Liver Transplantation

What Is a Liver Transplant?

A liver transplant is a surgical procedure in which a person's diseased liver is completely removed and replaced with either a whole liver or a portion of a healthy liver from a donor. A liver transplant can be performed using part or whole of a liver from a living donor or a deceased donor.

Who Needs a Liver Transplant?

A liver transplant may be considered when a person's liver function becomes severely reduced or completely fails because of a serious long-term or sudden liver disease. When the liver can no longer perform its essential functions and liver failure develops, transplantation may become necessary.

What Conditions May Require a Liver Transplant?

Liver transplantation may be needed for many serious liver conditions, including:

• Chronic hepatitis B, hepatitis C, or hepatitis D
• Alcohol-related liver cirrhosis
• Cirrhosis caused by NASH (nonalcoholic steatohepatitis)
• Primary sclerosing cholangitis (PSC)
• Primary biliary cirrhosis (PBC)
• Certain metabolic disorders
• Biliary atresia in children
• Cirrhosis caused by other liver diseases

Additionally, a liver transplant may also be necessary in some cases of acute liver failure (fulminant hepatic failure), which can develop suddenly because of:

• Viral infections
• Certain medications or drug toxicity
• Severe alcohol-related liver injury

Liver transplantation may also be used for selected patients with primary liver cancer, depending on the stage of the cancer and how well the liver is functioning.

When Does a Patient Need a Liver Transplant?

In people with advanced chronic liver disease, transplantation may be considered when repeated complications begin to seriously affect health and daily life.

Warning signs may include:

• Severe and persistent fatigue and weakness
• Repeated vomiting of blood
• Repeated bleeding from the digestive tract, including blood in the stool
• Very low blood albumin levels
• Severe accumulation of fluid in the abdomen (ascites)
• Excessive sleepiness
• Confusion or changes in mental awareness (encephalopathy)
• Hepatic coma
• Repeated hospital admissions because of complications of liver disease

In these situations, liver transplantation may become a life-saving treatment. However, transplantation should ideally be considered before the patient becomes critically ill or develops irreversible complications.

In cases of acute liver failure, transplantation may sometimes be the final life-saving treatment when the liver is unlikely to recover on its own.

Where Does a Donor Liver Come From?

There are two main sources of donor livers.

1. Living-Donor Liver Transplantation (LDLT): A healthy living person may donate part of their liver (usually the right or left portion) to a suitable recipient, who is often a close relative. Because the liver can regenerate, both the donor's remaining liver and the transplanted portion can grow and adapt after surgery.
2. Deceased-Donor Liver Transplantation (DDLT): In this type of transplantation, a whole liver is recovered from a person who has been declared brain-dead (when there is no longer any chance of survival after life-sustaining support is withdrawn) and it is then transplanted into a suitable recipient.

Who Can Become a Living Liver Donor?

Donating part of one's liver while alive is an extraordinary gift. A healthy adult may be considered for living donation if they meet the medical, psychological, and legal requirements for donation. The usual age range for donation is 18 to 65 years and alongside that the blood-group compatibility is also considered when evaluating a donor and recipient.

Before a person is accepted as a living donor, the liver transplant team performs a detailed evaluation that may include:

• A complete physical examination
• Mental and psychological health assessment
• Blood tests
• Liver function tests
• Imaging studies

In such cases, the physical safety of the donor is considered of utmost importance to ensure that the life of a perfectly healthy donor is not endangered in any way.

In Bangladesh, donor and recipient selection must also comply with the relevant laws and regulations and therefore the selection of the donor and recipient must be made in accordance with the “Human Organ Transplantation Act” of the Government of the People's Republic of Bangladesh.

Blood-Group Compatibility

The blood groups of the liver donor and the recipient must be matched according to the compatibility chart (blood group matching).

How Is a Liver Transplant Performed?

Living-donor transplantation requires two coordinated surgical teams, usually working in separate operating rooms. One team removes the diseased liver from the recipient whilst the other removes the appropriate portion of the donor's healthy liver and carefully prepares the donor liver graft for transplantation. The donor liver portion is then transferred to the recipient and connected to the recipient's blood vessels and bile ducts.

Meanwhile, in deceased donor liver transplants, after a donor has been declared brain-dead according to established medical and legal criteria, the liver is surgically removed and preserved for transplantation. The whole liver may then be transplanted into a suitable recipient. In selected circumstances, a donor liver may be divided for transplantation into more than one recipient (split liver).

