Liver Transplant

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Liver Transplant Overview
Currently, more than 17,000 people in the United States are waiting for liver transplants. According to the United Network for Organ Sharing (UNOS), about5,300 liver transplantations were performed in the United States in 2002.
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. In this case, the
  liver donor is someone who has recently died. The 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 a
  solution to the shortage of liver donors. It is becoming the most
  frequent 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 (1) glucose, a basic sugar and energy source; (2) proteins, the
  building blocks for growth; (3) blood-clotting factors, substances that aid
  in healing wounds; and (4) 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.
  

• Determining whose need is most critical: The United Network for Organ Sharing uses measurements of clinical and laboratory problems 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.
    
  • 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 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. Next, if there are no local recipients, the liver is
    offered regionally, in the same order, and finally, on a national level.
    
  • Status 7 (inactive) is defined as patients who are considered to be temporarily unsuitable for transplantation.
    
  
  
  </li>
  
• 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: Cancers in locations other than just the liver weigh against a transplant.
    
  • Advanced heart and lung disease: These conditions prevent 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
    
  
  </li>
  
• The transplantation team: If a liver transplant is
  recommended by a primary doctor, the person must also be evaluated by a
  transplantation team. The usual candidate has advanced liver disease but
  is otherwise in good health.
  
  
  
  • The transplantation team usually consists of a transplant coordinator, 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 because 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 may be 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.
    
  </li>
  

• 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.
    
  </li>
  

• 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.
    
  </li>
  

• 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.
  

Liver Transplant Causes

Liver disease severe enough to require a liver transplant can come
from many causes. Doctors have developed various systems to determine
the need for the surgery. Two commonly used methods are by specific
disease process or a combination of laboratory abnormalities and
clinical conditions that arise from the liver disease. Ultimately, the
transplantation team takes into account the type of liver disease, the
person's blood test results, and the person's health problems in order
to determine who is a suitable candidate for transplantation.
In adults, chronic active hepatitis and cirrhosis (from alcoholism, unknown cause, or biliary)
are the most common diseases requiring transplantation. In children,
and in adolescents younger than 18 years, the most common reason for
liver transplantation is biliary atresia, which is an incomplete development of the bile duct.
Laboratory test values and clinical or health problems are used to determine a person's eligibility for a liver transplant.

• For certain clinical reasons, doctors may decide that a person needs
  a liver transplant. These reasons may be health problems that the
  person reports, or they may be signs that the doctor notices while
  examining the potential recipient. These signs usually occur when the
  liver becomes severely damaged and forms scar tissue, a condition known
  as cirrhosis. The most common clinical and quality-of-life indication for a liver transplant is ascites, or fluid in the belly
  due to liver failure. In the early stage of this problem, ascites may
  be controlled with medicines (diuretics) to increase urine output and
  with dietary modifications (limiting salt intake). Another serious
  consequence of liver disease is hepatic encephalopathy.
  This is mental confusion, drowsiness, and inappropriate behavior due to
  liver damage. Both ascites and encephalopathy are used in the current
  classification system to determine the severity of liver disease.
  

• Several other clinical problems may arise from liver disease. Infection in the abdomen, known as bacterial peritonitis,
  is a life-threatening problem. It occurs when bacteria or other
  organisms grow in the ascites fluid. Liver disease causes scarring,
  which makes blood flow through the liver difficult and may increase the blood pressure in one of the major blood vessels that supply it. This process may result in serious bleeding. Blood may also back up into the spleen and cause it to increase in size and to destroy blood cells. Blood may also go to the stomach and esophagus (swallowing tube). The veins in those areas may grow and are known as varices. Sometimes, the veins bleed and may require a gastroenterologist to pass a scope down a person's throat
  to evaluate them and to stop them from bleeding. These problems may
  become very difficult to control with medicines and can be a serious
  threat to life. A liver transplant may be the next step recommended by
  the doctor.
  
