Liver transplantation or hepatic transplantation is the replacement of a
diseased liver with the healthy
liver
The liver is a major Organ (anatomy), organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of proteins and biochemicals necessary for ...
from another person (
allograft
Allotransplant (''allo-'' meaning "other" in Greek) is the transplantation of cells, tissues, or organs to a recipient from a genetically non-identical donor of the same species. The transplant is called an allograft, allogeneic transplant, o ...
). Liver transplantation is a treatment option for
end-stage liver disease and
acute liver failure
Acute liver failure is the appearance of severe complications rapidly after the first signs (such as jaundice) of liver disease, and indicates that the liver has sustained severe damage (loss of function of 80–90% of liver cells). The complicati ...
, although availability of donor organs is a major limitation. The most common technique is orthotopic transplantation, in which the native liver is removed and replaced by the donor organ in the same anatomic position as the original liver. The surgical procedure is complex, requiring careful harvest of the donor organ and meticulous implantation into the recipient. Liver transplantation is highly regulated, and only performed at designated transplant medical centers by highly trained transplant physicians and supporting medical team. The duration of the surgery ranges from 4 to 18 hours depending on outcome. Favorable outcomes require careful screening for eligible recipient, as well as a well-calibrated live or
cadaver
A cadaver or corpse is a dead human body that is used by medical students, physicians and other scientists to study anatomy, identify disease sites, determine causes of death, and provide tissue to repair a defect in a living human being. Stud ...
ic donor match.
Medical uses
Liver transplantation is a potential treatment for acute or chronic conditions which cause irreversible and severe ("end-stage") liver dysfunction.
Since the procedure carries relatively high risks, is resource-intensive, and requires major life modifications after surgery, it is reserved for dire circumstances.
Judging the appropriateness/effectiveness of liver transplant on case-by-case basis is critically important (''see
Contraindications
In medicine, a contraindication is a condition that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a reason to use a certain tre ...
''), as outcomes are highly variable.
Contraindications
Although liver transplantation is the most effective treatment for many forms of end-stage liver disease, the tremendous limitation in allograft (donor) availability and widely variable post-surgical outcomes make case selection critically important. Assessment of a person's transplant eligibility is made by a multi-disciplinary team that includes surgeons, medical doctors, psychologists and other providers.
The first step in evaluation is to determine whether the patient has irreversible liver-based disease which will be cured by getting a new liver.
Thus, those with diseases which are primarily based outside the liver or have spread beyond the liver are generally considered poor candidates. Some examples include:
* someone with advanced liver cancer, with known/likely spread beyond the liver
* active alcohol/substance use
* severe heart/lung disease
* existing high cholesterol levels in the patient
* severe Wilson's disease
*
* dyslipidemia
Importantly, many contraindications to liver transplantation are considered reversible; a person initially deemed "transplant-ineligible" may later become a favorable candidate if their situation changes.
Some examples include:
* partial treatment of liver cancer, such that risk of spread beyond liver is decreased (for those with primary liver cancer or secondary spread to the liver, the medical team will likely rely heavily on the opinion of the patient's primary provider, the oncologist, and the radiologist)
* cessation of substance use (time period of abstinence is variable)
* improvement in heart function, e.g. by
percutaneous coronary intervention
Percutaneous coronary intervention (PCI) is a non-surgical procedure used to treat narrowing of the coronary arteries of the heart found in coronary artery disease. The process involves combining coronary angioplasty with stenting, which is the ...
or
bypass surgery
Bypass surgery refers to a class of surgery involving rerouting a tubular body part.
Types include:
* Vascular bypass surgery such as coronary artery bypass surgery, a heart operation
* Cardiopulmonary bypass, a technique used in coronary artery ...
* treated HIV infection (''see
Special populations'')
* for those with high cholesterol or triglyceride levels or other dyslipidemias, using lifestyle changes (diet, portions, exercise) and drugs and counseling to lower one's levels, and to control any hyperglycemia or (pre-)diabetes or obesity
Risks/complications
Graft rejection
After a liver transplantation, immune-mediated rejection (also known as rejection) of the allograft may happen at any time. Rejection may present with lab findings: elevated AST, ALT, GGT; abnormal liver function values such as prothrombin time, ammonia level, bilirubin level, albumin concentration; and abnormal blood glucose. Physical findings may include encephalopathy, jaundice, bruising and bleeding tendency. Other nonspecific presentation may include malaise, anorexia, muscle ache, low fever, slight increase in white blood count and graft-site tenderness.
Three types of graft rejection may occur: hyperacute rejection, acute rejection, and chronic rejection.
* Hyperacute rejection is caused by preformed anti-donor antibodies. It is characterized by the binding of these antibodies to antigens on vascular endothelial cells.
Complement activation
The complement system, also known as complement cascade, is a part of the immune system that enhances (complements) the ability of antibodies and phagocytic
Phagocytosis () is the process by which a cell uses its plasma membrane to engulf a ...
is involved and the effect is usually profound. Hyperacute rejection happens within minutes to hours after the transplant procedure.
* Acute rejection is mediated by T cells (versus B-cell-mediated hyperacute rejection). It involves direct cytotoxicity and cytokine mediated pathways. Acute rejection is the most common and the primary target of immunosuppressive agents. Acute rejection is usually seen within days or weeks of the transplant.
* Chronic rejection is the presence of any sign and symptom of rejection after one year. The cause of chronic rejection is still unknown, but an acute rejection is a strong predictor of chronic rejections.
