Recently, a drug that specifically eliminates B cells, the cells infected by EBV, has become available. Today, a common approach is therefore to give this drug, rituximab, in conjunction with less drastic cuts of the immunosuppression drugs. If this approach does not control PTLD, then more conventional chemotherapy drug regimens typically given to treat lymphomas that develop in non-immunosuppressed patients, are used. The majority of PTLD cases can be successfully treated with preservation of the transplanted organ.
Skin cancers are the most common malignancy in the post-transplant population. In light of this substantial risk, it is strongly recommended that all transplant recipients minimize sun exposure. Moreover, all transplant recipients should be regularly examined to ensure early diagnosis and expeditious treatment of any skin cancer. There is some evidence to suggest that sirolimus, an immunosuppressant in the class of mTOR inhibitors see Immunosuppression section does not increase risk of skin cancers.
Therefore, transplant recipients who develop multiple skin cancers can be considered for a switch to a sirolimus-based, calcineurin-inhibitor free immunosuppression regimen. Currently, there is no data to indicate that liver transplant recipients are at increased risk to develop other common cancers such as breast, colon, prostate, or other cancers.
Overall, outcomes for liver transplantation are very good, but vary significantly depending on the indication for liver transplant as well as factors associated with the donor. As mentioned above, these results vary significantly based on the indication for liver transplantation. The encouraging trend is that over the past 20 years short and long term patient survival has continued to improve.
With advances in surgical technique, organ preservation, peri-operative care, and immunosuppression, survival will hopefully continue to improve in the future. This discussion of liver transplantation was written by transplant surgeons Kayvan Roayaie, M. Office Hours Mon - Fri: am — pm. Liver Transplant A liver transplant is an operation that replaces a patient's diseased liver with a whole or partial healthy liver from another person.
Liver Anatomy and Function The liver is a vital organ, meaning that one cannot live without it. Back to top Who Needs a Liver transplant?
Acute Liver Failure Acute liver failure, also known as fulminant hepatic failure , occurs when a previously healthy liver suffers massive injury resulting in clinical signs and symptoms of liver insufficiency. Chronic liver failure The liver has a remarkable ability to repair itself in response to injury. Back to top Signs and Symptoms of Decompensated Liver Disease Gastrointestinal bleeding: As the liver becomes increasingly scarred, the resistance to portal blood flow increases leading to increased pressure in the portal venous system.
This portal hypertension necessitates alternative routes for blood to return to the heart. Small veins throughout the abdomen, but outside of the liver, then become enlarged and thin-walled due to the abnormally high amount of blood flowing through them under increased pressure.
These fragile veins, called varices, often line portions of the gastrointestinal tract, especially the esophagus and the stomach, and are prone to rupture and bleeding. When bleeding occurs into the intestinal tract, it can be life-threatening. Fluid retention : One function of the liver is to synthesize many of the proteins circulating in the bloodstream, including albumin. Albumin and other proteins in the blood stream retain fluid in the vascular space by exerting what is known as an oncotic or osmotic pressure.
In liver failure, low albumin levels force fluid out of the bloodstream, which cannot be re-absorbed. Fluid therefore accumulates in tissues and body cavities, most commonly, in the abdominal cavity, which is termed "ascites. Fluid retention is treated first by strict limitation of dietary salt intake, second with medications diuretics that force increased salt and water loss through the kidneys and, lastly, by intermittent drainage through insertion of a needle into the abdominal or chest cavity.
Encephalopathy : Failure of the liver to clear ammonia and other toxins from the blood allows these substances to accumulate. These toxins result in cognitive dysfunction that ranges from disturbed sleep-wake cycle patterns to mild confusion to coma. Jaundice : One of the main functions of the liver is to eliminate the degradation products of hemoglobin, the molecule that carries oxygen in our blood. Bilirubin is one of those degradation products processed and excreted by the liver.
In liver failure, bilirubin is not cleared from the body and bilirubin levels increase in the blood. The skin and all tissues of the body will then assume a yellow color. Alcoholic Liver Disease Liver failure due to alcohol abuse is the second most common indication for liver transplantation in the United States. Metabolic Liver Disease Non-alcoholic steatohepatitis NASH : Deposition of fat within liver cells may result in inflammation that injures and scars the liver.
Seventy percent of patients with PSC also suffer from ulcerative colitis, an autoimmune disorder of the colon. Neonatal sclerosing cholangitis infection and scarring of the bile ducts in the liver of an infant Biliary atresia absence of bile ducts outside the liver Caroli's disease abnormality of the bile ducts within the liver TPN-induced cholestasis.
Patients who receive intravenous nutrition, termed total parenteral nutrition TPN sometimes develop bile stasis slowing or stopping of normal bile flow that can, over time, lead to liver injury and failure.
Genetic Liver Disease Hemachromatosis: excess iron deposition in the liver Wilson's disease: abnormal copper metabolism Alpha-1 anti-trypsin deficiency: lack of a gene product that limits the activity of trypsin, an enzyme that digests protein. Over time this leads to progressive destruction of the liver and lung. Glycogen storage disease type I, III, IV : an inherited metabolic disorder Tyrosinemia: a disorder of tyrosine metabolism Vascular Liver Disease Budd-Chiari syndrome is thrombosis clotting of the hepatic veins which leads to poor blood flow though the liver.
Hepatocellular Carcinoma Hepatocellular carcinoma HCC is a primary cancer of the liver, meaning that it originates from abnormal liver cells. Back to top Who Are Not Candidates for a Liver Transplant There are many people with cirrhosis and decompensated liver disease but not all are appropriate candidates for liver transplantation. The MELD score is determined by the results of three objective and readily available laboratory tests: Total bilirubin, a measure of jaundice Prothrombin time, a measure of clotting ability Creatinine, a measure of kidney function.
