Center for Advanced Liver Diseases and Transplantation

The Transplant Process Pre-Transplant

All patients with severe liver disease referred to the Liver Center are considered for liver transplantation. Before the decision to transplant is made, each case is evaluated thoroughly to determine the exact cause and extent of the liver disease. Depending upon those findings, it may be determined that the patient's liver disease can be managed appropriately through alternative therapies to transplantation, either on a short- or long-term basis. The decision to transplant is made when all other alternatives have been exhausted.

Patients and their referring doctors are asked to provide the transplant team with a complete record of prior tests and treatments to facilitate the evaluation process.

 

What to Expect at the Evaluation

The Liver Transplant office is located in the Ambulatory Care Center,(ACC), 140 Bergen Street, Level D, Suite 1650.

Patients do not need to fast for this office visit and should take all of their prescribed medications.

Upon arrival, patients sign in with the receptionist and complete a form. After a short wait, the patient will be seen by one of our hepatologists. This consultation takes approximately one hour and includes a detailed history and physical examination. Patients meet with a transplant coordinator and may also be seen by a social worker, psychiatrist, nutritionist, or financial coordinator, as determined by individual need.

The following items are needed for the first office visit:

• All medical records, including X-ray films (CT scans, MRI, ultrasound)
• All insurance information and cards
• Address and phone number of the referring physician
• All medications currently being taken
• A list of all drug and food allergies
• A list of all emergency phone numbers, including family members, friends and physicians

After this initial visit, the hepatologists contacts the referring physician, and the transplant work-up will be initiated. This may be accomplished either through the University Hospital complex, or, with the assistance of the referring physician, the work up may be completed closer to the patient's home. Please be assured that any recent test results will be accepted as part of the transplant work up:

The Medical Assessment

The transplant team will perform a complete evaluation of the patient's medical history and current health status. The patient may be asked to undergo any of the following procedures:

• A complete laboratory assessment including urine analysis, complete blood count, blood chemistries, liver function tests, and blood and tissue typing. In addition, blood tests for certain infections will be checked.
  
  
• Several X-ray tests, including:
  
  
  1. Chest X-ray- to tell if the lungs are healthy.
     
     
  2. Ultrasound with Doppler- checks the blood flow into and out of the liver looking at the liver's veins and arteries, as well as the bile ducts.
     
     
  3. CT scan- a computerized image of the abdomen, particularly to determine the size of the liver, major blood vessels, and the presence of any tumors.
     
     
  4. MRI (magnetic resonance imaging)- may be used in place of a CT scan.
     
     
  5. Total-body bone scan- if a liver tumor is present, this test will ensure that it has not spread to the bones.
     
     
  6. Hepatic angiogram- dye (contrast) is injected into one of the patient's arteries to see if there are any abnormalities or blockages in the liver's blood vessels. This is performed under X-ray and only if the ultrasound detects a serious problem in the liver's blood vessels.
     
     
  7. Cholangiogram- to reveal if there are any blockages or growths in the liver's bile ducts.
     
     
• Some heart function tests, including:
  
  
  1. Electrocardiogram (EKG)- to see how well the heart is functioning. It may reveal a previously undetected heart problem.
     
     
  2. Echocardiogram- This test is an ultrasound of the heart. It will detect any problem in the heart's valves and show how well the heart pumps blood.
     
     
  3. Persantine thallium stress test- a special type of echocardiogram. It is a stress test performed without the patient walking or running on a treadmill. If there are any special concerns or abnormalities found on the echocardiogram, this test will determine the risk of a heart attack.
     
     
  4. Lung (pulmonary) function tests- to reveal how well the lungs are working. A blood sample may be taken from the patient's wrist to help determine the amount of oxygen in the blood.
     
     
• Upper endoscopy- involves passing a tube down the patient's throat (esophagus) into the stomach to determine if there are varices (varicose veins that may rupture and bleed), ulcers, inflammation, or any other disease.
  
  
• Lower endoscopy (colonoscopy)- involves passing a flexible tube into the rectum and colon to determine if there are any rectal or intestinal abnormalities.
  
  
• Kidney tests- The patient will be asked to collect urine for 24 hours to determine if the kidneys are working correctly.
  
  
• Miscellaneous tests may be necessary, such as: Pap smear and mammogram for women, PSA blood test for men to detect cancer of the prostate, dental X-rays to detect cavities or infections, and a stool test for hidden blood, which may indicate intestinal bleeding.
  