Biliary complications
Biliary complications include biliary stenosis, biliary leak, and ischemic cholangiopathy. The risk of ischemic cholangiopathy increases with longer durations of cold ischemia time, which is the time that the organ does not receive blood flow (after death/removal until graft placement).
Vascular complications
Vascular complications include
thrombosis
Thrombosis (from Ancient Greek "clotting") is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel (a vein or an artery) is injured, the body uses platelets (thro ...
, stenosis, pseudoaneurysm, and rupture of the hepatic artery.
Venous complications occur less often compared with arterial complications, and include thrombosis or stenosis of the portal vein, hepatic vein, or vena cava.
Technique
Before transplantation, liver-support therapy might be indicated (bridging-to-transplantation). Artificial liver support like
liver dialysis
A liver support system or diachysis is a type of therapeutic device to assist in performing the functions of the liver. Such systems focus either on removing the accumulating toxins (liver dialysis), or providing additional replacement of the met ...
or bioartificial liver support concepts are currently under preclinical and clinical evaluation. Virtually all liver transplants are done in an orthotopic fashion; that is, the native liver is removed and the new liver is placed in the same anatomic location.
The transplant operation can be conceptualized as consisting of the hepatectomy (liver removal) phase, the anhepatic (no liver) phase, and the postimplantation phase. The operation is done through a large incision in the upper abdomen. The hepatectomy involves division of all ligamentous attachments to the liver, as well as the common bile duct, hepatic artery, hepatic vein and portal vein. Usually, the retrohepatic portion of the inferior vena cava is removed along with the liver, although an alternative technique preserves the recipient's vena cava ("piggyback" technique).
The donor's blood in the liver will be replaced by an ice-cold organ storage solution, such as UW (
Viaspan Viaspan was the trademark under which the University of Wisconsin cold storage solution (also known as University of Wisconsin solution or UW solution) was sold. Currently, UW solution is sold under the Belzer UW trademark and others like Bel-Gen o ...
) or
HTK, until the allograft liver is implanted. Implantation involves anastomoses (connections) of the inferior vena cava, portal vein, and hepatic artery. After blood flow is restored to the new liver, the biliary (bile duct) anastomosis is constructed, either to the recipient's own bile duct or to the small intestine. The surgery usually takes between five and six hours, but may be longer or shorter due to the difficulty of the operation and the experience of the surgeon.
The large majority of liver transplants use the entire liver from a non-living donor for the transplant, particularly for adult recipients. A major advance in pediatric liver transplantation was the development of reduced size liver transplantation, in which a portion of an adult liver is used for an infant or small child. Further developments in this area included split liver transplantation, in which one liver is used for transplants for two recipients, and living donor liver transplantation, in which a portion of a healthy person's liver is removed and used as the allograft. Living donor liver transplantation for pediatric recipients involves removal of approximately 20% of the liver (
Couinaud
Claude Couinaud (12 February 1922, in Neuilly-sur-Seine – 4 May 2008, in Paris) was a French surgeon and anatomist who made significant contributions in the field of hepatobiliary
The biliary tract, (biliary tree or biliary system) refers ...
segments 2 and 3).
Further advance in liver transplant involves only resection of the lobe of the liver involved in tumors and the tumor-free lobe remains within the recipient. This speeds up the recovery and the patient stay in the hospital quickly shortens to within 5–7 days.
Radiofrequency ablation
Radiofrequency ablation (RFA), also called fulguration, is a medical procedure in which part of the electrical conduction system of the heart, tumor or other dysfunctional tissue is ablated using the heat generated from medium frequency alternat ...
of the liver tumor can be used as a bridge while awaiting liver transplantation.
Cooling
Between removal from donor and transplantation into the recipient, the allograft liver is stored in a temperature-cooled preservation solution. The reduced temperature slows down the process of deterioration from normal metabolic processes, and the storage solution itself is designed to counteract the unwanted effects of cold ischemia. Although "static" cold storage method has long been standard technique, various dynamic preservation methods are under investigation. For example, systems which use a machine to pump blood through the explanted liver (after it is harvested from the body) during a transfer have met some success (''see
Research section for more'').
Living donor transplantation
Living donor liver transplantation (LDLT) has emerged in recent decades as a critical
surgical
Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
option for patients with end stage liver disease, such as
cirrhosis
Cirrhosis, also known as liver cirrhosis or hepatic cirrhosis, and end-stage liver disease, is the impaired liver function caused by the formation of scar tissue known as fibrosis due to damage caused by liver disease. Damage causes tissue repai ...
and/or
hepatocellular carcinoma
Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer in adults and is currently the most common cause of death in people with cirrhosis. HCC is the third leading cause of cancer-related deaths worldwide.
It occurs in t ...
often attributable to one or more of the following: long-term
alcohol use disorder
Alcoholism is, broadly, any drinking of alcohol that results in significant mental or physical health problems. Because there is disagreement on the definition of the word ''alcoholism'', it is not a recognized diagnostic entity. Predomin ...
, long-term untreated
hepatitis C
Hepatitis C is an infectious disease caused by the hepatitis C virus (HCV) that primarily affects the liver; it is a type of viral hepatitis. During the initial infection people often have mild or no symptoms. Occasionally a fever, dark urine, a ...
infection, long-term untreated
hepatitis B
Hepatitis B is an infectious disease caused by the ''Hepatitis B virus'' (HBV) that affects the liver; it is a type of viral hepatitis. It can cause both acute and chronic infection.
