Liver transplant

Indication and contraindication

Liver cirrhosis due to

• acute liver failure, e.g. after acute hepatitis A or B infection
• Metabolic disease, e.g. familial amyloidosis, primary hyperoxaluria, hepatitis B or C, alcoholic liver cirrhosis

and all other forms of liver cirrhosis as soon as liver function is impaired (Child-Pugh stage B/C) and the quality of life is severely restricted by the liver cirrhosis, e.g. severe pruritus that cannot be treated with medication or if a small liver cancer has developed.

The following concomitant diseases or complications are generally considered contraindications:

• Tumor disease too advanced
• Continued alcohol consumption
• Severe heart or lung disease

Clarifications

f a liver transplant is a viable option, a detailed assessment of the benefits and risks of a liver transplant is required for 4-5 days at our hospital before the patient is placed on the waiting list.

The following examinations must be carried out as a minimum:

• Blood and urine tests
• ECG and possibly further cardiac examinations
• Computed tomography of the abdomen
• Psychological assessment

Discussions are also held with all those involved in the transplant. These may be specialists in transplant surgery, hepatology, anesthesia, intensive care medicine, psychology/psychiatry and transplant coordination.

During a subsequent colloquium, the results of the examination are used to assess whether the patient is eligible for a liver transplant and can be placed on the waiting list.

Waiting list

Formal inclusion on the national liver transplant waiting list takes place following the interdisciplinary colloquium. The timing of the transplant cannot be predicted and the waiting time can vary depending on the recipient’s blood group. The donor organs can be provided by living or deceased organ donors.

Once a patient has been placed on the waiting list, he or she must expect to be called to the hospital for a transplant at any time. For this reason, liver recipients must be available at all times during the waiting period.

Opportunities and risks?

• For many patients with advanced liver disease, liver transplantation offers the only chance of a cure. Of the patients transplanted at our center, over 90% are still alive after five years. This means that the chances of survival after a transplant are much better than without.
• However, not only are the chances of survival better, but the quality of life often improves dramatically after a transplant.
• However, liver transplantation is a major and complex operation, so there is also a small risk (5 – 10 %) of dying as a result of the transplant.

What happens during a transplant?

Before the operation

If a suitable donor organ is available, the transplant coordination team will contact the recipient and he or she will be brought to the University Hospital Zurich as quickly as possible. On admission, some tests such as blood tests, ECG and chest X-ray are repeated. A final assessment is made by the surgeon and the anesthetist.

During the operation

An incision is made below the right and left costal arches, which in rare cases is extended upwards to the sternum. In an operation lasting around six hours, the diseased liver is removed and the new liver inserted. The corresponding vessels of the liver are connected to the blood vessels. The bile duct of the new liver is connected directly to the bile duct or the small intestine of the recipient. After the operation, the patient is taken to the intensive care unit. Depending on the degree of recovery, the patient is transferred to the transplant center department as soon as possible.

The department will then give precise instructions on how to take the drugs that prevent rejection (immunosuppressants). The inpatient stay at the USZ is usually followed by a recovery stay in a rehabilitation clinic.

After discharge, the patient is regularly called to our transplant consultation.

Do I have to take medication?

After the transplant, recipients must take medication for the rest of their lives to suppress the immune system and thus prevent rejection of the new liver. These drugs are called immunosuppressants. Immediately after the transplant, the patient initially receives relatively strong immunosuppression, which can be significantly reduced over time. The medication levels in the blood are checked regularly so that each patient receives the optimum dose for them.

How are recipients looked after?

In the first few weeks after discharge, weekly follow-up checks are carried out in our transplant consultation. Here we monitor the clinical course, laboratory parameters and immunosuppression.

Over time, if liver function and immunosuppression are stable, the interval between outpatient appointments can be extended; the GP may then be able to take over the check-ups and our specialists will only see the patient once or twice a year.

Of course, we will continue to be available to recipients at any time if they have any questions or problems.

Life after the transplant?

There are very few restrictions after the transplant, except that regular medication must be taken to prevent rejection. In addition, patients in whom excessive alcohol consumption has led to liver cirrhosis must not drink alcohol even after the transplant. Recipients who have received a liver transplant for other reasons may only drink alcohol occasionally. In the first three months, until the wound has completely healed, the abdominal muscles should not be strained too much. However, physical exercise such as walking and cycling are not a problem. A return to working life is not only possible but desirable. Depending on the physical strain, the patient can usually return to work within 3 – 6 months.

What are the results?

More than 90% of transplanted patients are still alive in our center after 5 years.

However, not only are the chances of survival better, but the quality of life often improves dramatically after a transplant.