Liver transplantation in Turkey is the definitive surgical treatment for patients with end-stage liver disease and patients with acute liver failure that improves liver function and survival after transplantation.
Liver transplantation is a final solution to many liver problems, as this process saves the lives of patients with acute liver failure, andLiver transplant side effects It can be avoided with the progress of medicine in Turkey.
So what is it Liver transplant success rate? How many hours does the liver donation process take? What are the contraindications and conditions for a liver transplant? Is liver donation dangerous? Find out with us the answer to these questions in the following article.
An introduction to the liver transplant process
The first was made Liver transplant In 1963 in the United States by surgeon Thomas Starzl, this operation today is the most effective treatment for end-stage liver failure and acute liver failure, and liver transplantation has been performed for more than 80,000 patients with chronic liver failure in the world.
Over the past three decades, liver transplantation has become an option for saving the lives of patients with end-stage liver disease, liver malignancies, metabolic diseases with liver damage, or acute liver failure. The purpose of the transplant is to prolong the life of the recipient and improve their quality of life.
Survival rates have increased Life after a liver transplant In addition to numerous advances in surgical techniques, recipient selection and donor management, preservation of transplant organs, intraoperative anesthesia procedures, advances in postoperative care and therapies Immunosuppression increases long-term survival success after liver transplantation.
Conditions for a liver transplant
Three underlying principles dictate which patients should be referred for and potentially undergo transplant.
- The recipient must have acute or chronic liver disease that cannot be cured and is expected to be fatal without a liver transplant.
- The patient must be able to survive during and around the surgery.
- The patient should be expected to have a good survival and quality of life benefit after liver transplantation.
What are the reasons for a liver transplant?
- Acute liver failure: The most common cause is an overdose of acetaminophen 39%.
- Hepatic artery thrombosis within 14 days of liver transplantation.
- cirrhosisWith decompensation (variceal bleeding, hepatic encephalopathy, or ascites), or with pulmonary hepatorenal syndrome or pulmonary hypertension.
- Primary hepatocellular carcinomas: hilar cholangiocarcinoma fHepatocellular carcinoma.
- Congenital metabolic diseases: cystic fibrosis associated with lung and liver disease, primary hyperoxaluria type I with Renal insufficiency Large, familial amyloid neuropathy.
Contraindications for liver transplantation
Certain contraindications for a liver transplant include:
- Active extrahepatic malignancy
- Intrahepatic cholangiocarcinoma
- Hepatocellular carcinoma outside Milan criteria or metastatic
- Severe cardiopulmonary disease
- Uncontrolled infections
- Active alcohol or illicit substance abuse
- Acquired Immunodeficiency Syndrome (AIDS)
- Persistent non-compliance or lack of social support
- Technical and/or anatomic barriers to liver transplantation
- advanced age
- Portal venous thrombosis
- Human immunodeficiency virus (HIV) infection
- Morbid obesity (body mass index [BMI] ≥ 40)
- Poor medical compliance or social support
- Effective psychiatric comorbidities (3)
Evaluation of the recipient's condition prior to a liver transplant
LT entails the physical and hemodynamic demands of a major surgery, a potentially protracted recovery period, the risks of chronic immunosuppression, and increased psychosocial stress. As such, the pre-transplant evaluation process is designed to screen for patients who are:
- Is in sufficient physical health to survive the liver transplant and the period around it.
- Adherent with medical recommendations to ensure compliance with postoperative care.