• Liver Transplant Symptoms
  
  People who have liver disease may have many of the following problems:
  
• Jaundice - Yellowing of the skin or eyes
  
• Itching
  
• Dark, tea-colored urine
  
• Gray- or clay-colored bowel movements
  
• Ascites - An abnormal buildup of fluid in the abdomen
  
• Vomiting of blood
  
• Tendency to bleed
  
• Mental confusion, forgetfulness
  

When to Seek Medical Care

Call the doctor whenever a patient with a newly transplanted liver feels unwell
or has concerns about his or her medications. The patient should also
call the doctor if new symptoms arise. These problems may commonly occur
before a liver transplantation and indicate
that a patient's liver disease is worsening. They may also occur after
transplantation and be a possible sign that the liver is being rejected.
The doctor may recommend that the patient be taken to a hospital emergency department for further evaluation.
Rejection usually occurs in the first 1-2 weeks after the
transplantation. It is common for the patient to require 1 admission to
the hospital for either rejection or infection. The following are just a
few examples of when to call the doctor:

• A patient may bleed after surgery, which may be detected by an
  increase in the amount of blood put out in what are called Jackson-Pratt
  (JP) drains, rather than by a decrease of blood over time. Usually,
  this indicates that one of the blood vessels going to the liver is
  bleeding
  

• The patient's belly is more tender than usual, and he or she has a fever. Infection of the fluid in the belly can be a serious complication.
  Infection is diagnosed by removing a small amount of fluid from the
  abdomen and sending it to the laboratory for testing. If infection is
  present, antibiotics are usually prescribed, and the patient is admitted
  to the hospital. Infection in liver transplant recipients is usually
  seen 1-2 months after transplantation.
  

• After surgery, the patient's belly is more tender and the skin is
  turning yellow. This may indicate that bile is backing up and not
  draining from the liver properly. The doctor may need to evaluate this
  problem by doing tests, such as a CT scan, ultrasound, or angiography.
  If a major problem exists, the doctor may reoperate (exploratory
  surgery), use nonoperative treatment, or list for urgent
  retransplantation.
  
• Exams and Tests
  
  If a patient comes to the hospital or an emergency department, the
  doctor will obtain blood tests, liver function tests, blood clotting
  tests, electrolytes, and kidney function tests. The doctor may also draw blood levels of certain immunosuppressive medications to make sure they are in the right range. If an infection is considered possible, cultures for viruses, bacteria, fungi, and other organisms may be grown. These may be checked for in the urine, sputum, and blood.
  Pretransplant tests are done to evaluate the severity of the
  liver disease and to determine where the patient should be placed on the
  waiting list. Once this initial evaluation is complete, the case is
  presented to a review committee of physicians and other staff members of
  the hospital. If the person is accepted as a candidate, he or she is
  placed on the waiting list for a liver transplant. A recipient may
  undergo some of the following tests before the transplantation:
  
• CT scan of the abdomen: This is a computerized picture of the liver
  that allows the doctor to determine the liver size and to identify any
  abnormalities, including liver tumors, that may interfere with the
  success of a liver transplantation.
  
• Ultrasound of the liver: This is a study that uses sound waves
  to create a picture of the liver and the surrounding organs. It also
  determines how well the blood vessels that carry blood to and from the
  liver are working.
  
• ECG: Short for electrocardiogram, this is a study that shows the electrical activity of the heart.
  
• Blood tests: These include blood type, blood cell
  count, blood chemistries, and viral studies.
  
• Dental clearance: A person's regular dentist may fill out the
  form. Immunosuppressive medications may affect the teeth; therefore, a
  dental evaluation is important before beginning these medicines.
  
• Gynecological clearance: The patient's gynecologist may provide clearance.
  
• Purified protein derivative (PPD) skin test: The PPD test is performed on the arm to check for any exposure to tuberculosis.
  
• Liver Transplant Treatment
  
  Self-Care at Home
  
  Home care involves building up endurance to carry out daily life
  activities and recovering to the level of health that the patient had
  before surgery. This can be a long, slow process that includes simple
  activities. Walking may require assistance at first. Coughing and deep breathing are very important to help the lungs stay healthy and to prevent pneumonia.
  Diet may at first consist of ice chips, then clear liquids, and,
  finally, solids. It is important to eat well-balanced meals with all
  food groups. After about 3-6 months, a person may return to work if he
  or she feels ready and it is approved by the primary doctor.
  