Many people have no symptoms during an initial infection. Fo ...
infection. The concept of LDLT is based on (1) the remarkable regenerative capacities of the human liver and (2) the widespread shortage of
cadaver
A cadaver or corpse is a dead human body that is used by medical students, physicians and other scientists to study anatomy, identify disease sites, determine causes of death, and provide tissue to repair a defect in a living human being. Stud ...
ic livers for patients awaiting
transplant. In LDLT, a piece of healthy liver is surgically removed from a living person and transplanted into a recipient, immediately after the recipient's diseased liver has been entirely removed.
Historically, LDLT began with terminal pediatric patients, whose parents were motivated to risk donating a portion of their compatible healthy livers to replace their children's failing ones. The first report of successful LDLT was by
Silvano Raia
Dr. Silvano Raia is a Brazilian surgeon who specializes in liver diseases. He is a professor emeritus at the Faculty of Medicine of the University of São Paulo (FMUSP).
Raia was the first doctor to achieve a successful living donor liver transp ...
at the
University of Sao Paulo
A university () is an institution of higher (or tertiary) education and research which awards academic degrees in several academic disciplines. Universities typically offer both undergraduate and postgraduate
Postgraduate or graduate educa ...
Faculty of Medicine in July 1989.
It was followed by
Christoph Broelsch at the
University of Chicago Medical Center
The University of Chicago Medical Center (UChicago Medicine) is a nationally ranked academic medical center located in Hyde Park on the South Side of Chicago. It is the flagship campus for The University of Chicago Medicine system and was establis ...
in November 1989, when two-year-old Alyssa Smith received a portion of her mother's liver. Surgeons eventually realized that adult-to-adult LDLT was also possible, and now the practice is common in a few reputable medical institutes. It is considered more technically demanding than even standard, cadaveric donor liver transplantation, and also poses the ethical problems underlying the indication of a major surgical operation (
hemihepatectomy
Hepatectomy is the surgical resection (removal of all or part) of the liver. While the term is often employed for the removal of the liver from a liver transplant donor, this article will focus on Segmental resection, partial resections of hepatic ...
or related procedure) on a healthy human being. In various case series, the risk of complications in the donor is around 10%, and very occasionally a second operation is needed. Common problems are
biliary fistula
A biliary fistula is a type of fistula in which bile flows along an abnormal connection from the bile ducts into nearby hollow structure. Types of biliary fistula include:
* bilioenteric fistula: abnormal connection to small bowel, usually duodenu ...
,
gastric stasis and
infection
An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
s; they are more common after removal of the right lobe of the liver. Death after LDLT has been reported at 0% (Japan), 0.3% (USA) and <1% (Europe), with risks likely to decrease further as surgeons gain more experience in this procedure. Since the law was changed to permit altruistic non-directed living organ donations in the UK in 2006, the first altruistic living liver donation took place in Britain in December 2012.
In a typical adult recipient LDLT, 55 to 70% of the liver (the right lobe) is removed from a healthy living donor. The donor's liver will regenerate approaching 100% function within 4–6 weeks, and will almost reach full volumetric size with recapitulation of the normal structure soon thereafter. It may be possible to remove up to 70% of the liver from a healthy living donor without harm in most cases. The transplanted portion will reach full function and the appropriate size in the recipient as well, although it will take longer than for the donor.
Living donors are faced with risks and/or complications after the surgery. Blood clots and biliary problems have the possibility of arising in the donor post-op, but these issues are remedied fairly easily. Although death is a risk that a living donor must be willing to accept prior to the surgery, the mortality rate of living donors in the United States is low. The LDLT donor's immune system does diminish as a result of the liver regenerating, so certain foods which would normally cause an upset stomach could cause serious illness.
Donor requirements
Any member of the family, parent, sibling, child, spouse or a volunteer can donate their liver. The criteria
[Living Donor Liver Transplantation FAQ - Columbia University Dept of Surgery](_blank)
Retrieved on 2018-06-10.
, Retrieved on 2018-06-10.
for a liver donation include:
* Being in good health
* Having a
blood type
A blood type (also known as a blood group) is a classification of blood, based on the presence and absence of antibodies and inherited antigenic substances on the surface of red blood cells (RBCs). These antigens may be proteins, carbohydrate ...
that matches or is compatible with the recipient's,
although some centres now perform blood group incompatible transplants with special immunosuppression protocols.
* Having a charitable desire of donation without financial motivation
* Being between 20 and 60 years old
(18 to 60 years old in some places
)
* Have an important personal relationship with the recipient
* Being of similar or larger size than the recipient
* Before one becomes a living donor, the donor must undergo testing to ensure that the individual is physically fit, in excellent health, and not having uncontrolled high blood pressure, liver disease, diabetes or heart disease.
Sometimes CT scans or MRIs are done to image the liver. In most cases, the work up is done in 2–3 weeks.
Complications
Living donor surgery is done at a major center. Very few individuals require any
blood transfusions
Blood transfusion is the process of transferring blood products into a person's circulation intravenously. Transfusions are used for various medical conditions to replace lost components of the blood. Early transfusions used whole blood, but mod ...
during or after surgery. All potential donors should know there is a 0.5 to 1.0 percent chance of death. Other risks of donating a liver include bleeding, infection, painful incision, possibility of
blood clots
A thrombus (plural thrombi), colloquially called a blood clot, is the final product of the blood coagulation step in hemostasis. There are two components to a thrombus: aggregated platelets and red blood cells that form a plug, and a mesh of cr ...
and a prolonged recovery.
[Liver Transplant](_blank)
Retrieved on 2010-01-20. The vast majority of donors enjoy complete and full recovery within 2–3 months.
[Post Operative Care](_blank)
Retrieved on 2021-05-05.