- He has a safe post-liver transplant psychosocial support system.(3)
Laboratory tests for liver transplantation in Türkiye
The main purpose of these pre-transplant examinations is to confirm blood type (which must be matched with a donor organ), assess liver and kidney function status, and rule out associated infections that may require treatment or could affect post-transplant care or outcome. This includes:
- ABO and Rh blood typing
- Basic metabolic panel
- Complete blood count
- Liver-associated enzymes and coagulation parameters
- Calcium and Vitamin D
- Urine drug screen
- Serological testing for hepatitis A, hepatitis B, hepatitis C, HIV, varicella-zoster virus (VZV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), and screening for tuberculosis(3)
Adequate CT scans for surgical planning should be performed prior to liver transplantation. Triphasic CT or gadolinium-enhanced MRI are the most common and may help identify potential technical barriers to liver transplantation including portal vein thrombosis, varicose veins around the liver, and anatomical abnormalities in the liver. liver, and sequelae of previous abdominal surgeries.(3)
If a CT or MRI scan cannot be obtained prior to liver transplantation, ultrasound with Doppler flow assessment may be sufficient. Hepatic radiography is particularly critical for the accurate diagnosis of patients with intrahepatic malignancy in order to confirm their candidacy for liver transplantation. .(3)
Heart tests before liver transplantation aim to screen for coronary artery disease, valvular disease, and/or cardiomyopathy if present. Specific therapeutic interventions can be performed before or during liver transplantation as needed. If there is advanced heart disease, it may be performed. Cancellation of the liver transplant.(3)
An age-appropriate cancer screening should be performed in all patients, given that the presence of metastasis outside the liver is a definite contraindication to a liver transplant.(3)
Bone Density Testing
This test is performed prior to liver transplantation as advanced liver disease leads to osteoporosis through relative inactivity, hypogonadism, low vitamin D levels, poor intestinal calcium absorption, and in some patients the direct effects of alcohol, steroids or iron excess.(3)
Infectious Diseases Considerations
Dysfunction of hepatocytes places liver transplant candidates at increased risk of a variety of infections including spontaneous bacterial peritonitis, aspiration pneumonia, urinary infections, and intravenous catheter-associated blood infections. Active infections should be appropriately addressed prior to liver transplantation. .(5)
Liver transplant patients should be vaccinated against hepatitis A and B if serologic tests do not show immunity, and tetanus, diphtheria and whooping cough vaccines should be up-to-date, in addition to influenza and pneumococcal vaccinations.(3)
Pulmonary hypertension (mean pulmonary artery hypertension MPAP ≤ 25 mmHg) is caused by the presence of portal hypertension and is referred to as pulmonary hypertension (POPH), detected in 4-8% liver transplant candidates, not considered hypertension Mild (MPAP < 35 mmHg) pulmonary hematopoiesis is of major concern but moderately elevated (MPAP ≤ 35 mmHg) and severe (MPAP ≤ 45 mmHg) are a predictor of increased mortality after liver transplantation.(5)
Smoking is involved in a number of adverse outcomes in the liver transplant recipient, including death from cardiovascular causes and an increased incidence of hepatic artery thrombosis. Oropharyngeal, oropharyngeal, and other tumors following liver transplantation are associated with smoking and can result in a high mortality rate that is avoidable in the long term. .(5)
There are compelling reasons to ban all methods of smoking in liver transplant candidates. Some transplant programs consider smoking cessation a condition for liver transplantation and this requires a series of negative nicotine tests to document smoking cessation.(5)
The Liver Transplantation Operation steps
The liver transplant process in Turkey has four steps, which are:
Excise the recipient liver and prepare for transplantation
Recipient liver resection is the first step in liver transplantation and can be a challenging procedure due to the close anatomical relationship between the liver and the hepatic tributary of the inferior vena cava in the case of coagulopathy and portal hypertension.(6)
Hepatectomy can be performed using one of two techniques, but no study in the literature has proven superiority of one technique over the other:
Conventional technique: In which the hepatic tributary of the primordial inferior vena cava is removed from the liver, the conventional technique requires complete closure of the vena cava and for this reason some surgeons prefer to use venous bypass during the hepatic phase to avoid hemodynamic instability caused by total closure of the inferior vena cava.(6)
dorsal technique: the entire liver is stripped from the inferior vena cava, thus the hepatic tributary is only partially preserved upon completion of the liver resection, and one of the main advantages of this technique is the preservation of the venous return during the hepatic phase, so this technique is only possible when The venous tributary to the inferior vena cava is absent from the hepatic graft.(6)
Portal vein anastomosis
After completion of the inferior vena cava anastomosis, the portal vein anastomosis is performed in a comprehensive manner and the blood is reperfused back into the liver. Reperfusion is one of the most important parts of the transplantation process as it can be associated with profound hemodynamic instability (bradycardia and hypotension) resulting from the sudden entry of fluid residue The cold and cytokine-rich liver graft leads to systemic circulation. To avoid this, the liver graft is washed with saline solution at room temperature and then with systemic blood either from the portal vein or the inferior vena cava to wash and warm the liver graft before re-infusion of blood into it.(6)
Hepatic artery anastomosis
End-to-end anastomosis between the abdominal axis in a donor and the recipient's common hepatic artery (at its junction with the gastroduodenal artery) is the most common and frequently used technique for hepatic artery reconstruction. Depending on surgeon preference and anatomical factors, the level of hepatic artery reconstruction may vary as the focus is on Allowing only one simple anastomosis in the recipient, anastomosis of the recipient's separate right hepatic artery branch with the trunk of the gastroduodenal artery in a donor is the easiest and most common method of reconstruction.(6)
After vascular anastomosis and establishment of good hemostasis, the gallbladder is removed and the bile ducts are reconstructed from a donor. The preferred anastomosis is a channel to channel between the donor and recipient's common bile ducts. When there is an unacceptable mismatch in duct size or the recipient's bile duct is unusable (due to Primary sclerosing cholangitis) Hepatic duct-jejunal anastomosis is performed.(6)
Postoperative care of liver transplantation
A patient who has had a liver transplant requires special care and must follow the doctor's recommendations completely.
