By Bob Aronson
The liver is an incredibly important organ and the only one in the human body that can regenerate itself. It is second only in size to the skin (yes the skin is an organ) and has been described as boomerang shaped. Virtually every nutrient we consume passes through the liver so it can be processed and turned into a different biochemical form for use by other organs.
The liver is the only organ in the body that can easily replace damaged cells, but if enough cells are lost, the liver may not be able to meet the needs of the body.
The liver is like a very complex factory. Included in its many functions are: http://www.medicinenet.com/liver_anatomy_and_function/images-quizzes/index.htm
- Production of bile that is required in the digestion of food, in particular fats;
- Storing of the extra glucose or sugar as glycogen, and then converting it back into glucose when the body needs it for energy;
- Production of blood clotting factors;
- Production of amino acids (the building blocks for making proteins), including those used to help fight infection;
- The processing and storage of iron necessary for red blood cell production;
- Manufacture of cholesterol and other chemicals required for fat transport;
- Conversion of waste products of body metabolism into urea that is excreted in the urine; and
- Metabolizing medications into their active ingredient in the body.
- Cirrhosis is a term that describes permanent scarring of the liver. In cirrhosis, the normal liver cells are replaced by scar tissue that cannot perform any liver function.
- Acute liver failure may or may not be reversible, meaning that on occasion, there is a treatable cause and the liver may be able to recover and resume its normal functions.
The Liver can be affected by any one of a number of diseases. Click on the item of interest in the list below for a complete explanation.
liver disease. http://www.liverfoundation.org/abouttheliver/info/
- Alagille Syndrome
- Alcohol-Related Liver Disease
- Alpha-1 Antitrypsin Deficiency
- Autoimmune Hepatitis
- Benign Liver Tumors
- Biliary Atresia
- Clinical Trials
- Gilbert Syndrome
- Hepatitis A
- Hepatitis B
- Hepatitis C
- Hepatocellular Carcinoma
- Hepatic Encephalopathy
- Liver Biopsy
- Liver Cysts
- Liver Cancer
- Liver Function Tests
- Liver Transplant
- Newborn Jaundice
- Non-Alcoholic Fatty Liver Disease
- Primary Biliary Cirrhosis (PBC)
- Primary Sclerosing Cholangitis (PSC)
- The Progression of Liver Disease
- Reye Syndrome
- Type I Glycogen Storage Disease
- Wilson Disease
- Intrahepatic Cholestasis of Pregnancy (ICP)
How does alcohol affect the liver? (From the American Liver Foundation) http://www.liverfoundation.org/abouttheliver/info/alcohol/
Alcohol can damage or destroy liver cells.
What are the different types of alcohol-related liver disease?
There are three main types of alcohol-related liver disease: alcoholic fatty liver disease, alcoholic hepatitis, and alcoholic cirrhosis.
Alcoholic fatty liver disease
Alcoholic fatty liver disease results from the deposition of fat in liver cells. It is the earliest stage of alcohol-related liver disease. There are usually no symptoms. If symptoms do occur, they may include fatigue, weakness, and discomfort localized to the right upper abdomen. Liver enzymes may be elevated, however tests of liver function are often normal. Many heavy drinkers have fatty liver disease. Alcoholic fatty liver disease may be reversible with abstinence of alcohol.
Alcoholic hepatitis is characterized by fat deposition in liver cells, inflammation and mild scarring of the liver. Symptoms may include loss of appetite, nausea, vomiting, abdominal pain, fever and jaundice. Liver enzymes are elevated and tests of liver function may be abnormal. Up to 35 percent of heavy drinkers develop alcoholic hepatitis and of these 55% already have cirrhosis.
Alcoholic hepatitis can be mild or severe. Mild alcoholic hepatitis may be reversed with abstinence. Severe alcoholic hepatitis may occur suddenly and lead to serious complications including liver failure and death.
