What is a liver transplant?

A liver transplant is an operation performed to replace a child’s diseased or malfunctioning liver with a healthy one from another person. The liver may come from a deceased organ donor or from a family member who willing to donate a part of his or her liver and a suitable candidate. In Pakistan due to the scarcity of brain dead donors; the liver from a living donor the only chance for transplantation in sick children. Usually, parents and close family members are suitable donors. Their generous act of altruism can save a child’s life. Those who donate a portion of their livers can live healthy lives with the remaining liver.

The donor will donate only left lateral segment of the liver (which is 15-20% of your liver) if donating for an infant and left lobe of the liver (which is 30-40% of the liver) if donating for a child. The remaining organ will even grow back to the original size of the whole liver. the liver the only vital organ in the human body that has the ability to grow.

Preparing for liver transplant surgery

Once your child has been evaluated by the liver transplant team, and it’s determined that he needs a new liver, your child should continue to visit primary care pediatrician for well visits and immunizations, as well as when he or she sick. It’s very important that your child as healthy as possible for the liver transplant. Care provided by your child’s liver transplant team should not replace regular pediatrician visits.

Recipient Exclusion Criteria (contraindications to transplant):

• A severe, irreversible, medical illness that limits short term life expectancy.
• Severe Pulmonary Hypertension (Mean PA pressure > 50mmHg).
• Sepsis or uncontrollable infection.
• Severe, uncontrolled Psychiatric illness.
• Uncorrectable congenital abnormalities which are severe and life-threatening.

Relative Exclusion Criteria:

• Advanced malnutrition
• Active Infection
• Inability to comply with medications and conform to follow up regimens.

 

The Assessment Process

It a stepwise assessment of the recipient and the donor. The purpose of a stepwise assessment to avoid unnecessary investigations. Assessment starts from the recipient once he/ she has clear indications of liver transplantation. The timing of the transplant crucial, so an objective assessment process is mandated.

Objectives of liver transplant assessment:

1. Right recipient selection
2. Right donor selection
3. Better outcome

 

 

Stepwise Recipient Assessment:

Patients are examined by hepatologists and liver transplant surgeons. After the initial assessment, if a patient is a candidate for a liver transplant, detailed briefings given to the patient and their family regarding the risks and benefits of the transplant operation.

Patients given time to think and plan transplantation. They are also provided with educational material. Once the patient and family made the final decision for liver transplantation, the detailed assessment process is started that includes the following:

Radiological assessment 

1. Ultrasound of the abdomen
2. Liver dynamic CT abdomen, and Chest CT to rule out/stage HCC, determine extent of liver disease
3. MRI and CT brain in selected cases

Cardiac Assessment:

1. ECG
2. Echocardiogram/stress echo including PA pressure
3. Coronary angiogram (selected cases )
4. Cardiologist comments

Pulmonology assessment

1. CXR
2. Pulmonary function tests
3. Pulmonologist evaluation

Nephrology assessment

1. Renal function tests
2. Routine urine analysis
3. Urine culture
4. Nephrologists evaluation

Psychiatry assessment

1. Consultation & Evaluation

 

Stepwise donor evaluation:

Once it assured that patient is fulfilling the liver transplant criteria and fit enough to undergo major surgery, the donor workup starts. We accept donors from within the family (close blood relatives and non-close blood relatives) according to the following criteria:

Living Donor selection criteria:

• A blood-related person or a spouse who shares a compatible blood group with the patient.
• Donors must be healthy individuals with no major health problem.
• Must be in good physical and mental health
• between the ages of 18 and 50 years
• Voluntarily, altruistic donation
• Have a body mass index (BMI) less than 35
•  a compatible blood type with the recipient
• free from the following:
  • Significant organ diseases (i.e., Heart, Lung & Kidney disease, etc.)
  • Ongoing malignancy (cancer)
  • HIV/AIDS
  • Hepatitis
  • Active or chronic infections
  • Active substance abuse

Laboratory work-up the living donor:

The purpose of the stepwise evaluation of the donor to avoid unnecessary investigations. If the donor found to unsuitable at any step, the other investigations should abandoned. Before starting the investigations of the donor, detailed history, and physical examination including height, weight, BMI recorded. Steps of donor evaluation are as follows:

 Special Considerations and/or Issues in Donor Evaluation:

Donor Advocate:

Usually, a physician outside of the transplant team, who will help the donor understand the process, procedure, risks, and benefits of live organ donation.  The donor advocate will protect and promote the interests and well-being of the donor. Donors can opt to withdraw at any time during the assessment process.  The reasons for withdrawal kept confidential.

Liver Biopsy:

Our program may perform a liver biopsy on potential donors based on clinical findings that suggest some degree of concern regarding the histological status of the liver, i.e., elevated AST/ALT, presence of steatosis on imaging studies, and so on.

Cost of Donor Evaluation:

Financial considerations of the donor evaluation and hepatectomy important to consider because of the process complex and expensive and some of the donors “failed donor evaluations,” i.e., potential donors who undergo testing and rejected for donation. Living donation not possible for all the donors due to medical and technical reasons.