Inputting these three numbers into the following formula yields the actual numerical score. Geography and DSAs Another complicating factor in liver allocation policy is geography.
Back to top Types of Organ Donors Brain dead organ donors Most livers used for transplantation are obtained from patients that are brain dead. Cardiac death organ donors Sometimes a patient suffers a devastating brain injury and carries a dismal neurological prognosis but fails to meet the strict criteria defining brain death in that there is still detectible brain function. Living Donors Although each person has only one liver and would die without it, it is possible to donate a portion of the liver for transplantation into another individual.
The liver is divided into eight 8 segments reflecting the eight 8 major divisions of the portal vein and the bile duct. For someone undergoing liver transplantation, the sequence of events in the operating room is as follows: Incision Evaluation of the abdomen for abnormalities that would preclude liver transplantation for example: undiagnosed infection or malignancy Mobilization of the native liver dissection of the liver attachments to the abdominal cavity Isolation of important structures the inferior vena cava above, behind, and below the liver; the portal vein; the common bile duct; the hepatic artery Transection of the above mentioned structures and removal of the native, diseased liver.
Figure 7 Sewing in the new liver: First, venous blood flow is re-established by connecting the donor's and the recipient's inferior vena cava and portal veins. Next, arterial flow is re-established by sewing the donor's and recipient's hepatic arteries.
Finally, biliary drainage is achieved by sewing the donor's and recipient's common bile ducts. Ensuring adequate control of bleeding Closure of the incision Surgical Complications As with any surgical procedure, complications related to the operation may occur, in addition to the many possible complications that may happen to any patient who is hospitalized. The risk is doubled in patients who receive a living donor transplant.
The liver cells themselves typically do not suffer from losing blood flow from the hepatic artery because they are primarily nourished by blood by the portal blood flow. In contrast, the bile ducts depend strongly on the hepatic artery for nutrition and loss of that blood flow may lead to bile duct scarring and infection. If this occurs, then another transplant may be necessary. Portal vein thrombosis or clotting of the large vein that brings blood from the abdominal organs the intestines, the pancreas, and the spleen - the organs that belong to the portal circulation to the liver occurs infrequently.
This complication may or may not require a second liver transplant. Biliary complications: In general, there are two types of biliary problems: leak or stricture. Biliary leak means that bile is leaking out of the bile duct and into the abdominal cavity. Most frequently, this occurs where the donor and recipient bile ducts were sewn together.
This is often treated by placing a stent, or plastic tube, across the connection through the stomach and small intestine and then allowing the connection to heal. In the case of living donor or split liver transplants, bile can also leak from the cut edge of the liver.
Typically, a drain is placed and left during the transplant operation along the cut edge to remove any bile that may leak. As long as the bile does not collect in the abdomen, the patient does not become ill. Leaks will often heal with time, but may require additional treatment procedures. Biliary stricture means narrowing of the bile duct, resulting in relative or complete blockage of the bile flow and possible infection.
Most frequently, the narrowing occurs at a single site, again where the donor and recipient ducts are sewn together. If these methods are unsuccessful, surgery is often done to create a new connection between the liver's bile duct and a segment of intestine. Rarely, biliary strictures occur at multiple or innumerable sites throughout the biliary tree.
This occurs most frequently because the biliary tree was poorly preserved during the period when the liver was not in either the donor or recipient circulation.
Advanced techniques for complex liver transplants UPMC's team of liver transplant experts performs many complex liver transplant operations. Liver Transplant Surgery Risks Although many liver transplants occur with little to no problems, there are some risks including: Bleeding Rejection of the donor liver Infection Biliary complications Primary graft dysfunction when the liver does not function right away These complications can lead to: Longer hospital stays Increased recovery time Even death, in some cases UPMC uses innovative surgical methods and medications to help prevent or quickly respond to any complications from liver transplant surgery.
What to Expect After Liver Transplant? Once stable, you'll move to a patient room on the transplant floor. During this time, your liver transplant care team will: Help you get up and move around. Being too still right after surgery will increase your risk for blood clots. Manage your meals to help you work your way back to eating solid foods. Work with you to create a treatment plan for you to follow when you go home. Before leaving the hospital, your liver transplant care team will review: Eating and nutrition guidelines.
Your medication schedule. Tips for becoming more active and things you can and cannot do. Follow up visit schedule. What happens Having a liver transplant involves 3 main stages: Having an assessment — to find out if you're suitable for a liver transplant, you'll have several tests and will be asked about your health and lifestyle.
Going on the waiting list — if you're suitable for a transplant, you'll need to wait for a healthy donor liver to become available, which could take several months or more. Having the operation — when a liver is available, you'll go into hospital for surgery to remove your damaged liver and replace it with the healthy donor one.
This can be a long and difficult process, both physically and emotionally. This content does not have an Arabic version. Living-donor liver transplant Overview Living-donor liver procedure Open pop-up dialog box Close. Living-donor liver procedure During living-donor liver donation, surgeons remove a portion of the donor liver and place it into the recipient.
Living-donor liver organ regeneration Open pop-up dialog box Close. Living-donor liver organ regeneration Within a couple of months after living-donor liver surgery, the donor's liver typically grows back to its normal size, volume and capacity.
Request an Appointment at Mayo Clinic. Share on: Facebook Twitter. Show references Cotler S. Living donor liver transplantation. Accessed Sept. Liver transplant. American Liver Foundation.
0コメント