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All patients with severe liver disease referred to the
New Jersey Medical School Liver Center and University
Hospital Liver Transplant Program 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 Doctors
Office Center (DOC) in Suite 7100 (seventh floor). 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 surgeons. 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, 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 surgeon 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:
- chest X-ray-
to tell if the lungs are healthy.
- 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.
- 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.
- MRI (magnetic
resonance imaging)- may be used in place of a
CT scan.
- total-body bone scan-
if a liver tumor is present, this test will ensure
that it has not spread to the bones.
- 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.
- cholangiogram-
to reveal if there are any blockages or growths
in the liver's bile ducts.
- Some heart function tests, including:
- electrocardiogram
(EKG)- to see how well the heart is functioning.
It may reveal a previously undetected heart
problem.
- 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.
- 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.
- 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 psychiatrist and social worker 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, a dietitian, nurse coordinators, a psychiatrist,
and a financial coordinator. They make the final decision
on each transplant case.
Patients accepted for transplantation are placed on
the waiting list. Sometimes patients are not be 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
and what lies ahead with the patient.
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 ensure
that the sickest patients have priority when a donor
liver becomes available. A key element of the criteria
is the Child-Turcotte-Pugh (CTP) Scoring System, which
assign points based on the presence or absence of certain
factors. Other medical conditions also are taken into
account, i.e., the deterioration of kidney function.
The status levels are as follows:
Status 1:
The patient has fulminant (sudden and severe) liver
failure and a life expectancy of less than 7 days
without a liver transplant.
Status 2A:
The patient has chronic liver failure and a life expectancy
of less than 7 days without a liver transplant.
He or she has a CTP score of greater than or equal to
10 and meets other medical criteria.
Status 2B:
The patient has a CTP score greater than or equal to
10, or has a CTP score greater than
or equal to 7 and meets other medical criteria.
Status 3:
The patient has a CTP score greater than or equal to
7.
Status 7:
The patient is considered to be temporarily
inactive on the waiting list but continues to accrue
waiting time up to 30 days.
While waiting for a donor organ, patients continue
medical therapy as supervised by their family physician,
with periodic visits to see the transplant team. Patients
may be given a pager so they can be reached when a liver
becomes available. The range of the pager extends from
the southern tip of New Jersey to the New York metropolitan
area. 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 the "Liverable People" group, a support
group consisting of former transplant patients.
They are available to provide first-hand accounts of
the transplant experience and to answer any questions
a candidate may have. In addition, there is a southern
New Jersey transplant support group. For further information
about either group, please contact the transplant office
at (973) 972-7218.
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.
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The
Transplant Process
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