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LIVER TRANSPLANTATION Indications for Liver Transplantation in Adults  1.Fulminant Hepatic Failure  2. Alcoholic Liver Disease  3.

Chronic Hepatitis C  4. Chronic Hepatitis B  5. Non-alcoholic steatohepatitis  6. Autoimmune Hepatitis  7. Primary Biliary Cirrhosis  8. Primary Sclerosing Cholangitis  9. Hepatic tumors  10. Metabolic and genetic disorders Manifestations of End-Stage Liver Disease  Progressive jaundice  Intractable ascites  Spontaneous bacterial peritonitis  Hepatorenal Syndrome  Encephalopathy  Variceal bleeding  Intractable pruritus  Chronic fatigue (such as resulting in loss of gainful employment)  Bleeding diathesis or coagulopathy

Preoperative management of complications associated with hepatic failure & decompensated cirrhosis  Hepatic Encephalopathy  Cerebral Edema  Acute Renal Failure  Infection & Sepsis  Metabolic Derangements  Malnutrition  Coagulopathy  Portal Hypertension

Post-operative complications & management of liver transplant patients  Right pleural effusion May affect ventilation, necessitating drainage.

 Hepatic edema secondary to aggressive resuscitation & increased intravascular volume. Goal CVP 6-10. Minimize increased hepatic vein pressures, sinusoidal congestion that impair graft perfusion & exacerbate reperfusion injury.  Renal failure Elevation of creatinine & BUN observed in nearly all transplant patients secondary to ATN, hepatorenal syndrome. Usually selflimiting. May necessitate therapy with loop diuretics, renal replacement therapy. Allograft rejection  Hyperacute rejection Secondary to preformed Ab to graft antigen. Extremely rare. Necessitates retransplantation.  Acute Cellular Rejection 70% of patients 5 to 14 days following transplant. Heralded by fever, jaundice, elevation of liver enzymes. Diagnosed by liver biopsy. Demonstrates endothelialitis & nonsuppurative cholangitis.

Details of the procedure What happens the day before surgery? The donor will be asked to come to the hospital the day before surgery. He or she will NOT be admitted at that time, but may need some additional testing done. All donors will be given a bottle of antibacterial soap. The abdomen should be scrubbed from nipples to knees the evening before the surgery, and twice in the morning on the day of surgery, before the donor comes to the hospital. This soap helps to reduce the chance of getting an infection in the incision after surgery. If

any donor is allergic to antibacterial soap products, please notify the transplant coordinator. After 12 noon on the day before surgery, the donor should only have clear liquids. After 12 midnight the day of surgery, the donor should have absolutely no food or drinks. This fasting will decrease the possibility of nausea or vomiting during and after surgery and will help clear the bowel before surgery. Smoking is not permitted in the hospital after the donor is admitted. Smoking increases the risk of heart and lung problems (such as pneumonia) after surgery. What type of anesthesia will be used? A liver transplant is performed under a general anesthetic, which will keep you asleep during surgery. What happens during surgery, and how is the surgery performed? Your surgeon will make an incision between the rib cage and extending down to the right and left of the rib cage. What happens the day of surgery? The donor is admitted the day of surgery to the Same Day Admission Unit . The donor will be given a pair of TEDs (which stands for thromboembolic disease): these are special elastic stockings that increase the circulation in the legs. Only a hospital gown may be worn to surgery. All dentures and glasses, nail polish, lipstick, makeup, jewelry, and hairpins must be removed. Valuables should be left in the hospital room, they will be sent to Protection Services or with relatives for safekeeping. A nursing assistant will bring a cart to the hospital room to transport the donor to the Pre-Induction Room (PIR) outside of the Operating Room. Families may come into this area. They will then be directed to the Surgery Waiting Area . After the surgery is done, the doctors will meet with the family there. In the PIR, an intravenous line will be inserted so that anesthesia medications can be administered. The doctor in charge of anesthesia (the anesthesiologist) will come to see the donor.

