Liver transplantation is the second most common form of solid organ transplantation in the US, with over 6,000 procedures performed annually. Hepatitis C (HCV) infection, which is the cause of about 40% of cases of chronic liver disease, accounts for up to 70% of liver transplants.1-3
HCV infection causes inflammation that scars the tissue of the liver. Although the liver has the capacity to regenerate and repair itself to some extent, if inflammation continues without treatment, the damage to the liver can be irreversible. The most common and dangerous complication that occurs with HCV infection is cirrhosis, in which the tissue of the liver is replaced by scar tissue (called fibrosis). As the body tries to repair damaged tissue, nodules or lumps form. Fibrosis and cirrhosis develop, which progressively impairs the liver’s ability to function. In cases of advanced cirrhosis (called end-stage liver disease), where the liver can no longer take care of the functions that are necessary for life, the only curative treatment option is liver transplantation.4
What is liver transplantation?
Liver transplantation involves replacement of a diseased liver that no longer functions normally with all or part of a healthy liver from a donor. Orthotopic transplantation is the most commonly used technique. It involves removal of the diseased liver and replacing the donated organ in the same location as the removed organ (the term orthotopic literally means “correct place” from the Greek words ortho for “correct” or “straight” and topos for “place”).1
How is a liver transplant performed?
A liver transplant is a long and complex operation that can take anywhere from 4 to 18 hours, depending on individual patient requirements and other factors. Usually, a team of surgeons and anesthesiologists, supported by transplant nurses, are required to complete the surgery. Liver transplantation is so complex because it requires disconnecting the diseased liver and reconnecting the donated organ to blood vessels and abdominal and liver tissue. Additionally, for a liver transplant to work, a suitable match must be made between the recipient and a donated liver.2
Most liver transplants, particularly those in adults, involve use of the entire donated liver from a deceased donor. Liver transplants in children may use a portion of an adult liver. Living donor liver transplantation (LDLT) has become more common because of the difficulty of acquiring donated livers. Living donor transplants are a popular option in cases where a parent wishes to donate part of the liver to a child. In a living donor transplant, a portion (about 20%) of the healthy liver is removed from the living donor and placed into the recipient immediately after the diseased organ has been removed.2 Because of the liver’s extraordinary capacity to regenerate, the donor’s liver, and the portion of the liver transplanted into the recipient grows to full size within a few weeks.
How do you become eligible for a liver transplant and how long do you have to wait?
The first step in becoming eligible for a liver transplant is to get a referral from your doctor. After that, a transplant team will evaluate your physical health and other factors to determine your eligibility. If you are eligible, you will be added to the transplant waiting list. People waiting for liver transplants are prioritized based on the severity of their illness, measured by the Model for End-Stage Liver Disease (MELD) score. MELD uses blood tests measuring values for bilirubin, serum creatinine, and prothrombin time to determine survival time. Based on the results of these tests, a MELD score ranging from 6 to 40 is assigned, with higher scores indicating more severe disease and higher priority for a liver transplant.
The time you have to wait for a donated liver will vary from person to person and depend on factors, including blood type, stage of liver disease, overall health, and the availability of a matching donor. There are currently over 16,000 Americans on the national transplant waiting list for liver transplant. Unfortunately, in the US there are many more people who need a liver transplant than there are donated livers. This is especially true for certain regions and locations. This means that a person in such a location faces a greater risk of dying before they can get a liver transplant. One option available to someone in this situation is to move to a transplant center in an area of the country where the waiting list is shorter.
What is organ rejection?
After the transplant is performed, the recipient must receive immunotherapy to prevent rejection of the new organ by the body. In most transplants where an organ recipient receives another person’s organ, the body’s immune system perceives the new organ as something foreign to the body and may mount an immune attack targeted against the new organ. Immunosuppressive drugs (drugs that suppress the immune system) are used to prevent rejection of the new organ. These drugs typically include corticosteroids and a calcineurin inhibitor such as cyclosporin or tacrolimus.2
The signs of organ rejection after liver transplant include lab abnormalities such as abnormal liver function tests, including elevated levels of liver enzymes alanine transaminase (ALT) and aspartate transaminase (AST), bilirubin, and ammonia, increased albumin concentration, increased prothrombin time, and increased blood glucose. Increased white blood cell count may also be a sign of organ rejection. Symptoms of liver rejection include jaundice, a tendency to bruise or bleed, and encephalopathy, or non-specific signs, such as malaise, muscle ache, low-grade fever, anorexia, and graft-site tenderness.2
Risk of rejection after liver transplant is generally lower than for other organs. Rates of survival at 1 year following liver transplant are 90% for people who receive a liver from a living donor and 86% for people who receive a liver from a deceased donor. Rates of survival at 3 years following liver transplant are approximately 80%.2
Who is a candidate for liver transplant?
Liver transplant is a treatment option for a person who has end-stage liver disease, where the liver can no longer carry out normal functions adequately. A person with HCV who has end-stage liver disease is a candidate for liver transplant, if that person does not have other health conditions that preclude the possibility of a successful transplant. Health conditions that are contraindications (this means something that poses a barrier to a treatment) to a transplant include uncontrolled metastatic cancer outside of the liver, an active septic infection (an infection that has entered the blood), and active drug or alcohol abuse. HIV infection was once considered a contraindication for liver transplant, but is no longer considered one. Other conditions or factors that may prevent liver transplantation are serious heart or lung disease and advanced age.2
If I have HCV, will I be infected after a liver transplant?
Most people with HCV who have a liver transplant become infected again after the transplant. Ideally, antiviral treatment to eradicate HCV before transplantation would increase the chances for remaining HCV-free after transplantation. However, antiviral treatment for people with decompensated cirrhosis is difficult, with interferon-based therapy being associated with encephalopathy, infections, and other serious adverse effects, as well as low rates of sustained virology response.1
Learn more about IDSA/AASLD treatment recommendations for people with who have had liver transplantation.
- Verna EC, Brown RS, Jr. Liver transplantation for hepatitis C virus infection. Uptodate. Chopra S, Travis AC, eds. Accessed at: www.uptodate.com. 2014.
- Liver Transplantation. Merck Manual for Healthcare Professionals. Available at: http://www.merckmanuals.com/professional/immunology_allergic_disorders/transplantation/liver_transplantation.html?qt=liver%20transplant&alt=sh. Accessed on 061014.
- Liver Transplants. American Liver Foundation. Available at: www.liverfoundation.org. Access on 061014.
- Bonis PAL, Chopra S. Patient information: Hepatitis C (Beyond the Basics). Di Bisceglie AM, Bloom A, eds. Accessed at: www.uptodate.com. 2014.