• KIDNEY TRANSPLANTATION
• LIVER TRANSPLANTATION
• PANCREAS TRANSPLANTATION
• BONE MARROW TRANSPLANTATION
• SMALL BOWEL TRANSPLANTATION

LIVER TRANSPLANTATION

Liver transplantation has been performed since 1963, and is now an accepted mode of treatment for patients with chronic end stage liver disease (due to viral hepatitis B & C, alcohol, etc.), acute fulminant hepatic failure, inborn errors of metabolism and selected unresectable primary hepatic malignancies isolated to the liver. Liver transplant patients have a one year survival of 85%, although long term survival of 15-20 years is well documented The overall 1-year graft survival after liver transplant approaches 80%. National Kidney and Transplant Institute has an active liver transplant program.

For the most part, all patients with cirrhosis or Liver failure should be considered as possible transplant recipients. Furthermore, in the presence of life threatening complications (e.g., bleeding, recurrent episode of encephalopathy, coagulopathy, spontaneous bacterial peritonitis, and for pediatric patients, deep jaundice, growth and development retardation, metabolic bone disease, and malnutrition), transplantation is indicated.

Before placing these patients on a waiting list, however, they should be evaluated by a transplant team to be certain that no contraindications exist and to ensure that the patient and the family understand the full benefits, risks and anticipated outcome of the therapy.

CONTRAINDICATIONS TO ORTHOTOPIC LIVER TRANSPLANTATION

Medical

• Presence of an acceptable alternative therapy
• Refractory impairment of other organ(s) that interfere with the surgical procedure or the quality of life after transplant, e.g. severe CNS injury or irreversible heart disease.
• Systemic infections
• HIV infection.
• Hepatocellular carcinoma with extra-hepatic metastasis.

Social

• Lack of family support and commitment in the care of the patient before, during or after transplant will certainly compromises the outcome.
• Lack of co-operation with the medical team.
• Lack of understanding of the procedure and complications. This is considered because transplantation is very demanding and efforts are done to give the scarce organ to the right person.

Patients should be referred as soon as they are identified to have end stage liver disease and will likely require transplantation. Although a lot of these patients may not need transplantation and would benefit more from alternative medical therapies, it is still wise to refer those patients before complications related to liver disease set in.

The evaluation of the liver transplant candidate involves relatively straight forward non-invasive and invasive tests intended to:
I. Define the precise diagnosis, stage, prognosis, speed of expected progression and expected outcome of the disease after transplantation;
2. Outline the intra-abdominal anatomy;
3. Establish the status of the patient with regard to infectious processes that might present a problem after transplantation;
4. Establish a good working relationship with the relatives and care providers to provide optimal care for the patient;
5. Assess the psychosocial and financial status of the family;
6. Consult with different specialties as needed, and
7. Establish an efficient communication system with patient/relatives at the time of transplant.

ADULT LIVER TRANSPLANT WORKUP LIST

Hematology:

• CBC
• Different count and platelet count
• Blood type and screen
• PT
• PTT

Renal/Liver Function Test
Serological examinations
Tissue Typing Test
Urine examinations
Other Tests:

CXR PA and lateral
Abdominal ultrasound with Doppler hepatic vessels
Abdominal and Chest Ct scan/ MRI
Abdominal angiogram (for non-visualization of hepatic and portal veins and hepatic artery on ultrasound)
Upper endoscopy
Pulse oxymetry overnight and blood gases.
ECG
2-D Echo of the Heart, if needed
Liver Biopsy, if needed
PPD skin test read at 48 ours and 72 hours
Stool for ova and parasites x 3

Consultation with the following specialties:

Anesthesia
Hepatology/ GI
Pulmonary
Cardiology
Dentistry
Dietitian
Psychiatry
Social worker

AFTER THE TRANSPLANT

ACTIVITY

The majority will resume routine activities that they have missed doing either because they were too tired or too sick prior to transplantation.

NUTRITION

After transplantation, there are no restrictions to intake of food, salt or beverages. A diet adequate in calories, proteins, vitamins and minerals is important in the rehabilitation process and also for maintaining good nutritional status. Although rapid weight gain will be observed initially, obesity should be avoided at all costs as it can be detrimental to the health of the liver transplant patient.

ROUTINE CARE

1. Bathing and Wound Care . The patient may shower with staples or stitches in place. He should not bathe in a tub until after the staples or stitches are removed. Any wound redness, tenderness, swelling, or foul smelling discharge should be reported right away.
2. Mouth Care . Good oral hygiene is important to prevent oral infection, so regular brushing of the teeth after eating is imperative. His mouth should be checked for any blisters, ulcers or white film and if present, should be reported right away.

OTHER CONCERNS

1. Birth Control . There has been no scientific evidence in favor of or against pregnancy for transplant recipients. The effects of Immunosuppressive drugs (FK506 or Cyclosporine) on fetal development are not known. The choice to become sexually active is an important decision that is influenced by a number of factors that should be discussed with the patient, spouse, doctors, and gynecologist.
Female patients generally resume their menstrual cycle after liver transplantation. High dose prednisone may stop the menstrual flow, but ovulation may continue, therefore, they may still get pregnant. The acceptable methods of birth control are: foam with condom, or a diaphragm with spermecidal gel. Permanent methods of birth control should be discussed with the physicians.
2. Driving . Caution and restraint in this early post-operative period will help assure patient's personal safety and safety of others.

After discharge, it is important that blood works continue to be done to monitor function of the transplanted organ, as well as the patient's general health conditions.

The following are the laboratory works required during initial visits:

• CBC.
• AST, ALT, alkaline phosphatase, total bilirubin, PT, PTT, total protein, albumin and amylase.
• Sodium, Potassium, Chloride, Bicarbonate, Creatinine, BUN, Fasting Blood Sugar, Calcium, Phosphorus and Magnesium.
• Trough serum Cyclosporin or FK506 levels

Initially blood tests will be done every week during the first three months post transplantation. Then it will be reduced to every two weeks from 3-6 months and then every month for one year and then every 3 months, thereafter.

Patients, who live outside Manila, may have their blood tests done as per protocol in their local hospital, provided that results are sent to the Liver Transplant team by fax as soon as possible.

Since CyA or FK506 levels are not usually available in those outlying hospitals, as much as possible we encourage our patients to come to our transplant center to have their blood works done. This will not only solve the problem of unavailability of FK506 or CyA level monitoring in other hospitals, but will also minimize laboratory result discrepancies between hospitals, and assure continued follow-up of our patients.

CLINIC VISITS

Initially patients will be seen every week by the transplant physician and transplant surgeon for the first 3 months. Subsequently they will be seen every 2 weeks from 3-6 months and every one-month for the rest of the year. After the first year, visits are arranged every 3-6 months.