In collaboration with French association SOS hépatites.
When the liver is too damaged to fulfill its functions, one last possibility remains: transplant. It consists of replacing the diseased liver with a healthy one, taken (most of the time) from a donor who is brain dead.
In a country like France, some 1,300 to 1,400 liver transplants are performed each year (2015 data), for an average of 3,000 applicants. In other words, more than two candidates for a single donor!
To find out who can benefit from a transplant, two questions must be answered:
– Is the transplant justified?
– And if so, does the patient have priority?
In which cases is a liver transplant justified?
A transplant is considered when the liver no longer able to fulfill its vital functions.
– In case of advanced cirrhosis (decompensated cirrhosis),
– In case of liver cancer.
Who has priority?
Since there are not enough transplants, priorities need to be set: the most seriously affected people go before those who can wait. But to make the intervention successful, the general condition of the patient must allow the operation.
Too severe hepatic insufficiency increases the risk of operative and postoperative complications, and thus the chances of survival … It is considered that the transplant should be attempted if the chances of survival at 5 years are at least 50%.
In many countries, the main criteria used to objectify priorities in case of hepatic insufficiency is the Model for End-stage Liver Disease (MELD) score, which integrates various parameters and crosses them with the origin of cirrhosis.
But this MELD score does not say everything. It can – and should – alsobe supplemented by expert advice, taking into account specific criteria.
A long waiting … and sometimes you get off of the list
Some people, even in decompensated cirrhosis, have difficulty accessing the transplant because other patients are in a worse situation than theirs.
The time spent on the waiting list is variable, but it can reach a year or more. Of course, careful monitoring of these people is essential (CT and MRI every three months). If their situation gets worse, then they become priority.
But with the new treatments for hepatitis C, another phenomenon mayoccur: some people eligible for a liver transplant and who have managed to getrid of the virus see their situation improve to the point that they are nolonger considered as transplant candidates and leave the waiting list.
Strategies to deal with the shortage
To face the lack of grafts taken from people in brain death, severalstrategies are possible. Because of the very high regenerative capacity of theliver, a part of the organ can be taken from a living donor, or a liver can bedivided between two recipients…
The living donor
Organ donation by a living donor is mostly done for the kidney. But one can also consider a liver sample on living donor. Since the liver is unique in its regenerative properties, it is possible to take a part of the liver from a healthy donor and transplant it into the patient with liver disease. Over time, the partial liver transplant will develop into a fully functioning liver. The spouse of the recipient, his brothers or sisters, sons or daughters, grandparents, uncles or aunts, first cousins and first cousins and the spouse of his father or mother may be authorized to lend.
The donor may also be any personbringing proof of a life of at least two years with the recipient. Of course,the donor must be “compatible” at the genetic level. It must also bemajor, and previously informed by a committee of experts.
The split of the liver
It is possible to divide a liver in two parts, and implant each of theseparts on a different recipient. Unfortunately, this split is rarely possibleamong two adults: the part of the left liver, very small, can be graftedeffectively only on a child or a very small adult.
The domino transplant
In case of hereditary neurological disease related to the liver, a”domino” transplant can be performed. A person with this disease mustultimately benefit from an organ donation. But its own liver, although carryingthe genetic anomaly, can be implanted on another person who urgently needs atransplant. The disease can then appear in the recipient, but many years lateronly.
The positive donor for hepatitis C virus
Now, with the progress of hepatitis C treatments, it is possible to transplantotherwise healthy HCV infected livers intoHCV infected recipients. In this case, the patient will be treated for the HCVinfection post transplant, resulting in a virus free liver in a virus freepatient.
Before transplant, the waiting period can be extremely distressing for both patient and surroundings. We do not dare to leave, we have the phone permanently at hand, and we can feel helpless in the face of the advance of the disease. It is important not to be alone during these moments of doubt, and to be able to share them with third parties, psychologists, caregivers or other patients.
The period preceding the operation can also be used to focus on the social situation of the person awaiting transplant, by meeting with a social worker from the hospital or transplant center, as soon as the pre- graft. You can also talk to a local social worker (Municipal Social Action Center, County Council, Social Security, etc.) present in some associations. It is a useful way not to remain inactive while facing the disease, and to project yourself into post-transplant.
