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Liver Transplantation Liver Transplantation National Digestive Diseases Information Clearinghouse What is liver Who needs a liver transplantation? transplant? Liver transplantation is surgery to remove People with either acute or chronic liver fail- U.S. Department a diseased or injured liver and replace it ure may need a liver transplant to survive. of Health and with a healthy whole liver or a segment of a Human Services • � Acute liver failure (ALF) happens sud- liver from another person, called a donor. denly. Drug-induced liver injury (DILI) A successful liver transplant is a life-saving NATIONAL is the leading cause of ALF in the treatment for people with liver failure, a INSTITUTES United States. The most common cause OF HEALTH condition in which the liver no longer works of DILI is an overdose of acetamino- as it should. phen (Tylenol). • � Chronic liver failure, also called end- stage liver disease, progresses over What does the liver do? months, years, or decades. Most often, The body’s largest internal organ, the chronic liver failure is the result of cir- liver has many important functions rhosis, a condition in which scar tissue including replaces healthy liver tissue until the liver cannot function adequately. • preventing infections In U.S. adults, the most common reason for • removing bacteria and toxins from needing a liver transplant is cirrhosis caused the blood by chronic hepatitis C, followed by cirrhosis • controlling immune responses caused by long-term alcohol abuse. Many other liver diseases also cause cirrhosis, • processing nutrients, medications, including and hormones • � other forms of chronic hepatitis, includ- • making proteins that help the ing chronic hepatitis B and autoimmune blood clot hepatitis • producing bile, which helps the • � diseases that affect the bile ducts— body absorb fats—including tubes that carry bile from the liver to cholesterol—and fat-soluble vitamins the gallbladder and small intestine— • storing vitamins, minerals, fats, and including biliary atresia, Alagille syn- sugars for use by the body drome, primary biliary cirrhosis, and primary sclerosing cholangitis A healthy liver is necessary for survival. A healthy liver can regenerate most of its own cells when they become damaged. • � hemochromatosis, a genetic condition in • � passing black stools which iron builds up in the liver • � ascites, the buildup of fluid in the • � Wilson disease, a genetic condition in abdomen which copper builds up in the liver • � forgetfulness or confusion • � nonalcoholic steatohepatitis, or NASH, a disease caused by fat and inflamma- What is the process for tion in the liver getting a liver transplant? In children, biliary atresia is the most com- The process for getting a liver transplant mon cause of liver failure and the need for a begins with a referral by a doctor to a trans- liver transplant. Biliary atresia is a disease in plant center. People seeking a liver trans- newborns in which the bile ducts are absent, plant are carefully evaluated by a team at the damaged, or blocked. As a result, toxic bile transplant center to determine whether they builds up in the liver, resulting in cirrhosis. are suitable candidates for transplantation. Other reasons for liver transplantation The evaluation includes a complete medi- include cancers originating in the liver such cal history, physical examination, blood and as hepatocellular carcinoma, hepatoblas- urine tests, x rays and other imaging tests, toma, and cholangiocarcinoma. and tests to check the function of the heart, lungs, and kidneys. The transplant team usually includes liver transplant surgeons; What are the signs and liver specialists, called hepatologists; nurses; symptoms of liver failure? transplant coordinators; social workers; a The signs and symptoms of liver failure may psychiatrist; and other specialists. A finan- include cial counselor may help with making arrange- ments to pay for the transplant. • � jaundice, a condition that causes yellow- ing of the skin and the whites of the eyes The evaluation of a transplant candidate typically includes assessment of • � fatigue • � the status of the person’s liver disease • � weakness • � other diseases and conditions the per- • � loss of appetite son has • � nausea • � the likelihood the person will survive • � weight loss the transplant operation • � muscle loss • � the person’s ability to follow instruc- • � itching tions and the complex medical regimen required after a transplant • � bruising or bleeding easily because blood does not clot � • � the person’s mental and emotional health � • � bleeding in the stomach • � the person’s support system • � vomiting blood 2 � Liver Transplantation A liver transplant selection committee Scoring Systems reviews the results of the evaluation, deter- When people are registered on the waiting mines whether the person meets the trans- list, they are assigned a score that indicates plant center’s criteria for a transplant, and how urgently they need a transplant. The decides whether