Liver Transplant

With a living donor transplant, a healthy person donates part of his or her liver to the recipient. This procedure has been increasingly successful and shows promise as an option to avoid long waiting times due to a shortage of liver donors.

• The liver is the second most commonly transplanted major organ, after the kidney, so it is clear that liver disease is a common and serious problem in this country.
• It is important for liver transplant candidates and their families to understand the basic process involved with liver transplants, to appreciate some of the challenges and complications that face liver transplant recipients (people who receive livers), and to recognize symptoms that should alert recipients to seek medical help.
• Some basics are as follows:
  • The liver donor is the person who gives or donates, all or part of his or her liver to the waiting patient who needs it. Donors are usually people who have died and wish to donate their organs. Some people, however, donate part of their liver to another person (often a relative) while living.
  • Orthotopic liver transplantation refers to a procedure in which a failed liver is removed from the patient's body and a healthy donor liver is transplanted into the same location. This procedure is the most common method used to transplant livers.
  • With a living donor transplant, a healthy person donates part of his or her liver to the recipient. This procedure has been increasingly successful and shows promise as an option to avoid long waiting times due to a shortage of liver donors. It is also an option in children, partly because child-sized livers are in such short supply. Other methods of transplantation are used for people who have potentially reversible liver damage or as temporary measures for those who are awaiting liver transplants. These other methods are not discussed in detail in this article.
• The body needs a healthy liver. The liver is an organ located on the right side of the abdomen below the ribs. The liver has many vital functions.
• It is a powerhouse that produces varied substances in the body, including

1. glucose, a basic sugar, and energy source;
2. proteins, the building blocks for growth;
3. blood-clotting factors, substances that also aid in healing wounds; and
4. bile, a fluid stored in the gallbladder and necessary for the absorption of fats and vitamins.

• As the largest solid organ in the body, the liver is ideal for storing important substances like vitamins and minerals. It also acts as a filter, removing impurities from the blood. Finally, the liver metabolizes and detoxifies substances ingested by the body.
• Liver disease occurs when these essential functions are disrupted.
• Liver transplants are needed when damage to the liver severely impairs a person's health and quality of life.

People who have the liver disease may have many of the following problems:

• Jaundice - Yellowing of the skin or eyes
• Itching
• Dark, tea-colored urine
• Gray- or clay-colored bowel movements
• Ascites - An abnormal buildup of fluid in the abdomen
• Vomiting of blood
• Blood in the stool
• Tendency to bleed
• Mental confusion, forgetfulness

Liver disease severe enough to require a liver transplant can come from many causes. Doctors have developed various systems to determine the need for the surgery. Two commonly used methods are by specific disease process or a combination of laboratory abnormalities and clinical conditions that arise from the liver disease. Ultimately, the transplantation team takes into account the type of liver disease, the person's blood test results, and the person's health problems in order to determine who is a suitable candidate for transplantation.

In adults, cirrhosis from alcoholism, hepatitis C, biliary disease, or other causes are the most common diseases requiring transplantation. In children, and in adolescents younger than 18 years, the most common reason for liver transplantation is biliary atresia, which is an incomplete development of the bile ducts.

Laboratory test values and clinical or health problems are used to determine a person's eligibility for a liver transplant.

• For certain clinical reasons, doctors may decide that a person needs a liver transplant. These reasons may be health problems that the person reports, or they may be signs that the doctor notices while examining the potential recipient. These signs usually occur when the liver becomes severely damaged and forms scar tissue, a condition known as cirrhosis.
  • Common clinical and quality-of-life indications for a liver transplant include ascites, or fluid in the belly due to liver failure.
  • In the early stage of this problem, ascites may be controlled with medicines (diuretics) to increase urine output and with dietary modifications (limiting salt intake).
  • Another serious consequence of liver disease is hepatic encephalopathy. This is mental confusion, drowsiness, and inappropriate behavior due to liver damage.
• Several other clinical problems may arise from liver disease.
  • Infection in the abdomen, known as bacterial peritonitis, is a life-threatening problem. It occurs when bacteria or other organisms grow in the ascites fluid.
  • Liver disease causes scarring, which makes blood flow through the liver difficult and may increase the blood pressure in one of the major blood vessels that supply it. This process may result in serious bleeding.
  • Blood may also back up into the spleen and cause it to increase in size and to destroy blood cells.
  • Blood may also go to the stomach and esophagus (swallowing tube). The veins in those areas may grow and are known as varices. Sometimes, the veins bleed and may require a gastroenterologist to pass a scope down a person's throat to evaluate them and to stop them from bleeding.
• These problems may become very difficult to control with medicines and can be a serious threat to life. A liver transplant may be the next step recommended by the doctor.