Hemodynamic monitoring after liver transplantation
Hemodynamic monitoring after liver transplantation is critical in postoperative care, and severe changes in hemodynamics that are not properly diagnosed or treated can lead to impaired liver graft function, prolonged ICU stay, and increased Mortality. Management of post-operative circulatory motility problems begins with a thorough understanding of the underlying pathophysiology.(7)
End-stage liver disease usually causes elevated cardiac output and decreased systemic vascular resistance, and this process begins to reverse after successful liver transplantation leading to a decrease in cardiac output and increased systemic vascular resistance with improved maintenance of systolic blood pressure.(7)
Early endotracheal extubation after liver transplantation
Early respiratory endotracheal extubation after liver transplantation is often possible due to advances in surgical and anesthetic techniques. The concept of early postoperative endotracheal extubation began with cardiac surgery and was applied to liver transplant patients in the late 1990s. Supporters argue that it reduces the risk of associated pneumonia. It improves visceral and hepatic blood flow, and has also been shown to reduce the length of stay in the intensive care unit.(7)
It is common that early tracheal extubation is not performed in the operating room in liver transplant patients, especially those with pre-existing pulmonary disease, and there is a group of patients who will need a ventilator for a long time, which makes them vulnerable to additional lung complications in the postoperative period, so It is critical to identify these patients and prevent them from developing ventilator-associated pneumonia.(7)
Pain management after a liver transplant
Liver transplantation is a major surgical procedure and may be associated with severe surgical pain after the operation. Pain during and after the operation is usually controlled with fentanyl by intravenous infusion or intermittent dosing. Opioid analgesics such as morphine and hydromorphone are avoided if possible due to their long half-lives. hepatic failure(7)
Some patients may need to use a patient-controlled analgesia pump in parallel with long-acting analgesics, or switch to oral medications around the clock if pain persists. Thoracic epidural anesthesia is useful for pain control after abdominal surgery but is not routinely used for liver transplant patients.(7)
Monitoring blood electrolytes after liver transplantation
Appropriate management of electrolytes can be difficult in post-liver transplant patients, and patients often present with several electrolyte disturbances that must be closely monitored and corrected.(7)
Hypernatremia is a less common complication in liver transplant patients and results from excessive free water loss in patients who are using an osmotic laxative (such as lactulose) to reduce hepatic encephalopathy.(7)
Hyperkalemia may be the most serious electrolyte disturbance due to the rapid progression of arrhythmias and death. The causes of hyperkalemia after liver transplantation are often multifactorial as many liver transplant patients either have pre-existing renal impairment or will develop transient renal impairment in the operative period. and beyond, which can impair potassium homeostasis mechanisms.(7)
Hypocalcemia is frequently diagnosed in liver transplant patients, and it is important to remember that these patients often have low levels of albumin and that total calcium does not necessarily reflect free calcium levels so ionic calcium levels are more accurate in this case.
Low calcium levels can result from chelation with the citrate anticoagulant in blood products and dialysis agents, and hypocalcemia should be suspected in a hypotensive patient despite adequate resuscitation. (7)
Blood sugar levels after liver transplantation are of great importance for both prognosis and complications. Hypoglycaemia in the postoperative period may be a sign of bacteremia or impaired liver graft function, while hyperglycemia (which is more common postoperatively) may be a sign of celiac disease. Latent diabetes or in response to stress or steroids.
Severe hyperglycaemia (glucose >200 mg/dL) is associated with an increased risk of liver transplant rejection, operative site infections, and increased mortality.(7)
Coagulation disorders after liver transplantation
Coagulation disorders do not improve immediately after liver transplantation and often persist in the intensive care period after surgery. This is due to a multifactorial etiology that can include excessive fibrinolysis, disseminated intravascular coagulopathy, thrombocytopenia, platelet retention in the liver graft, The presence of heparin-like effect.