• Preventing rejection: Home care also involves taking several
  medications to help the liver survive and to prevent the patient's own
  body from rejecting the new liver. A person with a new liver must take
  medications for the rest of his or her life. The immune system works to protect the body from invading bacteria, viruses, and foreign organisms.
  Unfortunately, the body cannot determine that the newly transplanted
  liver serves a helpful purpose. It simply recognizes it as something
  foreign and tries to destroy it. In rejection, the body's immune system attempts to destroy the newly transplanted liver. Without the intervention
  of immunosuppressive drugs, the patient's body would reject the newly
  transplanted liver. Although the medications used to prevent rejection
  act specifically to prevent the new liver from being destroyed, they
  also have a general weakening effect on the immune system. This is why
  transplant patients are more likely to get certain infections. To
  prevent infections, the patient must also take preventive medications.
  There are 2 general types of rejection, as follows:
  
  
  
  • Immediate, or acute, rejection occurs just after surgery, when the
    body immediately recognizes the liver as foreign and attempts to destroy
    it. Acute rejection occurs in about 2% of patients.
    
  • Delayed, or chronic, rejection can occur years after surgery,
    when the body attacks the new liver over time and gradually reduces its
    function. This occurs in 2-5% of patients.
    
  </li>
  

• The first 3 months after transplantation is when the patient
  requires the most medication. After that time, some medicines can be
  stopped or their dosages decreased. Some of the medication is dosed
  according to the patient's weight. It is important for the patient to be
  familiar with the medications. It is also important to note their side
  effects and to understand that they may not occur with everyone. The
  side effects may lessen or disappear as the doses of medicine are
  lowered over time. Not every patient having a liver transplant takes the
  same medications. Some commonly used medications are as follows:
  

• Cyclosporine
  A (Neoral/Sandimmune) helps prevent rejection. It comes in pill and
  liquid form. If the liquid is given, it is important to mix the liquid
  in apple juice, orange juice, white milk, or chocolate milk. The patient
  can "shoot" it directly into the mouth and then follow it with any liquid. Cyclosporine should not be mixed in a paper or Styrofoam cup because they absorb the drug. It should only be mixed in a glass container directly before taking the drug.
  
• Tacrolimus (Prograf)
  helps prevent and treat rejection and works in a similar way to
  cyclosporine. Certain medications and substances, including alcohol,
  antibiotics, antifungal medicines, and calcium channel blockers (high blood pressure medications), may elevate levels of tacrolimus and cyclosporine. Other medications, including antiseizure medicines (phenytoin and barbiturates) and other antibiotics, may decrease tacrolimus and cyclosporine levels.
  

• Prednisone (Deltasone, Meticorten), a steroid, acts as an immunosuppressant to decrease the inflammatory response. Initially, prednisone is given intravenously. Later, prednisone is given in pill form. Prednisone may cause the following side effects:
  
  
  
  • Increased susceptibility to infection
    
  • Weakened bones (osteoporosis)
    
  • Muscle weakness
    
  • Salt and water retention
    
  • Potassium loss
    
  • Easy bruising
    
  • Stretch marks
    
  • Nausea
    
  • Vomiting
    
  • Gastric (stomach) ulcers
    
  • Increased cholesterol and triglyceride levels
    
  • Increased hunger
    
  • Blurred vision
    
  • Rounded face ("chipmunk cheeks")
    
  • Enlarged abdomen
    
  • Inability to sleep
    
  • Mood swings
    
  • Hand tremors (shaking)
    
  • Acne
    
  • Steroid dependency
    
  
  Note: Patients must never stop or reduce the prednisone without medical advice.
  The body normally produces small amounts of a chemical similar to
  prednisone. When a person takes in extra amounts of this substance, the
  body senses this and may reduce or stop its natural production of this
  chemical. Therefore, if a person suddenly stops taking the medication
  form of prednisone, the body may not have enough natural prednisone-like
  chemical available. Serious side effects may result.
  </li>
  
• Azathioprine (Imuran) is an immunosuppressant that acts on the bone marrow by decreasing the amount of cells that would attack the new liver. The dose is based on the person's weight and white blood cell count.
  

