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Liver transplantation

Liver transplantation is the replacement of a diseased liver with a new, healthy one. This is a treatment option for patients with end-stage chronic liver disease that cannot be treated with any other method and restores adequate function of the liver to meet the body’s needs. Liver transplantation also improves quality of life and extends lifespan.

Source of Donor Liver
  • Deceased donor liver transplant involves using a liver from a deceased donor registered with the Organ Donation Center of the Thai Red Cross. The donor would have been declared “brain dead” by a team of doctors.
  • Living donor transplant involves removing a part of a living person’s liver and transplanting it in the patient with the diseased liver. This portion of the liver will then grow until it reaches a normal size after approximately two months. Donors must be immediate family members, such as parents, children, siblings, or a spouse.
The procedure is used to treat end-stage liver disease. After successful liver transplantation the patient will have improved quality of life and can lead a normal life.
 
If the patient and their family have decided on treatment with liver transplantation, the patient will be registered on the waiting list of the Organ Donation Center of the Thai Red Cross, with the following procedure:
  1. The patient will be assessed for physical and mental readiness before the transplant.
  2. While waiting for the transplant the patient must be prepared for the procedure by regularly seeing a hepatologist and a liver transplant surgeon.
While waiting for a donated liver or when you have a procedure date, please do the following:
  1. Fast for at least eight hours before the procedure and carefully follow the pre-operative instructions given to you by the Organ Transplant Clinical Nurse Coordinator.
  2. Wait for the results of your blood test or human leukocyte antigen (HLA) tissue typing from the Organ Transplant Clinical Nurse Coordinator.
  3. Please let your doctor or the Organ Transplant Clinical Nurse Coordinator know if you are not ready to accept the organ, such as if you are unable to travel to the hospital for appointments/procedures, if you are sick, or if you have other personal reasons. Your medical team can give you the appropriate advice.
  4. Please don’t travel once you receive news that an organ is available. Please stay close to the hospital so you can quickly get to the hospital for the procedure as soon as you are asked.
  5. When you are informed that an organ is allocated, please get to the hospital as soon as possible.
  6. The doctor will remove your liver and place the donated liver in your body. In most cases, the new liver can function immediately and level of liver function test will return to normal quickly
  7. The patient and their family will receive care information from the organ transplant team.
  8. In the case that the patient chooses to use a living donor, the donor will have to be assessed for physical and mental readiness in the same way that the patient was.