A liver transplant is a major operation and may take around 12–14 hours.

What Happens to the Living Donor's Liver After Donation?

The liver has a remarkable ability to regenerate and restore its function. After donation, the remaining liver in a living donor begins to enlarge and adapt and thus within approximately 6–12 weeks the donor's liver can regain its previous functional capacity.

What Happens to the Recipient's Liver After Transplantation?

The transplanted liver, known as the graft, begins to adapt rapidly inside the recipient's body. As it grows and functions, it begins performing the essential functions of a healthy liver.

How Successful Is Living-Donor Liver Transplantation?

After a successful liver transplant from a living donor, the survival rate can be as follows:

• 1-year survival: approximately 90%
• 3-year survival: approximately 81%
• 5-year survival: approximately 73%
• 10-year survival: approximately 61%

Generally the survival rates may be even better in children than in adults.

What Is Rejection?

Our body's immune system remains constantly active to protect the body from external substances (those that are not part of our body). After a transplant, the immune system may recognize the new liver as foreign and try to attack it to prevent it from functioning. This process is called organ rejection. To prevent or control rejection, transplant recipients must take immunosuppressive or anti-rejection medications after the transplant.

What Problems Can Occur After a Liver Transplant?

After transplantation, the recipient may become more vulnerable to infections and this may be intensified by the effects of immunosuppressive medicines which reduce the activity of the immune system.

Long-term use of these medicines may also increase the risk of:

• High blood pressure
• Weight gain
• High cholesterol
• Diabetes
• Bone weakness
• Kidney damage

Can a Liver Transplant Recipient Return to Normal Daily Life?

After a successful liver transplant, many recipients are able to return to their usual daily activities.

Recovery mainly depends on:

• The patient's health before transplantation
• The original cause of liver disease
• How advanced the disease was at the time of transplantation

Maintaining a healthy and disciplined lifestyle is one of the most important ways to protect the new liver. Recipients should remain under the regular care of a liver transplant specialist to monitor for:

• Rejection
• Infection
• Blood-vessel complications
• Bile duct problems

A balanced diet, limited intake of unhealthy fats and added sugars, healthy weight, regular physical activity, and avoidance of smoking and alcohol can help protect the transplanted liver.

Women should avoid pregnancy for the first year after the transplant.

Immunosuppression After Liver Transplantation

To prevent rejection, immunosuppressive medicines are started soon after transplantation. Although the cost of these medications is somewhat higher during the first few months, it decreases to one or two medications within the following year, and to just a single medication within two to four years—a regimen that must be continued for life. In this case, it is advisable to monitor liver function and blood drug levels through regular testing.

Liver transplantation is considered one of the major advances in modern medicine for people with end-stage liver disease. It has given many people with liver failure the opportunity to live longer and return to meaningful daily activities.

Help Save the Lives of People With Liver Failure

You may donate a portion of your liver (either the left or right side) while alive, in accordance with the ‘Human Organ Transplantation Act’ of the Government of the People's Republic of Bangladesh. Millions of people around the world are alive today thanks to the transplantation of a liver segment donated by a healthy individual.

Around the world, people also help save lives through deceased organ donation. Donating the liver and other organs following a sudden death is a noble act; patients suffering from liver or other organ failure can receive these donated organs and gain a new lease on life. Saving a terminally ill person through voluntary organ donation—thereby offering them the chance to live a new life—is a priceless gift and a noble initiative.

As of now, the source states that a deceased-donor organ donation program has not yet been established in Bangladesh.

Let us support people living with liver failure and work toward making life-saving transplantation more accessible.

Liver transplantation is a life-saving and transformative treatment. Many people who have undergone liver transplantation in Bangladesh and abroad are living active and productive lives. However, following medical advice and maintaining a healthy lifestyle after transplantation are extremely important for long-term survival and for protecting the transplanted liver. This section is dedicated to liver transplant recipients, with the hope that they will enjoy a long and healthy life.

Introduction

For people with advanced liver disease, liver transplantation may be the final treatment for:

• Liver cirrhosis
• Liver cancer
• Liver failure

Millions of people around the world have received liver transplants and have gone on to live for many years. Many have returned to their normal daily activities and workplaces.

A liver transplant is a complex surgical procedure and is considered a treatment for end-stage liver disease. However, transplantation should not be thought of as the end of all medical care. It marks the end of one chapter and the beginning of another.