Pediatric transplantation
![Left Liver Transplant](https://upload.wikimedia.org/wikipedia/commons/f/f1/Left_Liver_Transplant.jpg)
In children, living liver donor transplantation has become very accepted. The accessibility of adult parents who want to donate a piece of the liver for their children/infants has reduced the number of children who would have otherwise died waiting for a transplant. Having a parent as a donor also has made it a lot easier for children – because both patients are in the same hospital and can help boost each other's morale.
National Digestive Diseases Information Clearinghouse (NDDIC), Retrieved on 2010-01-20.
Benefits
There are several advantages of living liver donor transplantation over cadaveric donor transplantation, including:
* Transplant can be done on an elective basis because the donor is readily available
* There are fewer possibilities for complications and death than there would be while waiting for a cadaveric organ donor
* Because of donor shortages,
UNOS
The United Network for Organ Sharing (UNOS) is a non-profit, scientific and educational organization that administers the only Organ Procurement and Transplantation Network (OPTN) in the United States, established () by the U.S. Congress in 1984 b ...
has placed limits on cadaveric organ allocation to foreigners who seek medical help in the USA. With the availability of living donor transplantation, this will now allow foreigners a new opportunity to seek medical care in the USA.
Screening for donors
Living donor transplantation is a multidisciplinary approach. All living liver donors undergo medical evaluation. Every hospital which performs transplants has dedicated nurses that provide specific information about the procedure and answer questions that families may have. During the evaluation process, confidentiality is assured on the potential donor. Every effort is made to ensure that organ donation is not made by coercion from other family members. The transplant team provides both the donor and family thorough counseling and support which continues until full recovery is made.
[Liver Donor: All you need to know](_blank)
Retrieved on 2010-01-20.
All donors are assessed medically to ensure that they can undergo the surgery. Blood type of the donor and recipient must be compatible but not always identical. Other things assessed prior to surgery include the anatomy of the donor liver. However, even with mild variations in
blood vessels
The blood vessels are the components of the circulatory system that transport blood throughout the human body. These vessels transport blood cells, nutrients, and oxygen to the tissues of the body. They also take waste and carbon dioxide away f ...
and
bile duct
A bile duct is any of a number of long tube-like structures that carry bile, and is present in most vertebrates.
Bile is required for the digestion of food and is secreted by the liver into passages that carry bile toward the hepatic duct. It ...
, surgeons today are able to perform transplantation without problems. The most important criterion for a living liver donor is to be in excellent health.
[Liver Transplant Program And Center for Liver Disease](_blank)
, University of Southern California Department of Surgery, Retrieved on 2010-01-20.
Post-transplant immunosuppression
Like most other allografts, a liver transplant will be
rejected
''Rejected'' is an animated film directed by Don Hertzfeldt that was released in 2000. It was nominated for an Academy Award for Best Animated Short Film the following year at the 73rd Academy Awards, and received 27 awards from film festivals ...
by the recipient unless
immunosuppressive
Immunosuppression is a reduction of the activation or efficacy of the immune system. Some portions of the immune system itself have immunosuppressive effects on other parts of the immune system, and immunosuppression may occur as an adverse reacti ...
drugs are used. The immunosuppressive regimens for all solid organ transplants are fairly similar, and a variety of agents are now available. Most liver transplant recipients receive
corticosteroid
Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involv ...
s plus a calcineurin inhibitor such as
tacrolimus
Tacrolimus, sold under the brand name Prograf among others, is an immunosuppressive drug. After allogeneic organ transplant, the risk of organ rejection is moderate. To lower the risk of organ rejection, tacrolimus is given. The drug can also ...
or
ciclosporin
Ciclosporin, also spelled cyclosporine and cyclosporin, is a calcineurin inhibitor, used as an immunosuppressant medication. It is a natural product. It is taken orally or intravenously for rheumatoid arthritis, psoriasis, Crohn's disease, ...
, (also spelled cyclosporine and cyclosporin) plus a purine antagonist such as
mycophenolate mofetil
Mycophenolic acid (MPA) is an immunosuppressant medication used to prevent rejection following organ transplantation and to treat autoimmune conditions such as Crohn's disease and lupus. Specifically it is used following kidney, heart, and live ...
. Clinical outcome is better with tacrolimus than with ciclosporin during the first year of liver transplantation. If the patient has a co-morbidity such as active hepatitis B, high doses of hepatitis B immunoglubins are administrated in liver transplant patients.
Due to both the pharmacological immunosuppression and the immunosuppression of underlying liver disease, vaccinations against vaccination-preventable diseases are highly recommended before and after liver transplantation. Vaccine hesitancy in transplant recipients is less than in the general population.
Liver transplantation is unique in that the risk of chronic rejection also decreases over time, although the great majority of recipients need to take immunosuppressive medication for the rest of their lives. It is possible to be slowly taken off anti rejection medication but only in certain cases. It is theorized that the liver may play a yet-unknown role in the maturation of certain cells pertaining to the
immune system
The immune system is a network of biological processes that protects an organism from diseases. It detects and responds to a wide variety of pathogens, from viruses to parasitic worms, as well as cancer cells and objects such as wood splinte ...
. There is at least one study by
Thomas E. Starzl
Thomas Earl Starzl (March 11, 1926 – March 4, 2017) was an Health care in the United States, American physician, Medical research, researcher, and expert on organ transplants. He performed the first human liver transplants, and has often been ...
