Liver Transplant

Liver: The Largest Organ in the Human Body

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The liver is the largest organ in the human body. It is located in the upper right side of your abdomen, nestled under the ribs and just below the lungs. The liver performs numerous vital functions.

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Some of these functions include:

• Converting the food you eat into nutrients that your body can use.

• Producing factors, enzymes, and proteins essential for blood clotting.

• Storing iron, vitamins, and energy sources.

• Detoxifying harmful substances such as alcohol and drugs.

Liver Disease

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The liver has a remarkable ability to regenerate after many diseases. However, in some cases, the liver can sustain irreversible damage. This can occur due to genetic abnormalities, excessive alcohol or drug use, cancer, or infections caused by hepatitis viruses.

A condition called cirrhosis arises when the liver becomes hardened, shrinks, and develops lumps of varying sizes. Liver cirrhosis can lead to severe complications, including bleeding, jaundice, abdominal fluid accumulation (ascites), infections, and toxic waste buildup, potentially resulting in coma or death. In such cases, a liver transplant—replacing the diseased liver with a healthy one—is the only life-saving option.

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Symptoms of Liver Disease

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One of the most prominent signs of liver disease is jaundice, which results from the accumulation of harmful substances in the blood, causing yellowing of the eyes and skin. Other symptoms include:

• Dark-colored urine

• Confusion or coma

• Vomiting blood

• Easy bruising and increased tendency to bleed

• Gray or clay-colored stools

• Abdominal fluid accumulation (ascites)

• Extreme fatigue

• Drowsiness and tremors

These symptoms indicate serious liver disease and require immediate medical attention.

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Liver Transplantation

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Liver transplantation can be performed for individuals with liver disease by using a piece of liver donated by a living relative. Volunteers can include parents, siblings, spouses, or other close family members. Before donation, extensive testing must confirm that the donor is healthy enough to proceed without any risks.

These tests are divided into two main categories:

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General Health Examinations​

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To ensure no harm comes to the donor, comprehensive evaluations are conducted to assess the function of major organs such as the heart, lungs, and digestive system. Additionally, the donor's psychological state is assessed.

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Liver Examinations​

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Detailed investigations of the liver are performed, focusing on its structural characteristics. Blood vessels, bile ducts, and the liver’s overall anatomy are thoroughly evaluated, often using imaging techniques to create a "map" of the liver.

If the donor is deemed healthy after all examinations, they are approved for organ donation. For child recipients, typically the left lobe of the liver is used, while for adult recipients, the right lobe is generally taken.

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Information for Liver Donors

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Giving a piece of your liver to a loved one can be an incredible act of kindness, offering them a chance to overcome their illness and reclaim their life. However, it is natural to feel apprehensive about the potential impact on your own health.

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Remember, the liver starts to regenerate immediately after surgery and typically returns to its original size within about three months. Similarly, the portion transplanted into the recipient grows to reach normal liver size in the same timeframe.

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Before making the decision to donate, your health will be thoroughly assessed. If any risks are identified that could endanger you, the donation will not proceed, and this will be communicated to you and your loved one. In such cases, a new donor will need to be found.

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Tests for Liver Donors

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Potential liver donors undergo extensive tests, including:

• Comprehensive blood and urine tests

• Tumor markers

• Liver function tests

• Viral hepatitis tests

• Infectious disease screening

• Chest X-rays

• Heart evaluations (ECG, echocardiography if needed)

• Abdominal ultrasound

• Doppler ultrasound to assess liver vessels

• CT scan to measure liver volume

• Magnetic resonance cholangiography (MRCP) for bile ducts

• Angiography for detailed examination of liver vessels

Eligibility for Liver Donation

The minimum age for liver donation is 18. Although there is no strict upper age limit, health problems common in individuals over 60 may pose challenges to the procedure.

The primary requirement for liver donation is blood type compatibility.

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The Rh factor is not a critical criterion in organ transplantation.
In some special cases, especially with infants, liver transplantation can be performed without blood group compatibility.

