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Life Expectancy After Liver Transplant

Not all diseases can be cured with just medications; sometimes extreme measures like organ transplant become necessary. A liver transplant is one of the commonest organ transplants happening around the world at the time. It is done on individuals with terminal or advanced liver disease.

Today there are more than one hundred liver transplant centers in over 80 countries around the globe. In the year 2018 alone, there have been nearly 34,000 liver transplants in the entire world. Of them, the majority was conducted in the United States with an approximate value of 12,221 per year.(1)

Reason behind liver transplantation

One simply cannot live without a liver! It is in fact one of the most important organs in the body. When the liver reaches a point where it can no longer function properly in order to serve the body, without any other means of compensation, or in other words; at the end-stage of liver disease, a liver transplant becomes the only option.

Cirrhosis is the main culprit behind terminal liver disease and it the result of a long-term process happening progressively inside the liver. Healthy tissues in the liver get damaged and are replaced by scar tissue formation. As a result, the liver fails to perform its vital functions giving rise to symptoms like abdominal swelling, bleeding abnormalities, yellowish-discoloration of the skin, itchiness and many more.

The main causative factor behind liver disease is excessive alcohol consumption. Some times viral infections like Hepatitis-B and Hepatitis-C can also lead to liver cirrhosis. Apart from them, non-alcoholic steatohepatitis, a condition that causes inflammation of the liver due to extreme fat deposition, is another common reason.

Here are a few other indications for liver transplant:

Different Types of liver transplant

There are 2 main types of liver transplants in the world at the moment. The liver to be transplanted can come from either a donor who is alive or from a person who has passed away.

Living Donor Transplants

This procedure usually happens among family members or close relatives. A living donor gives a part of his/her liver in order to replace the damaged liver of the recipient.

The unique feature of a liver is that it has the ability to regrow into its regular size with time. Both the donor’s and the recipient’s livers achieve their regular sizes over time giving full function to both individuals.

However, when compared with diseased donor transplants, living donor transplants are relatively less common.

Deceased donor transplants

This is the most common type of liver transplant performed in the world at the moment. The donor liver comes from an individual who has just passed away, especially from someone who is brain-dead.

In this surgical procedure, the already damaged liver is surgically resected and replaced with the donor’s healthy liver.

Since, it is difficult to come across donor organs all the time, a single liver can be shared among a couple of recipients; giving a large portion to an adult and a smaller portion to a child.

The Transplant Evaluation Process

A comprehensive evaluation process is carried out by a multidisciplinary team prior to liver transplantation. Usually the team consists of a number of professionals including a transplant surgeon, a hepatologist, nurses, dietitian, social workers and many more.

The main goals of transplant evaluation is to define the indication for transplant and to determine the best timing for listing.(2)It is important to identify special circumstances that each and every case could comprise of. It is also mandatory to plan for care and support needed in advance, to minimize risk at transplantation and beyond.

Survival after liver transplant

The main aim of performing liver transplantation or any kind of organ transplant for that matter, is to prolong survival and to improve the quality of life.

In the earliest days of liver transplant, as in the early 1970s the success rate of the procedure was limited to about 30%. The main reason behind this was that a majority of liver transplant recipients died as a result of organ rejection after surgery either with or without infection.

However, today liver transplant is considered more as a life-saving procedure and not vice versa.

Current statistics show that;

The indications with better survival rates include primary biliary cirrhosis and autoimmune cirrhosis. On the other hand, individuals with liver malignancies or Hepatitis-B infection may have comparatively worse outcomes, mainly due to high rates of disease recurrence.

Factors that influence the survival rate after liver transplantation

Many factors may influence the overall success of the liver transplant procedure. These factors could be due to donor factors, recipient factors, peri-operative conditions and post-operative conditions.

Donor factors that might result in poor outcomes after surgery

 Recipient factors that might result in poor outcomes after surgery

Perioperative factors that might result in poor outcomes after surgery

Postoperative factors that might result in poor outcomes after surgery

Complications after liver transplantation

No matter how impressive the latest survival rates have become, liver transplant recipients have an estimated loss of 7 years in their lifetime when compared with a similar group of individuals with the same age and sex in the general population.(5)

Complications of liver transplant surgery can be categorized into two main groups.

Short-term complications

Studies show that the majority of deaths related to the transplantation procedure occurs immediately after surgery. Some other instances might require re-transplantation as well. Primary non-function and infections are the main reasons behind such failures.

There’s a chance that the recipient’s body might reject the newest addition and start attacking it. Besides, the new liver might not work properly quite as anticipated owing to a number of reasons, mainly due to graft failure.

In order to prevent rejection, the recipient may need to be on life-long immunosuppression medications. In addition, avoiding crowded places and dodging any contact with another person with an ongoing infection during the first few months is quite important.

After the initial period, occurrence of de-novo malignancies in the liver can occur as well. Furthermore, there’s a possibility of recurrence of hepatitis-like infections and other co-morbidities including cardiovascular diseases after this period.

