Liver Transplant (cont.)
The search for a donor: Once a person is accepted for transplantation, the search for a suitable donor begins. All people waiting are placed on a central list at UNOS. Local and national agencies are involved in finding suitable livers. The United States has been divided into regions to try to fairly distribute this scarce resource. 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. Rejection occurs when the patient's body attacks the new liver.
- With the shortage of donor organs and the need to match donor and patient blood and body type, the waiting time may be long. A patient with a very common blood type has less chance of quickly finding a suitable liver because so many others with his or her blood type also need livers. Such patients are likely to receive a liver only if they are in the intensive care unit and have very severe liver disease. A patient with an uncommon blood type may receive a transplant more quickly if a matching liver is identified because people higher on the transplant list may not have this unusual blood type.
- The length of time a person waits for a new liver depends on blood type, body size, and how soon the patient needs a transplant. During the wait, it is important to stay in good physical health. Following a nutritious diet and a light
exercise plan are important. In addition, regularly scheduled visits with the transplantation team may be scheduled for health examinations. A patient also receives vaccines against certain bacteria and viruses that are more likely to develop after the transplantation because of immunosuppression (antirejection) medication.
Living donors: Avoiding a long wait is possible if a person with liver disease has a living donor who is willing to donate part of his or her liver. This procedure is known as living donor liver transplantation. The donor must have major abdominal surgery to remove the part of the liver that will become the graft (also called a liver allograft, which is the name for the transplanted piece of liver). As techniques in liver surgery have improved, the risk of death in people who donate a part of their liver has dropped to about 1%. The donated liver will be transplanted into the patient. The amount of liver that is donated will be about 50% of the recipient's current liver size. Within 6-8 weeks, both the donated pieces of liver and the remaining part in the donor grow to normal size.
- Until 1999, living donor transplantation was generally considered experimental, but it is now an accepted method. In the future, this procedure will be used more often because of the severe lack of livers from recently deceased donors.
- The live donor procedure also allows greater flexibility for the patient because the procedure may be done for people who are in the lower stages of liver disease.
- At present, only patients with the most severe liver disease are allowed to receive transplants. These are often patients in intensive care units who have a very short life expectancy, often classified as stage 1, or patients with very high MELD or PELD scores.
- With a living donor, patients healthy enough to live at home may still receive a liver transplant. The living donor transplantation may also be more widely used because of the increase in
hepatitis C virus infection and the importance of quickly finding transplants for people who have
liver cancer. Finally, the success with living donor kidney transplants has encouraged increased use of such techniques.
- Recipients of a living donor liver transplant go through the same evaluation process as those receiving a cadaveric liver (a liver from someone who has died). The donor also has blood tests and imaging studies of the liver performed to make sure it is healthy. The living donors, as with the deceased donors, must have the same blood type as the recipient. They must be aged 18-55 years, have a healthy liver, and be able to tolerate the surgery. The donor cannot receive any money or other form of payment for the donation. Finally, the donor must have a good social support system to aid in emotional aspects of going through the procedure.
- People who have liver disease or
alcoholism are not allowed to donate part of their liver. Those who smoke chronically or who are obese or pregnant also cannot make such donations. If the potential donor does not have a compatible blood type or does not meet these criteria, the recipient may continue to be listed on the UNOS registry for a transplant from a deceased donor.
A donor is found: Once a suitable cadaveric liver donor has been found, the patient is called to the hospital. It is best that the patient carry a beeper as he or she rises on the transplant list, so that getting to the hospital can be done quickly. Donor livers function best if they are transplanted within 8 hours, although they can be used for up to 24 hours. Presurgical studies, including blood tests, urine tests, chest
x-rays, and an
ECG, are performed. Before surgery, an IV line is started. The patient also receives a dose of
steroids-one of the medicines to prevent rejection of the new liver-and a dose of
antibiotics to prevent infection. The liver transplantation procedure takes about 6-8 hours. After the transplantation, the patient is admitted to the intensive care unit.
Robert M McNamara, MD, FAAEM
Francisco Talavera, PharmD, PhD
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