Liver transplantation the most important cases requiring the procedure and the treatment method

The liver is one of the most important organs in the body, with vital functions essential for life. It is responsible for filtering the blood, producing essential proteins, and storing energy. However, certain diseases and medical conditions can lead to complete liver failure, making liver transplantation the only option to save a life. In this Dalily Medical article, we will explore the main conditions that require a liver transplant, explaining each case in a simple and clear way, along with tips for patients before and after the procedure to ensure the best possible outcomes.

How long does a patient live after a liver transplant?
Life expectancy after a liver transplant varies depending on the patient’s overall health, the cause of liver failure, and adherence to post-operative medications. Statistics indicate that approximately 75% of patients live at least five years after transplantation. Many patients live 20 years or more if they follow their doctor’s instructions carefully.

Is liver transplantation difficult?
Liver transplantation is a major and complex surgery that requires a highly skilled surgical team. The operation typically lasts 6 to 12 hours. However, modern techniques and intensive post-operative care reduce risks and increase the chances of success. Most patients recover well when they adhere to medical guidance and are patient during the recovery period.

Does the liver donor die?
No, the donor does not die. The surgery involves removing only a portion of the liver, which usually regenerates fully within a few months. Choosing an experienced surgeon is essential to minimize risks and ensure a successful outcome.

How long is the isolation period after liver transplantation?
After transplantation, patients need strict isolation and protection because immunosuppressive medications weaken the immune system:

The patient usually stays in the ICU for a few days for close monitoring.
Hospitalization typically lasts 1–2 weeks.
Full recovery may take about 6 months or more, during which:
- Crowded places should be avoided.
- Sick individuals should be kept at a distance.
- Strict personal hygiene must be maintained.

When is sexual activity allowed after a liver transplant?
Patients are advised to avoid sexual activity for a period to allow the body to heal. The appropriate time to resume is determined by the treating physician and is usually several weeks to a few months after surgery.

When does the patient wake up after liver transplantation?
Awakening after a liver transplant is a critical stage for monitoring bodily functions. Typically, it takes 24 to 48 hours for the patient to wake up. Upon awakening, the patient may experience:

Severe fatigue and general weakness.
The need for breathing exercises to improve lung function.

The medical team monitors blood pressure, fluid balance, and oxygen levels, while carefully managing pain.

How long does the liver transplant surgery take?
The procedure usually takes 8 to 12 hours and may take longer in complex cases. After surgery, the patient is awakened as soon as possible for close monitoring. Hospital stay is generally 1–2 weeks until the patient regains basic strength and begins recovery.

What happens to the donor after liver transplantation?
In living donor cases:

A portion of the liver is removed and transplanted into the recipient.
The liver has a unique ability to regenerate, so both donor and recipient typically have a fully functional liver within 6–8 weeks.
Hospital stay: 5–7 days.
Full functional recovery: 4–6 weeks.
Donors are monitored for pain, liver function, and overall health.
After recovery, the donor can return to normal daily activities.
Generally, donation is safe for healthy individuals, with a low risk of long-term complications.

Is pregnancy possible after liver transplantation?
In most cases, pregnancy is possible about one year after transplantation, provided:

Liver function is stable.
Immunosuppressive medications are properly managed.
Pregnancy is closely monitored by a specialist, and some medication doses may need adjustment.

When does a patient need a liver transplant?
A liver transplant is not the first-line treatment for liver problems but becomes necessary when the liver fails to perform its essential functions. The main causes include:

Chronic Liver Failure
Occurs gradually over years due to persistent liver disease, where medications or other interventions are insufficient. Key causes:

Cirrhosis: from hepatitis B or C, or alcohol.
Autoimmune diseases: such as primary biliary cholangitis.
Metabolic disorders: like Wilson’s disease or alpha-1 antitrypsin deficiency.

Indications for transplant:

Severe cirrhosis with complications such as ascites, esophageal variceal bleeding, or hepatic encephalopathy.
Significant liver dysfunction unresponsive to treatment.

Acute Liver Failure
Occurs suddenly, often due to:

Drug toxicity, e.g., acetaminophen overdose.
Severe viral infections.
Exposure to toxins.

Indications for transplant:

Rapid loss of liver function in detoxifying blood or producing essential proteins.
Development of severe hepatic encephalopathy or coagulopathy.

Liver Cancer at a Certain Stage
Some cases of hepatocellular carcinoma may require transplantation if the tumor is limited and suitable for transplant criteria, especially if traditional surgery is not possible.
Other Rare Conditions

Congenital liver diseases in children, such as biliary atresia or metabolic disorders.
Rare diseases causing ongoing liver failure despite treatment.

Steps of Liver Transplant Surgery

Preoperative Preparation

Comprehensive medical evaluation.
Fasting for 6–8 hours before surgery.
Preoperative medications as needed to prevent infection or control coagulation.
General anesthesia.