• Muromonab-CD3
  
  (Orthoclone OKT3) is an immunosuppressant used for people who are
  rejecting the transplant, for those in whom prednisone is not working
  well enough, and for those who cannot take tacrolimus or cyclosporine.
  
• Mycophenolate mofetil (CellCept) is an antibiotic that acts as an immunosuppressant and is used for acute rejection.
  
• Sirolimus (Rapamune) is an antibiotic used as an immunosuppressant.
  

• Sulfamethoxazole-trimethoprim (Bactrim, Septra), an antibiotic, acts to prevent Pneumocystis carinii pneumonia, which occurs more often in people who are immunosuppressed.
  

• Acyclovir/ganciclovir (Zovirax/Cytovene) acts to prevent viral
  infections in people who are immunosuppressed. These drugs work
  particularly against cytomegalovirus (a type of herpes virus) infection.
  

• Clotrimazole (Mycelex) comes in a troche (lozenge) and prevents yeast infection of the mouth.
  

• Nystatin vaginal suppository is an antifungal that prevents vaginal yeast infection.
  

• Baby aspirin is used to decrease blood clotting and to prevent blood clots from forming in the new liver's arteries and veins.
  

Medications
Pretransplantation medications
Lactulose:
It is important to continue taking this medication because it helps
clear the toxins that cannot be cleared when the liver isn't working

• 
  
  
  
  • well. With the doctor's approval, the patient can adjust the lactulose
    dose to produce 2-3 soft bowel movements per day
    
  • Diuretics: These medications promote removal of excess fluid
    from various parts of the body, such as the abdomen and legs. The excess
    fluid is lost through urination, and the patient may do this
    frequently. Daily monitoring of weight is helpful in determining the
    ideal dose. Routine monitoring of blood test results is an important
    part of diuretic therapy
    because important substances are also removed in the urine and may need to be replenished.
    
  • Anti-ulcer medications: These medications are routinely given
    both before and after liver transplantation to prevent ulcers from
    forming in the stomach or bowels.
    
  • Beta-blockers: These medications reduce the chance of bleeding from the gastrointestinal (feeding) tract. They also lower blood pressure and heart rate. They sometimes make the patient feel tired.
    
  • Antibiotics: People with liver disease can be more susceptible
    to infections. The doctor may put the patient on long-term antibiotics
    if the patient gets repeated infections. The patient should call the
    doctor if feeling unwell or if he or she has symptoms of infection.
    
  </li>
  

Posttransplantation medications are discussed in Self-Care at Home.
Rejection of the liver is most commonly managed by high-dose steroids,
followed by tapering of the medicine over 5-7 days. This treatment is
usually effective. Other treatments may be used as alternatives, and
these include muromonab-CD3 (Orthoclone OKT3), an immunosuppressive
medicine. Rejection therapy also involves treating any infection that
may be present with appropriate antibiotic, antiviral, or antifungal medications
Surgery
The incision on the belly is in the shape of an upside-down Y. Small, plastic, bulb-shaped drains are placed near the incision to drain

• blood and fluid from around the liver. These are called Jackson-Pratt
  (JP) drains and may remain in place for several days until the drainage
  significantly decreases. A tube called a T-tube may be placed in the
  patient's bile duct to allow it to drain outside the body into a small
  pouch called a bile bag. The bile may vary from deep gold to dark green,
  and the amount produced is measured frequently. The tube remains in
  place for about 3 months after surgery. Bile production early after the
  surgery is a good sign and is one of the indicators surgeons look for to
  determine if the liver transplant is being "accepted" by the patient's
  body.
  

After surgery, the patient is taken to the intensive care unit, is

• monitored very closely with several machines. The patient will be on a
  respirator, a machine that breathes for the patient, and will have a
  tube in the trachea (the body's natural breathing tube) bringing oxygen
  to the lungs. Once the patient wakes up enough and can breathe alone,
  the tube and respirator are removed. The patient will have several blood
  tests, x-ray
  films, and ECGs during the hospital stay. Blood transfusions may be
  necessary. The patient leaves the intensive care unit once he or she is
  fully awake, able to breathe effectively, and has a normal temperature,
  blood pressure, and pulse,
  usually after about 3-4 days. The patient is then moved to a room with
  fewer monitoring devices for a few days longer before going home. The
  average hospital stay after surgery is 1-3 weeks.
  