Alcoholic cirrhosis, the most advanced type of alcohol induced liver injury is characterized by severe scarring and disruption of the normal structure of the liver — hard scar tissue replaces soft healthy tissue. Between 10 and 20 percent of heavy drinkers develop cirrhosis. Symptoms of cirrhosis may be similar to those of severe alcoholic hepatitis. Cirrhosis is the most advanced type of alcohol-related liver disease and is not reversed with abstinence. However, abstinence may improve the symptoms and signs of liver disease and prevent further damage
The Liver Transplant
Liver transplants are performed only for patients with end-stage liver disease for whom standard medical and surgical therapies have failed. Conditions that can lead to liver transplantation include: (http://www.barnesjewish.org/conditions-leading-to-liver-transplant)
- Cirrhosis: cryptogenic, alcoholic, autoimmune, hepatitis B, hepatitis C, fatty liver disease (NASH)
- Hepatocellular carcinoma (liver cancer)
- Primary sclerosing cholangitis (disease of the liver bile ducts)
- Primary biliary cirrhosis (PBC – bile ducts in the liver slowly deteriorate)
- Alpha-1-antitrypsin deficiency (genetic disorder leading to abnormal amounts of A1AT protein in liver cells)
- Acute liver failure
- Cholangiocarcinoma (bile duct cancer)
- Wilson’s disease
Liver transplants are the second most common transplants after kidneys. They require that the blood type and body size of the donor match the person receiving the new organ. There are more 6,000 liver transplants are performed each year in the United States. The surgery usually takes between four and twelve hours and most patients can expect a hospital stay of up to three weeks following surgery. . .
Essential Information For The Transplant Patient
Most transplant centers function in pretty much the same manner, but Johns Hopkins Medical Center in Baltimore, Maryland offers one of the best summaries of what the transplant patient can expect. http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/liver_transplantation_procedure_92,P07698/
Risks of the procedure
As with any surgery, complications can occur. Some complications from liver transplantation may include, but are not limited to, the following:
- Blockage of the blood vessels to the new liver
- Leakage of bile or blockage of bile ducts
- Initial lack of function of new liver
The new liver may not function for a brief time after the transplant. The new liver may also be rejected. Rejection is a normal reaction of the body to a foreign object or tissue. When a new liver is transplanted into a recipient’s body, the immune system reacts to what it perceives as a threat and attacks the new organ, not realizing that the transplanted liver is beneficial. To allow the organ to survive in a new body, medications must be taken to trick the immune system into accepting the transplant and not attacking it as a foreign object.
Contraindications for liver transplantation include, but are not limited to, the following:
- Current or recurring infection that cannot be treated effectively
- Metastatic cancer. This is cancer that has spread from its primary location to one or more additional locations in the body.
- Severe cardiac or other medical problems preventing the ability to tolerate the surgical procedure
- Serious conditions other than liver disease that would not improve after transplantation
- Noncompliance with treatment regimen
- Alcohol consumption
There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.
Before the procedure
In order to receive a liver from an organ donor who has died (cadaver), a recipient must be placed on a waiting list of the United Network for Organ Sharing (UNOS). Extensive testing must be done before an individual can be placed on the transplant list.
Because of the wide range of information necessary to determine eligibility for transplant, the evaluation process is carried out by a transplant team. The team includes a transplant surgeon, a transplant hepatologist (doctor specializing in the treatment of the liver), one or more transplant nurses, a social worker, and a psychiatrist or psychologist. Additional team members may include a dietitian, a chaplain, and/or an anesthesiologist.
Components of the transplant evaluation process include, but are not limited to, the following:
- Psychological and social evaluation. Psychological and social issues involved in organ transplantation, such as stress, financial issues, and support by family and/or significant others are assessed. These issues can significantly impact the outcome of a transplant.
- Blood tests. Blood tests are performed to help determine a good donor match, to assess your priority on the donor list, and to help improve the chances that the donor organ will not be rejected.
- Diagnostic tests. Diagnostic tests may be performed to assess your liver as well as your overall health status. These tests may include X-rays, ultrasound procedures, liver biopsy, and dental examinations. Women may receive a Pap test, gynecology evaluation, and a mammogram.
The transplant team will consider all information from interviews, your medical history, physical examination, and diagnostic tests in determining your eligibility for liver transplantation.
Once you have been accepted as a transplant candidate, you will be placed on the UNOS list. Candidates in most urgent need of a transplant are given highest priority when a donor liver becomes available based on UNOS guidelines. When a donor organ becomes available, you will be notified and told to come to the hospital immediately.