Determining whose need is most critical: The United Network for Organ Sharing uses measurements of clinical and laboratory tests to divide patients into groups that determine who is in most critical need of a liver transplant. In early 2002, UNOS enacted a major modification to the way in which people were assigned the need for a liver transplant. Previously, patients awaiting livers were ranked as status 1, 2A, 2B, and 3, according to the severity of their current disease. Although the status 1 listing has remained, all other patients are now classified using the Model for End-Stage Liver Disease (MELD) scoring system if they are aged 18 years or older, or the Pediatric End-Stage Liver Disease (PELD) scoring system if they are younger than 18 years. These scoring methods were set up so that donor livers could be distributed to those who need them most urgently.

• Status 1 (acute severe disease) is defined as a patient with the only recent development of liver disease who is in the intensive care unit of the hospital with a life expectancy without a liver transplant of fewer than 7 days, or someone who received a liver transplant and the donor organ never worked properly.
• MELD scoring: This system is based on the risk or probability of death within 3 months if the patient does not receive a transplant. The MELD score is calculated based only on laboratory data in order to be as objective as possible. The laboratory values used are a patient's sodium creatinine, bilirubin, and international normalized ratio, or INR (a measure of blood-clotting time). A patient's score can range from 6 to 40. In the event of a liver becoming available to 2 patients with the same MELD score and blood type, time on the waiting list becomes the deciding factor.
• PELD scoring: This system is based on the risk or probability of death within 3 months if the patient does not receive a transplant. The PELD score is calculated based on laboratory data and growth parameters. The laboratory values used are a patient's albumin, bilirubin, and INR (a measure of blood-clotting capability). These values are used together with the patient's degree of growth failure to determine a score that can range from 6 to 40. As with the adult system, if a liver were to become available to two similarly sized patients with the same PELD score and blood type, the child who has been on the waiting list the longest will get the liver.
• Based on this system, livers are first offered locally to status 1 patients, then according to patients with the highest MELD or PELD scores. Patients on the local list with a MELD score above a certain level are offered the liver first, then it is allocated to regional and national listed patients. Once that list is exhausted, the liver is offered to other patients on the local regional, and national levels, in that order. There are ongoing discussions to modify the liver allocation process to ensure that the sickest patients receive them first, regardless of where they live.
• Status 7 (inactive) is defined as patients who are considered to be temporarily unsuitable for transplantation.

Who may not be given a liver: A person who needs a liver transplant may not qualify for one because of the following reasons:

• Active alcohol or substance abuse: Persons with active alcohol or substance abuse problems may continue living the unhealthy lifestyle that contributed to their liver damage. Transplantation would only result in failure of the newly transplanted liver.
• Cancer: Active cancers in locations other than just the liver weigh against a transplant.
• Advanced heart and lung disease: These conditions prevent a patient with a transplanted liver from surviving.
• Severe infection: Such infections are a threat to a successful procedure.
• Massive liver failure: This type of liver failure accompanied by associated brain injury from increased fluid in brain tissue rules against a liver transplant.
• HIV infection

The transplantation team: If a liver transplant is considered an option by a primary doctor, the person must also be evaluated by a transplantation team to determine their candidacy. The transplantation team usually consists of a number of people, including a transplant coordinator, a social worker, a hepatologist (liver specialist), and a transplant surgeon. It may be necessary to see a cardiologist (heart specialist) and pulmonologist (lung specialist), depending on the recipient's age and health problems.

• The potential recipient may also see a psychiatrist or psychologist because of psychiatric or substance abuse issues, and the liver transplantation process may be a very emotional experience that may require life adjustments.
• The liver specialist and the primary doctor manage the person's health issues until the time of transplantation.
• A social worker is involved in the case. This person assesses and helps develop the patient's support system, a central group of people on whom the patient can depend throughout the transplantation process. A positive support group is very important to a successful outcome. The support group can be instrumental in ensuring that the patient takes all the required medicines, which may have unpleasant side effects. The social worker also checks to see that the recipient is taking medications appropriately.

