates part of his or her liver to the recipient. This procedure has been increasingly successful and shows promise as an option to avoid long waiting times due to shortage of liver donors. It is also an option in children, partly because child-sized livers are in such short supply. Other methods of transplantation are used for people who have potentially reversible liver damage or as temporary measures for those who are awaiting liver transplants. These other methods are not discussed in detail in this article.
- 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 also aid in healing wounds; and
- 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.
Who Determines What Patients Receive a Liver Transplant?
Determining whose need is most critical: The United Network for Organ Sharing uses measurements of clinical and laboratory tests to divide patients into groups that determine who is in most critical need of a liver transplant. In early 2002, UNOS enacted a major modification to the way in which people were assigned the need for a liver transplant. Previously, patients awaiting livers were ranked as status 1, 2A, 2B, and 3, according to the severity of their current disease. Although the status 1 listing has remained, all other patients are now classified using the Model for End-Stage Liver Disease (MELD) scoring system if they are aged 18 years or older, or the Pediatric End-Stage Liver Disease (PELD) scoring system if they are younger than 18 years. These scoring methods were set up so that donor livers could be distributed to those who need them most urgently.
- Status 1 (acute severe disease) is defined as a patient with only recent development of liver disease who is in the intensive care unit of the hospital with a life expectancy without a liver transplant of fewer than 7 days, or someone who received a liver transplant and the donor organ never worked properly.
- MELD scoring: This system is based on the risk or probability of death within 3 months if the patient does not receive a transplant. The MELD score is calculated based only on laboratory data in order to be as objective as possible. The laboratory values used are a patient's sodium creatinine, bilirubin, and international normalized ratio, or INR (a measure of blood-clotting time). A patient's score can range from 6 to 40. In the event of a liver becoming available to 2 patients with the same MELD score and blood type, time on the waiting list becomes the deciding factor.
- PELD scoring: This system is based on the risk or probability of death within 3 months if the patient does not receive a transplant. The PELD score is calculated based on laboratory data and growth parameters. The laboratory values used are a patient's albumin, bilirubin, and INR (measure of blood-clotting capability). These values are used together with the patient's degree of growth failure to determine a score that can range from 6 to 40. As with the adult system, if a liver were to become available to two similarly sized patients with the same PELD score and blood type, the child who has been on the waiting list the longest will get the liver.
- Based on this system, livers are first offered locally to status 1 patients, then according to patients with the highest MELD or PELD scores. Patients on the local list with a MELD score above a certain level are offered the liver first, then it is allocated to regional and national listed patients. Once that list is exhausted, the liver is offered to other patients on the local regional, and national level, in that order. There are ongoing discussions to modify the liver allocation process to ensure that the sickest patients receive them first, regardless of where they live.
- Status 7 (inactive) is defined as patients who are considered to be temporarily unsuitable for transplantation.
Who may not be given a liver: 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: Active cancers in locations other than just the liver weigh against a transplant.
- Advanced heart and lung disease: These conditions prevent a patient with 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
The transplantation team: If a liver transplant is considered an option by a primary doctor, the person must also be evaluated by a transplantation team to determine their candidacy. The transplantation team usually consists of a number of people, including a transplant coordinator, a social worker, a hepatologist (liver specialist), and a transplant surgeon. It may be necessary to see a cardiologist (heart specialist) and pulmonologist (lung specialist), depending on the recipient's age and health problems.
- The potential recipient may also see a psychiatrist or psychologist because of psychiatric or substance abuse issues, and the liver transplantation process may be a very emotional experience that may require life adjustments.
- The liver specialist and the primary doctor manage the person's health issues until the time of transplantation.
- A social worker is involved in the case. This person assesses and helps develop the patient's support system, a central group of people on whom the patient can depend throughout the transplantation process. A positive support group is very important to a successful outcome. The support group can be instrumental in ensuring that the patient takes all the required medicines, which may have unpleasant side effects. The social worker also checks to see that the recipient is taking medications appropriately.
Medically Reviewed by a Doctor on 11/28/2016
Robert M McNamara, MD, FAAEM
Francisco Talavera, PharmD, PhD
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