  
• A liver biopsy is a small sample of the patient's liver obtained by a needle. It can be done at the bedside or under the guidance of an ultrasound or CT scan. A local anesthetic is used. The biopsy is obtained by passing a needle into the liver and removing a tiny piece of liver tissue. The specimen allows the doctors to determine the nature and severity of the liver problem. Biopsies are also performed after liver transplant to detect rejection or other post-transplant complications, including infection.

The Psychosocial Assessment

The social worker and a psychiatrist if needed help patients develop coping mechanisms for the stress they will undergo throughout the transplant process. In cases where prior alcohol and substance abuse exist, the psychiatrist and social worker will undertake a detailed analysis of the situation and recommend (within Department of Health guidelines) approaches designed to minimize the chances of the problem recurring after transplant.

The Nutritional Assessment

The nutritional assessment is an integral component of the transplant evaluation process. Studies show that malnutrition can adversely affect patients and their recovery from a liver transplant. The registered dietitian assesses all patients during the evaluation process to identify nutrient deficiencies and educates patients and their families on appropriate diets to meet their nutritional needs. The dietitian reviews the patient's dietary habits with him or her and family members to help develop and maintain an appropriate diet before and after the transplant. The dietitian can also provide the patient with recipes and helpful hints to reduce health risks.

Financial Counseling

A financial coordinator will meet with the patient, and, if desired, family members, to discuss any financial issues related to his or her medical care, both before and after the transplant.

The financial coordinator contacts the patient's insurance company to obtain prior authorizations and to determine the level of coverage, as well as the patient's financial responsibilities. For patients with inadequate health insurance coverage, the coordinator will make referrals to an appropriate agency for eligibility.

The Selection Committee

The final step to becoming a liver transplant candidate at University Hospital involves formal consideration by a selection committee. This multidisciplinary team includes hepatologists, transplant surgeons, social workers, financial coordinator, a dietitian, nurse coordinators, psychiatrists, an anesthesiologist and other specialists as needed.

Patients accepted for transplantation are placed on the waiting list. Sometimes patients are not accepted for a transplant. In some of those cases, the team may need more information, such as additional work-up studies or assessment, before they can be listed. In either case, a physician and a nurse coordinator discuss the decision with the patient and explain what lies ahead.

The Waiting Period and Patient Status

Patients accepted as liver transplant candidates are placed on the United Network for Organ Sharing (UNOS) national computer list. This organization supervises organ recovery and allocation throughout the nation. It may take a few weeks to several months for a suitable liver, which is retrieved from a "brain dead" organ donor, to become available. To match a patient with a liver donor, the donor must be:

• Approximately the same weight and body size as the patient
• Free from disease, infection, or injury that affects the liver
• Usually of the same or a compatible blood type (see table below)

Blood type	Can receive a liver from	Can donate a liver to
O	O	O, A, B, AB
A	A, O	A, AB
B	B, O	B, AB
AB	O, A, B, AB	AB

Another very important factor that determines when patients receive a liver is their status.These criteria, overseen by UNOS, measure medical urgency and insure that the sickest patients have priority when a donor liver becomes available.

While waiting for a donor organ, patients continue medical therapy as supervised by their family physician, with periodic visits to see the transplant team. If patients travel outside of this area, which is not recommended, they must provide the nurse coordinator with a telephone number where they can be reached.

If patients must be hospitalized before the transplant, they may be admitted either into a hospital close to their home or University Hospital. The transplant coordinator must be notified when a liver transplant candidate is hospitalized, whatever the reason.

Transplant candidates must be prepared to travel to University Hospital the moment a liver becomes available. While that notification often brings hope for the patients, there are times when the donor liver is not appropriate for the candidate or is not in transplantable condition. If this happens, the patient is sent home until the next opportunity arises.

Support Groups and Services

Unquestionably, the transplant process is stressful. To help answer questions and provide practical as well as emotional support, the transplant program provides several resources.

One is a support group consisting of former transplant patients and future candidates.They are available to provide first-hand accounts of the transplant experience and to answer any questions a candidate may have. In addition we offer peer mentors who have had transplants. For further information, please contact the Liver Center at 973-972-LIVR (5487).

Transplant social workers assist with many concerns, such as transportation to and from the hospital, referrals for community-based assistance, and resolving problems in the home.

The dietitian on the transplant team not only provides nutritional assessments for patients during the transplant evaluation, but also provides nutritional care to patients following liver transplantation. Obesity, high blood pressure, high cholesterol, diabetes, and osteoporosis are some medical conditions that are important to manage after liver transplant. The dietitian provides individual counseling and monthly group education sessions on some of these medial conditions and preventative health awareness.