The following consultation about liver transplantation could apply to a number of different situations in which an adult male or female has a liver disease that has resulted in a poorly functioning liver. In our example, the patient is a 41-year-old woman who has severe cirrhosis of the liver. Also present in the examining room is the patient’s adult daughter, who will care for her mother after the operation.
This consultation is presented for purposes of general information. If you think you have a similar condition, please see your doctor to discuss your individual case and the exams and treatments that are best for you.
In cirrhosis of the liver, scar tissue replaces normal, healthy liver tissue, blocking the flow of blood through the organ and preventing it from working as it should. Cirrhosis is the twelfth leading cause of death by disease, killing about 26,000 people each year. In the United States, chronic alcoholism and hepatitis C are the most common causes of cirrhosis of the liver. Alcoholic cirrhosis usually develops after more than a decade of heavy drinking. In our example, the patient is a 41-year-old woman and recovering alcoholic who now has alcoholic liver disease. She has brought her adult daughter with her to the appointment because the daughter will care for her after the surgery.
Consultation
Doctor: Hello. How are you this morning?
Patient: I’m okay, thank you. And this is my daughter.
Doctor: How do you do. And you are here to learn more about the procedure that your mother may be having.
Daughter: That’s right. My Mom is living with me and I would take care of her if she has surgery.
Doctor: Good. Let’s get started. I understand from your medical record that you have been having problems, and I had a call from your hepatologist about the fact that you’ve also had some swelling in your abdomen and some bleeding as well. So please tell me how this all started and what has been going on with you.
Patient: Well, last year I started having episodes of jaundice where my skin became very yellow. And I started having swelling here in my belly and the doctor said it was fluid collecting in the abdomen from my liver not working. It become so bad they had to use a needle to remove the fluid. Three times they’ve had to remove the fluid. And then about ten months ago, I vomited blood. At that point they did an endoscopy and some x-rays, upper and lower GI tests, and blood tests.
Doctor: And what did your doctor tell you at that time?
Patient: He said I have alcoholic liver disease and I needed to stop drinking.
Doctor: And at that point he began talking with you about the possibility of a liver transplant.
Patient: Yes, he said I might be a candidate for a liver transplant that would give me another chance, if I stopped drinking and if I could get on the list. At that time I made the decision to stop.
Doctor: What has been your approach to stopping drinking?
Patient: I entered a recovery program. Today I have one hundred ninety-three days clean and sober. My doctor feels that I am ready now to talk with you about a liver transplant. I didn’t know you do liver transplants for this.
Doctor: Yes, we do, when all of the records and tests are complete and satisfactory and when we are confident that the patient understands exactly what is involved in having a surgery like this, and when they demonstrate that they are committed to stopping drinking.
Patient: I am.
Doctor: For how long were you drinking before?
Patient: Twenty-four years. Since I was seventeen.
Doctor: And I see from the results of your tests that you do not have hepatitis C. Do you have a history of drug use?
Patient: No. Just alcohol.
Doctor: I see. As you know, when you come to see me we assume that you have been counseled about the importance of stopping the use of alcohol, and you have documentation that you have been sober for at least six months, and that you are not taking any recreational drugs. From what you have told me, and from the test results and documentation here in your chart, I see that this is true in your case.
Patient: Yes, it is. So what will happen now?
Doctor: You are being evaluated for a liver transplant, and whether you are a candidate will be determined by our selection committee. In this consultation, I will make a determination of whether I think you will make a good candidate and whether I can recommend to the committee that we put you on the list for a transplant.
Patient: Okay.
Doctor: Looking at your chart, I see all the blood tests have been done, and I will do a brief physical exam now and get your blood pressure, height and weight.
Patient: All right.
The doctor performs a physical examination, examining the patient’s eyes, chest, heart, and abdomen. He records the patient’s blood pressure, height and weight, and asks a number of questions about the patient’s medical history and the health of her immediate family members (parents, siblings, and children). When this exam is complete, he begins to describe what is involved in the operation.
Doctor: From examining you, I see your blood pressure is normal and you don’t have any overweight issues. Knowing that you have not had any abdominal surgeries, I expect this would be a straightforward operation in your case.
Patient: Good.
Doctor: Now you and I should talk to each other about the risks and benefits of the operation and what the operation involves, if you were to get to the stage where you would be listed for a liver transplant. And I would like to talk with you about where you are in your life today.
Patient: All right. It’s a serious surgery, isn’t it?
Doctor: Yes. It involves blood transfusions and staying in the ICU for a long time. It also involves a strong and very long-term commitment once you are out of the hospital and recovering from the surgery itself. One of the things that makes a person a strong candidate for a liver transplant is that we are assured that you understand the importance of coming to the follow-up visits with us for a long time, and being available to make changes if we call you after a follow-up exam and inform you that a change needs to be made. And we want to make very sure you know that if you go back drinking you will never get another liver transplant.
Patient: I do understand that.
Doctor: First, I’d like to ask you about your family and your support system. You have your daughter, here, who could take care of you when you come home from the hospital?
Patient: Yes. My daughter is prepared to take care of me after the surgery. And I have a great deal of support from my sister and from my recovery program.
Doctor: All right. First of all, as I believe you know, a liver transplant is a major procedure. People have actually died just because of the operation.
Patient: I understand that. What is the success rate of the operation?
Doctor: It’s very good. At our center, the five-year survival rates are very good, close to the results from national series, and about 95% of patients are alive and well at one year.
Patient: How long does the surgery itself take?
Doctor: The operation takes about anywhere from 5 hours to 8-9 hours.
Patient: And how long will I be in the hospital?
Doctor: After the operation, you might be in the hospital anywhere from a week to a few months. If everything goes well, you should be out of the hospital in about a week to ten days.