Surgical Incision and Abdominal Access

A long incision is made, usually from the upper to lower abdomen, sometimes Y-shaped.
The diseased liver is carefully separated from surrounding organs.
Major blood vessels are controlled to ensure safety.

Removal of Diseased Liver

After isolating blood vessels and bile ducts, the diseased liver is removed.
The area is cleaned to remove blood or residual tissue.

Preparation of the Donor Liver

From a living donor: a portion (right or left lobe) is used.
From a deceased donor: the entire liver is prepared and connected directly.

Connection of Blood Vessels

Hepatic artery, portal vein, and hepatic veins are carefully attached.
Ensures no bleeding or vessel obstruction.

Connection of Bile Ducts

The donor bile duct is connected to the patient’s duct or intestine.
Precise connection prevents leaks or obstruction.

Verification of Liver Function

Checks liver color, blood flow, and bile production.

Closure of the Abdomen

Drains may be placed if needed.
The incision is closed layer by layer.
Patient is transferred to ICU for monitoring.

Immediate Postoperative Care

Vital signs and liver/kidney functions are closely monitored.
Immunosuppressive medications are administered to prevent rejection.
Any bleeding or infection is managed promptly.

Types of Liver Transplantation

Deceased Donor Liver Transplantation

Donor: brain-dead individual whose family consents.
Advantages: full-size liver, simpler procedure.
Disadvantages: long waiting times, difficult emergency intervention if no suitable liver is available.

Living Donor Liver Transplantation

Donor: a compatible relative or person donating a portion of their liver.
Advantages: shorter waiting time, planned procedure.
Disadvantages: surgical risks to donor (bleeding, infection, partial liver failure), requires highly skilled surgeons.
Types: right lobe (usually for adults), left lobe (for children or small adults).

Partial Liver Transplantation

From living or deceased donor.
Advantages: transplanted portion can grow in the recipient, suitable for children or small adults.
Disadvantages: more complex surgery, higher risk of vascular or bile duct complications.

Pediatric Liver Transplantation

Usually a lobe from a living adult or full liver from a deceased donor.
Advantages: matches child’s body size, liver grows with child.
Disadvantages: complex due to small blood vessels and bile ducts.

Auxiliary Liver Transplantation

A portion of liver is transplanted alongside the existing liver.
Advantages: original liver may recover if failure is temporary, reduces risk of permanent liver loss.
Disadvantages: complex surgery, higher risk of rejection.

Eligibility Criteria for Liver Transplantation

Medical Criteria for the Patient

Degree of Liver Failure: advanced chronic or acute liver failure, assessed using MELD (adults) or PELD (children).
Other Organ Health: heart, lungs, and kidneys must tolerate surgery.
Infections and Chronic Disease Control: active infections must be managed, chronic conditions (diabetes, hypertension) must be under control.

Tumors

Widespread cancer outside the liver usually prevents transplantation.
Localized liver cancer may be acceptable depending on tumor size and the number of nodules, following Milan criteria.

2. Psychological and Social Requirements

The patient must be able to strictly adhere to medications and follow-ups after transplantation.
Family support is essential for continuous care after surgery.
Patients with alcohol or drug addiction must be recovered and psychologically stable before being eligible for transplantation.

Contraindications for Liver Transplantation

1. Permanent Medical Contraindications
These conditions permanently prevent transplantation as they may cause transplant failure or endanger the patient’s life:

a. Severe diseases of other organs

Severe heart disease, such as congestive heart failure or untreated valve problems.
Advanced or acute lung disease.
Untreatable or dialysis-dependent kidney disease.

b. Active cancers outside the liver

Presence of metastatic cancer reduces the chance of a successful transplant.

c. Severe or uncontrolled infections

Chronic or untreated infections may spread after taking immunosuppressive medications.

d. Poor psychological state or non-compliance

Patients unable to adhere to medications and follow-ups.
Severe psychiatric issues or untreated addiction (alcohol or drugs).

2. Temporary Contraindications
These conditions may be resolved, after which the patient becomes eligible:

Active infections, e.g., pneumonia or bloodstream infections.
Severe malnutrition or cachexia, requiring nutritional improvement before surgery.
Temporarily treatable liver issues, such as bile duct obstruction or esophageal variceal bleeding.

Eligibility Criteria for Liver Donors

1. General Health

Good overall health without serious chronic diseases (heart, lungs, liver, kidneys).
Normal liver function: liver enzymes normal, no cirrhosis or bile duct problems.
Controlled or absent blood pressure and diabetes.
No infectious diseases such as HIV or chronic hepatitis B or C.

2. Age and Weight

Ideal age: typically 18–55 years, depending on recovery ability.
Liver size must be sufficient for recipient needs, while donor can safely recover from partial liver removal.

