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Liver Transplantation

By Martin Hertl, MD, PhD, Jack Fraser Smith Professor of Surgery, Director of Solid Organ Transplantation, and Chief Surgical Officer, Rush University Medical Center

Liver transplantation is the second most common type of organ transplantation procedure. It is the only option for people whose liver no longer functions.

A whole liver can be obtained only from a person who has died, but a living donor can provide a part of the liver. A donated liver can be stored for up to 18 hours.

Many people die while waiting for a suitable liver, but after transplantation, the percentage of liver transplant recipients who survive is

  • At 1 year: 86 to 90%

  • At 3 years: 79%

  • At 5 years: 73%

Most recipients are people whose liver has been destroyed by cirrhosis (replacement of liver tissue with scar tissue), often due to hepatitis C. Other reasons for liver transplantation include primary sclerosing cholangitis (scarring of the bile ducts, causing cirrhosis), autoimmune liver disorders, and, in children, partial or complete destruction of the bile ducts (biliary atresia) and metabolic disorders.

People whose liver has been destroyed by alcoholism can receive a transplant if they stop drinking. Liver transplantation is also done for some people who have liver cancer that is not too far advanced.

Although hepatitis C and autoimmune disorders tend to recur in the transplanted liver, survival is still good.

Donors

Nearly all donated livers come from people who are brain dead and whose heart is still beating. The blood type and heart size of the donor and recipient must match. Tissue type does not always have to match exactly.

Some transplants come from living donors, who provide part of a liver. A few transplants come from people who are brain dead and whose heart has stopped beating. However, the liver from such donors is often damaged because it was not receiving blood.

Procedure

The damaged liver is removed through an incision in the abdomen, and the new liver is connected to the recipient’s blood vessels and bile ducts. Usually, blood transfusions are required.

Typically, the operation lasts 4 1/2 hours or more, and the hospital stay is 7 to 12 days.

Drugs to inhibit the immune system (immunosuppressants), including corticosteroids, are started the day of transplantation. These drugs can help reduce the risk that the recipient will reject the transplanted liver. Compared with transplantation of other organs, liver transplantation requires the lowest doses of immunosuppressants.

Complications

Transplantation can cause various complications.

Rejection

Liver transplants are rejected somewhat less vigorously than transplants of other organs, such as the kidney and heart. Nonetheless, immunosuppressants must be taken after transplantation.

If the recipient develops an enlarged liver, nausea, pain, fever, jaundice, or abnormal liver function (detected by blood tests), doctors may do a biopsy using a needle. Biopsy results help doctors determine whether the liver is being rejected and whether immunosuppressant therapy should be adjusted.

Rejection can be treated with corticosteroids or, if they are ineffective, other immunosuppressants (such as antithymocyte globulin). Another liver, if available, may be transplanted if drugs are ineffective.

Hepatitis

Most people are given a liver transplant because they had cirrhosis due to viral hepatitis. Immunosuppressants, which are needed to help prevent rejection of the transplanted liver, also make the body less able to defend against infections. As a result, hepatitis B or C recurs in nearly all liver transplant recipients.

Other complications

Some complications of liver transplantation can occur within 2 months. For example, the liver may malfunction, blood clots may block blood vessels to or from the liver, or bile may leak out of the bile ducts. Complications that occur soon after transplantation typically cause fever, low blood pressure, and abnormal results on tests to evaluate liver function.

Later, the most common complication is scarring and narrowing of the bile ducts. This disorder can cause jaundice, dark urine, light-colored stools, and itchiness all over the body. Sometimes the narrowed ducts can be reopened, but often, another transplant is required.