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The Call to Hospital
If a suitable organ is found, the patient will be contacted
by the transplant coordinator by telephone or using the pager.
The coordinator will tell the patient when he or she should
be in the hospital and where the admission formalities will
be dealt with. There will be enough time for the patient to
get ready calmly and to organise transport to the hospital.
Patients are instructed not to eat or drink anything more
after the telephone call.
Preparations
for the operation
The patient is met by the transplant coordinator at reception
and taken to the department. There everything has been prepared
by those responsible for the required pre-operative tests
(blood tests, chest x-ray, ECG and if necessary an ultrasound
scan of the liver). The departmental doctor will examine the
patient, explain the transplant procedure again, together
with the risks, and obtain his or her written consent for
the operation to go ahead. It can only be certain that the
transplant will be performed or not when the liver from the
donor has been assessed by the surgeon. As the removal of
the organ from the donor and the preparations for the transplant
progress to some extent in parallel, a few hours can pass
before a final decision can be made.
Occasionally, it is discovered during the removal operation
that the donor liver does not meet the clinical requirements,
and the liver transplant unfortunately has to be called off
at short notice. Our patients receive detailed information
about this eventuality, but nevertheless disappointment after
all the hope and excitement is understandable. We hope, however,
that our patients will have faith in our decision, as a positive
operative result is dependent on the patient receiving a first-class
organ that functions well.
The liver transplant
The transplant is performed under general anaesthesia and
takes from 4 to 6 hours. In the first stage, the diseased
liver is removed. In order to make the implantation of the
new liver easier and to avoid serious loss of blood, the venous
blood in the lower half of the body which normally flows into
the liver and then into the heart is often diverted from the
area of the operation using a pump in order that it can circulate
outside the body.
The donor liver is then joined to the circulation of the
recipient by four vascular sutures. The bile duct of the donor
liver is thereafter joined to that of the recipient. In order
to splint the suture, a so-called T-drain is attached, through
which the bile drains away to a bag outside the body. This
has the advantage that we can assess the colour and composition
of the bile and decide whether the transplanted liver is functioning
properly. In the case of patients with primary sclerosing
cholangitis, the bile duct of the new liver will be connected
directly to the small intestine (Y-Roux). After inserting
the drainage tubes that are intended to drain the secretions
from the wound away to the outside of the body, the operation
area is closed up.
After theTransplant
The intensive care unit
After the operation the patient wakes up in the intensive
care unit. For 1 to 3 days, the patient remains here while
cardiovascular and lung function and the fluid balance are
monitored and stabilised. As the patient's own ability to
breathe is insufficient immediately after the operation (due
to the anaesthetics), the patient will be supported by a ventilator
for a few hours. Other than the wound drainage and the ventilator
tube, after they wake up patients find that they have a catheter
to monitor blood pressure and to drain away urine, a catheter
to measure cardiac pressure and for the administration of
liquid medicines, and a stomach tube. These tubes will be
removed as quickly as progress allows, in order to keep the
risk of infection as low as possible. In the first few hours
after the operation patients feel tired and weak, but even
on the day of the operation a start will be made with breathing
exercises and mobilisation.
Medical and nursing care in the transplantation
department
After an average of 1-3 days, patients are moved from the
intensive care unit to the transplantation department. How
soon the move can be planned for the most part depends on
the patients themselves. The nursing staff help patients to
regain their independence as quickly as possible. Patients
learn very quickly to take their medicines according to the
plan and without any assistance. The visits from the transplant
team take place twice a day, at 8.00 a.m. and at 5.00 p.m.
The patients are examined and additional treatments decided
on.
Labortests und Untersuchungen
Laboratory tests and investigations Blood is taken for testing
on a daily basis in order to check the functioning of the
liver and the kidneys and to determine the medicines to be
administered. In addition, in the first post-operative week,
two important routine tests are carried out.
1. T-Drain-Cholangiography
This examination is carried out on the fifth day following
the operation. It involves a painless x-ray investigation
of the bile ducts using a contrast medium. It allows a check
to be made on whether the bile is flowing unobstructed or
whether there is any constriction of the bile ducts. After
the examination the drainage tube will be sealed up, and the
bile is no longer made to flow into a bag, but can flow naturally
into the small intestine. The bile drain is left in place
for a further 3 months. In order to remove it after this period,
the patient will have to come into hospital again for one
day.