Long-term complications

Since liver transplantation is a very complex surgical procedure, complications can arise even after a very long post-operative duration.

Here’s a list of such complications that can occur with long-term survival.

Who cannot undergo liver transplantation?

Just like the liver transplant procedure itself, the indications and contraindications of liver transplantation has drastically evolved over the past years as well.

Some instances where this life-saving procedure was not recommended in the early years of practice have now become routine indications with excellent survival rates.

For example, in the earliest days, patients with Hepatitis B infection were not recommended to undergo liver transplant surgery, since their chance of survival after the procedure was quite low as a result of uncontrolled viral replication. Note this was way before the introduction of all the sophisticated antivirals and hepatitis B immunoglobulin like treatment modalities that we have now.

Not only that, there was a time when HIV-infected individuals were also advised against undergoing liver transplantation. At the time, HIV was considered as an absolute contraindication.

However, with the introduction of highly active antiviral therapies along with new insight on various drug interactions, this perception has drastically changed. Now they are also regarded as potential candidates and their suitability to undergo surgery is evaluated individually in each case as relevant.

It is clear that with time and the introduction of new ways to overcome the obstacles, liver transplantation has become a more appropriate and widely available option for many individuals with terminal liver disease along with multiple co-morbidities.

Now, we’ll look at a few conditions which are absolute and relative contraindications for liver transplantation. Absolute contraindications mean the surgery cannot be performed no matter what. But on the other hand, in relative contraindications, the surgical procedure can be done after assessing each and individual case scenario.

Absolute contraindications

Relative contraindications

Post-transplant Care

After liver transplant surgery, a close follow-up program is mandatory. The main goal of post-transplant care is to reduce complications such as infections and cardiovascular risk. Thorough monitoring for cancers and the resurgence of any recurrent illnesses should be given high priority as well.

In the long-term follow up of a transplant patient, the care system gradually shifts from a transplant center to primary gastrointestinal and primary care teams in a systematic manner.

Medications are gradually weaned off and if everything goes well, the patient can stop steroids at 3 months and most other prophylactic drugs at 6 months. In the case of a child, return to school can be done at early as 3 months after surgery.(2)

However, most of the immunosuppressant medications have to be continued life-long. A dose reduction is usually done after a period of one year to achieve a minimal dose as possible, in order to overcome rejection.

As long as no serious complications arise, yearly follow-ups would be sufficient after the initial period.

Here are a few steps that can be taken to improve liver transplantation care.

Apart from the above technical steps, the individuals who undergo liver transplants can also implement changes in their lifestyles to protect their new livers.

It is important to maintain healthy dietary habits and consume a balanced diet as much as possible. For this purpose, the help of a dietitian can be obtained quite easily.

Also, regular exercise will keep cardiovascular diseases like co-morbidities at bay making them physically fit. However, strenuous or vigorous exercise should be avoided at all costs during the first three months of surgery and it is always better to seek medical advice before starting an extensive exercise schedule.

Meanwhile staying hydrated, avoiding smoking, avoiding alcohol and not getting into contact with individuals with infections are a few other initiatives that can be taken.

Liver transplantation has become a less risky and more efficient surgical procedure now than it had been 50 years back. With the introduction of novel surgical techniques, immunosuppressant medications, prophylaxis treatments for infections and new ways of defeating recurrent diseases, it has achieved a very high success rate.

Not to mention with the implementation of efficient organ allocation and donor selection programs the entire process has become reasonably smooth going and more accessible to thousands across the globe.

This particular branch of transplant surgery is constantly evolving like any other. Perhaps the discovery of better ways to beat long-term complications caused by immunosuppressants on other vital organs inside the body like the kidneys, could lead to better and much improved survival rates and favorable outcomes in the future than we experience today.

References

1.          Liver transplants worldwide number by region 2018 | Statista [Internet]. [cited 2021 Mar 3]. Available from: https://www.statista.com/statistics/398685/liver-transplants-by-world-region/

2.         Rawal N. Pediatric Liver Tra n s p l a n t a t i o n. Pediatr Clin NA [Internet]. 2017;64(3):677–84. Available from: http://dx.doi.org/10.1016/j.pcl.2017.02.003

3.         Song ATW, Avelino-Silva VI, Pecora RAA, Pugliese V, D’Albuquerque LAC, Abdala E. Liver transplantation: Fifty years of experience. World J Gastroenterol. 2014;20(18):5363–74.

4.         Definition & Facts of Liver Transplant | NIDDK [Internet]. [cited 2021 Mar 5]. Available from: https://www.niddk.nih.gov/health-information/liver-disease/liver-transplant/definition-facts

5.         Barber K, Blackwell J, Collett D, Neuberger J. Life expectancy of adult liver allograft recipients in the UK. Gut. 2007;56(2):279–82.