The search for a donor: Once a person is accepted for transplantation, the search for a suitable donor begins. All people waiting are placed on a central list at UNOS, the national agency involved in finding suitable livers. Local agencies, the Organ Procurement Organizations (OPO), facilitate the identification and procurement of livers for distribution through UNOS. The United States has been divided into regions to try to fairly distribute this scarce resource. Many donors are victims of some sort of trauma and have been declared brain dead. A donor with the right blood type and similar bodyweight is sought. Rejection occurs when the patient's body attacks the new liver.

• With the shortage of donor organs and the need to match donor and patient blood and body type, the waiting time may belong. A patient with a very common blood type has less chance of quickly finding a suitable liver because so many others with his or her blood type also need livers. Such patients are more likely to receive a liver-only if they have very severe liver disease or are in the intensive care unit. A patient with an uncommon blood type may receive a transplant more quickly if a matching liver is identified because people higher on the transplant list may not have this less usual blood type.
• The length of time a person waits for a new liver depends on blood type, body size, and how sick the patient is who needs a transplant. Where the patient lives can also impact the availability of donor organs. During the wait, it is important to stay in good physical health. Following a nutritious diet and a light exercise plan are important. In addition, regularly scheduled visits with the transplantation team may be scheduled for health examinations. A patient also receives vaccines against certain bacteria and viruses that are more likely to develop after the transplantation because of immunosuppression (antirejection) medication.

Living donors: Avoiding a long wait is possible if a person with liver disease has a living donor who is willing to donate part of his or her liver. This procedure is known as living donor liver transplantation. The donor must have major abdominal surgery to remove the part of the liver that will become the graft (also called a liver allograft, which is the name for the transplanted piece of liver). As techniques in liver surgery have improved, the risk of death in people who donate a part of their liver has dropped to about 1%. The donated liver will be transplanted into the patient. The amount of liver that is donated will be about 50% of the recipient's current liver size. Within 6-8 weeks, both the donated pieces of liver and the remaining part in the donor grow to normal size.

• Until 1999, living donor transplantation was generally considered experimental, but it is now an accepted method. In the future, this procedure will be used more often because of the severe lack of livers from recently deceased donors.
• The live donor procedure also allows greater flexibility for the patient because the procedure may be done for people who are in the lower stages of liver disease.
• With a living donor, patients healthy enough to live at home may still receive a liver transplant electively when their health is optimum for the operation. The living donor transplantation may also be more widely used because of the increase in hepatitis C virus infection and the importance of quickly finding donors for people who have liver cancer. Finally, the success with living donor kidney transplants has encouraged increased use of such techniques.
• Recipients of a living donor liver transplant go through the same evaluation process as those receiving a deceased donor liver (a liver from someone who has died). The donor also has blood tests and imaging studies of the liver performed to make sure it is healthy. The living donors, as with the deceased donors, must have a compatible blood type to the recipient. They usually are 18-55 years old, have a healthy liver, and be able to tolerate the surgery. The donor cannot receive any money or other form of payment for the donation. Finally, the donor must have a good social support system to aid in the emotional aspects of going through the procedure.
• People who have liver disease or alcoholism are not allowed to donate part of their liver. Those who smoke chronically or who are obese or pregnant also cannot make such donations. If the potential donor does not have a compatible blood type or does not meet these criteria, the recipient may continue to be listed on the UNOS registry for a transplant from a deceased donor.

A donor is found: Once a suitable deceased donor liver has been found, the patient is called to the hospital. The patient should carry a beeper or cell phone as he or she rises on the transplant list so that they can be contacted and get to the hospital. Donor's livers function best if they are transplanted within 8 hours, although they can be used for up to 24 hours. Presurgical studies, including blood tests, urine tests, chest X-rays, and an ECG, are performed. Before surgery, several IV lines are started. The patient also receives a dose of steroids-one of the medicines to prevent rejection of the new liver-and a dose of antibiotics to prevent infection. The liver transplantation procedure takes about 6-8 hours. After the transplantation, the patient is admitted to the intensive care unit.

