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, cirrhosis from alcoholism, hepatitis C, biliary disease, or other causes 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 ducts.

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.
  • Common clinical and quality-of-life indications for a liver transplant include 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.
• 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. 

 

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
• Blood in the stool
• Tendency to bleed
• Mental confusion, forgetfulness

When Should I Call the Doctor About Liver Transplant Complications?

Call the transplant team whenever a patient with a newly transplanted liver feels unwell or has concerns about his or her medications. The patient should also call the transplant doctor if new symptoms arise. These problems may commonly occur before 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.

Acute rejection usually occurs in the first 1-2 months 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. This may indicate 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 cholangiography. If a major problem exists, the doctor may reoperate (exploratory surgery), use nonoperative treatment, or list for urgent retransplantation.

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, bile, and blood.

Pretransplant tests are done to evaluate the severity of the liver disease and to determine when 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 increase the chance of infection and if the teeth have cavities or periodontal disease, this can lead to infection. 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.

What Is Self-Care at Home When Healing from a Liver Transplant?

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 in the hospital 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 transplant 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 hyperacute, rejection occurs just after surgery, when the body immediately recognizes the liver as foreign and attempts to destroy it. Hyperacute rejection occurs in about 2% of patients.
• Acute rejection usually occurs in the first two months after transplant and is usually treatable with medication adjustments. About 25% of patients have at least one acute rejection episode.
• 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.

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 1-2 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 about 2 weeks.

 

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 may also see the patient, but the transplant doctor 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 transplant doctor in 1-2 days.

 

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, as the immunosuppressive medications may need to be changed. 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.

 

The 1-year survival rate after liver transplantation is about 88% for all patients, but will vary depending on whether the patient was at home when transplated or critically in the intensive care unit. At 5 years, the survival rate is about 75%. 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.

• Infections: Infections may result from being on the 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.
• 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.
• Other infections: Pneumocystis carinii is similar to a fungus 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.
• Diabetes: Diabetes is a condition in which blood sugar 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.
• High Cholesterol: This may be a side effect of the medications, the patient’s doctor will monitor the cholesterol levels periodically with blood tests and may recommend diet changes or start medications if necessary.