's team at the
University of Pittsburgh
The University of Pittsburgh (Pitt) is a public state-related research university in Pittsburgh, Pennsylvania. The university is composed of 17 undergraduate and graduate schools and colleges at its urban Pittsburgh campus, home to the universit ...
which consisted of
bone marrow
Bone marrow is a semi-solid tissue found within the spongy (also known as cancellous) portions of bones. In birds and mammals, bone marrow is the primary site of new blood cell production (or haematopoiesis). It is composed of hematopoietic ce ...
biopsies
A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a diseas ...
taken from such patients which demonstrate genotypic
chimerism
A genetic chimerism or chimera ( ) is a single organism composed of cells with more than one distinct genotype. In animals, this means an individual derived from two or more zygotes, which can include possessing blood cells of different blood ty ...
in the bone marrow of liver transplant recipients.
Recovery and outcomes
The prognosis following liver transplant is variable, depending on overall health, technical success of the surgery, and the underlying disease process affecting the liver. There is no exact model to predict survival rates; those with transplant have a 58% chance of surviving 15 years. Failure of the new liver (primary nonfunction in liver transplantation or PNF) occurs in 10% to 15% of all cases. These percentages are contributed to by many complications. Early graft failure is probably due to preexisting disease of the donated organ. Others include technical flaws during surgery such as revascularization that may lead to a nonfunctioning graft.
History
As with many experimental models used in early surgical research, the first attempts at liver transplantation were performed on dogs. The earliest published reports of canine liver transplantations were performed in 1954 by Vittorio Staudacher at Opedale Maggiore Policlinico in Milan, Italy. This initial attempt varied significantly from contemporary techniques; for example, Staudacher reported "arterialization" of the donor portal vein via the recipient hepatic artery, and use of cholecystostomy for biliary drainage.
The first attempted
human
Humans (''Homo sapiens'') are the most abundant and widespread species of primate, characterized by bipedalism and exceptional cognitive skills due to a large and complex brain. This has enabled the development of advanced tools, culture, ...
liver transplant was performed in 1963 by
Thomas Starzl
Thomas Earl Starzl (March 11, 1926 – March 4, 2017) was an American physician, researcher, and expert on organ transplants. He performed the first human liver transplants, and has often been referred to as "the father of modern transplantatio ...
, although the pediatric patient died intraoperatively due to uncontrolled bleeding.
Multiple subsequent attempts by various surgeons remained unsuccessful until 1967, when Starzl transplanted a 19-month-old girl with
hepatoblastoma
Hepatoblastoma is a malignant liver cancer occurring in infants and children and composed of tissue resembling fetal liver cells, mature liver cells, or bile duct cells. They usually present with an abdominal mass. The disease is most commonly di ...
who was able to survive for over one year before dying of metastatic disease.
Despite the development of viable surgical techniques, liver transplantation remained experimental through the 1970s, with one year patient survival in the vicinity of 25%. The introduction of
ciclosporin
Ciclosporin, also spelled cyclosporine and cyclosporin, is a calcineurin inhibitor, used as an immunosuppressant medication. It is a natural product. It is taken orally or intravenously for rheumatoid arthritis, psoriasis, Crohn's disease, ...
by Sir
Roy Calne
Sir Roy Yorke Calne, FRCP, FRCS, FRS (born 30 December 1930) is a British surgeon and pioneer in organ transplantation.
Career
His most notable achievements are the world's first liver, heart, and lung transplant together with John Wallwork ...
, Professor of Surgery Cambridge, markedly improved patient outcomes, and the 1980s saw recognition of liver transplantation as a standard clinical treatment for both adult and pediatric patients with appropriate indications. Liver transplantation is now performed at over one hundred centers in the US, as well as numerous centres in Europe and elsewhere.
The limited supply of
liver
The liver is a major Organ (anatomy), organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of proteins and biochemicals necessary for ...
allograft
Allotransplant (''allo-'' meaning "other" in Greek) is the transplantation of cells, tissues, or organs to a recipient from a genetically non-identical donor of the same species. The transplant is called an allograft, allogeneic transplant, o ...
s from non-living donors relative to the number of potential recipients spurred the development of
living donor liver transplantation
Liver transplantation or hepatic transplantation is the replacement of a diseased liver with the healthy liver from another person (allograft). Liver transplantation is a treatment option for end-stage liver disease and acute liver failure, al ...
. The first altruistic living liver donation in Britain was performed in December 2012 in St James University Hospital Leeds.
Society and culture
Famous liver transplant recipients
See also:
:Liver transplant recipients and
List of organ transplant donors and recipients
This list of notable organ transplant donors and recipients includes people who were the first to undergo certain organ transplant procedures or were people who made significant contributions to their chosen field and who have either donated or ...
*
Eric Abidal
Eric Sylvain Abidal (; born 11 September 1979) is a French former professional footballer who played as a left-back or centre-back.
In his career, he played mainly for Lyon and Barcelona, winning 18 trophies with both teams combined, including t ...
(born 1979), French footballer (
Olympique Lyonnais
Olympique Lyonnais (), commonly referred to as simply Lyon () or OL, is a men and women's French professional football club based in Lyon in Auvergne-Rhône-Alpes. The men play in France's highest football division, Ligue 1. Founded in 1950, th ...
,
FC Barcelona
Futbol Club Barcelona (), commonly referred to as Barcelona and colloquially known as Barça (), is a professional football club based in Barcelona, Catalonia, Spain, that competes in La Liga, the top flight of Spanish football.
Founded ...
),
transplant in 2012
*
Gregg Allman
Gregory LeNoir Allman (December 8, 1947 – May 27, 2017) was an American musician, singer and songwriter. He was known for performing in the Allman Brothers Band. Allman grew up with an interest in rhythm and blues music, and the Allman Br ...
