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Liver transplantation is a procedure that is the only method of treating liver failure. Unfortunately, despite great advances in child transplantation, the number of people waiting for a liver transplant is still high. What are the indications for a liver transplant? Who has the best chance of getting an organ? How long does the procedure take? What is the prognosis after surgery?

Liver transplantis a procedure that is performed more and more frequently every year. Nevertheless, the number of liver transplants in Poland is still insufficient. All because of the advantage of cadaver transplants over those for living donors and the lack of widespread social acceptance for donating organs from the deceased, as well as still little knowledge about transplants.

Liver transplant - indications

The indication for liver transplantation is chronic or acute liver failure as a result of a disease that permanently damages its parenchyma. According to the Polish Hepatological Society, the main indications for liver transplantation in adults are: ¹

  • inflammatory cirrhosis of the liver (against the background of HBV, HCV infection)
  • cholestatic liver disease (primary biliary cirrhosis, primary sclerotic cholangitis)
  • alcoholic liver disease (excludes active alcoholism and alcohol dependence syndrome)
  • autoimmune cirrhosis
  • metabolic liver diseases (Wilson's disease, hemochromatosis, alpha1-antitrypsin deficiency)
  • fulminant liver failure (poisoning with paracetamol or other hepatotoxic drugs, toadstool poisoning, fulminant hepatitis B, acute decompensation of Wilson's disease, other causes of acute liver dysfunction)
  • liver tumors

Until recently, HIV infection was also an absolute contraindication. However, in recent years, due to the high effectiveness of antiretroviral therapy, transplantation procedures are also performed in recipients infected with this virus. The first liver transplant in Poland in a patient with HIV took place in 2011. It was carried out by transplantologists from the Medical University of Warsaw.

According to the Polish Hepatological Society, the main indications for liver transplantation inthe children are: ¹

  • cholestatic syndromes, e.g. Allagille's syndrome
  • cirrhosis of the liver as a result of viral infection
  • other inflammatory cirrhosis of the liver in the course of e.g. autoimmune hepatitis
  • cirrhosis of the liver in congenital metabolic diseases, e.g. cystic fibrosis
  • primary liver tumors, e.g. hepatocarcinoma
  • diseases that do not cause liver failure, but are an indication for transplantation, e.g. Crigler-Najjar syndrome type I
  • other, e.g. the Buddha-Chiari syndrome

Liver transplant - who qualifies for the procedure?

From the group of people with indications for liver transplantation, only those with less than 90 percent chances of surviving for a year, as well as those where liver transplantation can ensure long-term survival.

The process of qualifying for surgery involves many different tests. This procedure is necessary because its aim is to exclude factors that could not only adversely affect the course of the operation itself, but also worsen the prognosis after the procedure.

Important

Liver transplant - contraindications¹

Absolute contraindications

  • extrahepatic neoplasms
  • advancement of cardiovascular disease
  • active addiction to psychoactive substances
  • psychosis
  • social or family problems that prevent liver transplantation (e.g. homelessness, incapacitation)
  • multi-organ failure

Relative contraindications:

  • acquired immune deficiency syndrome (AIDS)
  • hepatocellular carcinoma outside Milan criteria
  • kidney failure
  • very deep protein and caloric malnutrition
  • active infection outside the urinary tract
  • portal vein thrombosis if associated with mesenteric or splenic vein thrombosis
  • HBV infection with high viral load

Liver transplant - how long do you have to wait for surgery?

The average waiting time for people with chronic liver failure to receive an organ from a deceased person is 4-6 months. While waiting for a transplant, one can live normally with chronic insufficiency (eg cirrhosis) of the liver. During this time, a proper diet, hepatotropic agents and a he althy lifestyle are very important. Then the process of liver cirrhosis may stop, and thus - you can wait for a liver transplant.

In cases of acute liver failure, the procedure should be performed as soon as possible (usually within 10days). Unfortunately, according to statistics, only about 20 percent. people with acute liver failure survive the transplant.

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Liver transplantation is performed in approx. 50 percent. waiting

In 2015, 332 liver transplants were performed (including 22 liver fragments from living donors for children). In 2014, 366 procedures were performed, and in 2013 - 336. Unfortunately, on the waiting list in 2015 and in previous years, there were approx. 600 people, which means that only approx. 50 percent. people waiting for a liver transplant get this organ.

Data: www.poltransplant.org.pl

Liver transplant - what does the procedure look like?

The treatment consists of two stages. The first involves the removal of the patient's own liver with the preservation or excision of a fragment of the inferior vena cava lying behind the liver. In the second stage, vascular anastomosis is performed in the inferior vena cava, portal vein and hepatic artery of the donor and recipient, and biliary anastomosis.