Caring for your Incision

  • Check the incision daily for signs of infection, such as swelling, redness, tightness, warmth to the touch, and leaking/seeping of discharge/fluid.
  • Do not remove the bandage placed on the incision. The bandage will fall off on its own and does not need to be replaced when it does.
Important Information about Medication
  • Take your medication at the same time every day.
  • Do not adjust dosage or stop your medication on your own, even if you are feeling better.
  • If you do forget to take the medication within 6 hours (if you are on a 12-hour medication regimen), take the medication as soon as you remember. Then take the next dose at the usual time. Do not double dosage.
  • If you unintentionally take too much of a medication or skip a dose, please inform your doctor immediately.
  • Do not take expired medication.
  • Inform the doctor immediately of any new side effects from the medication or any abnormal symptoms that occur from taking the medication.
  • Do not buy the medication from a drugstore yourself without your doctor’s prescription.
  • Store the medication in a cool, dry place away from sunlight. Keep away from children.
  • Do not store the medication in the refrigerator unless specified by the doctor or pharmacist.
  • Be ensured that you have enough medication to get through the holidays.
  • When the doctor increases the medication dosage, please check first if there is enough medication as immunosuppressive drugs are not available in some places.
Activity and Exercise
  • Avoid lifting or pulling objects heavier than two kilograms and avoid strenuous activity for six weeks after the operation.
  • Slowly increase your activity level over the first three months after the operation until you are able to do as much as you did before the transplant.
  • You may drive and use the seat belt normally when pain at the incision recedes.
  • You can resume your exercise 6 weeks after the transplant, but avoid heavy exercise.
  • Avoid contact sports or sports that require close contact with a large number of people.
  • Avoid pressing down on the incision.
  • Avoid the risk of infection, such as a cold, by staying away from large groups of people and avoiding those that are coughing, sneezing, or sick. If necessary wear a mask over your mouth and nose to prevent infection.
Diet
  • Eat clean, freshly cooked food. Avoid pickled food and limit food according to your condition or as recommended by your doctor.
  • Avoid raw vegetables for the first 3 months after transplant. Eat fruits that can be peeled.
  • Eat a low-fat and low-sugar diet to control your weight and blood sugar.
  • Limit salty foods.
  • Wash your hands before eating or cooking a meal.
Environment
  • Spend time in areas that are ventilated well and dry (not humid).
  • Clean your fans or air-conditioner filters regularly.
Inform your Transplant Team Immediately if:
  • You have a chronic cough or have difficulty breathing or catching your breath.
  • You are at risk catching measles, chickenpox or other infectious diseases.
  • You are vomiting and unable to take your medicine.
  • You have diarrhea.
  • You are admitted into other hospitals for treatment.
  • You have any other problems or questions.
General Guidelines
  • Do not drink alcohol.
  • Do not smoke.
  • Take care of your general health including your dental health. Visit a dentist every six months.
  • Use sunblock with SPF50 or higher when exposed to direct sunlight.
  • Avoid contact with animals. If necessary, wear a mask when in contact with animals. Keep your pets clean. Always wash your hands after touching animals.
  • No plants in your house or bedroom to avoid contamination with soil microorganism. Wear a mask and gloves when planting.
  • Practice safe sex and consult your doctor when you plan to conceive.
  • Talk to your doctor before getting any vaccination.
Follow-Up Visits
  • Have a comprehensive health check-up every year.
  • Female transplant patients should undergo an internal (pelvic) exam and breast exam every year.
  • Male transplant patients should undergo a prostate examination or have their hormones tested.
  • Have a dental check-up every six months and inform the dentist that you are taking immunosuppressive drugs.
  • Have an eye test every year to check for diabetes and any changes in vision.

Doctor Visits

Bring cyclosporine (Neoral®), tacrolimus (Prograf®), sirolimus (Rapamune®) or myclophenolate mofetil (Cellcept®) with you on every visit at the Outpatient Department of Bumrungrad Hospital. Before you see your doctor you will need to undergo blood tests to assess the function of the kidneys and others. The level of immunosuppressant medication must be measured before you take medication.

After liver transplantation the patient may resume their normal life. They may exercise and play sports, and have normal sexual relations. Women can conceive. Liver transplantation extends the lifespan of a patient with end-stage liver disease and improves their quality of life so it matches that of the general public. However, the patient must take immunosuppressive medication their entire life and will be more prone to infection when compared with others. There is also still the chance of liver rejection, even with medication. Thus the patient should continue to be monitored by their doctor, undergo regular liver function tests, and have their immunosuppressive medication adjusted to appropriate by their doctor to prevent rejection of the new liver and side effects of the medication or risk of infection.