2. Liver biopsy
On the seventh post-operative day, an ultrasound controlled
liver biopsy is carried out. Other than a little pinprick
for the local anaesthetic, the patient should feel little
in the way of discomfort. The liver tissue obtained is then
tested in the microbiology laboratory for bacterial and viral
pathogens and in the pathology laboratory for any indications
of rejection.
Preparations for discharge from hospital
Normally, discharge from hospital can be planned after 8 to
10 days, which means that patients can on average leave the
hospital after 12 to 14 days. This is of course dependent
on recovery progressing without any complications such as
an infection or a rejection reaction.
Before discharge, patients learn how to take their medicines,
how to rinse out and change the dressing on the T-Drain, and
some rules on how they should modify their behaviour in their
daily lives. The nursing staff prepare patients carefully
for discharge from the hospital. Our social worker is also
available in case support is needed for the initial period
at home. A special recuperative period following the stay
in hospital is not required, as it is basically better for
recovery if patients return to their normal daily lives within
their families as quickly as possible. Before discharge an
appointment for the first check-up in the hepatology out-patients
department will be organised. The patients will receive a
prescription for their medicines and if they are released
at the weekend they will be given an adequate supply of dressings
and medication to cover the first few days. In addition, they
will be given a list of telephone numbers to be used in the
case of any "emergencies" (high temperature, vomiting etc.).
After the transplant
Return to normal life
We recommend that out patients should return to their normal
lives as soon as possible after discharge from hospital. Patients
can judge for themselves what they are capable of achieving.
Light housework, walking or other physical exercise combined
with a healthy diet promotes the building of muscles and contributes
to the patient soon being able to live a normal life and return
to work. A few rules must nevertheless be followed after the
transplant:
· If the patient's temperature rises to over 38.5 °C the transplantation
center must be contacted immediately (during the day: duty
doctor in the hepatology out-patients department; at night:
duty doctor in the transplant surgery section). A raised temperature
can indicate a rejection reaction or infection, so any increase
in temperature must be medically investigated immediately
and a suitable treatment begun.
· As the medicines are taken in high dosages to begin with,
large gatherings of people and people with viral infections
(influenza, childhood diseases) should be avoided in the first
few months.
· Avoid sunbathing for long periods of time (increased risk
of skin cancer due to the consumption of immuno-suppressant
drugs)
· Follow the recommendations of the nursing staff in relation
to bodily and oral hygiene
· Enjoy a new life
Working life
The time required before patients can start work again is
very much dependent on the type of work involved, whether
it is a sedentary occupation or whether it involves major
physical activity. Normally, however, patients are in a position
to go back to work after 6 months at the most. Generally it
is our aim to allow patients with liver transplants to lead
a normal productive life. In principle, patients should avoid
lifting heavy weights for four to six months, as due to the
delayed healing of the wound, there is a danger of an incisional
hernia (a complication commonly encountered after a liver
transplant, above all in the case of men).
Sexual Relations
The speed with which patients resume their sexual activities
after the transplant very much depends on the recovery process
and is determined by the patients themselves. From a medical
point of view, there is no reason not to have an active sex
life. Some men can become impotent as a result of liver disease,
and physical weakness and tiredness also contribute to the
problem. After the transplant, sexual potency normally returns.
Certain medication such as that for high blood pressure or
high dosages of steroids can however prolong the period of
impotence following a liver transplant. Women who have stopped
menstruating due to liver disease will begin to have periods
again within a few months of the transplant after the functioning
of their organs and their hormonal balance normalises. Even
though the cycle can be irregular, ovulation and therefore
fertilisation is possible. It is therefore essential for sexually
active patients of child-bearing age to use some form of contraception.
The method used should always be discussed with a doctor.