If a patient comes to the hospital or an emergency department, the doctor will obtain blood tests, liver function tests, blood clotting tests, electrolytes, and kidney function tests. The doctor may also draw blood levels of certain immunosuppressive medications to make sure they are in the right range. If an infection is considered possible, cultures for viruses, bacteria, fungi, and other organisms may be grown. These may be checked for in the urine, sputum, bile, and blood.

Pretransplant tests are done to evaluate the severity of the liver disease and to determine when the patient should be placed on the waiting list. Once this initial evaluation is complete, the case is presented to a review committee of physicians and other staff members of the hospital. If the person is accepted as a candidate, he or she is placed on the waiting list for a liver transplant. A recipient may undergo some of the following tests before the transplantation:

• CT scan of the abdomen: This is a computerized picture of the liver that allows the doctor to determine the liver size and to identify any abnormalities, including liver tumors, that may interfere with the success of liver transplantation.
• Ultrasound of the liver: This is a study that uses sound waves to create a picture of the liver and the surrounding organs. It also determines how well the blood vessels that carry blood to and from the liver are working.
• ECG: Short for electrocardiogram, this is a study that shows the electrical activity of the heart.
• Blood tests: These include blood type, blood cell count, blood chemistries, and viral studies.
• Dental clearance: A person's regular dentist may fill out the form. Immunosuppressive medications may increase the chance of infection and if the teeth have cavities or periodontal disease, this can lead to infection. Therefore, a dental evaluation is important before beginning these medicines.
• Gynecological clearance: The patient's gynecologist may provide clearance.
• Purified protein derivative (PPD) skin test: The PPD test is performed on the arm to check for any exposure to tuberculosis.

Call the transplant team whenever a patient with a newly transplanted liver feels unwell or has concerns about his or her medications. The patient should also call the transplant doctor if new symptoms arise. These problems may commonly occur before liver transplantation and indicate that a patient's liver disease is worsening. They may also occur after transplantation and be a possible sign that the liver is being rejected. The doctor may recommend that the patient be taken to a hospital emergency department for further evaluation.

Acute rejection usually occurs in the first 1-2 months after the transplantation. It is common for the patient to require 1 admission to the hospital for either rejection or infection. The following are just a few examples of when to call the doctor:

• A patient may bleed after surgery, which may be detected by an increase in the amount of blood put out in what are called Jackson-Pratt (JP) drains, rather than by a decrease of blood over time. This may indicate that one of the blood vessels going to the liver is bleeding.
• The patient's belly is more tender than usual, and he or she has a fever. Infection of the fluid in the belly can be a serious complication. Infection is diagnosed by removing a small amount of fluid from the abdomen and sending it to the laboratory for testing. If infection is present, antibiotics are usually prescribed, and the patient is admitted to the hospital. Infection in liver transplant recipients is usually seen 1-2 months after transplantation.
• After surgery, the patient's belly is more tender and the skin is turning yellow. This may indicate that bile is backing up and not draining from the liver properly. The doctor may need to evaluate this problem by doing tests, such as a CT scan, ultrasound, or cholangiography. If a major problem exists, the doctor may reoperate (exploratory surgery), use nonoperative treatment, or list for urgent retransplantation.

Pretransplantation medications

• Lactulose: It is important to continue taking this medication because it helps clear the toxins that cannot be cleared when the liver isn't working well. With the doctor's approval, the patient can adjust the lactulose dose to produce 2-3 soft bowel movements per day
• Diuretics: These medications promote the removal of excess fluid from various parts of the body, such as the abdomen and legs. The excess fluid is lost through urination, and the patient may do this frequently. Daily monitoring of weight is helpful in determining the ideal dose. Routine monitoring of blood test results is an important part of diuretic therapy because important substances are also removed in the urine and may need to be replenished.
• Anti-ulcer medications: These medications are routinely given both before and after liver transplantation to prevent ulcers from forming in the stomach or bowels.
• Beta-blockers: These medications reduce the chance of bleeding from the gastrointestinal (feeding) tract. They also lower blood pressure and heart rate. They sometimes make the patient feel tired.
• Antibiotics: People with liver disease can be more susceptible to infections. The doctor may put the patient on long-term antibiotics if the patient gets repeated infections. The patient should call the doctor if feeling unwell or if he or she has symptoms of infection.