to register the person on the two scoring systems are the Model for End- national waiting list for a transplant. stage Liver Disease (MELD) scoring system, The national waiting list is maintained by the used for people age 12 and older, and the United Network for Organ Sharing (UNOS), Pediatric End-stage Liver Disease (PELD) which administers the U.S. Organ Procure- scoring system, used for children younger ment and Transplantation Network (OPTN) than 12. under contract with the Health Resources MELD and PELD scores are calculated by and Services Administration (HRSA) of computer using the results of blood tests. the U.S. Department of Health and Human MELD scores range from 6 to 40. PELD Services. scores can range from negative numbers to Not everyone sent to the transplant center is 99. These scores are used to estimate the advised to have a transplant, and not every likelihood of dying within the next 90 days person who starts an evaluation is placed on without a transplant. A higher score indi- the transplant list. While undergoing evalu- cates a more urgent need for a liver trans- ation, and while waiting for a transplant, plant. While patients are on the national list patients should take care of their health. wait for a transplant, their MELD or PELD score may go up if their condition worsens or Even if the liver transplant selection com- go down if their condition improves. mittee approves a candidate for a transplant, he or she may choose not to proceed with it. The MELD score is calculated using the To ensure the person can make an informed results of three blood tests: decision about having a transplant, the trans- • � bilirubin, which tests the amount of bile plant team provides information about the pigment in the blood • selection process for transplantation • � creatinine, which tests kidney function • operation and recovery • � international normalized ratio (INR), • � long-term demands of living with a liver which tests the blood’s ability to clot transplant The MELD score calculation also considers whether a patient who has poor kidney func- tion is on dialysis. 3 � Liver Transplantation The PELD score is calculated based on What might prevent a • the results of blood tests for bilirubin, person from having a liver INR, and albumin, the major protein in transplant? the blood Each transplant center has its own guidelines • the child’s degree of growth failure regarding eligibility for liver transplantation. • the child’s age at time of registration A center might determine that a person with acute or chronic liver failure is not a candi- The MELD and PELD scoring systems have date for a liver transplant if the person has been in place since early 2002 and have helped reduce the size of the waiting list and • cancer outside the liver the amount of time a person has to wait to • infection throughout the body receive a transplant. The MELD and PELD scoring systems continue to be studied to see • advanced heart or lung disease whether adding other factors in the calcu- • an alcohol or drug abuse problem lations can increase the ability to predict • AIDS the risk of death without a transplant. The UNOS uses MELD and PELD scores in allo- • the inability to follow a treatment cating livers for transplantation to patients regimen on the national waiting list. More informa- • a lack of psychosocial support tion about the MELD and PELD scoring systems is available from the UNOS at www. In addition, the transplant candidate may unos.org/resources/meldPeldCalculator.asp decide not to go forward with a transplant. and www.unos.org/SharedContentDocuments/ MELD_PELD(1).pdf. Status 1 Patients Critically ill patients with acute liver fail- ure who are likely to die within a week are categorized as status 1 patients and are given highest priority for liver transplantation. 4 Liver Transplantation Where do donated livers A small number of liver transplants are performed using living donors. Most living come from? donors are relatives of the recipient. In liv- Most donated livers come from deceased ing donor transplantation, a segment of the donors—donors who have recently died. donor’s healthy liver is surgically removed Adults usually receive the entire liver from a and transplanted into the recipient. Because deceased donor, although a segment of the a healthy liver can regenerate, the donor’s liver can be transplanted when the donor liver soon grows back to normal size after liver is too large. Because few donor liv- the surgery, while the segment of the liver ers come from children, pediatric recipients that was transplanted into the recipient also more often receive a portion of a liver from grows to normal size. an adult donor. Occasionally, an adult liver is split into two portions and given to two dif- The entire left lobe or a portion of the left ferent recipients. For example, the smaller lobe of the liver from a living adult donor left lobe may be given to a child and the is usually sufficient for transplantation in a larger right lobe given to an adult.
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