Liver transplantation 517879 224999259 2008-07-11T11:37:47Z 220.237.1.124 {{Interventions infobox | Name = Liver transplantation | Image = Liver 1.jpg | Caption = Human liver | ICD10 = | ICD9 = 50.5 | MeshID = D016031 | OtherCodes = | }} '''Liver transplantation''' or '''hepatic transplantation''' is the replacement of a diseased [[liver]] with a healthy liver [[allograft]]. The most commonly used technique is orthotopic transplantation, in which the native liver is removed and the donor organ is placed in the same anatomic location as the original liver. Liver transplantation nowadays is a well accepted treatment option for end-stage liver disease and acute liver failure. [[Francis Chan]] (born [[November]] [[3]], [[1991]]) is believed to be the youngest liver transplant patient in [[Australia]]. He was 2 months old when he unwent two transplant operations 3 days apart at [[The Children's Hospital at Westmead]]. ==History== The first [[human]] [[liver transplant]] was performed in 1963 by a surgical team led by Dr. [[Thomas Starzl]]<ref>{{cite journal |author=STARZL T, MARCHIORO T, VONKAULLA K, HERMANN G, BRITTAIN R, WADDELL W |title=Homotransplantation Of The Liver In Humans |journal=Surg Gynecol Obstet |volume=117 |issue= |pages=659–76 |year= |pmid=14100514}}</ref> of [[Denver, Colorado]], [[United States]]. Dr. Starzl performed several additional transplants over the next few years before the first short-term success was achieved in 1967 with the first one-year survival posttransplantation. Despite the development of viable surgical techniques, liver transplantation remained experimental through the 1970s, with one year patient survival in the vicinity of 25%.<ref>{{cite journal |author = Starzl TE, Klintmalm GB, Porter KA, Iwatsuki S, Schroter GP. |title=Liver transplantation with use of cyclosporin A and prednisone |journal=New England Journal of Medicine |volume=305 |year=1981 |pages=266–269 |pmid=7017414}}</ref> The introduction of [[ciclosporin|cyclosporine]] by Sir [[Roy Calne]] markedly improved patient outcomes, and the 1980s saw recognition of liver transplantation as a standard clinical treatment for both adult and pediatric patients with appropriate indications. Liver transplantation is now performed at over one hundred centres in the [[USA]], as well as numerous centres in Europe and elsewhere. One year patient survival is 85-90%, and outcomes continue to improve, although liver transplantation remains a formidable procedure with frequent complications. Unfortunately, the supply of [[liver]] [[allograft]]s from non-living donors is far short of the number of potential recipients, a reality that has spurred the development of [[#Living donor transplantation|living donor liver transplantation]]. ==Indications== Liver transplantation is potentially applicable to any acute or chronic condition resulting in irreversible liver dysfunction, provided that the recipient does not have other conditions that will preclude a successful transplant. Metastatic cancer outside liver, active drug or alcohol abuse and active septic infections are absolute contraindications. While infection with HIV was once considered an [[absolute contraindication]], this has been changing recently. Advanced age and serious heart, pulmonary or other disease may also prevent transplantation ([[relative contraindication]]s). Most liver transplants are performed for chronic liver diseases that lead to irreversible scarring of the liver, or [[cirrhosis]]. ==Techniques== Before transplantation liver support therapy might be indicated (bridging-to-transplantation). Artificial liver support like [[liver dialysis]] or bioartificial liver support concepts are currently under preclinical and clinical evaluation. Virtually all liver transplants are done in an orthotopic fashion, that is the native liver is removed and the new liver is placed in the same anatomic location. The transplant operation can be conceptualized as consisting of the hepatectomy (liver removal) phase, the anhepatic (no liver) phase, and the postimplantation phase. The operation is done through a large incision in the upper abdomen. The hepatectomy involves division of all ligamentous attachments to the liver, as well as the common bile duct, hepatic artery, and portal vein. Usually, the retrohepatic portion of the inferior vena cava is removed along with the liver, although an alternative technique preserves the recipient's vena cava ("piggyback" technique). The donor's blood in the liver will be replaced by an ice-cold organ storage solution, such as UW ([[Viaspan]]) or [[Histidine-tryptophan-ketoglutarate|HTK]] until the allograft liver is implanted. Implantation