After liver transplantation, the patient will gain better health, be able to perform daily activities as close to normal and take care of him/herself. He/she will have better mental health and better sexual ability. However, there are possible risks as follows:
Physical
  • Complications of general anesthesia including nausea, vomiting, dizziness.
  • Post-procedure hemorrhage may cause lower blood pressure which blood transfusion may be needed.
  • Changes to the heart and cardiovascular system, such as heart failure, arrhythmia, and high blood pressure.
  • Injury to abdominal organs, fluid accumulation, and fibrosis inside the abdominal cavity.
  • Digestive problems, such as constipation or bloating.
  • Pain or uncomfortable at the surgical site which may progress to chronic pain.
  • Graft failure
Normally, a new liver should function immediately after transplantation. Sometimes, the new liver does not start to work right away because there is no blood flow to the liver. This may occur immediately or slowly. The signs are jaundice (yellow skin and eyes), ascites, and changes in consciousness. The doctor will give medications to reduce the symptoms, but the patient may undergo liver retransplantation.
  • Liver rejection
Normally a transplant patient will begin taking anti-rejection medication before the surgery, while in surgery, and after the procedure, and thus an acute rejection of the transplanted liver is rare. It is very important that a transplant patient takes their immunosuppressive medication regularly and continuously as instructed by their doctor to prevent acute rejection. Chronic rejection is a slow rejection of the transplanted liver and may occur due to a number of factors. Unfortunately, it cannot be completely prevented, but the risk of rejection can be controlled by managing any existing conditions. The patient must continuously take immunosuppressive medication as prescribed by their doctor.
  • Infection
After the liver transplant the patient’s immunity will be compromised, making them prone to infections, such as pneumonia, or other opportunistic viruses like cytomegalovirus (CMV), herpes virus, Epstein-Barr virus (EBV), fungus, parasites, and tuberculosis. Patients may have to take medication to prevent infection for a while after surgery, depending on the decision of their doctor.
  • Bile leakage
This is the most common complication found in 5-15% of patients with liver transplantation. Bile leakage can be healed by an endoscope with a plastic tube to release the bile in order to reduce the pressure or using a soft tube to transfer the bile to other areas to let the wound heal.
  • Biliary atresia (a blockage of the bile ducts)
This is rare and can be treated by using endoscopic biliary stenting to dilate the blocked part of the bile duct.
  • Other complications after long-term liver transplantation such as diabetes, hypertension, hyperlipidemia, and cancer mostly occur due to the effects of immunosuppressive medications used.
Mental
The quality of life of a patient who has suffered with end-stage chronic liver disease will dramatically improve after the transplant, but some patients may suffer emotional complications, such as depression and agitation. Furthermore, some patients are at risk for not strictly following the post-transplant regimen of immunosuppressive drugs, perhaps even causing them to lose the donor liver.
 
  • Travelers to Thailand should stay in the country for at least four to six weeks after the procedure.
  • If you plan to travel after the procedure, please talk to your doctor before making reservations or buying tickets.
  • At your follow-up appointment your medical team will assess your health and wound and you will receive documents that include your medical and treatment history as well as a “fit to fly” certificate (if needed).
  • The success rate of liver transplantation at Bumrungrad Hospital is comparable to that in the United States, Canada, and Western Europe. Statistical data of Bumrungrad Hospital in the past 10 years showed the one-year survival rate of liver transplant patients is 97%, the five-year survival rate is 82%, and the ten-year survival rate is 67%.
  • The success and survival rates of patients depend on a number of factors, including:
    • The age, health, and condition of both the donor and recipient.
    • The health of the donor liver.
    • Rejection of the donor liver.
    • Other post-surgical complications.
    • Side effects of the medications prescribed.
    • How the recipient takes care of themselves.
 
What if the procedure is not performed?
The liver is the largest organ in the body and is located in the abdomen, under the right ribs, extending under the xiphoid process towards the left ribs. The liver’s functions are important and cannot be replaced by any other organs. No matter the liver disease is caused by hepatitis, fatty liver, cancer, or cirrhosis, when the disease reaches the end-stage, if the patient does not receive liver transplantation he/she will have a shorter life span.
 
Liver transplantation is the best treatment option, with the objective of extending the patient’s life and improving quality of life. The procedure has been carried out regularly in Thailand, with the outcomes as successful as those overseas. Other treatments can only stop the damage from progressing or slow it down, which includes:
  • Avoiding alcohol and over-the-counter medications.
  • Palliative care to alleviate symptoms, such as using diuretics to relieve swelling.
  • Treatment of side effects of liver failure when liver function is very low.

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