If you are to receive a section of liver from a living family member (living-related transplant), the transplant may be performed at a planned time. The potential donor must have a compatible blood type and be in good health. A psychological test will be conducted to ensure the donor is comfortable with the decision.
The following steps will precede the transplant:
- Your doctor will explain the procedure to you and offer you the opportunity to ask any questions about the procedure.
- You will be asked to sign a consent form that gives your permission to do the surgery. Read the form carefully and ask questions if something is not clear.
- For a planned living transplant, you should fast for eight hours before the operation, generally after midnight. In the case of a cadaver organ transplant, you should begin to fast once you are notified that a liver has become available.
- You may receive a sedative prior to the procedure to help you relax.
- Based on your medical condition, your doctor may request other specific preparation.
During the procedure
Liver transplantation requires a stay in a hospital. Procedures may vary depending on your condition and your doctor’s practices.
Generally, a liver transplant follows this process:
- You will be asked to remove your clothing and given a gown to wear.
- An intravenous (IV) line will be started in your arm or hand. Additional catheters will be inserted in your neck and wrist to monitor the status of your heart and blood pressure, as well as for obtaining blood samples. Alternate sites for the additional catheters include the subclavian (under the collarbone) area and the groin.
- You will be positioned on the operating table, lying on your back.
- If there is excessive hair at the surgical site, it may be clipped off.
- A catheter will be inserted into your bladder to drain urine.
- After you are sedated, the anesthesiologist will insert a tube into your lungs so that your breathing can be controlled with a ventilator. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
- The skin over the surgical site will be cleansed with an antiseptic solution.
- The doctor will make a slanting incision just under the ribs on both sides of the abdomen. The incision will extend straight up for a short distance over the breast bone.
- The doctor will carefully separate the diseased liver from the surrounding organs and structures.
- The attached arteries and veins will be clamped to stop blood flow into the diseased liver.
- Depending on several factors, including the type of transplant being performed (whole liver versus a portion of liver), different surgical techniques may be used to remove the diseased liver and implant the donor liver or portion of the liver.
- The diseased liver will be removed after it has been cut off from the blood vessels.
- The doctor will visually inspect the donor liver or portion of liver prior to implanting it.
- The donor liver will be attached to the blood vessels. Blood flow to the new liver will be established and then checked for bleeding at the suture lines.
- The new liver will be connected to the bile ducts.
- The incision will be closed with stitches or surgical staples.
- A drain may be placed in the incision site to reduce swelling.
- A sterile bandage or dressing will be applied.
After the procedure In the hospital
After the surgery you may be taken to the recovery room before being taken to the intensive care unit (ICU) to be closely monitored for several days. Alternately, you may be taken directly to the ICU from the operating room. You will be connected to monitors that will constantly display your EKG tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level. Liver transplant surgery requires an in-hospital stay of seven to 14 days, or longer.
You will most likely have a tube in your throat so that your breathing can be assisted with a ventilator until you are stable enough to breathe on your own. The breathing tube may remain in place for a few hours up to several days, depending on your situation.
You may have a thin plastic tube inserted through your nose into your stomach to remove air that you swallow. The tube will be removed when your bowels resume normal function. You will not be able to eat or drink until the tube is removed.
Blood samples will be taken frequently to monitor the status of the new liver, as well as other body functions, such as the kidneys, lungs, and blood system.
You may be on special IV drips to help your blood pressure and your heart and to control any problems with bleeding. As your condition stabilizes, these drips will be gradually weaned down and turned off as tolerated.
Once the breathing and stomach tubes have been removed and your condition has stabilized, you may start liquids to drink. Your diet may be gradually advanced to more solid foods as tolerated.
Your immunosuppression (antirejection) medications will be closely monitored to make sure you are receiving the optimum dose and the best combination of medications.
When your doctor feels you are ready, you will be moved from the ICU to a room on a regular nursing unit or transplant unit. Your recovery will continue to progress here. Your activity will be gradually increased as you get out of bed and walk around for longer periods of time. Your diet will be advanced to solid foods as tolerated.
Nurses, pharmacists, dietitians, physical therapists, and other members of the transplant team will teach you how to take care of yourself once you are discharged from the hospital.