involves anastomoses (connections) of the inferior vena cava, portal vein, and hepatic artery. After blood flow is restored to the new liver, the biliary (bile duct) anastomosis is constructed, either to the recipient's own bile duct or to the small intestine. The surgery usually takes between five and six hours, but may be longer or shorter due to the difficulty of the operation and the experience of the surgeon. The large majority of liver transplants use the entire liver from a non-living donor for the transplant, particularly for adult recipients. A major advance in pediatric liver transplantation was the development of reduced size liver transplantation, in which a portion of an adult liver is used for an infant or small child. Further developments in this area included split liver transplantation, in which one liver is used for transplants for two recipients, and living donor liver transplantation, in which a portion of healthy person's liver is removed and used as the allograft. Living donor liver transplantation for pediatric recipients involves removal of approximately 20% of the liver ([[Couinaud]] segments 2 and 3). ==Immunosuppressive management== Like all other allografts, a liver transplant will be [[Transplant rejection|rejected]] by the recipient unless [[Immunosuppression|immunosuppressive]] drugs are used. The immunosuppressive regimens for all solid organ transplants are fairly similar, and a variety of agents are now available. Most liver transplant recipients receive [[corticosteroid]]s plus either [[tacrolimus]] or [[Cyclosporin]] or [[Mycophenolic acid|Mycophenolate Mofetil]]. Liver transplantation is unique in that the risk of chronic rejection also decreases over time, although recipients need to take immunosuppresive medication for the rest of their lives. It is theorized that the liver may play a yet-unknown role in the maturation of certain cells pertaining to the [[immune system]]. There is at least one study by Dr. Starzl's team at the [[University of Pittsburgh]] which consisted of [[bone marrow]] [[biopsies]] taken from such patients which demonstrate genotypic [[chimerism]] in the bone marrow of liver transplant recipients. ==Results== Prognosis is quite good. 1-year survival (in Finland) is 83%, 5-year survival is 76% and 10-year survival is 66%.{{Fact|date=October 2007}} Majority of deaths happen during the first three months after transplantation.{{Fact|date=October 2007}} ==Living donor transplantation== ''Living donor liver transplantation'' (LDLT) has emerged in recent decades as a critical [[Surgery|surgical]] option for patients with end stage liver disease, such as [[cirrhosis]] and/or [[hepatocellular carcinoma]] often attributable to one or more of the following: long-term [[Alcoholism|alcohol]] abuse, long-term untreated [[Hepatitis C]] infection, long-term untreated [[Hepatitis B]] infection. The concept of LDLT is based on (1) the remarkable regenerative capacities of the human liver and (2) the widespread shortage of [[cadaver]]ic livers for patients awaiting [[Organ transplant|transplant]]. In LDLT, a piece of healthy liver is surgically removed from a living person and transplanted into a recipient, immediately after the recipient’s diseased liver has been entirely removed. Historically, LDLT began as a means for parents of children with severe liver disease to donate a portion of their healthy liver to replace their child's entire damaged liver. The first report of successful LDLT was by Dr. [[Silvano Raia]] at the [[Universidade de São Paulo]] (USP) Medical School in 1986. Surgeons eventually realized that adult-to-adult LDLT was also possible, and now the practice is common in a few reputable medical institutes. It is considered more technically demanding than even standard, cadaveric donor liver transplantation, and also poses the ethical problems underlying the indication of a major surgical operation ([[hepatectomy]]) on a healthy human being. In various case series the risk of complications in the donor is around 10%, and very occasionally a second operation is needed. Common problems are [[biliary fistula]], [[gastric stasis]] and [[infection]]s; they are more common after removal of the right lobe of the liver. Death after LDLT has been reported at 0% (Japan), 0.3% (USA) and <1% (Europe), with risks likely to improve further as surgeons gain more experience in this procedure.