Overview
Like other organs, the demand for liver transplants outweighs the supply. Decisions regarding transplants are made based on multidisciplinary meetings which involve discussing prognosis, the risk of liver disease recurrence, and whether other treatments are possible. The Model for End-Stage Liver Disease (MELD) scoring system is often used for patients who are waiting for a liver transplant.
The average waiting time for a liver transplant in the UK for an adult is around 2-5 months.
Types of liver transplant
In most cases of a liver transplant, the diseased liver is removed and replaced with an entire liver from a deceased donor. This is known as an orthotopic transplant.
Since the liver can regenerate, sections of the liver can be taken from living donors and transplanted, resulting in two normal-sized, functioning livers. This is known as a living donor liver transplant.
In some cases, the liver of a deceased donor can be split into two sections and transplanted into two patients, which regenerate. This is known as a split donation.
Indications
Overview
The indications for liver transplantation can broadly be divided into:
- Acute liver failure:
- Examples are paracetamol overdose, acute viral hepatitis, Budd-Chiari syndrome etc.
- Chronic liver failure:
- Examples are alcoholic liver disease (see below), chronic hepatitis B or C, hepatocellular carcinoma, non-alcoholic fatty liver disease, autoimmune hepatitis, haemochromatosis, and biliary disorders such as primary biliary cholangitis.
In general, patients with acute liver failure move to the top of the waiting list and those with chronic liver disease that can wait longer are put on a standard waiting list.
Contraindications
Overview
Some contraindications to liver transplant include:
- Ongoing alcohol misuse (around 6 months abstinence is required)
- Ongoing illicit drug use
- Severe, irreversible pulmonary disease
- Untreated HIV
- Ongoing extra-hepatic sepsis
- Active or previous extra-hepatic cancer
- Severe extrahepatic disease with predicted mortality >50%
- Certain anatomic variants
- Liver cancer outside of certain criteria
Management
Surgery
Surgery is performed in a specialist transplant centre. A ‘rooftop’ or ‘Mercedes Benz’ incision is made across the lower costal margin. In cases of orthotopic liver transplants, the old liver is removed and the donor liver is put in its place and the blood vessel and bile ducts are anastomosed.
In some cases, parts of the liver may need to be transplanted if the body sizes between the donor and recipient vary significantly. In general, right lobe transplants are suitable for adults, and left lobe transplants are suitable for children or adults with small body sizes. In infants and young children, liver segment transplants may be used.
Aftercare
After transplantation, patients require lifelong immunosuppression (often with a combination of drugs including corticosteroids, azathioprine, ciclosporin, and tacrolimus). Patients should avoid alcohol consumption, smoking, and intravenous drug use.
They are also monitored for evidence of transplant rejection and/or disease recurrence (by monitoring liver function tests) and for cancer, as immunosuppression increases its risk.
Transplant Rejection
Overview
Acute transplant rejection may present with:
- Non-specific symptoms such as fever, lethargy, abdominal pain
- Jaundice and pruritus
- Deranged liver function tests