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Preparation Before Hospital Admission

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Having a pre-packed bag at home is a good idea to save time and ensure you're ready before heading to the hospital. Your bag should include the following items:

• Pajamas

• Slippers and nightgowns

• Several pairs of underwear

• Sportswear, t-shirts, and socks

• A toiletries bag (razor, toothbrush, etc.)

• Books

• Cutlery, knives, and cups

• Paper towels and napkins

Dental Examination Recommendation

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It is advisable to visit a dentist and have your teeth checked while waiting for a donor organ. Any problematic teeth can be treated, reducing the risk of post-surgery infections.

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Preparation for Liver Donation

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If you are receiving a liver segment from a relative, both the recipient and the donor will be admitted to the hospital several days before the surgery. Therefore, the above-mentioned items should be prepared separately for both individuals.

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The Surgery Process and Preparation

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When you arrive at the hospital, several preoperative tests will be conducted to detect any hidden infections. These include:

• A general physical examination

• Urine and blood tests

• Chest X-rays

• An electrocardiogram (ECG) to evaluate your heart

Your entire body will be cleansed with an antiseptic solution, and the surgical area will be shaved by a nurse.

Your transplant surgeon and anesthesiologist will thoroughly explain the surgery and potential risks. You will be asked to sign a consent form to proceed with the surgery.

Live Liver Transplantation

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Live liver transplantation has become more common over the last 30 years and is technically more challenging than cadaveric transplants, requiring a larger team. The surgical team often works simultaneously, with one group removing the donor's liver segment while the other prepares the recipient.

The liver segment from a relative is transplanted into the recipient after the diseased liver is removed, preserving the major abdominal veins.

This complex procedure typically involves:

• 2 surgeons

• 4 surgical assistants

• 3 operating nurses

• 2 anesthesiologists

• 2 anesthesia technicians

• 4 intensive care nurses

The surgery is a demanding procedure, lasting between 6 and 18 hours. Even during the final stages, the surgery may be postponed or canceled due to donor organ incompatibility or other complications.

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Postoperative Intensive Care

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After surgery, you will be transferred to the intensive care unit and connected to a mechanical ventilator. If all goes well, you may be removed from the ventilator within 24–48 hours, though it may take longer if needed.

Post-surgery, you will have drainage tubes (e.g., T-tube) placed in your abdomen to remove fluid buildup around the liver. These tubes are usually removed before discharge.

Following a few days in intensive care, you will move to the transplant unit for a 2–3 week recovery period. During this time, you will be closely monitored for signs of organ rejection, including:

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• High fever

• Pain

• Jaundice

• Fluid retention

• Medication side effects

• Liver function deterioration

Recovery involves both physical and mental rehabilitation, and your effort will significantly impact your healing.

Post-Hospital Care

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After discharge, you will attend weekly or bi-weekly outpatient check-ups in the first few months. During these visits:

• Your liver function will be evaluated.

• Physical exams will be conducted to detect infections.

• Blood tests will be done to adjust medication dosages.

Correct medication dosing is crucial. Excessive doses can overly suppress your immune system, increasing the risk of infection, while insufficient doses may lead to organ rejection.

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As the risk of infection and rejection decreases, the frequency of check-ups will also decrease. These follow-up visits are essential for tracking recovery and identifying complications early.

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Post-Discharge Self-Care

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Now that your hospital care is complete, you are primarily responsible for your ongoing recovery. However, your transplant team will always be available for support if any problems arise.

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Wound Care​

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• Use antiseptic soap to clean the surgical wound.

• Contact your doctor immediately if you notice redness, swelling, or fluid discharge.

If a T-tube for bile drainage is in place:

• Clean the area around the tube with antiseptic soap.

• Avoid sudden movements that could damage the wound or dislodge the tube.

Monitoring Your Temperature

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• Check your temperature if you feel feverish, experience chills, or feel unwell.

• Fever may be an early sign of infection or organ rejection.

• If your temperature exceeds 38°C (100.4°F) multiple times, contact your transplant team immediately.

• Do not take any medication without consulting your doctor.

Blood Pressure and Pulse Monitoring

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Your nurse will teach you how to measure your blood pressure and pulse. Knowing your normal values is essential so you can alert your doctor if there are irregularities.