The first three months after transplantation is when the patient requires the most medication. After that time, some medicines can be stopped or their dosages decreased. Some of the medications are dosed according to the patient's weight. The patient needs to be familiar with the medications. It is also important to note their side effects and to understand that they may not occur with everyone. The side effects may lessen or disappear as the doses of medicine are lowered over time. Not every patient having a liver transplant takes the same medications. Some commonly used medications are as follows:

• Cyclosporine A (Neoral/Sandimmune) helps prevent rejection. It comes in pill and liquid form. If the liquid is given, it is important to mix the liquid in apple juice, orange juice, white milk, or chocolate milk. The patient can "shoot" it directly into the mouth and then follow it with any liquid except grapefruit juice. Cyclosporine should not be mixed in a paper or Styrofoam cup because they absorb the drug. It should only be mixed in a glass container directly before taking the drug.
• Tacrolimus (Prograf) helps prevent and treat rejection and works in a similar way to cyclosporine. Certain medications and substances, including alcohol, antibiotics, antifungal medicines, and calcium channel blockers (high blood pressure medications), may elevate levels of tacrolimus and cyclosporine. Other medications, including antiseizure medicines (phenytoin and barbiturates) and other antibiotics, may decrease tacrolimus and cyclosporine levels.
• Prednisone (Deltasone, Meticorten), a steroid, acts as an immunosuppressant to decrease the inflammatory response. Initially, prednisone is given intravenously. Later, prednisone is given in pill form. Prednisone may cause the following side effects:
  • Increased susceptibility to infection
  • Weakened bones (osteoporosis)
  • Muscle weakness
  • Salt and water retention
  • Potassium loss
  • Easy bruising
  • Stretch marks
  • Nausea
  • Vomiting
  • Gastric (stomach) ulcers
  • Increased cholesterol and triglyceride levels
  • Increased hunger
  • Blurred vision
  • Rounded face ("chipmunk cheeks")
  • Enlarged abdomen
  • Inability to sleep
  • Mood swings
  • Hand tremors (shaking)
  • Acne
  • Steroid dependency

Note: Patients must never stop or reduce the prednisone without medical advice. The body normally produces small amounts of a chemical similar to prednisone. When a person takes in extra amounts of this substance, the body senses this and may reduce or stop its natural production of this chemical. Therefore, if a person suddenly stops taking the medication form of prednisone, the body may not have enough natural prednisone-like chemicals available. Serious side effects may result.

• Azathioprine (Imuran) is an immunosuppressant that acts on the bone marrow by decreasing the number of cells that would attack the new liver. The dose is based on the person's weight and white blood cell count.
• Muromonab-CD3 (Orthoclone OKT3) and thyroglobulin are immunosuppressants used for people who are rejecting the transplant, for those in whom oral medications are not working well enough.
• Mycophenolate mofetil (CellCept) is an antibiotic that acts as an immunosuppressant and is used for acute rejection.
• Sirolimus (Rapamune) is an immunosuppressant.
• Sulfamethoxazole-trimethoprim (Bactrim, Septra), an antibiotic, acts to prevent Pneumocystis carinii pneumonia, which occurs more often in immunosuppressed people.
• Acyclovir/ganciclovir (Zovirax/Cytovene) acts to prevent viral infections in immunosuppressed people. These drugs work, particularly against cytomegalovirus (a type of herpes virus) infection.
• Clotrimazole (Mycelex) comes in a troche (lozenge) and prevents yeast infection of the mouth.
• Nystatin vaginal suppository is an antifungal that prevents vaginal yeast infection.
• Baby aspirin is used to decrease blood clotting and to prevent blood clots from forming in the new liver's arteries and veins.

The incision on the belly is in the shape of an upside-down Y. Small, plastic, bulb-shaped drains are placed near the incision to drain blood and fluid from around the liver. These are called Jackson-Pratt (JP) drains and may remain in place for several days until the drainage significantly decreases. A tube called a T-tube may be placed in the patient's bile duct to allow it to drain outside the body into a small pouch called a bile bag. The bile may vary from deep gold to dark green, and the amount produced is measured frequently. The tube remains in place for about 3 months after surgery. Bile production early after the surgery is a good sign and is one of the indicators surgeons look for to determine if the liver transplant is being "accepted" by the patient's body.