In most cases, the whole liver is transplanted, usually from a deceased person (OLT - Orthotopic Liver Transplantation). Adult-adult liver transplantation is extremely difficult and risky. You have to collect as much as 40 percent from the donor. organ. This is a lot, because although the liver can regenerate itself, it must deal with a serious injury immediately after taking a fragment of it. The risk of death with such downloads is quite high, as it amounts to 0.5-0.6%.

Other methods of liver transplantation are:

  • RLT (Reduced-size Liver Transplantation) - a fragment of the liver is transplanted, which is taken from a deceased person;
  • SLT (Split Liver Transplantation) - the operation involves splitting the liver from a deceased person for two recipients, a child and an adult. The left lobe is given to the child, and the rest to the adult;
  • LDLT (Living Doneer Liver Transplantation) - transplantation of a fragment of the liver that is taken from a living, most often related donor and implantation of the recipient, most often a child.Family liver transplantis the best the solution for young children;
  • DLT (Domino Liver Transplantation) - the so-called domino method - transplantation of liver fragments from several donors to several recipients;

After a liver transplant, the patient must take immunosuppressive drugs for the rest of his life. Their goal is to weaken the immune system to prevent transplant rejection.

According to an expertprof. dr hab. n. med. Krzysztof Zieniewicz, transplant surgeon, president of the Polish Transplant Society

Transplantsplit liver

In some countries, two pieces of one divided liver are transplanted. It is a way of increasing the organ pool when waiting times exceed reasonable limits. A measure of this waiting time is the death rate on the waiting list. In countries where the mortality rate is high and exceeds 8-9%, this method of treatment is used. In our reality, it is not absolutely necessary, because this indicator in our statistics is much lower. In a technical sense, this is an extremely difficult operation. Not every liver intended for transplantation can be divided, the flesh of such a liver must be of very good quality. Moreover, it has been proven that the complication rate, the number of these complications, and the survival of patients are worse.

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Liver transplant in Poland - where is it performed?

In Poland, adult liver transplants are performed only in a few centers in Poland:

  • Bydgoszcz - Department of Liver Surgery and General Surgery, University Hospital no. Dr. A. Jurasza in Bydgoszcz
  • Katowice: Department and Clinic of General and Transplant Surgery SPSK im. A. Mielęcki, Medical University of Silesia;
  • Szczecin: Department of General and Transplant Surgery, Primary Hospital, Provincial Complex Hospital
  • Warsaw:

- Department and Clinic of General, Transplant and Liver Surgery, Medical University of Warsaw - Department and Clinic of General and Transplant Surgery Institute of Transplantology, Medical University of Warsaw Infant Jesus Clinical Hospital - Department of Pediatric Surgery and Organ Transplantation Institute "Monument - Children's He alth Center"

  • Wrocław

- Department and Clinic of Vascular, General and Transplant Surgery, Medical University of Wrocław, University Clinical Hospital Jana Mikulicza-Radeckiego- Surgical Clinic, 4th Military Clinical Hospital with Polyclinic SP ZOZ

Data: www.poltransplant.org.pl

Liver transplant - complications in the recipient

The complications in the recipient most often include thrombosis, stenosis and kinking in the hepatic artery and portal vein, and impaired outflow of blood from the transplanted liver. They occur in about 8-10 percent. adult recipients and slightly more often in children.

Liver transplant - prognosis

A year after liver transplantation, approximately 90 percent of the population survives. people, and in 5 years 75 percent. recipients. Acute organ rejection is reported in 40-50 percent. patients, and chronic in less than 4 percent. people after the transplant.

Important

Liver transplant - information for liver donors

The indication for living donor liver transplantation is generally congenital liver disease in young children. The indication may also be acute liver failure.

The risk of death of a liver donor is approximately 0.5%.

Complications after the procedure may include (in 10-20% of donors): bile leakage, bleeding, infection, severe abdominal pain, thromboembolic complications, gastritis.

The liver has a remarkable ability to regenerate. At the donor, it is able to renew up to 95%. starting weight and dimensions. It is a quick process and occurs in the first three months after the procedure.

For one year after the procedure, every three months, the donor should have blood tests to assess liver function and ultrasound of the liver.

Bibliography:

1. Standards of the Polish Hepatological Society in determining indications and contraindications for liver transplantation, www.pasl.pl/wp-content/uploads/2014/10/rekomendacje_pth_do_oltx.pdf

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Category:

Gastrology