<ref>{{cite journal |author=Umeshita K, Fujiwara K, Kiyosawa K, ''et al'' |title=Operative morbidity of living liver donors in Japan |journal=Lancet |volume=362 |issue=9385 |pages=687–90 |year=2003 |month=August |pmid=12957090 |doi=10.1016/S0140-6736(03)14230-4}}</ref> In a typical adult recipient LDLT, 55% of the liver (the right lobe) is removed from a healthy living donor. The donor's liver will regenerate to 100% function within 4-6 weeks and will reach full volumetric size with recapitulation of the normal structure soon thereafter. It may be possible to remove 70% to 75% of the liver from a healthy living donor without harm in most cases. The transplanted portion will reach full function and the appropriate size in the recipient as well, although it will take longer than for the donor. [http://www.reachmd.com/xmsegment.aspx?sid=1675] ==References== {{reflist}} ==Further reading== * {{cite journal | author=Eghtesad B, Kadry Z, Fung J | title=Technical considerations in liver transplantation: what a hepatologist needs to know (and every surgeon should practice) | journal=Liver Transpl | year=2005 | pages=861–71 | volume=11 | issue=8 | pmid=16035067 | doi=10.1002/lt.20529}} * {{cite journal | author=Adam R, McMaster P, O'Grady JG, Castaing D, Klempnauer JL, Jamieson N, Neuhaus P, Lerut J, Salizzoni M, Pollard S, Muhlbacher F, Rogiers X, Garcia Valdecasas JC, Berenguer J, Jaeck D, Moreno Gonzalez E | title=Evolution of liver transplantation in Europe: report of the European Liver Transplant Registry | journal=Liver Transpl | year=2003 | pages=1231–43 | volume=9 | issue=12 | pmid=14625822 | doi=10.1016/j.lts.2003.09.018}} * {{cite journal | author=Reddy S, Zilvetti M, Brockmann J, McLaren A, Friend P | title=Liver transplantation from non-heart-beating donors: current status and future prospects | journal=Liver Transpl | year=2004 | pages=1223–32 | volume=10 | issue=10 | pmid=15376341 | doi=10.1002/lt.20268}} * {{cite journal | author=Tuttle-Newhall JE, Collins BH, Desai DM, Kuo PC, Heneghan MA | title=The current status of living donor liver transplantation | journal=Curr Probl Surg | year=2005 | pages=144–83 | volume=42 | issue=3 | pmid=15859440 | doi=10.1067/j.cpsurg.2004.12.003}} * {{cite journal | author=Martinez OM, Rosen HR | title=Basic concepts in transplant immunology | journal=Liver Transpl | year=2005 | pages=370–81 | volume=11 | issue=4 | pmid=15776458 | doi=10.1002/lt.20406}} * {{cite journal | author=Krahn LE, DiMartini A | title=Psychiatric and psychosocial aspects of liver transplantation | journal=Liver Transpl | year=2005 | pages=1157–68 | volume=11 | issue=10 | pmid=16184540 | doi=10.1002/lt.20578}} * Nadalin S, Malagò M, et al. Current trends in live liver donation. ''Transpl. Int.'' 2007;20:312-30. * Vohra V. Liver transplantation in India. ''Int Anesthesiol Clin.'' 2006;44:137-49. * Strong RW. Living-donor liver transplantation: an overview. ''J Hepatobiliary Pancreat Surg.'' 2006;13:370-7. * Fan ST. Live donor liver transplantation in adults. ''Transplantation.'' 2006;82:723-32. ==External links== *[http://unos.org/ Official organ sharing network of U.S.] *[http://www.optn.org/ Official organ procurement center of the U.S.] *[http://www.liverfoundation.org American Liver Foundation: Comprehensive information about Hepatitis C, Liver Transplant and other liver diseases, including links to chapters for finding local resources] *[http://www.medsci.org/v02p0041.htm Management of HBV Infection in Liver Transplantation Patients] *[http://www.medsci.org/v03p0079.htm Management of HCV Infection and Liver Transplantation] *[http://www.medsci.org/v03p0075.htm Antiviral therapy of HCV in the cirrhotic and transplant candidate] *[http://www.livingdonorsonline.org Living Donors Online] *[http://liverdonor.blogspot.com Liver Donor] *[http://www.globehealthtours.com/directory/Liver Liver Transplantation Guide and Liver Transplant Surgery in India] *[http://www.emedicine.com/ped/topic2840.htm History of pediatric liver transplantation]<!--do we need a separate listing for pediatric liver transplantation?--> *[http://www.abcsalutaris.com/article1.php?a=504 ABC Salutaris: Living Donor Liver Transplant] *[http://causaleffect.blogspot.com Organ Donation Awareness and former potential donor blog] *[http://www.mssm.edu/rmti/liverdonor.shtml All You Need to Know about Adult Living Donor Liver Transplantation] <!--the immunosuppressive management is often left to the gastroenterologists--> *[http://www.childliverdisease.org/transplant Children's Liver Disease Foundation] {{Organ transplantation}} {{Digestive system surgical procedures}} [[Category:Surgery]] [[Category:Gastroenterology]] [[Category:Transplantation medicine]] [[Category:Hepatology]] [[bg:Чернодробна трансплантация]] [[de:Lebertransplantation]] [[fr:Transplantation hépatique]] [[it:Trapianto di fegato]] [[he:השתלת כבד]] [[nl:Levertransplantatie]] [[pl:Przeszczepienie wątroby]] [[pt:Transplante de fígado]] [[fi:Maksansiirto]]