Liver Pre Transplant
There are several phases of the transplant process. The first phase is considered the pre-transplant evaluation phase. There is an extensive pre-evaluation process where providers and transplant nurse coordinators review your medical information, a patient access services staff person will review your insurance benefits and a financial counselor will review your ability to afford all of the costs associated with transplantation.
Your insurance company will need to review your case, and give authorization for the costs associated with transplant. Many forms and tests need to be completed before you can be added to the liver transplant waitlist. Once we receive authorization from your insurance company and hospital administration, and it has been determined you are medically acceptable, you will move to the next phase.
The evaluation usually requires a 1-3 day stay in Portland if you do not live locally. Your transplant evaluation is usually done on an outpatient basis unless you are critically ill and require hospitalization. You will attend a class that will teach you about transplantation and review information. You will also have the opportunity to ask questions.
During the evaluation, you will have appointments with many specialists in addition to members of the liver transplant team. You will also have lab work and diagnostic tests performed. The tests vary for each person.
Selection Process and Waitlist
After all the testing and appointments have been completed, your case is presented at the liver committee review meeting which is held once a week. Members of the liver transplant team are present and your case is discussed. It will be decided if you meet all the criteria to be a liver transplant candidate.
The team may require additional testing or requirements to be met before you can be put on the liver transplant waitlist. Once all of the team's recommendations are completed and you are an acceptable candidate, you will be placed on the liver transplant waiting list.
Liver Transplant Surgery
Once you have been called in for your liver transplant surgery, it is important for you to have this day planned out ahead of time. How will you get to the hospital? Where do you go? What do you bring?
When you get the call for your transplant, you need to arrive at OHSU South Hospital 9th floor Admitting. You will then go to Unit 4A where the nurses and doctors will prepare you for the surgery.
The time before the surgery is very busy. A resident, intern, or physician assistant will perform a physical examination and take a complete history. You will need to bring a complete list of all your medications. At this time you will be asked to sign one or more consent forms giving your permission to the surgeons to perform the surgery.
In addition to the physical, you will receive a chest X-ray, EKG and blood tests. The nurses will start an intravenous line (IV) for antibiotics to prevent infection. Finally, you will need to scrub twice with a special antibacterial soap prior to going to the operating room. When it is time, the nurses will take you to the operating room. Once you are placed under anesthesia, the transplant team goes to work.
Length of Surgery
The average length of time for a liver transplant is eight hours and may vary from less than six hours to more than 13 hours. The length of time does not predict the success of the surgery. Patients with a past history of abdominal surgery usually take longer during liver transplant because of old scar tissue present in the abdominal cavity. When the surgery is complete, the surgeons close your incision. The incision is closed on the outside with staples. The staples stay in place for at least three weeks and are removed during one of your clinic visits.
While you are in surgery, your family and friends can wait in the intensive care waiting area. The operating room nurses may come out during the surgery to give you a progress report. It's helpful to identify one spokesperson when communicating to the nursing staff, who will then pass along information to family and friends.
Surgical Intensive Care Unit (SICU)
You will wake up from the transplant operation in the Surgical Intensive Care Unit. The sights and sounds may seem strange to you. You will be attached to many tubes, IV lines, and monitors. The average length of stay in the SICU is 2 days. This will vary depending on how you respond to the surgery, how quickly you recover from the anesthetic and how sick you were prior to the transplant. When you wake up, you may experience some confusion due to the anesthetic. When you are stable, the doctors will remove some of the monitors, intravenous (IV) lines and tubes, and you will be transferred to the Transplant Unit.
The Transplant Unit
The average length of stay on the Transplant Unit is 5-8 days. This makes your total hospitalization stay approximately 10 days. This varies depending on your overall post-transplant recovery. After your surgery you may feel many different emotions. Many people feel relief that it is over. It is not uncommon to feel depressed or anxious after the surgery. All these emotions are common and most people feel a little of each. While you are on the Transplant Unit you have some important responsibilities before you can be discharged, including eating, walking, coughing and deep breathing.
The Transplant Team will discharge you when:
- You are physically stable.
- You know your medications and can set up each dose.
- You know your clinic and lab schedule.
- You meet the conditions identified on the discharge review worksheet (reviewed by the coordinators).
- You have arrangements for a place to stay when leaving the hospital.
You will learn all about your new liver, how to take care of it, how to prevent infection, your medications and your clinic and lab schedule. The coordinators, nutritionists, pharmacists and nurses will teach you how to take care of yourself now that you have your new liver. You will have received a manual. This is your lifelong guide that you will need to continue to refer to. The transplant team expects you and your social support to participate in your education during your hospital stay. The transplant coordinator and the pharmacist will come to your room to answer questions and review your medications. Prior to your discharge, you and your support will need to complete a worksheet on the information you learned.
Caring for Yourself After a Liver Transplant
You are the most important member of your care team. You need to be actively involved in your care by attending clinic appointments, getting your labs drawn, communicating with members of your care team and understanding how to take care of your new liver.
To help care for your liver, you will need to:
- Take medications as directed, and ask your doctor before taking any other medications, including over-the-counter medications and dietary supplements.
- Eat a healthy diet, exercise, not smoke cigarettes and not drink alcohol.
- Contact your doctor if you are feeling ill.
- Have your labs drawn as directed by your doctor, including any additional testing.
- Follow lifting, walking, showering and activity restrictions.
- Refrain from driving until you are no longer taking narcotics and are down to 10mg of prednisone per day.
At the end of 2-3 months you will return to your local provider for care. The transplant team will continue to monitor your liver function, and medication levels through routine lab work. We will work with your local provider to help manage your care. You will have regular follow-up visits during the first year post transplant and then annually for the first five years, and then as needed every five years.
It is very important to learn how to manage your medications. You will need to understand what they are for, when they need to be taken, how it is given, and what side effects you might experience. There can be many possible drug interactions between your post-transplant medications and herbs/over-the-counter dietary supplements.
Do not take herbs or dietary supplements without first consulting with your transplant physician.
Transplant patients should never take medications or herbs intended to "boost" their immune system. Only the transplant team should make changes to your kidney drugs (immunosuppression medications). If any of your other doctors want to make changes, please have them contact the transplant team.
For the first month following transplant you will have your labs drawn twice a week on Mondays and Thursdays. The table below shows a normal lab schedule for a liver transplant patient.
|Months Post Transplant||Lab Schedule|
|1 month||Monday, Thursday|
|2-6 months||Every Monday|
|7-12 months||Every other Monday|
|1 year and thereafter||First Monday of every month|
Liver rejection is usually diagnosed by looking at the liver function tests. Your doctor may suspect that you have rejection if any of these numbers are increased from the normal range. This could be confirmed by a liver biopsy.