• Next Steps
  Follow-up
  After liver transplantation, the patient must visit the transplant
  surgeon or hepatologist frequently, about 1-2 times a week over about 3
  months. After this time, the primary doctor resumes follow-up care by
  seeing the patient about once a month for the remainder of the first
  year after transplantation. Ideally, the transplant surgeon and
  hepatologist monitor the patient's progress through blood tests and
  contact with the primary doctor. One year after transplantation,
  follow-up care is individualized. If a patient ever requires a visit to
  an emergency department, and is discharged from there, he or she should
  generally follow up with his or her primary doctor in 1-2 days.
  

Prevention

Before undergoing liver transplantation, people who have liver
disease should avoid medications that may further damage the liver.

• Large amounts of acetaminophen (Tylenol) may be harmful and can damage the liver. (Acetaminophen is contained in many over-the-counter drugs; therefore, patients with liver disease must be particularly watchful.) Sleeping pills and benzodiazepines
  (Valium and similar medicines) can build up faster in the blood when
  the liver doesn't work well. They can make a person confused, worsen
  existing confusion, and, in some cases, cause coma. If possible, try to avoid taking these medicines.
  
• Alcohol is an ingredient in some cough syrups and other medications. Alcohol can severely damage the liver, so it is best to avoid alcohol-containing medications.
  
• The female transplantation patient should not take oral contraceptives because of the increased risk of blood clot formation.
  

No transplant recipient should receive live virus vaccines (especially polio), and no household contacts should receive these either.
Pregnancy

• should be avoided by transplant recipients until at least 1 year after
  transplantation. If a woman wants to become pregnant, she should speak
  with her transplantation team regarding any special risks. In many
  cases, women successfully become pregnant and give birth normally after
  transplantation, but they should be carefully monitored because of the
  higher incidence of premature births. Mothers should avoid breastfeeding because of the risk of the baby's exposure to the immunosuppressive medicines through the milk.
  
• Outlook
  The 1-year survival rate after liver transplantation is about 90% for
  patients living at home and about 60% for those who are critically ill
  at the time of the surgery. At 5 years, the survival rate is about 80%.
  Survival rates are improving with the use of better immunosuppressive
  medications and more experience with the procedure. The patient's
  willingness to stick to the recommended posttransplantation plan is
  essential to a good outcome.
  Generally, anyone who develops a fever within a year of receiving
  a liver transplant is admitted to the hospital. Patients who cannot
  take their immunosuppressive medicines because they are vomiting should
  also be admitted. Patients who develop a fever more than a year after
  receiving a liver transplant and who are no longer on high levels of
  immunosuppression may be considered for management as an outpatient on an individual basis.
  Complications are problems that may arise after liver
  transplantation. Many should be recognizable by the patient, who should
  call the transplantation team to inform them of the changes.
  
• Possible complications after liver transplantation
  

• Infection of the T-tube site: This tube drains bile to the outside
  of the body into a bile bag. Not all patients require such a tube. The
  site may become infected. This can be recognized if the patient notices
  warmth around the T-tube site, redness of the skin around the site, or discharge from the site.
  
• Dislodgement of the T-tube: The tube may come out of place,
  which may be recognized by breakage of the stitch on the outside of the
  skin that holds the tube in place or by an increase in the length of the
  tube outside the body.
  
• Bile leak: This may occur when bile leaks outside of the ducts. The patient may experience nausea, pain over the liver (the right upper side of the abdomen), or fever.
  
• Biliary stenosis: This is narrowing of the duct, which may
  result in blockage. The bile may back up in the body and result in
  yellowing of the skin.
  