The contraceptive pill is often incompatible with immuno-suppressant
drugs and is not suitable as a means of contraception most
particularly because of its effect on the liver. An intrauterine
device (coil) is not suitable because of the increased risk
of infection. What is recommended is a combination of the
use of condoms, the diaphragm and spermicidal creams. If it
is decided not to have any children, surgical sterilisation
(tubectomy, vasectomy) is the safest method. For patients
who are sexually active but who have no permanent partner,
it is vital that condoms are used as a protection against
sexually transmitted diseases (AIDS, syphilis, gonorrhoea,
hepatitis or herpes).
Pregnancy
Women are advised to avoid becoming pregnant for at least
two years after the transplant, as by this time the immuno-suppressant
drugs are normally only given in small doses. A pregnancy
should always be planned and the possible risks must be discussed
with the hepatologist dealing with the case. Despite the increased
risks for both mother and child, it is possible to carry a
healthy child to the full term following a liver transplant.
The initially high dosage of immuno-suppressants can damage
the genetic make-up of the sperm or even the sperm themselves.
Therefore, men who have had transplants should wait before
fathering children until the dosage of the medication has
been significantly reduced. In comparison with the rest of
the population, there is very little increased risk of malformation
in the children of couples where either the man or the woman
has had a liver transplant.
Check-ups in the hepatology out-patients
department (clinical pharmacology)
The follow-up examinations initially take place in the clinical
pharmacology out-patients department once or twice a week.
At these check-ups, the vital signs (blood pressure, pulse,
temperature etc.), the region of the wound, the combination
of medicines (Neoral or Prograf) and the blood values are
tested. The patients arrive for the check up having had nothing
to eat or drink and bring their morning dosage of medication
with them. After a sample of blood is taken, they are given
a small snack and can then take their tablets. If the dosage
of immuno-suppressants has to be changed to accord with the
current composition of the blood, the patient will be informed
of this by telephone by the doctor responsible the same afternoon.
As soon as the condition of the patient has stabilised, after
a few weeks the check-ups will increasingly be taken over
by the patient's family doctor.
Medication
and Complications
Medication
General Guidelines
The patients themselves are responsible for the correct consumption
of the medication prescribed and will receive precise instructions
from nursing staff when being prepared for discharge on:
· The name and effect of the medication
· When
· How
· and for how long the medication must be taken
· The main side-effects
· What to do if you forget to take your medication
Immuno-suppressants
These drugs suppress the rejection reaction and are the "life
insurance" of the transplant patient, so to speak. In the
initial months after the transplant, the patients receive
a combination of three immuno-suppressant drugs. According
to how matters progress, the dosage will be reduced after
a while, or the patient may even stop taking one or two of
the drugs.
Cyclosporin-A (brand name: Neoral, Sandimmune)
Cyclosporin-A is one of the most important immuno-suppressants,
drugs which inhibit the body's immune defences. It prevents
the transplanted liver from being recognised by the organism
as a foreign body and the immune defences thus being activated.
It specifically affects the T-cells of the immune system.
Main side-effects:
· Increased risk of infection
· Increased risk of high blood pressure and kidney disorders
· Swollen gums
· Increased growth of hair all over the body
· Severe trembling of the hands can be an indication that
there is too much cyclosporin in the bloodstream
Azathioprin (brand name: Imurek)
Imurek is also a drug which suppresses the immune defences,
and which prevents formation of nucleic acid (main component
of DNA). DNA is mainly formed in cells which divide quickly.
As the immune system also consists of fast-dividing cells,
taking Imurek prevents cell multiplication. Due to the effect
on the bone marrow, Imurek can drastically reduce the number
of white blood cells and blood platelets.
Main side-effects
· Increased risk of infection due to the reduction in white
blood cells
· Nausea, vomiting
· Bleeding tendency due to reduction in blood platelets
Corticosteroid (brand name Prednison, Prednisolon)
This is a hormone which is itself produced by the body in
small quantities in the adrenal gland. It has an important
influence on the infection and immune processes in the body.
Side effects:
· Retention of salt and water in the body, possibly leading
to oedemas in the legs and back of the feet.