3. Blood Type and Compatibility

Compatible blood type to ensure transplant success and prevent rejection.
Immune compatibility testing to improve acceptance of the transplanted liver.

4. Psychological and Social Status

Strong psychological readiness for high-risk surgery and long recovery.
Family and social support during recovery.
No addiction to alcohol or drugs.

5. Pre-Donation Medical Tests

Complete blood work: liver and kidney function, infections, blood type.
Imaging: CT or MRI to assess liver size and vascular anatomy.
Cardiac and pulmonary evaluation for anesthesia tolerance.
Psychological evaluation for adherence and coping ability post-surgery.

6. Additional Criteria

No severe obesity or malnutrition.
Liver free of tumors or cirrhosis.
Ability to return to normal life after recovery.

Alternatives to Liver Transplantation

1. Intensive Medical Therapy

Used for chronic liver diseases before complete failure.
Examples:
- Anti-inflammatory drugs for chronic hepatitis B or C.
- Immunosuppressive drugs for autoimmune liver diseases.
- Medications to reduce fat or toxins in fatty liver or metabolic disorders.
Limitations: effective only in early or moderate stages; ineffective in advanced cirrhosis or severe failure.

2. Interventional or Non-Transplant Surgery

Bile duct dilation or stone removal to temporarily improve liver function.
Treatment of esophageal or gastric varices to reduce bleeding.
Localized liver tumor removal or ablation.
Serves as temporary or bridging therapy.

3. Temporary Liver Support (Bridge Therapy)

Maintains patient life until a suitable liver is available.
Examples: plasmapheresis, MARS therapy, intensive nutritional support.
Temporary, not a definitive treatment.

4. Hepatocyte Transplantation

Transplanting healthy liver cells to improve function.
Advantages: less invasive, avoids major surgery.
Limitations: effective for some metabolic disorders or partial liver failure, usually temporary, often followed by full liver transplant.

5. Artificial Liver Support Devices

External devices perform temporary liver functions, detoxifying blood.
Advantages: buy time for recovery or waiting for transplant.
Limitations: do not treat the underlying cause, limited availability.

Preoperative Tests Before Liver Transplant

1. Basic Blood Tests

Liver function: ALT, AST, bilirubin, total protein & albumin, INR.
Kidney function: creatinine, urea.
Complete blood count.
Blood type for donor compatibility.
Infection screening: Hepatitis B & C, HIV, CMV, EBV, bile duct infections.

2. Imaging Tests

CT scan: liver size, vessels, surrounding organs.
MRI/MRCP: bile duct evaluation.
Echocardiogram & chest X-ray: heart and lung health.

3. Cardiac & Pulmonary Evaluation

ECG for heart rhythm.
Stress tests for patients over 40 or with cardiac issues.
Pulmonary function tests for chronic respiratory problems.

4. Nutritional and General Assessment

Height, weight, BMI.
Vitamin and mineral deficiencies assessment.

5. Psychological and Social Assessment

Ability to adhere to medications and follow-ups.
Family/social support during recovery.
Screening for psychiatric disorders or addiction.

6. Additional Tests (as needed)

Pediatric tests: growth, muscle function.
Cancer-specific tests: tumor staging and transplant eligibility.

Risks and Complications of Liver Transplant

1. Immediate Surgical Complications

Severe bleeding due to major vessels.
Infection at incision or inside abdomen.
Anesthesia complications (low blood pressure, heart/lung problems).
Blood clots in legs or lungs.

2. Rejection of Transplanted Liver

Body may recognize the new liver as foreign.
Signs: elevated liver enzymes, jaundice, itching, severe fatigue.
Types: acute (days–weeks), chronic (months–years).

3. Immunosuppressive Medication Complications

Increased infection risk.
Kidney problems.
High blood pressure, blood sugar, cholesterol issues.
Slightly higher risk of certain cancers long-term.

4. Bile Duct and Vascular Problems

Blockage or narrowing of vessels supplying the liver may cause partial failure or require surgery.
Bile leaks or infections cause pain, fever, or jaundice.

5. Psychological and Social Effects

Depression or anxiety adjusting to life post-transplant.
Fear of rejection or medication complications.
Lifestyle changes: strict medication, follow-ups, diet adherence.

6. Long-Term Complications

Recurring infections due to weakened immunity.
Kidney and heart problems from long-term medications.
Bone or joint issues occasionally.

Essential Tips for Living After a Liver Transplant

1. Strict Medication Adherence

Immunosuppressants are critical to prevent rejection.
Take medications exactly on time, never stop without consulting your doctor.
Report any side effects like swelling, high blood pressure, or kidney issues immediately.

2. Regular Follow-Up and Tests

Frequent doctor visits for liver, kidney, and heart monitoring.
Routine blood tests: liver enzymes, bilirubin, infection markers, kidney function.
Imaging of liver and vessels as advised.

3. Proper Nutrition