An endotracheal (ET) tube will be inserted in the donor's throat during surgery to help with breathing. The ET tube is placed after the donor is asleep from the anesthesia. If it is still in place when the donor first wakes up, he or she will not be able to talk. As soon as the donor is fully awake, the ET tube is removed. A Foley catheter will be inserted in the donor's bladder in the Operating Room to drain urine. A nasogastric (NG) tube will also be inserted through the nose and throat to the stomach. It drains the stomach contents to prevent nausea and vomiting and will remain in place for a couple of days after surgery, or until the bowels start to function. A small plastic drain is left in the donor's abdomen to collect blood and bile, which may accumulate in the area where the piece of liver is removed. This drain is usually removed 4 to 5 days after surgery. What happens after the surgery? Once the procedure is completed, you will be taken to a post-operative or recovery unit, where a nurse will monitor your recovery. Your body functions will be monitored closely, and blood tests will be performed regularly. You will be given medications to prevent your body from rejecting your new liver. Most patients will be required to take these medications for the remainder of their life. As you recover, the blood testing will be performed less frequently. You will be allowed to eat solid foods, and you will begin physical therapy to assist you in regaining muscle strength. You will be scheduled for monthly check-ups that will include blood tests and a visit with your doctor. Because your immune system will be impaired following surgery, you should take additional precautions to avoiding infection. Report any illness to your doctor immediately. How long will I be in the hospital? (donor) You will be in the hospital at least one week. The first few days following your surgery, you will be in an intensive care unit where you will be monitored continuously. What are the risks associated with a liver transplant? As with any surgery, there are risks such as infection, bleeding, or an adverse reaction to anesthesia. Your surgeon will inform you of the risks prior to surgery.

When can I expect to return to work and/or normal activities?(donor) Most patients can expect to return to work and normal activities within four to six months following a successful liver transplantation. What are the advantages of a Living Donor Liver Transplant? The greatest advantage of an Living Donor Liver Transplant (LDLT) is that it avoids the waiting time for a cadaver transplant. Currently, the organ shortage is severe. There are not enough cadaver livers for all of the patients who need one. Over 15,000 people are now waiting for liver transplants in the United States, but only 4,500 transplants are performed every year. Roughly 20% of patients will die of their liver disease before having the chance to undergo a transplant. For those who do end up receiving a cadaver transplant, the average waiting time is 1 to 2 years (from the day they are first placed on the waiting list). With an LDLT, this waiting time can be bypassed, allowing the transplant to be performed before the recipient's health deteriorates further - sometimes to the point where he or she is no longer able to undergo a transplant. If the transplant is performed before the recipient's health deteriorates, he or she is better able to tolerate the surgery and recovers more quickly. Another advantage of an LDLT is that the piece of liver from the donor may be placed in the recipient immediately after being removed from the donor. Therefore, the amount of time that the liver is kept on ice before the transplant is minimal. In contrast, a cadaver liver transplant may need to be in storage for several hours. Thus, the chance of an LDLT graft functioning immediately is probably higher. Finally, by performing an LDLT, the number of livers available for transplantation overall is increased. The LDLT recipient no longer requires a cadaver liver, which can then go to a patient who does not have a suitable living donor. What are Living Donor Liver Transplant results like? Since this is a relatively new procedure, long-term results are not available, especially for adult-to-adult Living Donor Liver Transplants. However, short-term results are promising. According to data from all centers in the United States, about 85% of LDLT recipients are alive 1 year after their transplant. Both adult and pediatric LDLT recipients have a good chance of leading a long and healthy life.