Following the correct medical and lifestyle recommendations after transplantation is essential. Failure to follow these recommendations can place the recipient's health and life at serious risk.

In addition to complications such as infection and rejection, the original liver disease may sometimes recur. Immunosuppressive medicines can also cause side effects and increase the risk of certain health problems.

After transplantation, recipients should make several healthy lifestyle changes, including:

• Eating a healthy, balanced diet
• Maintaining a healthy body weight
• Avoiding alcohol
• Avoiding smoking
• Exercising regularly as recommended
• Avoiding unnecessary exposure to crowded places, especially when infection risk is high
• Wearing a mask when medically appropriate
• Taking all prescribed medicines exactly as directed
• Attending regular follow-up appointments

Conditions such as the following should also be carefully controlled:

• Diabetes
• Excess body weight
• High blood pressure
• Kidney disease
• Abnormal cholesterol and other blood fats (dyslipidemia)
• Thyroid disorders

If any new or unusual health problem develops, the transplant team should be informed as soon as possible. The recipient's own awareness and the continued support of family members can play an important role in long-term transplant success.

Important Aspects of Life After Liver Transplantation

Rejection Prevention and Immunosuppression

The immune system naturally recognizes the transplanted liver as foreign and may attempt to attack it. If this immune response becomes strong enough, the transplanted liver may lose function and can eventually become severely damaged. This is called rejection. Rejection is one of the most important complications after transplantation because severe rejection can lead to liver failure and threaten the recipient's life. Rejection can occur at different times. Acute rejection most commonly occurs during the first several months (within 6–12 months) after transplantation and chronic rejection can develop over a longer period and may occur months or years after transplantation.

The most severe form is the hyperacute rejection, which can occur within a few minutes after the transplant.

Different immunosuppressive medicines may be used after liver transplantation to prevent rejection, including:

1. Cyclosporine or Tacrolimus
2. Azathioprine or Mycophenolate Mofetil
3. Corticosteroids, such as Prednisolone

In the early stages following a transplant, a combination of three drugs is used. Subsequently, this may be reduced to two or even a single medication. Cyclosporine should not be used with Tacrolimus. Similarly, Azathioprine should not be used alongside Mycophenolate Mofetil.

Before taking Cyclosporine or Tacrolimus, the specific level of the drug in the body (trough level) must be checked, and the medication used according to the prescribed regimen.

Prednisolone should generally be taken with food or after eating, according to the prescribed instructions.

Recipients taking cyclosporine or tacrolimus should avoid grapefruit and grapefruit juice because grapefruit can alter the way these medicines are processed by the body.

Immunosuppressive medicines can have many side effects, including:

• High blood pressure
• High blood sugar
• Diabetes or worsening diabetes
• Kidney problems
• Headaches
• Nausea
• Loss of appetite
• Increased hair growth
• Swollen or enlarged gums
• High cholesterol
• Fluid retention in the body
• Hair loss
• Bone loss
• Increased risk of fractures
• Mood changes or depression
• Difficulty sleeping
• Increased susceptibility to infections

Long-term immunosuppression can also increase the risk of certain cancers and lymphoproliferative disorders.

Important Advice for Liver Transplant Recipients

Continuing immunosuppressive treatment exactly as prescribed is one of the most important responsibilities of a transplant recipient to ensure that the transplanted liver (graft) functions properly. Being aware of the side effects and following the liver transplant team's guidance can help you live a long life through successful immunosuppression and keep your transplanted liver functioning.

Infections After Liver Transplantation

Because immunosuppressive medicines reduce immune activity, transplant recipients are more vulnerable to infections caused by:

• Viruses
• Bacteria
• Fungi

Cytomegalovirus, varicella, chickenpox virus, and Candida are notable among them. Prominent bacteria include Salmonella, E. coli, Listeria, and Pneumococcus, which can cause food poisoning, typhoid, and pneumonia.

Preventing Infections

Transplant recipients should take extra precautions to reduce their risk of infection.

Avoid Close Contact With People Who Are Sick

Avoid close contact with people who are sick and have infections such as:

1. Common colds
2. Flu-like illnesses
3. Coughs
4. Chickenpox
5. Other infectious diseases

Practice Good Hygiene

1. Wash your hands regularly with soap and water.
2. Keep your surroundings clean.
3. Follow food-safety precautions.
4. Avoid contaminated food and water.