Once you are home, it will be important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions. The stitches or surgical staples will be removed during a follow-up office visit, if they were not removed before leaving the hospital.
You should not drive until your doctor tells you to. Other activity restrictions may apply.
Notify your doctor to report any of the following:
- This may be a sign of rejection or infection.
- Redness, swelling, or bleeding or other drainage from the incision site
- Increase in pain around the incision site. This may be a sign of infection or rejection.
- Vomiting and/or diarrhea
Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.
What is done to prevent rejection?
To allow the transplanted liver to survive in a new body, you will be given medications for the rest of your life to fight rejection. Each person may react differently to medications, and each transplant team has preferences for different medications.
New antirejection medications are continually being developed and approved. Doctors tailor medication regimes to meet the needs of each individual patient.
Usually several antirejection medications are given initially. The doses of these medications may change frequently, depending on your response. Because antirejection medications affect the immune system, people who receive a transplant will be at higher risk for infections. A balance must be maintained between preventing rejection and making you very susceptible to infection.
Some of the infections you will be especially susceptible to include oral yeast infection (thrush), herpes, and respiratory viruses. You should avoid contact with crowds and anyone who has an infection for the first few months after your surgery.
The following are the most common symptoms of rejection. However, each individual may experience symptoms differently. Symptoms may include, but are not limited to, the following:
- A yellowing of the skin and eyes due to bile pigments in the blood.
- Dark urine
- Abdominal swelling or tenderness
- Fatigue or irritability
The symptoms of rejection may resemble other medical conditions or problems. Consult your transplant teaoncerns you have. Frequent visits to and contact with the transplant team are essential.
Organ transplants are expensive and the cost goes well beyond the surgery itself. If you are told you need a transplant and are sent to a transplant center for evaluation you can bet one of the first questions you will be asked is, “Do you have the financial resources to pay for your transplant?”
According to the National Foundation for Transplants http://www.transplants.org/faq/how-much-does-transplant-cost the average cost of a liver transplant and first year expenses in the United States is $575,000.
The Mayo Clinic developed this helpful list of questions that will help you develop the answer to that question. http://www.mayoclinic.org/departments-centers/transplant-center/liver-transplant/choosing-mayo-clinic/costs-insurance-information
Before your transplant, it’s important that you work closely with your insurance company to understand your benefit plan. You’ll be responsible for any of your transplant and medical care costs not covered by your insurance company.
You may want to ask your insurance company several questions regarding your transplant expenses, including:
- What is the specific coverage of my plan? What are my deductibles, coinsurance, copayments, lifetime maximum amount and annual maximum amounts for both medical care and transplant services?
- Does my plan have a pre-existing or waiting period clause? If so, what is the time frame? Can this be waived?
- Does my plan include pharmacy coverage? If so, will my plan cover my current medications and immunosuppressant medications?
- Does my plan require any special approvals for evaluation or transplant? How long does the approval process take once submitted to insurance?
- Does my plan cover my transportation and lodging expenses during my transplant care?
- Does my current insurance require enrollment in Medicare when eligible?
- Does my insurance follow Medicare Coordination of Benefits guidelines?
- How will my current coverage change after enrolling in Medicare? Will my plan become a supplemental or secondary plan?
If your plan is a Medicare supplement, ask questions including:
- Does my plan follow Medicare guidelines?
- Does my plan cover Medicare Part A and B deductible and coinsurance?
- Does my plan have a pre-existing or waiting period? If so, what is the time frame?
- Does my plan offer an option for Medicare Part D coverage?
Please plan for other expenses that may occur related to your transplant, which may include follow-up medical appointments, long-term medications, caregiver expenses, travel, parking, lodging and other expenses.
If you need an organ transplant, but don’t have the financial resources to pay for it you should first work with the transplant center social worker to see what is available. There are a number of resources for which you may qualify. Just click on this link for the complete list and explanation of services. http://www.transplantliving.org/before-the-transplant/financing-a-transplant/directory/
Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s over 4,200 member Organ Transplant Initiative (OTI) and the author of most of these donation/transplantation blogs. You may comment in the space provided or email your thoughts to me at firstname.lastname@example.org. And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love. You can register to be a donor at http://www.donatelife.net. It only takes a few minutes.