Who can be considered for a donor? The transplant team will consider many different individuals as potential donors. Usually, relatives are preferred, since they are most involved in the potential recipient's health. However, nonrelatives such as good friends or spouses may also be considered. The donor must have a compatible blood type and must also be similar in size to the recipient. Most important, the donor must be in good physical and mental health, with no significant history of major medical problems, liver disease, or excessive alcohol use. The transplant team will consider donors between the ages of 18 and 55 if they are in good health. What is the process for evaluating a donor? Once the potential donor is determined to be of similar size and compatible blood type, an evaluation or workup is done to ensure that he or she is medically, surgically, and psychologically fit for donation. 1. Medical evaluation The medical evaluation involves an intensive interview to obtain the donor's medical history. A complete physical examination is also performed. The donor must not have any medical problems that would increase his or her risk for a major operation and the removal of a portion of the liver. Medical problems that would rule out donation include heart or lung problems that require medication, current liver problems or hepatitis infection, a history of cancer, active alcohol abuse, or any history of very heavy alcohol use, HIV infection, diabetes of several years' duration requiring insulin use, and significant obesity. Besides the medical history and physical examination, many blood tests will be done to rule out any significant abnormalities and to make sure the donor's liver function is normal. 2. Surgical evaluation The liver is one large solid organ. It is made up of 2 lobes (right and left), which are further divided into a total of 8 smaller segments (1 through 8).

Figure 1 Each portion has its own blood supply (arteries and veins) for bringing the blood to and from the liver as well as its own bile duct draining the bile produced by the liver. An LDLT can be performed because it is possible to remove a portion of the liver with its own blood supply and bile duct intact. This portion can then be reconnected in the recipient. However, not all people's anatomy is suitable to splitting the liver in this fashion. So, the purpose of the surgical evaluation is to determine the anatomy of the donor's liver and make sure that donation is technically possible. Special x-rays of the liver, including a computed tomography (CT) scan and a magnetic resonance imaging (MRI) scan, will be performed. These x-rays provide information about the liver's appearance and blood supply. They may also be used to determine if the liver volume would be adequate for adult-to-child LDLTs. On rare occasions, these x-rays are not sufficient and an additional test called an angiogram is necessary. In an angiogram, a needle is placed directly into a blood vessel, dye is injected, and then an x-ray is obtained to more closely look at the liver's blood vessels. 3. Psychological evaluation The potential donor will also be interviewed by a social worker from the transplant team to make sure that the donation is entirely voluntary. The decision to donate should be made entirely by the potential donor after careful consideration of the risks and potential complications of the procedure, with no coercion from anyone.

What happens after the donor evaluation? Once the donor's evaluation is complete, all of the information will be carefully reviewed by the transplant team in order to make a final decision regarding that donor's suitability. Once the decision is made to accept a donor, a tentative transplant date can be chosen. We will then arrange for the donor to donate 2 units of blood before the surgery. Thus, if the donor requires a transfusion during the surgery, his or her own blood can be used. This process of "banking" one's own blood generally takes 2 to 3 weeks.

What is the donor operation like? If the LDLT recipient is an adult, a larger portion of the liver needs to be removed from the donor, usually the right portion of the liver: about 60% of the donor's total liver (see figure 3).

Figure 3 The blood vessels supplying the portion of the liver to be removed are separated out, the liver itself is divided, and the portion to be transplanted is removed. This portion is brought into a separate operating room for the recipient, where the transplant is then performed. The donor operation takes 6 to 8 hours. Liver for transplant can be obtained from two types of donors. Cadaveric Liver Donation Such donation is possible from a brain dead person whose family wishes to donate the person's organs before discontinuing life support. This situation arises only in a hospital ICU in a person after brain injury in an accident or in someone who has suffered fatal brain hemorrhage etc. In these circumstances, the whole liver can be used for an adult, and a part of it for a child. After removal from the donor (a process called liver retrieval) the liver can safely be kept preserved outside the body in special preservation solutions for 12-15 hours. Allocation of such organs is strictly according to blood group which must match, time on waiting list and urgency of requirement. Living Liver Donation Liver donation is also possible from a living donor who is a relative of the recipient

who can donate half his/her liver. The donor operation is entirely safe and the half liver quickly regenerates in both the donor and the recipient in a few weeks. In the first few days after operation even when regeneration is not complete, the half liver is enough to maintain normal donor functions due to the immense reserve in the liver.