• immunosuppressive medications. Although these medications are meant to
  prevent rejection of the liver, they also decrease the ability of the
  body to fight off certain viruses, bacteria, and fungi. The organisms
  that most commonly affect patients are covered with preventive
  medications. Notify the transplantation team if any of the following
  infections arise:
  

• Viruses
  
  
  
  • Herpes simplex viruses (types I and II): These viruses most commonly
    infect the skin but may occur in the eyes and lungs. Type I causes
    painful, fluid-filled blisters around the mouth, and type II causes
    blisters in the genital area. Women may have an unusual vaginal discharge.
    
  • Herpes zoster virus (shingles): This is a herpesvirus that is a reactivated form of chickenpox. The virus appears as a wide pattern of blisters almost anywhere on the body. The rash is often painful and causes a burning sensation.
    
  • Cytomegalovirus: This is one of the most common infections
    affecting transplant recipients and most often develops in the first
    months after transplantation. Symptoms include excessive tiredness, high temperature, aching joints, headaches, abdominal problems, visual changes, and pneumonia.
    
  </li>
  

• Fungal
  infections: Candida (yeast) is an infection that may affect the mouth,
  esophagus (swallowing tube), vaginal areas, or bloodstream. In the
  mouth, the yeast appears white, often on the tongue as a patchy area. It may spread to the esophagus and interfere with swallowing. In the vagina,
  a white discharge that looks like cottage cheese may be present. To
  identify yeast in the blood, the doctor will obtain blood cultures if
  the person has a fever.
  

• Bacterial infections: If a wound (including the incision site) has
  drainage and is tender, red, and swollen, it may be infected by
  bacteria. The patient may or may not have a fever. A wound culture (test
  for the organism) will be obtained and appropriate antibiotics given.
  

and may cause pneumonia. The patient may have a mild, dry cough and a fever. This infection is prevented with sulfamethoxazole-trimethoprim

• (Bactrim, Septra). If the patient develops this infection, it may be
  necessary to give higher doses or intravenous antibiotics.
  
• 
  

• levels are too high. This may be caused by the medications the person
  takes. Patients may experience increased thirst, increased appetite,
  blurred vision, confusion, and frequent, large volumes of urination. The
  transplantation team should be notified if these problems occur. They
  can perform a quick blood test (a fingerstick glucose test) to see if
  the blood sugar level is elevated. If it is, they may start the patient
  on medications to prevent it and recommend diet and exercise.
  

• High blood pressure: This may be a side effect of the medications.
  The patient's doctor will monitor the blood pressure with each clinic
  visit and, if it is elevated, may start medications to lower blood
  pressure.
  
• Synonyms and Keywords
  
  liver transplant, liver transplants, liver transplantation, orthotopic liver transplants, hepatology,
  ascites, encephalopathy, cirrhosis, United Network for Organ Sharing,
  UNOS, liver donor, organ donor, live donor, living donor, Model for
  End-Stage Liver Disease, MELD, pediatric end-stage liver disease, PELD,
  rejection, liver biopsy, hepatitis B,hepatitis C, acetaminophen (Tylenol) poisoning, medications for hepatitis C, current and future medications for hepatitis C,
  living donor transplant, transplantation team, search for a donor,
  liver disease, preventing rejection, pretransplantation medications,
  complications after
  liver transplant, posttransplantation medications
  
• Authors and Editors
  
  Author:Steve Guillen, MD,
  Staff Physician, Department of Emergency Medicine, Temple University Hospital.
  
  Coauthor(s): Martin
  Black, MD, FRCP, Head of Liver Unit, Professor, Departments of Pharmacology and
  Medicine, Section of Gastroenterology, Temple University School of Medicine;
  Grace Thomas, MD, Consulting Staff, Department of Emergency Medicine, Wake
  Emergency Physicians; Robert M McNamara, MD, FAAEM, Professor of Emergency
  Medicine, Temple University; Chief, Department of Internal Medicine, Section of Emergency Medicine, Temple University Hospital.
  
  Editors:Michael D Burg, MD, Assistant Clinical
  Professor, Department of Emergency Medicine, University Medical Center,
  University of California at San Francisco-Fresno; Francisco Talavera,
  PharmD,
  PhD, Senior Pharmacy Editor, eMedicine; James Ungar, MD, Medical
  Director, Chair Department of Emergency Medicine Santa Rosa Memorial
  Hospital.