Some patients also suffer from hypercoagulability after liver transplantation, which complicates the evaluation of their coagulation status. The cause of hypercoagulability is not fully clear, but it may result from poor synthesis of antithrombin by the liver.(7)
Immunosuppression after liver transplantation
Immunosuppression after liver transplantation is necessary to prevent rejection of the liver transplant. However, immunosuppression must be balanced with the preservation of other immune functions, especially preventing or recurring infections and malignancies. Rejection of a transplanted liver occurs less often than other organs, so lower doses can be used.(7)
Steroids are used to suppress and control immunity during the first year after liver transplantation as well as to treat acute rejection episodes. There is concern with the use of high doses of steroids due to accelerated rates of hepatitis C recurrence, recurrence of liver cancer and cirrhosis.(7)
Avoiding the use of steroids for immunosuppression has not been shown to benefit HCV-positive recipients. Common severe side effects of steroids in high doses include:
- High blood pressure
- glucose intolerance
- risk of infection
- Poor wound healing
Most of these signs and symptoms can be controlled, so steroid use is rarely discontinued.(7)
Rehabilitation after a liver transplant
Rehabilitation programs may help patients with liver disease and liver transplant recipients improve quality of life by increasing muscle strength, preventing excessive fatigue, enhancing aerobic capacity, and increasing the level of physical activity. stages of the disease by a physiotherapist. The physiotherapy after liver transplantation can be mainly divided into three periods: preoperative and postoperative physiotherapy and delayed postoperative physiotherapy. (8)
Reasons for participation in rehabilitation after liver transplantation and its contraindications should be well explained. Any sign of acute rejection of the transplanted liver, severe bleeding, imbalance of blood electrolytes, physiological instability, severe neurological complications, and severe cardiovascular disease may further affect the execution of movements. and specific exercises, so specialized stage-based assessment procedures must be implemented before physical therapy programs are planned.(8)
Evaluation of post-liver transplant physiotherapy should include muscle strength and endurance, ventilation capacity, level of physical activity, independence in activities of daily living and health-related quality of life. Neurological, metabolic or musculoskeletal comorbidities, level of pain and fatigue, smoking and alcohol habits should also be determined. in the course of conducting the evaluation.(8)
Risks and complications of a liver transplant
Liver transplantation has many complications, but we will go through it in detail and explain its cause to know its treatment and how to avoid it, and among the risks and complications:
Respiratory problems after a liver transplant
Pulmonary complications can be very common after liver transplantation, as many recipients develop respiratory impairment requiring care ranging from close monitoring to prolonged mechanical ventilation. Preoperative predisposing factors include underlying lung disease and smoking. In addition, patients Those who are intubated before surgery are at risk of needing mechanical ventilation after surgery due to the underlying underlying disease.(7)
Hepatopulmonary syndrome is a complication of cirrhosis that adds special concerns after liver transplantation as it leads to increased postoperative mortality, especially in severe cases (PaO 2 <50 mmHg in room air). Prolonged hypoxia after liver transplantation is a complication. Most common in patients with this syndrome.(7)
Infectious complications after liver transplantation
Infections are the leading cause of morbidity and mortality after liver transplantation, and the early period after transplantation (the first month) is often complicated by incisional and hospitalization-related infections including urinary tract infections, pneumonia, septicaemia, and pseudomembranous colitis.(7)
Patients after liver transplantation are at particular risk of developing bacterial infections in the liver and incision, including abscesses, cholangitis, and peritonitis. Therefore, standard antibiotics should be used prophylactically in the perioperative period to reduce the risk of infection.(7)
Renal complications after liver transplantation
Renal failure after liver transplantation is common, and some studies indicate a percentage of up to 50% cases. Acute ischemic tubular necrosis is the most common cause of early renal failure after liver transplantation.(7)
There are a number of factors that contribute to an increased risk of developing renal disorders after liver transplantation. These include:
- Hepatorenal syndrome
- Hepatitis C
- Hemodynamic instability during and after surgery
- Large blood transfusions
- Intravenous infusion of vasoconstrictors
- Repeated radiological procedures
- Kidney-damaging immunosuppressants and antibiotics (7)
Thrombocytopenia after liver transplantation
A low platelet count is a common disorder after a liver transplant. The causes of thrombocytopenia are varied but are related to a decrease in the number of platelets in the circulation and a decrease in their production.(7)