After a complete assessment of the recipient and the donor, the case presented in the Transplant Multidisciplinary Meeting (MDM).

Transplant Multidisciplinary Meeting (MDM) Guidelines:

1. a) Objective: Discussion of all patients under consideration for transplantation.

Attendees:

1. Hepatologist Consultant
2. Liver Transplant Surgeon(s) Consultant
3. Consultant Liver Transplant Anesthetist(s)
4. Intensivist(s) Consultant
5. Transplant Coordinator Team (including MDT Co-ordinator). The Co-ordinator will also act as a social worker
6. Physicians in training
7. Nurses responsible for care of patient

1. b) Agenda in brief: For each patient:
   1. Short/salient summary of each patient based on evaluation proforma and listing meeting outcome.
   2.  suitability for transplantation
   3. Discuss the necessity/appropriateness of further investigations
   4. Define an action plan (outcome) – listing/ time-frame – record outcome – Database.

1. c) Presentation at MDM:

2. List of all patients for discussion to be circulated to attendees 24hrs prior to the meeting (responsibility of MDT Co-ordinator). All names are forwarded 24 hours before the meeting.

Give short summary of patient’s history: indications for transplantation, presentation, referral source, suspected/confirmed diagnoses, and investigations +/- treatments to date.  Summarise all available relevant transplant assessment-related investigations.

1. d) Discussion:

• The rationalization for transplantation and absolute/relative contraindications.
• Exploration of other treatment options/further investigations.
• Recommendation of treatment(s) (e.g. abstinence programs etc).

1. e) Define an action plan:

• If accepted for listing, discuss priority/type of graft/immunosuppressant regimen.
• If not listed, define reasons/future candidacy/ follow up plan.
• If the patient to be re-discussed, define issues for re-discussion.
• Record outcome – with review date if appropriate.

1. f) Updates: Updates will only be discussed on the basis that they require a new decision from the Transplant MDM.
2. g) Acute Liver Failure: Patients with acute liver failure approaching or meeting listing criteria for urgent transplantation, discussed ad-hoc and listed upon agreement between Intensivist/Hepatologist/consultant transplant surgeons. We follow King’s College criteria for liver transplant in acute liver failure.

1. e) MDM- Responsibilities of Transplant Coordinator:

• Preparation of MDM
• Circulate list to all attendees 24hrs prior to the meeting.
• Record attendance and generate quarterly report for “Chair”.
• Ensure outcomes are recorded – check database & written record.
• Contribute to MDM discussion – additional information including influential factors e.g. social issues, previous experience of a patient.

After approval from transplant MDM both the donor and the recipient presented to the hospital Evaluation Committee for final approval. Hospital evaluation committee a legal requirement of Human Organs and Tissues Act, 2009 (No.F.9 (1)/2009-Legis).

1. g) The Hospital Evaluation Committee:

2. Ensures that no organ or tissue is retrieved from non-related living donors without the prior approval of the Evaluation Committee
3. Determine propriety of removal of a human organ from any living person using brain death protocol to be formulated; and

• Determine fitness or otherwise for transplantation of a human organ into any other body.

The hospital Evaluation Committee either approves the case (for close blood relatives) or forwards it to Human Organ Tissue Authority (for non-close blood relatives).

Documentary evidence of relation established by relevant national identity card, birth certificate and marriage certificate.

In case of non-close blood relatives the evaluation committee evaluate for the following:

1. There no commercial transaction between the recipient and the donor. No payment of money or money’s worth as referred to in HOTA act, made to the donor or promised to be made to the donor or any other person. In this connection, the Evaluation Committee shall take into consideration:

1. An explanation of the link between recipient and donor and the circumstances which led to the offer being made.
2. Documentary evidence of the link e.g. proof of relationship (NADRA Family Relationship Certificate-FRC).
3. Reason why the donor wishes to donate.
4. There no middleman / tout involved.

• The donor is not a drug addict or active substance abuse.

1. The next of kin of the proposed donor gives permission on stamp paper in case of non-close blood relatives.

SURGICAL PLANNING

After assessment of the recipient and the donor the surgical team designs surgical plan

For the living donor liver transplantation.

After this process is complete, both the recipient and the donor informed about the process of liver transplantation in detail and informed consent obtained separately from the donor and the recipient and the date of surgery is decided and the following plan is given all the risks and benefits of the transplant to the donor and to the recipient are explained in detail. The recipient, donor, and the family provided with the opportunity to enquire any other information regarding the whole process.

The recipient operation will take 6-8 hours. The recipient will stay 4-6 days in the ICU followed by another 2 weeks in the hospital. The recipient’s average hospital stay around 12-15 days. Donor’s total hospital stay should be 7-8 days. The recipient will be given prophylactic antibiotics, analgesia, low molecular weight heparin for DVT prophylaxis and immunosuppressive drugs (including Tacrolimus, Mycophenolate Mofetil and steroids), anti-fungal medication and Omeprazole.

The liver transplant co-coordinator will accompany the patient and their family throughout the process to facilitate them at each and every step.