After surgery, the patient is taken to the intensive care unit, is monitored very closely with several machines. The patient will be on a respirator, a machine that breathes for the patient, and will have a tube in the trachea (the body's natural breathing tube) bringing oxygen to the lungs. Once the patient wakes up enough and can breathe alone, the tube and respirator are removed. The patient will have several blood tests, X-ray films, and ECGs during the hospital stay. Blood transfusions may be necessary. The patient leaves the intensive care unit once he or she is fully awake, able to breathe effectively, and has a normal temperature, blood pressure, and pulse, usually after about 1-2 days. The patient is then moved to a room with fewer monitoring devices for a few days longer before going home. The average hospital stay after surgery is about 2 weeks.

After liver transplantation, the patient must visit the transplant surgeon or hepatologist frequently, about 1-2 times a week over about 3 months. After this time, the primary doctor may also see the patient, but the transplant doctor the patient about once a month for the remainder of the first year after transplantation.

Ideally, the transplant surgeon and hepatologist monitor the patient's progress through blood tests and contact with the primary doctor. One year after transplantation, follow-up care is individualized. If a patient ever requires a visit to an emergency department and is discharged from there, he or she should generally follow up with his or her primary transplant doctor in 1-2 days.

Before undergoing liver transplantation, people who have liver disease should avoid medications that may further damage the liver.

• Large amounts of acetaminophen (Tylenol) may be harmful and can damage the liver. (Acetaminophen is contained in many over-the-counter drugs; therefore, patients with liver disease must be particularly watchful.) Sleeping pills and benzodiazepines (Valium and similar medicines) can build up faster in the blood when the liver doesn't work well. They can make a person confused, worsen existing confusion, and, in some cases, cause coma. If possible, try to avoid taking these medicines.
• Alcohol is an ingredient in some cough syrups and other medications. Alcohol can severely damage the liver, so it is best to avoid alcohol-containing medications.
• The female transplantation patient should not take oral contraceptives because of the increased risk of blood clot formation.
• No transplant recipient should receive live virus vaccines (especially polio), and no household contacts should receive these either.
• Pregnancy should be avoided by transplant recipients until at least 1 year after transplantation. If a woman wants to become pregnant, she should speak with her transplantation team regarding any special risks, as the immunosuppressive medications may need to be changed. In many cases, women successfully become pregnant and give birth normally after transplantation, but they should be carefully monitored because of the higher incidence of premature births. Mothers should avoid breastfeeding because of the risk of the baby's exposure to immunosuppressive medicines through the milk.

The 1-year survival rate after liver transplantation is about 88% for all patients but will vary depending on whether the patient was at home when transplanted or critically in the intensive care unit. At 5 years, the survival rate is about 75%. Survival rates are improving with the use of better immunosuppressive medications and more experience with the procedure. The patient's willingness to stick to the recommended post-transplantation plan is essential to a good outcome.

Generally, anyone who develops a fever within a year of receiving a liver transplant is admitted to the hospital. Patients who cannot take their immunosuppressive medicines because they are vomiting should also be admitted. Patients who develop a fever more than a year after receiving a liver transplant and who are no longer on high levels of immunosuppression may be considered for management as an outpatient on an individual basis.

Complications are problems that may arise after liver transplantation. Many should be recognizable by the patient, who should call the transplantation team to inform them of the changes.

Possible complications after liver transplantation:

• Infection of the T-tube site: This tube drains bile to the outside of the body into a bile bag. Not all patients require such a tube. The site may become infected. This can be recognized if the patient notices warmth around the T-tube site, redness of the skin around the site, or discharge from the site.
• Dislodgement of the T-tube: The tube may come out of place, which may be recognized by breakage of the stitch on the outside of the skin that holds the tube in place or by an increase in the length of the tube outside the body.
• Bile leak: This may occur when bile leaks outside of the ducts. The patient may experience nausea, pain over the liver (the right upper side of the abdomen), or fever.
• Biliary stenosis: This is narrowing of the duct, which may result in blockage. The bile may back up in the body and result in yellowing of the skin.

