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Transplantation

The first liver transplant operation was performed in March, 1963 in Denver, Colorado by Dr Tom Starzl. Throughout the 1960's and 1970's, liver transplantation was performed in only a handful of centres worldwide and the results were very disappointing.

In 1982 there was a big breakthrough with the advent of Cyclosporin, a powerful immunosuppressant drug which was able to suppress the body's rejection of the new liver graft. Following the release of Cyclosporin there was a very marked improvement in success rates of liver transplantation and an enormous surge in the number of centres around the world performing this type of surgery. Further developments in immunosuppression include the introduction of Tacrolimus and Mycophenolate with additional drugs in the research and development phase.

It is anticipated that 45-50 adults and 2-4 children will require liver transplantation annually in Ireland although this may increase further as more forms of liver disease are added to the list of indications for liver transplantation. Currently the major influencing factor is the number of patients who have contracted Hepatitis C either from blood products or blood transfusions. It is estimated that 20 - 30% of these patients will require liver transplantation in the future.

Liver transplantation is usually performed for end-stage chronic liver disease when all other treatment options have failed.

The primary indications for liver transplantation at St. Vincent's University Hospital are:

·         Alcohol Related Liver Disease (ALD)

·         Auto Immune Chronic Active Hepatitis (AICAH) which affects, predominantly females either between the ages of 15 - 25 or between the ages of 45 and 55

·         Primary Biliary Cirrhosis (PBC)

·         Primary Sclerosing Cholangits (PSC) which mainly affects men

·         Viral hepatitis

However, acute liver failure and various congenital forms of liver disease are also becoming common indications for liver transplantation.

Contraindications
Contraindications to liver transplantation can be divided into those that are absolute and those that are relative. Absolute contraindications are conditions in which the outcomes of liver transplantation are so poor that it should not be offered. Relative contraindications are conditions that have a negative impact on survival, but not to the extent that they should be categorically withheld.
Absolute contraindications to liver transplantation include:
·         AIDS
·         Irreversible brain damage
·         Multi-system failure that is not correctable by liver transplantation
·         Malignancy outside the liver (not skin cancer)
·         Infection outside the hepatobiliary system
·         Active alcohol or substance abuse
·         Advanced cardiopulmonary or other systemic disease
Factors that increase the risk of liver transplantation include the following:
·         Advanced age
·         Advanced chronic renal failure
·         Cholangiocarcinoma
·         Hepatocellular carcinoma
·         Hypoxemia from intrapulmonary shunts
·         Massive ascites
·         Portal vein thrombosis
·         Severe malnutrition
Liver Transplantation
Liver Transplantation is a five phase process:
1.    Assessment
2.    Waiting
3.    The Operation
4.    Recovery in hospital
5.    Long term recovery and follow-up
1. Assessment for liver transplant
Assessment for liver transplant may be carried out as an in-patient or on an out-patient basis whichever is most suitable for the individual patient. An in-patient assessment requires a hospital stay of approximately one week during which you will meet the members of the transplant team, have a large number of tests carried out and receive information on the transplant process. This assessment may be carried out at St. Vincent's University Hospital, St. Vincent's Private Hospital or in St. Michael's Hospital, Dun Laoghaire, all members of the St. Vincent's Healthcare Group.
Alternatively some patients may be assessed on an out-patient basis. This requires several visits to the hospital to complete all of the investigations and to meet with the members of the transplant team. This assessment will be arranged by the transplant co-ordinators.
Once the assessment has been completed, and the results of the tests and investigations are available, the multi-disciplinary team will review the results and plan your care. If liver transplantation is part of this plan, a meeting will be arranged for you and your family/support person with the transplant co-ordinators to discuss all aspects of the transplant process including the risks and benefits of liver transplantation. This session will take about an hour to an hour and a half. To get the most benefit from this session you and your family members should have read the information booklet and written down any questions you may have. This meeting will provide you with the information required to sign the consent form for the liver transplant surgery and anaesthetic.
2. Waiting list
In general, patients are on the waiting list for 6-12 months depending on their blood group and the severity of their liver disease. Donor livers are matched with the recipient by blood group and size. During this time you will be reviewed regularly at the liver transplant clinic where bloods and swabs will be done at each visit as well as a consultation with the transplant team. A co-ordinator is available at each clinic for any queries or concerns you may have.
3. The Operation
Details of the anaesthetic and surgery will be provided during the information session.
4. Recovery in hospital
During your hospital stay the co-ordinators and other team members will meet with you and your family to keep you up to date with your progress and to plan your discharge from hospital. For some people this may include convalescence and rehabilitation. A further information booklet will be provided at this time to prepare for going home and a short information session will be held with your family prior to your discharge from hospital to address any areas of concern.
All information relating to your transplant medications will also be provided. The pharmacist and nursing staff on the ward will facilitate an education programme, relating to your medications.
5. Long term recovery and follow-up
On discharge from hospital, recipients require weekly bloods and are seen regularly at the transplant clinic for the initial few months. Gradually, the interval between these visits is increased and recipients who are two years from their transplant with no major complications are generally seen every six months.
A booklet will be sent to your G.P. with information pertaining to your transplant and the monitoring required afterwards.