Patient: What if it doesn’t go well?
Doctor: There can be complications. Sometimes when we put the liver in, it does not work, so we have to redo the operation with another liver. Sometimes the liver takes a long time to work. Sometimes there are complications like bleeding, or clots in the artery, in which case we have to take you back to the operating room once or twice or more than that. Having said that, I can tell you that most operations go well. Most patients have done very well in our hands, and a lot of patients leave the hospital within seven to ten days.
Patient: What happens then?
Doctor: Again, before you are discharged home we have to make sure you have a good support mechanism and that everything is in place at home, so that you go into an environment in which you will be able to take your medicines on time. And you will need to be available to make any changes in the medications if we call you after a followup appointment and notify you that we need to make a change. After you have recovered, you will be back to normal life, and most patients go back to work in about three months or so.
Patient: Where does the donor liver come from?
Doctor: The majority of the liver transplants have been done from donors who have died from an accident or any other mode of injury or sometimes even natural deaths.
Patient: And if there is a liver for me, what happens?
Doctor: The surgical team that takes out the donor liver will bring the liver to UCSD Hillcrest and it will be transplanted here. We give you a pager and you will be on a pager 24/7. You will get 6-7 to 24 hours notice that you might be in for a liver transplant. So we give you enough time to come in for this procedure.
Patient: Once I get the news, what do I have to do to prepare for the transplant procedure?
Doctor: We will instruct you not to take anything to eat or drink, and have someone bring you to the hospital.
Patient: And then my daughter will need to take care of me constantly when I go home after the surgery.
Doctor: Yes. It is important that we have that mechanism in place because it will help you and help us in reassuring ourselves that there is someone out there who is going to take care of you.
Patient: Will you know right away whether the transplant is successful?
Doctor: Yes, almost always the liver starts working within the first six to ten hours after the operation.
Patient: What if it doesn’t work?
Doctor: If the liver doesn’t work or there is a complication, then we would have to remove the liver and re-list you for another liver.
Patient: And what would happen to me without a liver?
Doctor: Well, you would be very sick. You would be in the hospital ICU and probably with a breathing tube, so you wouldn’t know much of it because if the liver doesn’t work, it really makes you very, very sick.
Patient: How long will I be on the waiting list before a liver becomes available for me?
Doctor: It depends on how sick a person is. The wait can be anywhere from a few months to a few years. The patients who are the most severely ill are the ones who get a higher priority.
Patient’s daughter: What about the drugs she would have to take afterwards?
Doctor: Well, she would go home from the hospital on about 6-10 types of medicines a day. For the first few months, it might sound and look overwhelming that she’s taking so many pills, but afterwards we reduce the number of medicines she’s on, and it will be reduced to maybe 3-4 types of pills a day.
Patient: What are the side effects?
Doctor: Some of these medications do have side effects, and these would include loss of hair reversible, sometimes nausea and vomiting, and sometimes some of these drugs affect the kidneys as well, and so it is important for you to understand that there can be some side effects. But we monitor your drugs and your levels in the blood very closely so that we don’t overdose you. We have been very successful at preventing rejection and at the same time making sure that your body doesn’t get hurt from the effects of the medications.
Patient: Will I have to take some of the medications for the rest of my life?
Doctor: Yes. One medicine, which we call Tacrolimus, we expect you to take forever.
Patient: And will I need to come back for follow-up for the rest of my life?
Doctor: Usually for the first three months. Overall it depends on how you are doing and how the liver is doing. If the liver is doing really well, for the first few weeks we will get your blood tested once or twice a week, and then after 4-6 weeks we can space it at every two weeks and then every month depending on how the liver is working.
Patient: What would happen to the new liver if I ever started drinking again?
Doctor: Well, it’s a bad sign. It shows that there is some breakdown in the process. If it were to happen, we would make sure that we immediately get you to be seen by a social worker and a psychiatrist to look into it more deeply to see what might have led to this. And we counsel you, as I am doing now, to make sure you understand that if you return to drinking then you might lose your life, because it would be very hard for us to be convinced that you are a candidate for another liver transplant if you are drinking or doing drugs.
Patient’s daughter: Would drinking or taking drugs affect the new liver too?
Doctor: Yes. Almost always people who start drinking again come back in the hospital showing abnormal laboratory tests, so it becomes obvious when we test your blood every week.
Patient: Are there scars after the procedure?
Doctor: Yes. You will have an incision we call a Mercedes-Benz incision on your belly and this is what it looks like, a Y shape on the abdomen. As you understand, it is a big organ so we make a big cut to be able to do this.
Patient: And you will do the operation?
Doctor: Yes, I will be one of the surgeons. We have a team of three excellent surgeons. Dr. Hart and Dr. Khanna are our other partners and we help each other out. There will be a lead surgeon and a surgeon who helps, a co-surgeon.
Patient: Doctor, at this point do you think I am a good candidate for a transplant?
Doctor: I see most of your workup is complete and all your tests are in order. I feel that you understand what you are getting into, you understand the details of the surgery and the follow-up. I am also convinced that you know the consequences of the drinking in damaging your liver and I see that you have documented 6 months of sobriety. We have a selection committee next week and once we present you to the committee, we will know whether we all agree to list you for the procedure.
Patient: So you will present my case to the committee.
Doctor: Yes. Just talking to you and meeting your daughter and knowing you have a supportive family, I don’t see any reason that we should not transplant you. You are an intelligent woman and I see that you understand that after the transplant you will be on anti-rejection medications and you will have to come to visit us for blood tests at least once a week and be available always to make any changes in the medications if we call you. So I think with all that in place you are a very good candidate and we will make strong recommendations to the committee to list you for this procedure. My office will contact you after the selection committee meeting and let you know the decision.
Patient: Thank you very much, Doctor.