(1947–2017), American musician (
The Allman Brothers Band
The Allman Brothers Band was an American rock band formed in Jacksonville, Florida in 1969 by brothers Duane Allman (founder, slide guitar and lead guitar) and Gregg Allman (vocals, keyboards, songwriting), as well as Dickey Betts (lead guita ...
),
transplant in 2010 (survival: 7 years)
*
George Best
George Best (22 May 1946 – 25 November 2005) was a Northern Irish professional footballer who played as a winger, spending most of his club career at Manchester United. A highly skilful dribbler, Best is regarded as one of the greatest pla ...
(1946–2005), Northern-Irish footballer (
Manchester United
Manchester () is a city in Greater Manchester, England. It had a population of 552,000 in 2021. It is bordered by the Cheshire Plain to the south, the Pennines to the north and east, and the neighbouring city of City of Salford, Salford to ...
),
transplant in 2002 (survival: 3 years)
*
David Bird (1959–2014), American journalist (''
The Wall Street Journal
''The Wall Street Journal'' is an American business-focused, international daily newspaper based in New York City, with international editions also available in Chinese and Japanese. The ''Journal'', along with its Asian editions, is published ...
''),
transplant in 2004 (survival: 10 years)
*
Jack Bruce
John Symon Asher Bruce (14 May 1943 – 25 October 2014) was a Scottish bassist, singer-songwriter, musician and composer. He gained popularity as the primary lead vocalist and bassist of British rock band Cream. After the group disbande ...
(1943–2014), English musician (
Cream
Cream is a dairy product composed of the higher-fat layer skimmed from the top of milk before homogenization. In un-homogenized milk, the fat, which is less dense, eventually rises to the top. In the industrial production of cream, this process ...
),
transplant in 2003 (survival: 11 years)
*
Frank Bough
Francis Joseph Bough (; 15 January 1933 – 21 October 2020) was an English television presenter. He was best known as the former host of BBC sports and current affairs shows including ''Grandstand'', '' Nationwide'' and '' Breakfast Time'', whi ...
(1933–2020), English television presenter,
transplant in 2001 (survival: 19 years)
*
Robert P. Casey (1932–2000), American politician (
42nd Governor of Pennsylvania),
transplant in 1993 (survival: 7 years)
*
David Crosby
David Van Cortlandt Crosby (born August 14, 1941) is an American singer, guitarist, and songwriter. In addition to his solo career, he was a founding member of both the Byrds and Crosby, Stills & Nash.
Crosby joined the Byrds in 1964. They got ...
(born 1941), American musician (
The Byrds
The Byrds () were an American rock band formed in Los Angeles, California, in 1964. The band underwent multiple lineup changes throughout its existence, with frontman Roger McGuinn (known as Jim McGuinn until mid-1967) remaining the sole cons ...
,
Crosby Stills, Nash (& Young)),
transplant in 1994
*
Gerald Durrell
Gerald Malcolm Durrell, (7 January 1925 – 30 January 1995) was a British naturalist, writer, zookeeper, conservationist, and television presenter. He founded the Durrell Wildlife Conservation Trust and the Jersey Zoo on the Channel Island ...
(1925–1995), British zookeeper (
Durrell Wildlife Park
Jersey Zoo (formerly Durrell Wildlife Park) is a zoological park established in 1959 on the island of Jersey in the English Channel by naturalist and writer Gerald Durrell (1925–1995). It is operated by the Durrell Wildlife Conservation Trust. ...
),
transplant in 1994 (survival <1 year)
*
Vaughn Eshelman
Vaughn Michael Eshelman (May 22, 1969 – July 24, 2018) was an American Major League Baseball pitcher who played from 1995 through 1997 for the Boston Red Sox. Listed at , 205 lb., he batted and threw left-handed.
Eshelman was born at the ...
(1969–2018), American Major League Baseball pitcher (
Boston Red Sox
The Boston Red Sox are an American professional baseball team based in Boston. The Red Sox compete in Major League Baseball (MLB) as a member club of the American League (AL) East division. Founded in as one of the American League's eight ...
),
transplant in 2018 (survival <6 months)
*
Shelley Fabares
Michele Ann Marie "Shelley" Fabares (; born January 19, 1944) is an American actress and singer. She is best known for her television roles as Mary Stone on the sitcom ''The Donna Reed Show'' (1958–1963) and as Christine Armstrong on the sitcom ...
(born 1944), American actress (''
The Donna Reed Show
''The Donna Reed Show'' is an American sitcom starring Donna Reed as the middle-class housewife Donna Stone. Carl Betz co-stars as her pediatrician husband Dr. Alex Stone, and Shelley Fabares and Paul Petersen as their teenage children, Mary an ...
'', ''
Coach
Coach may refer to:
Guidance/instruction
* Coach (sport), a director of athletes' training and activities
* Coaching, the practice of guiding an individual through a process
** Acting coach, a teacher who trains performers
Transportation
* Co ...
'') and singer ("
Johnny Angel
''Johnny Angel'' is a 1945 American film noir directed by Edwin L. Marin and written by Steve Fisher (adapted by Frank Gruber) from the 1944 novel ''Mr. Angel Comes Aboard'' by Charles Gordon Booth. The movie stars George Raft, Claire Trevor ...
"),
transplant in 2000
*
Freddy Fender
Freddy Fender (born Baldemar Garza Huerta; June 4, 1937 – October 14, 2006) was an American Tejano, country and rock and roll musician, known for his work as a solo artist and in the groups Los Super Seven and the Texas Tornados. He was bes ...
