Pathologies

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Liver transplantation is indicated on the one hand when there is no other alternative. On the other hand, the chance of success must be sufficiently large, since there is a shortage of organs. Some countries have legislation that promotes organ donation: donation via the principle of presumed consent. Which in itself can also raise deeper ethical questions.

The donor liver is implanted in the place of the original liver (orthotopic). When implanting the donor liver, connections are made to the hepatic artery, the vena cava and the portal vein. A part of the donor and recipient bile ducts are attached to each other (duct-to-duct anastomosis).

The main indications for liver transplantation are HCC and/or end-stage cirrhosis. The patient with the worst short-term prognosis has priority. For end-stage cirrhosis, the urgency is determined using the MELD score. Patients with HCC can be granted a standard exception. This means that they spontaneously receive extra MELD points every month, so that they can still be transplanted despite a low MELD score. A very poor quality of life can also be an indication, such as in patients with PCLD and malnutrition, PBC patients with severe pruritus and PSC patients with regular hospital admissions due to cholangitis.Contraindications for liver transplantation are patients with a greatly increased surgical risk due to comorbidities and insufficient compliance, such as patients with alcoholic cirrhosis who have a higher risk of relapse of alcohol abuse after transplantation. If HCC is the indication, the lesions must fall within the Milan criteria. is means that the number of lesions must be limited, that they may not be too large and that there may be no extrahepatic locations (such as macrovascular invasion in the portal vein). In these situations, there is a high probability of micrometastases that will grow rapidly due to immunosuppression. When selecting patients, it is taken into account that a one-year survival of more than 90% and a five-year survival of 80% are sought.

In the donor selection, the body type (height and weight) and the blood group of the donor and the acceptor are taken into account. In adults, cadaver livers (deceased persons) are almost exclusively used. In the case of small children, relatives can donate part of their liver (living donation). Usually the donation comes from a person who is brain dead due to an underlying disease, such as a cerebral hemorrhage, trauma, ... Until recently, a necessary spontaneous circulation of the blood (heart beating) was assumed. Since recently, non-heart beating donors are increasingly used. These are deceased patients, where the circulation stops spontaneously when the ventilation is stopped in intensive care.

All sorts of complications can occur after a liver transplant. Poor liver quality (post-factum) can cause primary non-function, especially in steatotic livers. The following technical problems can occur:

- post-bleeding;

- thrombosis of the hepatic artery;

- a bile leak at the choledochal anastomosis.

During the first few weeks, the patient must take a high dose of immunosuppressants and is at increased risk of bacterial infections or CMV (cytomegalovirus) infection. Patients are therefore given prophylaxis with antibiotics and, if necessary, ganciclovir during this period. T-cell mediated rejection (acute rejection) occurs in approximately 20% of patients, but can usually be successfully treated by increasing immunosuppression. Only rejections occurring more than 90 days after liver transplantation affect the prognosis. In contrast to other organ transplants, chronic (ductopenic) rejection after liver transplantation is very rare.

The most common complications after liver transplantation are biliary complications. Most often, these are ischemic strictures of the intrahepatic bile ducts. This ischemia occurs during the removal of the liver. The strictures must be treated endoscopically with balloon dilatations and by placing stents. They can sometimes be a reason for retransplantation. Strictures at the biliary anastomosis, between the donor and recipient choledochus, can be treated more easily endoscopically.

The basic immunosuppression after liver transplantation are calcineurin inhibitors, such as tacrolimus. Mycophenolate mofetil or everolimus are added to these. Calcineurin inhibitors have the disadvantage that they reduce kidney function, so the blood level must be kept as low as possible. Patients after liver transplantation are at increased risk for certain malignancies, including non-melanoma skin tumors, post-transplant lymphomas, and colorectal tumors in patients transplanted for PSC. Patients who smoke and have a history of alcohol use are also at increased risk for lung tumors.

Several diseases, such as PSC and PBC, can recur late after a liver transplant. However, the main cause of death after years is cardiovascular disease, due to metabolic syndrome.

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