In the operating room

Liver transplant surgery usually lasts six to eight hours, but this can vary considerably based on the child’s size, whether or not they have had prior surgery, and other factors. Throughout the surgery, a transplant coordinator or a member of the transplant team will update you regularly — generally at least once an hour — on the surgery’s progress.

The operating room staff will call for your child one hour before liver transplant surgery, so the anesthesiologist and nurses can prepare your child for the operation. They will give your child medication through the intravenous line to help him sleep. Once he’s sleeping, the staff will insert additional IV lines and an arterial line, as well as a central line inserted into a large neck vein. Blood drawn from this line, and it may remain in place during your child’s hospital stay. In addition, the team will monitor your child’s. Urine output, with a Foley catheter placed into the bladder.

• Vital signs:

• • Blood pressure, with a blood pressure cuff
  • Heart rate and breathing rate, with monitor leads placed on your child’s chest
  • Temperature, with a temperature probe
  • TheBlood oxygen level, with a pulse oximeter

Explanation:

The surgeon will remove the diseased liver and send it to the laboratory for examination, then sew the healthy liver in place. When all the vessels connected, the new liver will look pink and feel soft and blood will flow into the new liver. Next, the surgeon will connect the bile ducts. If your child is small or a Kasai procedure, the surgeon will connect the piece of intestine that was fashioned into a bile duct during the Kasai procedure to the bile duct of the donor liver. This allows bile to drain from the liver. Otherwise, the surgeon will connect the bile ducts to each other. Throughout the operation, your child may receive blood products, only if necessary, to replace any he may have lost.

Once the procedure is complete, your child  transferred to the Liver Intensive Care Unit.

Recovery and rehabilitation

The average length of stay following transplant approximately 10-12 days for otherwise healthy older children and 10 to 14 weeks for infants.

Your child’s first stop after liver transplant surgery will be the Liver Intensive Care Unit (LICU). When your child arrives in the LICU, the nurses and physicians will ask you to wait to see your child so they can get her settled.

The LICU a busy place with many different types of equipment, alarms and sounds. Your child may be hooked up to quite a few pieces of equipment, and you may find it all a bit overwhelming. It helps to know how all this technology helping your child. Here are some of the things you may see attached to her in the LICU:

More about Recovery and rehabilitation

• Monitors that check heart rate, respiratory rate, blood pressure and oxygen saturation.
• An endotracheal (ET) tube, which placed in your child’s trachea (windpipe) during the operation and connected to a ventilator to help her breathe. Your child won’t be able to talk, eat or drink with the ET tube in place. Doctors will remove the ET tube when your child no longer needs help breathing.
• An abdominal dressing over the incision. This will be removed on the first day for an ultrasound.
• A nasogastric (NG) tube, which passes through the nose and into the stomach, to help drain secretions from the stomach.
• Surgical drains in your child’s abdomen to help remove extra drainage from the surgical site.
• A Foley catheter to drain urine from the bladder.
• Multiple intravenous (IV) lines to provide pain relief, antibiotics and other medications and fluids.
• An arterial line to monitor blood pressure and provide blood samples. It will be removed before your child transferred from the PICU to a surgical unit.
• A central line — a flexible catheter inserted in a large vein — to give IV fluids and medications and, if necessary, provide blood samples.

LICU

Some of these tubes and lines will removed when your child transferred out of the LICU; others may stay in longer. If you have any questions, be sure to ask your child’s caregivers.

Your child will also monitored closely with routine studies and tests, such as:

• An ultrasound, performed either the day of or the day after surgery, to check blood flow in and out of the liver.
• Chest X-rays to assess your child’s lungs.
• Blood tests, done daily throughout the hospital stay, primarily to check for elevated enzyme levels, which can indicate rejection or bile duct problems.

Once your child medically stable and doesn’t require frequent monitoring, she’ll be transferred from the LICU to a transplant floor, where nurses will continue to care for her and assess her recovery.

When your child transferred to a room, the atmosphere more relaxed, because now the patients no longer need the continuous monitoring that they needed in the LICU. However, your child’s physicians and nurses will continue to monitor his vital signs and progress — and you, too, can play a role in helping your child’s recovery go smoothly. You can help your child with:

Explanation

• Walking, which helps build strength, stimulates the gastrointestinal system and encourages bowel movements. Take your child for walks around the room and hallway; you’ll notice he becomes more active with each passing day.
• Coughing and deep breathing exercises, which helps prevent fluid buildup in the lungs. The nurse will help your child with these exercises and may teach him to use an incentive spirometer, a plastic container that helps him take deeper breaths.
• Eating, which provides the calories your child needs to heal and grow following surgery. When your child allowed to eat, he will make a gradual transition from clear liquids to solid foods. It’s important that your child eat well-balanced meals, so a nutritionist will meet with you to help you develop a good diet plan. If he can’t eat enough to get adequate nutrition, your child may receive nutritional supplements through a nasogastric tube or an IV.
• Relaxation and play, which is an important part of your child’s physical and emotional recovery. The nurse specialist will help your child find toys and games to play with during the recovery period.