(1937–2006), American musician ("
Before the Next Teardrop Falls
''Before The Next Teardrop Falls'' is an album by Freddy Fender.
His first album, it was released in 1974. The album includes the number-one hits "Before the Next Teardrop Falls" and "Wasted Days and Wasted Nights". It peaked at No. 20 on the ...
," "
Wasted Days and Wasted Nights
"Wasted Days and Wasted Nights" is an American country and pop song recorded by Freddy Fender. It is considered by many to belong to the swamp pop idiom of south Louisiana and southeast Texas that had such a major musical impact on Fender.
Song ...
"),
transplant in 2004 (survival: 2 years)
*
"Superstar" Billy Graham
Eldridge Wayne Coleman (born June 7, 1943), better known by his ring name "Superstar" Billy Graham, is an American former professional wrestler. He gained recognition for his tenure as the WWWF Heavyweight Champion in 1977–1978. He is a three- ...
(born 1943), American wrestler (
WWF),
transplant in 2002
*
Larry Hagman
Larry Martin Hagman (September 21, 1931 – November 23, 2012) was an American film and television actor, director, and producer, best known for playing ruthless oil baron J. R. Ewing in the 1978–1991 primetime television soap opera, ''Dal ...
(1931–2012), American actor (''
Dallas
Dallas () is the List of municipalities in Texas, third largest city in Texas and the largest city in the Dallas–Fort Worth metroplex, the List of metropolitan statistical areas, fourth-largest metropolitan area in the United States at 7.5 ...
'', ''
Harry and Tonto
''Harry and Tonto'' is a 1974 road movie written by Paul Mazursky and Josh Greenfeld and directed by Mazursky. It features Art Carney as Harry in an Oscar-winning performance. Tonto is his pet cat.
Plot
Harry Coombes (Art Carney) is an elderly wi ...
'', ''
Nixon
Richard Milhous Nixon (January 9, 1913April 22, 1994) was the 37th president of the United States, serving from 1969 to 1974. A member of the Republican Party, he previously served as a representative and senator from California and was ...
'', ''
Primary Colors
A set of primary colors or primary colours (see spelling differences) consists of colorants or colored lights that can be mixed in varying amounts to produce a gamut of colors. This is the essential method used to create the perception of a bro ...
''),
transplant in 1995 (survival: 17 years)
*
Dahlan Iskan
Dahlan Iskan (born August 17, 1951 in Magetan) is the former Chief executive officer, CEO of Indonesian newspaper publisher, Jawa Pos, Jawa Pos Group.
He was the CEO of Indonesia's State Electricity Company, (Perusahaan Listrik Negara, PLN) from De ...
(born 1951), Indonesian minister,
transplant in 1987
*
Steve Jobs
Steven Paul Jobs (February 24, 1955 – October 5, 2011) was an American entrepreneur, industrial designer, media proprietor, and investor. He was the co-founder, chairman, and CEO of Apple; the chairman and majority shareholder of Pixar; a ...
(1955–2011), American businessman (
Apple Inc.
Apple Inc. is an American multinational technology company headquartered in Cupertino, California, United States. Apple is the largest technology company by revenue (totaling in 2021) and, as of June 2022, is the world's biggest company b ...
),
transplant in 2009 (survival: 2 years)
*
Chris Klug
Chris Klug (born November 18, 1972) is a professional alpine snowboarder. After receiving a liver transplant in 2000 to treat primary sclerosing cholangitis, he went on to compete in the 2002 Winter Olympics in Salt Lake City, winning a bronz ...
(born 1972), American snowboarder,
transplant in 2000
*
Evel Knievel
Robert Craig "Evel" Knievel (; October 17, 1938 – November 30, 2007) was an American stunt performer and entertainer. Over the course of his career, he attempted more than 75 ramp-to-ramp motorcycle jumps. Knievel was inducted into the Motor ...
(1938–2007), American stunt performer,
transplant in 1999 (survival: 8 years)
*
Chris LeDoux (1948–2005), American musician and rodeo champion,
transplant in 2000 (survival: 5 years)
*
Kyung Won Lee (born 1928), Korean-American journalist,
transplant in 1992
*
Phil Lesh
Philip Chapman Lesh (born March 15, 1940) is an American musician and a founding member of the Grateful Dead, with whom he played bass guitar throughout their 30-year career.
After the band's disbanding in 1995, Lesh continued the tradition of ...
(born 1940), American musician (
Grateful Dead
The Grateful Dead was an American rock music, rock band formed in 1965 in Palo Alto, California. The band is known for its eclectic style, which fused elements of rock, Folk music, folk, country music, country, jazz, bluegrass music, bluegrass, ...
),
transplant in 1998
*
Linda Lovelace
Linda Lovelace (born Linda Susan Boreman; January 10, 1949 – April 22, 2002) was an American pornographic actress who became famous for her performance in the 1972 hardcore film '' Deep Throat''. Although the film was an enormous success, Bor ...
(1949–2002), American pornographic actress (''
Deep Throat''),
transplant in 1987 (survival: 15 years)
*
Mickey Mantle
Mickey Charles Mantle (October 20, 1931 – August 13, 1995), nicknamed "the Commerce Comet" and "the Mick", was an American professional baseball player. Mantle played his entire Major League Baseball (MLB) career (1951–1968) with the New York ...
(1931–1995), American baseball player (
New York Yankees
The New York Yankees are an American professional baseball team based in the Boroughs of New York City, New York City borough of the Bronx. The Yankees compete in Major League Baseball (MLB) as a member club of the American League (AL) Amer ...