· Gastric ulcers (to prevent this medication will be prescribed
to reduce the production of gastric acid)
· Increase in blood sugar level (in some cases a special diet
may be required or it may be necessary to administer insulin
for a temporary period)
· Swelling up of the face (moon face) This symptom disappears
as the dosage is reduced
· Muscle weakness
· Night sweat, nightmares
· Delayed healing of the wound
· Acne
· Increase in appetite
Tacrolimus oder FK-506 (brand namePrograf)
Prograf is very similar to cyclosporin in its effects and
side-effects. Patients are prescribed either cyclosporin or
Prograf. Some basic differences of Prograf are:
· The incidence of high blood pressure is lower
· The incidence of increased blood sugar levels is higher
· Neurological disorders such as trembling, headaches, and
nightmares are sometimes more common
Rejection reaction
Around 50% of transplant patients experience a rejection
reaction in the early post-operative phase.
Rejection is a reaction of the immune system. The immune system
recognises the transplanted liver as something "foreign" and
then mobilises certain cells to attack the new organ. While
the patient is in hospital, any rejection will be very quickly
detected in the daily examinations. Often such a reaction
begins with a rise in temperature. Rejection can be dealt
with very effectively by giving the patient medication. The
patient receives high dosages of cortisone over 3 to 5 days.
The first 12 months after the transplant is the most likely
time for a rejection reaction. As any rejection must be treated
immediately, patients are instructed to keep a close watch
on their temperature at home and to inform the transplant
center without delay if it rises to over 38.5 °C. In most
cases the patient has to come into hospital in order for the
required diagnosis to be made and the rejection to be treated,
but often all that is needed is an increase in the dosage
of steroids in order to bring the immune reaction under control.
Infection
Infection
As the natural defences against infection are weakened by
the immuno-suppressants, the risk of infection is very high.
A distinction is made according to the type of pathogen between
viral, bacterial and fungal infections, with fungal infections
being the most feared, as they are very difficult to treat.
Common viral infections after transplants are:
Cytomegalovirus infection(CMV)
The cytomegalovirus is a herpes virus. Around 50% of the population
are carries of this virus, but it only becomes active when
the immune defences are weakened, such as in the case of transplant
patients, the elderly and the very young. The risk of infection
is at its highest in the first few months after the transplant.
The symptoms are: high temperature, tiredness, pain in the
joints, headaches, visual disturbances and pneumonia.
Herpes simplex infection type I + //
Herpes simplex type I very commonly affects the skin of the
face (cold sores), but can also infect the eyes and the lungs.
Type II normally causes genital infections (sexual transmission!).
Most infections with H. simplex are very mild. The main symptoms
are: painful blisters filled with fluid on the mouth or genitals.
Treatment: ZoviraxÒ (cream, tablets or injection)
Herpes zoster (shingles)
Shingles appears as a reddening of the skin or as fluid-filled
pustules mainly on the chest, the back or on the hips. Symptoms:
severe pain, erythema, high temperature
Treatment: according to the symptoms
Bacterial infections
Candidasis
Among the possible bacterial infections, infections of the
wound (the surgical incision) stand at the forefront. Symptoms:
reddening, swelling, pain and possible pustulant discharge
from the region of the wound. Treatment: antibiotics, after
the nature of the bacilli has been determined by a surface
biopsy of the wound
Pseudocystis carinii
Pseudocystis carinii is a fungal-type bacillus which can cause
serious pneumonia. Symptoms: a dry cough and high temperature.
Treatment: prevention (part of the medication after the transplant)
Bacterial Infections
The most common of the bacterial infections are infections
of the wound (operation scar). Symptoms: reddening, swelling,
pain and/or discharge of pus from the region of the wound.
Treatment: antibiotics after the nature of the bacilli has
been determined by a surface biopsy.
Surgical complications
Bile leakage
Bile leakage is when bile accumulates outside the bile ducts.
This is indicated by pain in the region of the liver, nausea,
vomiting and a high temperature.
Bile duct stenosis
The constriction of the bile duct close to the anastomosis
(junction), which can prevent the bile from draining away.
It can often be treated by endoscopic dilation or by inserting
a small tube. The symptoms are an increase in liver enzymes
and bilirubin and a yellowing of the skin.
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