Dental Care

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• Use a soft toothbrush to avoid damaging your gums.

• Brush your teeth after every meal and use an antiseptic mouthwash.

• If you wear dentures, clean them thoroughly after every meal.

Regular dental check-ups every six months are important to prevent infections and cavities. However, avoid dental visits during the first six months post-surgery unless you have a serious problem.

If dental treatment is required:

• Antibiotics may be necessary, starting 24 hours before the procedure and continuing for 48 hours afterward. Your doctor will prescribe the appropriate antibiotics when needed.

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General Body Hygiene

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Maintaining a high standard of personal hygiene is essential to reduce the risk of infections. Key points to keep in mind:

• Prefer taking showers over baths.

• Use liquid soap instead of bar soap for handwashing.

• Change your hand and face towels daily.

• Do not neglect washing your hands before meals and after using the toilet.

• Keep your nails clean using a nail brush.

For women:

• During menstrual periods, change pads or tampons regularly.

• Washing the vaginal area with mild soap and water is sufficient; avoid chemical hygiene products that may increase the risk of infection.

Skin and Hair Care

Cortisone use may cause acne on the face, chest, shoulders, or back. If this occurs:

• Wash affected areas three times a day with a gentle antibacterial soap.

• Ensure the soap is thoroughly rinsed off.

• Avoid squeezing or irritating the pimples.

• Do not use makeup or medicated cosmetics to cover the pimples, as this can delay healing.

• Consult a dermatologist for severe or infected acne.

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f your skin becomes very dry:

• Temporarily stop washing to allow your skin to restore its natural moisture.

• After bathing, use a gentle soap and moisturize your skin with care creams.

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Hair care:

• Cortisone may affect your hair texture. Permanent hair dyes, gels, and bleaches can make your hair more fragile and prone to breakage. Use these products cautiously.

• Opt for a good moisturizing product to strengthen your hair.

Unwanted Hair Growth

One side effect of certain immunosuppressive medications is the growth and thickening of facial hair, which can be distressing, especially for women and children. However, never stop taking immunosuppressive medications under any circumstances.

• You can use depilatory creams or techniques to bleach the hair for reduced visibility.

• Waxing or electrolysis can effectively remove excess hair.

• If hair growth becomes excessive, consult your doctor.

Sun Exposure

Excessive exposure to sunlight is harmful to everyone. The ultraviolet rays in sunlight can cause premature aging, sunburns, and skin cancer. Transplant patients, whose immune systems are suppressed, are at a higher risk of developing skin cancer. Protect your skin by taking the following precautions:

• Avoid going outside during peak sunlight hours (10:00 AM - 3:00 PM).

• Stay in the shade whenever possible.

• Wear appropriate clothing.

• Opt for hats, long-sleeved shirts, and lightweight trousers to minimize sun exposure.

• Use sunscreen.

• During spring and summer, use a high-quality sunscreen with at least SPF 15.

• Protect all exposed areas, especially the face, neck, and hands, with sunscreen.

• Reapply sunscreen regularly, especially after sweating or swimming.

Remember hidden dangers:

• UV rays can be harmful even on cloudy days.

• Reflected rays from surfaces like water, sand, snow, and concrete can also cause sunburn.

• Avoid tanning beds.

• Tanning beds can cause significant damage to your skin.

Check your moles:

• If you notice changes in the color, size, or shape of a mole, consult your doctor immediately.

• Due to immunosuppression, transplant patients have a higher risk of moles becoming cancerous.

Protecting your skin from sun damage is essential for maintaining your overall health.

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Post-Transplant Life

Organ transplant recipients often feel reborn and see their operation as the start of a new life. Many celebrate the day of their surgery as their "transplant birthday." A successful transplant means a much better life awaits you.

Returning home after a transplant is usually a joyful and emotional experience. However, during the first few weeks, this happiness may be accompanied by anxiety or even mild depression. It’s important to understand that the recovery process can take weeks. Both you and your family need time to adjust to this new way of life. Living with an organ transplant requires learning and adaptation.