),
transplant in 1995 (survival: <1 year)
*
Mike MacDonald
Michael MacDonald (born June 26, 1987) is an American football coach who is the head coach for the Seattle Seahawks of the National Football League (NFL). He previously served as the defensive coordinator for the Baltimore Ravens from 2022 to 2 ...
(1954–2018), Canadian comedian and actor (''
Mr. Nice Guy''),
transplant in 2013 (survival: 5 years)
*
Jim Nabors
James Thurston Nabors (June 12, 1930 – November 30, 2017) was an American actor, singer, and comedian, widely known for his signature character, Gomer Pyle.
Nabors was discovered by Andy Griffith while working at a Santa Monica, California, Sa ...
(1930–2017), American actor (''
The Andy Griffith Show
''The Andy Griffith Show '' is an American situation comedy television series that aired on CBS from October 3, 1960, to April 1, 1968, with a total of 249 half-hour episodes spanning eight seasons—159 in black and white and 90 in color.
The ...
''),
transplant in 1994 (survival: 23 years)
*
John Phillips (1935–2001), American musician (
The Mamas & the Papas
The Mamas & the Papas were a folk rock vocal group formed in Los Angeles, California, which recorded and performed from 1965 to 1968. The group was a defining force in the music scene of the counterculture of the 1960s. The group consisted of Am ...
),
transplant in 1992 (survival: 9 years)
*
James Redford (1962–2020), American documentary filmmaker and environmentalist,
transplant in 1993 (survival: 27 years)
*
Lou Reed
Lewis Allan Reed (March 2, 1942October 27, 2013) was an American musician, songwriter, and poet. He was the guitarist, singer, and principal songwriter for the rock band the Velvet Underground and had a solo career that spanned five decades. ...
(1942–2013), American musician (
The Velvet Underground
The Velvet Underground was an American rock band formed in New York City in 1964. The original line-up consisted of singer/guitarist Lou Reed, multi-instrumentalist John Cale, guitarist Sterling Morrison, and drummer Angus MacLise. MacLise w ...
),
transplant in 2013 (survival: <1 year)
*
U. Srinivas
Uppalapu Srinivas (28 February 1969 – 19 September 2014) was an Indian mandolin player in Carnatic classical music and composer. Because he was a child prodigy, he was sometimes called the Mozart of classical Indian music.
He was awarded the ...
(1969–2014), Indian musician,
transplant in 2014 (survival: <1 year)
Research directions
Cooling
There is increasing interest in improving methods for allograft preservation following organ harvesting. The standard "static cold storage" technique relies on decreased temperature to slow of anaerobic metabolic breakdown. This is currently being investigated at cold (hypothermic), body temperature (normothermic), and under body temperature (subnormothermic). Hypothermic machine perfusion has been used successfully at Columbia University and at the University of Zurich. A 2014 study showed that the liver preservation time could be significantly extended using a supercooling technique, which preserves the liver at subzero temperatures (-6 °C) More recently, the first randomised controlled clinical trial comparing machine preservation with conventional cold storage showed comparable outcomes, with better early function, fewer discarded organs, and longer preservation times compared with cold stored livers.
Special populations
Alcohol dependence
The high incidence of liver transplants given to those with alcoholic
cirrhosis
Cirrhosis, also known as liver cirrhosis or hepatic cirrhosis, and end-stage liver disease, is the impaired liver function caused by the formation of scar tissue known as fibrosis due to damage caused by liver disease. Damage causes tissue repai ...
has led to a recurring controversy regarding the eligibility of such patients for liver transplant. The controversy stems from the view of
alcoholism
Alcoholism is, broadly, any drinking of alcohol (drug), alcohol that results in significant Mental health, mental or physical health problems. Because there is disagreement on the definition of the word ''alcoholism'', it is not a recognize ...
as a self-inflicted disease and the perception that those with alcohol-induced damage are depriving other patients who could be considered more deserving. It is an important part of the selection process to differentiate transplant candidates who have alcohol use disorder as opposed to those who were susceptible to non-dependent alcohol use. The latter who gain control of alcohol use have a good prognosis following transplantation. Once a diagnosis of alcoholism has been established, however, it is necessary to assess the likelihood of future sobriety.
HIV
Historically, HIV was considered an absolute contraindication to liver transplantation. This was in part due to concern that the infection would be worsened by the immunosuppressive medication which is required after transplantation.
However, with the advent of highly active antiretroviral therapy (HAART), people with HIV have much improved prognosis. Transplantation may be offered selectively, although consideration of overall health and life circumstances may still be limiting. Uncontrolled HIV disease (AIDS) remains an absolute contraindication.
References
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Further reading
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External links
UNOS: United Network of Organ Sharing, U.S.American Liver FoundationHistory of pediatric liver transplantation!--do we need a separate listing for pediatric liver transplantation?-->
Liver Donation Surgery and RecoveryFacts about Liver TransplantationChildren's Liver Disease FoundationThe Toronto Video Atlas of Liver, Pancreas and Transplant Surgery – Living Donor Right Lobe Liver Transplant video (recipient)The Toronto Video Atlas of Liver, Pancreas and Transplant Surgery – Living Donor Left Lateral Lobe Liver Transplant video (donor)The Toronto Video Atlas of Liver, Pancreas and Transplant Surgery – Living Donor Right Posterior Sectionectomy (Segments 6/7) Liver Transplant video (donor)
{{DEFAULTSORT:Liver Transplantation
Accessory digestive gland surgery
Hepatology
Organ transplantation