When an entire liver is transplanted from a deceased donor to a recipient, it is known as an orthotopic transplant. This translates as straight (ortho-) in place (-topic).
The liver has the ability to regenerate. Therefore, it is possible to take a portion of the liver from a living donor, transplant it into a patient and have both regenerate to become two fully functioning organs. This is known as a living donor transplant.
It is also possible to split the liver of a deceased person into two and transplant it into two patients and have them regenerate to function normally in each recipient. This is known as a split donation.
Indications for liver transplants fall into two categories: acute liver failure and chronic liver failure. They may also be used in specific cases of hepatocellular carcinoma.
Acute liver failure usually requires an immediate liver transplant, and these patients are placed at the top of the list. The most common causes are acute viral hepatitis and paracetamol overdose.
Chronic liver failure patients can wait longer for their liver transplant and are put on a standard transplant list. It is usual for it to take around 5 months for a liver to become available.
Suitability for Liver Transplantation
The British Society of Gastroenterologists provides guidelines on liver transplantation (2019), including when to refer and the contraindications.
- Significant co-morbidities (e.g., severe kidney, lung or heart disease)
- Current illicit drug use
- Continuing alcohol misuse (generally 6 months of abstinence is required)
- Untreated HIV
- Current or previous cancer (except certain liver cancers)
The liver transplant surgery is carried out in a specialist transplant centre. It involves a “rooftop” or “Mercedes Benz” incision along the lower costal margin for open surgery. The liver is mobilised away from the other tissues and excised.
When an entire donor liver is implanted, the donor liver’s inferior vena cava, hepatic artery, portal vein and common bile duct are anastomosed with the recipient’s.
With a split donation, the remaining branches of the donated portion of liver are anastomosed with the recipient. For example, with a left lobe liver transplantation, the left hepatic vein, left hepatic artery, left portal vein and left hepatic duct are anastomosed with the recipient’s inferior vena cava, hepatic artery, portal vein and common bile duct.
Patients will require lifelong immunosuppression (e.g., steroids, azathioprine and tacrolimus) and careful monitoring of these drugs. They are required to follow lifestyle advice and require monitoring and treatment for complications:
- Avoid alcohol and smoking
- Treating opportunistic infections
- Monitoring for disease recurrence (e.g., autoimmune hepatitis or primary biliary cholangitis)
- Monitoring for cancer, as there is a significantly higher risk in immunosuppressed patients
Monitoring for evidence of transplant rejection:
- Abnormal LFTs
Last updated May 2023