In the case of severe liver cirrhosis, there is often significant retention of platelets in the spleen due to portal hypertension, and the new liver graft will retain platelets as well. There is a decrease in platelet production due to low levels of thrombopoietin in patients with liver failure. Significant in the postoperative period to thrombocytopenia increased in size.(7)
Graft rejection after liver transplant
There are many types of liver graft rejection that may occur after a liver transplant. It can be hyperacute, acute, chronic, or graft-versus-host disease.(7)
Rejection can be mediated by T-lymphocytes or mediated by antibodies, and the process often targets the interlobular bile ducts, the vascular endothelium of the portal vein, the hepatic veins, and occasionally the hepatic artery and its branches.(9)
Severe antibody-mediated rejection occurs within minutes to hours after liver transplant and occurs in 60% cases due to an ABO-incompatible allograft, in which case plasmapheresis, splenectomy, CD20 monoclonal antibody, and rituximab are used. To prevent a hyperacute rejection event, however, immediate replantation is often the only option.(7)
Acute rejection is caused by T lymphocytes and usually presents within days or weeks of liver transplantation in 36-75% cases.(7)
Rejection due to graft-versus-host disease occurs in 1-2% liver transplant recipients and is associated with a mortality rate of 85%. In solid organ transplantation, donor lymphocytes remaining in the parenchyma become detectable in the recipient within weeks after transplantation. Different cellular antigens present in the recipient. This form of rejection is divided between an acute pattern (which occurs within 100 days of transplantation) and a chronic pattern (100 days after transplantation).(7)
Results of liver transplant surgery
Outcomes for liver transplant patients continue to improve due to improved surgical techniques, immune stabilization regimens, and better management of infection and post-transplant complications, yet donor shortage remains the biggest challenge facing the liver transplantation industry today. (2)
Given the high morbidity and mortality associated with end-stage liver disease, it is essential that physicians caring for such patients have a valid and reproducible system for disease risk assessment and prognosis, which will be useful in identifying those who need a liver transplant.(2)
Physiological rather than chronological age determines the admission of an older patient for liver transplantation with careful attention to comorbidities and functional status. Overall results are acceptable in recipients over 70 years of age although they are of lower quality compared to younger age groups.(4)
Quality of life after 10 years and 30 years after liver transplantation was taken into account. Patients' expectation of quality of life was generally good and was low only in the elderly whose ability to perform physical activity decreased compared to the general population, and no difference was noted in terms of quality of transplantation. between male and female patients, but one study indicated that the overall quality of life was higher in male recipients than in female recipients.(4)
In the end, we find that the liver transplant is one of the best operations in Turkey to solve liver problems once and for all, and the cost of the liver transplant in Turkey is much lower than in other countries, and with almost the same quality and expected results, and that many patients talked about my experience with liver transplant In Turkey, all comments were positive and promising, even after a long period of liver donation or liver transplantation.
Liver transplant cost in Turkey
The cost of liver transplantation in Türkiye varies according to the type of center
As the cost of liver transplantation in state medical city hospitals ranges between 30 and 37 thousand US dollars.
While its cost in university hospitals specialized in organ transplantation, the cost of liver transplantation ranges between 45 and 55 thousand US dollars.
While the cost of liver transplantation in private hospitals ranges between 50 and 80 thousand US dollars.
- Bulur A and Sevmiş M. Clinical, surgical and histopathological characteristics of liver transplant recipients: An analysis of a large sample from Turkey. Gulhane Medical Journal 2022;64:60-66.
- Ionescu, VA, Diaconu CC, Bungau S, Jinga V, Gheorghe G. Current Approaches in the Allocation of Liver Transplantation. J.Pers. Med. 2022;12,1661.
- Mahmod N. Selection for Liver Transplantation: Indications and Evaluation. Current Hepatology Reports 2020;19:203-212.
- European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Liver transplantation. Journal of Hepatology 2016;64:433-485.
- Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alono-Coello P, et al. Evaluation for Liver Transplantation in Adults: 2013 Practice Guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. BMJ 2008;336:924-926.
- Miller C and Diago Uso T. The Liver Transplant Operation. Clinical Liver Disease 2013; 2,(4):192-196.
- Parekh KN, et al. Postoperative Care of the Liver Transplant Recipient. Springer 2017;29:365-384.
- Yıldırım MS, Yurdalan SU Physiotherapy in Liver Transplantation. InTech 2012;21:445-454.
- Zhu JH, et al. Medical complications of liver transplantation. AME Medical Journal 2018;3:1-10.