Avoid Environmental Risks

Limit exposure to:

1. Dust
2. Smoke
3. Crowded places when infection risk is high
4. Animal waste
5. Pesticides
6. Gasoline and other potentially harmful chemicals

Use gloves when appropriate, especially when handling potentially contaminated materials.

Vaccination

Vaccines such as the influenza vaccine and pneumococcal vaccine may be recommended for transplant recipients.

Kidney Problems After Liver Transplantation

Kidney problems are an important possible complication after liver transplantation.

• The risk may be higher with certain immunosuppressive medicines, particularly Cyclosporine and Tacrolimus but may be lower in some medicines such as Mycophenolate.
• Kidney problems are also more likely in patients who already had reduced kidney function before transplantation.
• Other risk factors may include: Hepatitis C, diabetes, high blood pressure and older age.

Kidney function may be monitored using:

• Blood creatinine levels
• Estimated glomerular filtration rate (eGFR)
• Urine protein testing

Recurrence of the Original Liver Disease

The disease that affected the original liver may sometimes develop again after transplantation. The recurrence of Hepatitis B and C largely depends on the viral load at the time of transplantation. The tendency for recurrence is significantly higher in Hepatitis C cases compared to Hepatitis B. For patients with NASH, controlling post-transplant obesity, diabetes, dyslipidemia, and hypothyroidism is crucial. In cases of alcohol-related liver cirrhosis, alcohol consumption must be completely avoided after transplantation. A tendency for disease recurrence is also frequently observed in cases of autoimmune hepatitis.

For patients who receive a transplant for liver cancer, the risk of recurrence depends on factors such as:

• The stage of the cancer at transplantation
• Tumor characteristics
• The alpha-fetoprotein (AFP/PIVKA-II) level
• Whether the cancer had spread beyond the liver

Diet After Liver Transplantation

After transplantation, appetite often improves significantly. As a result, some recipients may gain weight. Immunosuppressive medicines, particularly corticosteroids such as prednisolone, can also contribute to weight gain and changes in metabolism. Excess weight of more than 10 kg can lead to various problems. Patients who received a transplant because of NASH-related cirrhosis may also develop fatty liver disease again in the transplanted liver (graft) if metabolic risk factors are not controlled. Therefore,

• Limit foods and drinks that contain large amounts of added sugar.
• Limit foods high in unhealthy fats.
• Eat adequate amounts of protein, such as:
  • Fish
  • Lean meat
  • Eggs
  • Milk and other dairy products
  • Nuts
• Maintain a healthy body weight.
• Avoid alcohol.
• Do not smoke.
• Follow the advice of a registered dietitian or nutrition specialist when needed.

Daily Life After Liver Transplantation

• Many recipients may return to work approximately 6 weeks to 6 months after transplantation.
• During the first two months, begin with light physical activity as advised by the transplant team. Gradually increase activities as strength improves and avoid strenuous exercise until the surgical team confirms that it is safe.
• Sexual activity may generally be resumed around two months after transplantation, depending on the individual's recovery. Because immunosuppression can increase susceptibility to certain infections, including sexually transmitted infections, safer-sex practices are important.
• Women should not use birth control pills after a liver transplant.
• Women are generally advised to delay pregnancy during the early period after transplantation, often for at least one year, until the transplanted liver is stable and medications have been reviewed. Before planning pregnancy, the patient should inform the liver transplant team and receive specialist advice.
• Mycophenolate Mofetil can cause serious harm to an unborn baby and is generally not considered safe during pregnancy.
• Immunosuppression during pregnancy carries teratogenic and toxic effects for the fetus. Consultation with a specialist physician is essential.

Conclusion

Living with a transplanted liver requires lifelong care and attention.

• Follow a healthy lifestyle.
• Take immunosuppressive and other prescribed medicines exactly as directed.
• Never stop immunosuppressive medicines suddenly.
• Do not take unproven or unapproved medicines without discussing them with the transplant team.
• Attend regular appointments and follow the transplant team's recommendations.
• Monitor and control conditions such as diabetes, high blood pressure, obesity, high cholesterol, and kidney problems.
• Report new symptoms or health problems promptly.
• Protect yourself from infections.
• Follow a balanced diet and maintain a healthy weight.
• Stay physically active as recommended.
• Seek support from family members when needed.