Most people successfully navigate this process by adopting an active lifestyle and committing to their rehabilitation. After a sensitive period of about three months, the majority of liver transplant recipients return to their pre-illness lives. Despite potential challenges of living with a transplanted organ, most transplant patients achieve a normal lifestyle: they work, start families, raise children, and contribute to society.

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Nutrition

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Due to prolonged illness before your transplant, you may have experienced weight loss. Regular and balanced nutrition is a vital part of your recovery process. A healthy diet will help you recover both physically and mentally. However, the use of corticosteroids can increase appetite, which may lead to weight gain over time.

To maintain your weight, you may need a low-fat and low-sugar diet plan. Work with a nutritionist to create a balanced meal plan.

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• Weigh yourself daily.

• Avoid sugary and fatty snacks. Opt for fresh fruits or vegetables when hungry.

• Aim to drink approximately 2 liters of water daily. This helps protect your kidneys and aids in waste elimination.

• Wash and peel fresh fruits.

• Always peel and boil root vegetables like potatoes before consuming. Cooking vegetables in a pressure cooker helps preserve vitamins and saves energy.

• Avoid raw vegetables, unpasteurized dairy products, and moldy cheeses. Consume small amounts of milk, cheese, and yogurt while ensuring they are fresh.

Salt (Sodium)

Another side effect of corticosteroids is their tendency to cause the body to retain salt, leading to water retention and high blood pressure. It’s essential to limit your salt intake:

• Use only small amounts of salt when cooking.

• Do not add salt to cooked meals.

• Avoid salty snacks like potato chips and canned foods.

Exercise

Physical activities rejuvenate both body and mind. Regular exercise improves overall health and boosts energy levels. It also helps manage corticosteroid-induced weight gain and strengthens muscles weakened by prolonged illness.

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• Start your exercise program slowly and gradually increase intensity.

• Walking is one of the best beginner exercises. Walking in fresh air can improve sleep and support digestion.

• Climbing stairs is also beneficial, but rest if you feel tired.

• Activities like cycling and swimming help build overall muscle strength.

• After three months post-surgery, you can resume hobbies like tennis or running.

Exercise can also help counteract medication side effects such as bone loss. However, consult your doctor or transplant team before starting any exercise program.

Other Important Notes

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• Driving: Avoid driving during the first four weeks after the transplant.

• Alcohol: Completely abstain from alcohol as it can harm your liver.

• Smoking: Smoking is harmful to both you and those around you. Consult your doctor for help with quitting.

Sexual Activity

You can resume sexual activity a few months after the transplant when you feel well enough. Most men regain their sexual function post-transplant, and many women notice their menstrual cycles returning to normal within a few months. However, some medications may affect sexual functions. If you experience any issues, don’t hesitate to consult your doctor or transplant team.

• Birth Control Pills: Immunosuppressive drugs can reduce the effectiveness of birth control pills, so this method is not recommended.

• Intrauterine Devices (IUDs): Not advised due to increased infection risks.

• Condoms: The most reliable way to prevent both infections and unwanted pregnancies.

• Diaphragms: Another option; consult your gynecologist for guidance.

Reproduction

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Many men have fathered children, and many women have had healthy pregnancies after a transplant. However, discuss your desire to have children with your doctor or transplant team.

Pregnancy should be planned, and it is recommended to wait at least 1–2 years post-transplant before attempting to conceive. Your liver functions should be stable, and you should not have any health conditions that might threaten your or your baby’s well-being. Additionally, you should be on a low dose of immunosuppressive medication.

Vaccinations

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Post-transplant, you should not receive any live or attenuated virus vaccines (e.g., measles, chickenpox). However, you can receive inactivated or dead virus vaccines, such as tetanus. Always consult your doctor or transplant team before getting vaccinated.

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Pets and Plants

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• Pets: Pets are not recommended due to increased infection risks, though they can play a significant role in your recovery.

  • Low-risk pets: Fish, reptiles, small rodents.

  • Dogs: Prefer short-haired breeds.

  • Avoid: Cats (toxoplasmosis risk) and birds (staphylococcus bacteria risk).