• Infections: Infections may result from being on immunosuppressive medications. Although these medications are meant to prevent rejection of the liver, they also decrease the ability of the body to fight off certain viruses, bacteria, and fungi. The organisms that most commonly affect patients are covered with preventive medications. Notify the transplantation team if any of the following infections arise:

• Viruses
  • Herpes simplex viruses (types I and II): These viruses most commonly infect the skin but may occur in the eyes and lungs. Type I causes painful, fluid-filled blisters around the mouth, and type II causes blisters in the genital area. Women may have an unusual vaginal discharge.
  • Herpes zoster virus (shingles): This is a herpes virus that is a reactivated form of chickenpox. The virus appears as a wide pattern of blisters almost anywhere on the body. The rash is often painful and causes a burning sensation.
  • Cytomegalovirus: This is one of the most common infections affecting transplant recipients and most often develops in the first months after transplantation. Symptoms include excessive tiredness, high temperature, aching joints, headaches, abdominal problems, visual changes, and pneumonia.
• Fungal infections: Candida (yeast) is an infection that may affect the mouth, esophagus (swallowing tube), vaginal areas, or bloodstream. In the mouth, the yeast appears white, often on the tongue as a patchy area. It may spread to the esophagus and interfere with swallowing. In the vagina, a white discharge that looks like cottage cheese may be present. To identify yeast in the blood, the doctor will obtain blood cultures if the person has a fever.
• Bacterial infections: If a wound (including the incision site) has drainage and is tender, red, and swollen, it may be infected by bacteria. The patient may or may not have a fever. A wound culture (test for the organism) will be obtained and appropriate antibiotics are given.
• Other infections: Pneumocystis carinii is similar to a fungus and may cause pneumonia. The patient may have a mild, dry cough and a fever. This infection is prevented with sulfamethoxazole-trimethoprim (Bactrim, Septra). If the patient develops this infection, it may be necessary to give higher doses of intravenous antibiotics.
• Diabetes: Diabetes is a condition in which blood sugar levels are too high. This may be caused by the medications the person takes. Patients may experience increased thirst, increased appetite, blurred vision, confusion, and frequent, large volumes of urination. The transplantation team should be notified if these problems occur. They can perform a quick blood test (a fingerstick glucose test) to see if the blood sugar level is elevated. If it is, they may start the patient on medications to prevent it and recommend diet and exercise.
• High blood pressure: This may be a side effect of the medications. The patient's doctor will monitor the blood pressure with each clinic visit and, if it is elevated, may start medications to lower blood pressure.
• High Cholesterol: This may be a side effect of the medications, the patient's doctor will monitor the cholesterol levels periodically with blood tests and may recommend diet changes or start medications if necessary.

Home care involves building up endurance to carry out daily life activities and recovering to the level of health that the patient had before surgery. This can be a long, slow process that includes simple activities. Walking may require assistance at first. Coughing and deep breathing are very important to help the lungs stay healthy and prevent pneumonia. Diet in the hospital may at first consist of ice chips, then clear liquids, and, finally, solids. It is important to eat well-balanced meals with all food groups. After about 3-6 months, a person may return to work if he or she feels ready and it is approved by the primary transplant doctor.

Preventing rejection: Home care also involves taking several medications to help the liver survive and to prevent the patient's own body from rejecting the new liver. A person with a new liver must take medications for the rest of his or her life. The immune system works to protect the body from invading bacteria, viruses, and foreign organisms.

Unfortunately, the body cannot determine that the newly transplanted liver serves a helpful purpose. It simply recognizes it as something foreign and tries to destroy it. In rejection, the body's immune system attempts to destroy the newly transplanted liver. Without the intervention of immunosuppressive drugs, the patient's body would reject the newly transplanted liver. Although the medications used to prevent rejection act specifically to prevent the new liver from being destroyed, they also have a general weakening effect on the immune system. This is why transplant patients are more likely to get certain infections. To prevent infections, the patient must also take preventive medications. There are 2 general types of rejection, as follows:

• Immediate, or hyperacute, rejection occurs just after surgery, when the body immediately recognizes the liver as foreign and attempts to destroy it. Hyperacute rejection occurs in about 2% of patients.
• Acute rejection usually occurs in the first two months after transplant and is usually treatable with medication adjustments. About 25% of patients have at least one acute rejection episode.
• Delayed, or chronic, rejection can occur years after surgery, when the body attacks the new liver over time and gradually reduces its function. This occurs in 2-5% of patients.