After the operation, a completely different period of life begins,always punctuated by medical monitoring and medication.
After liver transplant, you can regain an almost normal diet. However, you must be extremely vigilant to prevent any food infection, because consequences can be particularly serious on a person under anti-rejection treatment.
Your diet should be varied, balanced and as regular as possible, because of the constraints posed by the different medications (3 meals a day, and possibly 1 or 2 snacks). It should also consider antirejection drugs, including corticosteroids that promote fluid retention, weight gain and diabetes.
Do not hesitate to read our article on this subject.
Prevention from food infections
During the first six months following the transplant, you will also need:
– To eliminate the following foods: cold cut meats, raw milk and dairy products, raw and undercooked shellfish, smoked fish, tarama, sprouted seeds, raw or undercooked eggs, chocolate mousse, homemade mayonnaise, delicatessen mayonnaise, vegetables raw or poorly washed, meat and fish unheated or not cooked;
– Banish ice cubes and filter decanters, which may be microbe nests;
– Eat fresh by respecting the expiry dates and not keeping leftovers for more than a day in your refrigerator;
– Respect the hygiene of the kitchen: wash your hands before preparing or taking meals, regularly clean the refrigerator with bleach diluted in cold water.
– Hydrate yourself, while avoiding too salty waters that favor retention.
– Forget alcohol, because of its toxicity on the liver.
– Limit the consumption of sugar and sweet products (sugar, jam, chocolate, cookies, pastries, sodas …) to prevent excessive weight gain.
– Avoid grapefruit whose components interact with immunosuppressive therapy.
The recovery of a physical activity is important after the transplant because it makes it possible to fight against overweight, arterial hypertension and diabetes. Everyone has to choose an activity adapted to their preferences and their health, while avoiding violent practices that can harm the liver.
Soft outdoor activities, such as walking or cycling, are highly recommended, except during periods of intense heat and as long as you are well hydrated.
In the first months, wearing a lap belt is required to support the weak abdominal muscles after transplant.
Swimming enthusiasts will have to reach the removal of the bile drain if it has been laid.
Remember to protect your skin from sunlight: the fall of the immune defenses favors the occurrence of skin cancers. Consult a dermatologist once a year, and for any mole or button that changes shape or does not heal.
Tell your doctor any fever over 38 ° C, any other sign of infection (cold, urinary tract infection, pimples on the skin, weight loss …) or anything that seems strange and unusual. Your immune defenses are weakened, so an infection needs to be treated quickly.
To limit the risks, it is also important to be vaccinated (at least six months after the transplant), especially against influenza, hepatitis A and B and pneumococcus. In contrast, all live vaccines are contraindicated (yellow fever, BCG, MMR, live attenuated influenza and chickenpox).
Finally, be aware that some heavy dental operations, with risk of infection (an extraction for example) may justify the prescription of a preventive treatment with antibiotic (but not any!).
Sexuality and pregnancy
There is no medical contraindication to sex after a transplant. However, anti-rejection treatments can also cause problems of libido or excitation (erection, lubrication).
Transplantation restoring the menstrual cycle, women of childbearing age should therefore consider a method of contraception, which should be discussed with the doctor (especially for the pill).
A pregnancy can be considered after a liver transplant, but it is better to wait at least 1 year, when the risk of rejection decreases. Immunosuppressive therapy will be maintained, but may need to be modified. Such project requires consultation between the hepatologist and the gynecologist, for an optimal follow-up.
Work recovery depends of course on your condition and the nature of the work, but it should not be too early. The hepatologist sets the initial duration of your work stoppage, but the date of recovery is the responsibility of the labour doctor. This recovery can be gradual, as part of a part-time therapeutic.
As for work, driving recovery must be progressive: driving is not an insignificant act! Get along the first few times, and start with small trips.
Before going on a trip, talk to the doctor who follows the transplant. You will have to:
– update your vaccinations (however, live vaccines, such as yellow fever, are contraindicated to transplant recipients);
– provide your medication for the duration of the trip (be careful, some are to be kept away from heat);
– check that you are covered for possible repatriation As soon as you plan your trip, make an appointment with the doctor who ensures your follow-up transplant. Make sure your insurance covers medical expenses and possible repatriation.
Want to know the steps of a liver transplant? Read our article