  • Avoid contact with animal waste; use gloves for cage cleaning or have someone else handle it. Wash areas touched by pets (hands, face) with soap and water.

• Potted Plants: Avoid potted plants as soil can harbor harmful microorganisms. Refrain from gardening during the first year post-transplant; if necessary later, always use gloves.

Home Cleaning

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• Bathrooms and Kitchens: Clean regularly, especially the refrigerator.

• Regular household detergents and liquid soaps are sufficient; special disinfectants are unnecessary.

• Change bedding weekly.

Immunosuppressive Medications

Your immune system perceives the transplanted liver as foreign and may attack it. Immunosuppressive drugs prevent this rejection but make you more vulnerable to infections. A delicate balance between immunosuppression and infection prevention is essential.

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• During the initial months post-transplant, higher doses of immunosuppressive medications are needed, but these doses will gradually decrease.

• These medications are typically required for the first few years after transplantation. Never reduce the dose or stop taking the medication without your doctor’s approval.

Immunosuppressive medications can cause side effects. Doctors often use combination therapies to minimize these effects while maintaining effective immunosuppression.

Each patient’s treatment needs vary. If your medication regimen differs from others, there’s no need for concern; your treatment plan is tailored to your specific needs.

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Post-Surgery Complications

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Patients who undergo major surgery, including liver transplantation, may experience post-surgical complications within the first few weeks. Don’t be alarmed if complications arise; your transplant team is equipped to minimize and address such issues promptly.

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Organ Rejection

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After a liver transplant, there is a risk of experiencing a rejection episode within the first weeks or months. Most transplant patients experience at least one episode of rejection.

Early Symptoms

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• Physical symptoms may not appear initially.

• You might notice mild, unexplained fever or a general feeling of fatigue.

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Diagnosis and Treatment

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• Organ rejection is typically confirmed through a liver biopsy.

• Mild rejection can be managed with adjustments to medication, while more severe cases may require high-dose corticosteroid treatment for three consecutive days.

• To prevent rejection, the immune system is suppressed, which may make you more susceptible to infections, such as colds and the flu, during the postoperative period.

Liver Transplantation in Children

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Globally, the most common reason for liver transplants in children is a congenital absence of bile ducts (biliary atresia). Other conditions leading to liver transplantation include:

Acute Liver Failure

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• Viral hepatitis

• Drugs and toxins

Metabolic Disorders

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• Wilson's disease

• Galactosemia

• Tyrosinemia

• Urea cycle defects

Chronic Liver Failure

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• Cholestatic diseases

• Autoimmune hepatitis

• Chronic viral hepatitis

Cancers

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• Hepatocellular carcinoma (HCC)

• Hepatoblastoma

Vascular Issues

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• Budd-Chiari syndrome

• Diseases causing venous obstruction

Others

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• Cryptogenic cirrhosis (cirrhosis with an unknown cause)

Living-Donor Liver Transplantation for Children

Living-donor liver transplantation is performed with detailed evaluations and technical planning to minimize potential postoperative complications for both the donor and the recipient.

Surgical Process Liver Retrieval from the Donor​​

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• The size of the liver segment to be retrieved depends on the child’s weight.

• The right, left, or a smaller portion of the liver may be taken.​

Recipient Surgery​

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• The recipient’s diseased liver is completely removed.

• The donor liver segment is placed into the recipient's liver area, ensuring the appropriate size for the child.

This meticulous process is designed to ensure a safe transplant for both donor and recipient.

Who Can Be a Donor ?

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According to Turkish law, an organ donor must meet the following criteria:

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• Be at least 18 years old.

• Have full mental capacity.

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Additionally, donors are determined based on the following relationships:

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1. First-degree relatives: Parents.

2. Second-degree relatives: Siblings, maternal and paternal grandparents.

3. Third-degree relatives: Uncles, aunts, nieces, and nephews.

4. Fourth-degree relatives: Children of third-degree relatives.

If the donor is not a relative up to the fourth degree or is connected to the recipient through a non-blood relationship:

• Spousal consent is required.

• Ethical committee approval is also mandatory.

These regulations aim to protect the rights of both the recipient and the donor while ensuring ethical standards are upheld.