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LIVER TRANSPLANTATION

DEFINITION: Liver transplantation is used to treat life threatening ESLD for which no other form of
treatment is available. The liver transplantation involves total removal of the diseased liver.

INDICATIONS:
 Biliary atresia
 Fulminant hepatic failure
 Chronic liver disease
 Hepatic tumor

PRE- OPERATIVE ASSESSMENT:

1. Blood group: In this ABO blood grouping is done to rule out any ABO incompatability.

DONOR BLOOD GROUP RECIPIENT BLOOD GROUP

O O, A, B, AB
A A or AB
B B or AB
AB AB

2. Tissue type matching: The purpose of histocompatibility testing is to identify the HLAs (human
leukocyte antigen) for both donors and recipients. In this the lymphocytes are isolated from peripheral
blood and then combined with the serum that contains antibodies to HLAs. Antigen A, B, DR are clinical
significant for transplantation. Antigen matches of five and six antigens have been found to have better
clinical outcomes i.e., the patient is less likely to reject the transplanted organ.

3. Cross match: In this serum from recipient mixed with donor lymphocytes to test any cytotoxic
antibodies to potential donor organ.

4. Other tests:
 Complete history and physical examination.
 Complete blood count, blood chemistry and electrolyte profiles
 24 hour urine study for creatinine clearance and total protein
 Viral marker testing i.e. HIV, HBsAg, HCV
 Coagulation studies including an international normalized ratio (INR) and partial prothrombin time
(to screen for coagulation abnormalities), homocysteine level, factor V Leiden, and prothrombin tests
 ECG and chest X-Ray
Before surgery: Preparation of recipient:
 Informed consent
 Assess the overall health status of recipient.
 Monitor vitals and weight of patient.
 Blood test and tissue type matching
 RFT and LFT
Preparation of living donor:
 Informed consent
 Assess the general physical, mental health status of donor.
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 Monitor vitals
 Assessment of reports of all investigations.
 Provide psychological support to patient.
 Provide loose and comfortable clothes to donor

PROCEDURE:
 During the procedure, the donor liver is freed from other structure, the bile is flushed from the gall
bladder to prevent damage to the walls of the biliary tract and the liver is perfused with a preservative
and cooled.
 Before the donor liver is placed in the recipient, it is flushed with cold lactated ringer’s solution to
remove potassium and air bubbles.
 The presence of portal hypertension increases the difficulty of the procedure. To minimize this
problem, many centers use venovenous bypass, which decompresses the venous system below the
diaphragm by temporarily shunting blood to the superior vena cava and the axillary vein.
 Anastomoses of the blood vessels and bile duct are performed between the donor liver and recipient
liver.
 There are two types of biliary anastomoses:
1. Roux-en-hepatojejunostomy: Biliary reconstruction is performed with an end- to –end anastomosis of
the donor and recipient common bile ducts, with a stented T-tube inserted for external drainage of bile. If
an end –to –end anastmosis is not possible because diseased or absent bile ducts, an end –to-end
anastomosis is made between the common bile duct of the graft and a loop of jejunum in this case , bile
drainage is internal and a T-tube is not inserted and the final closure and drain placement after liver
transplantation.
2. Auxiliary liver transplantation: In this native liver is not removed and a liver graft from the donor is
surgically placed in addition to the native liver. It is used in adults with fulminant hepatic failure

COMPLICATIONS:
 Bleeding: Bleeding is common in the post-operative period and may result from coagulopathy, portal
hypertension and fibrinolysis caused by ischemic injury to the donor liver. Hypertension may occur in
this phase, secondary to blood loss. Administration of platelets, fresh frozen plasma or other blood
products may be necessary.
 Infections and Diseases: Some infections are more serious in a child who is on immunosuppressant
medications after a liver transplant.

Signs or symptoms of infection:

 Fever
 Runny nose and cough that is not improving after several days or is severe
 Sore throat or sore ears
 Pains in the stomach
 Vomiting
 Diarrhea that has blood or mucous or is not improving after 1-2 days
 Feeling of burning or pain when peeing
 Sores on the lips and around the mouth
 Rejection: Rejection is a primary concern. A transplanted perceived by the immune system as foreign
antigen. This triggers an immune response; leading to the activation of T lymphocytes that attack and
destroy the transplanted liver. Immunosuppressive agents are used as long term therapy to prevent this
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response and rejection of the transplanted liver. These agents inhibit the activation of
immunocompetent T lymphocytes to prevent the production of effector T cells.
 Corticosteroid, azathioprine, basiliximab, daclizumab are used in various regimens of
immunosuppression, they may be used as the initial therapy to prevent rejection or used later to treat
rejection.
 Liver biopsy and ultrasound may be required to evaluate suspected episodes of rejection.
 Retransplantation is usually attempted if the transplanted liver fails, but the success rate of
retransplantatin does not approach that of initial transplantation.

Nursing management: [Postoperatively]

Nursing assessment:
 Assess the general condition of patient
 Monitor vitals of patient.
 Monitor urine output

Goals: Short term goals

 Maintain fluid and electrolyte balance.
 To reduce pain level.
 To reduce risk of infection
 Observe for any sign of rejection

Long term goals:

 To prevent further complications.
 To encourage patient to maintain personal hygiene to reduce risk of infection
 To encourage patient for regular follow up

Nursing diagnosis:
1) Risk for fluid volume imbalance related to inability of kidneys to excrete as evidenced by
decreased urine output.
Planning: Assess the general condition of patient
 Monitor vitals of patient.
 Monitor weight of patient daily if possible.
 Monitor urine output hourly.
 Restrict fluid intake as prescribed.
 Inform to physician.
Expected outcome: fluid volume balance will be maintained to some extend as evidenced by monitoring
urine output.

2) Acute pain related to surgical procedure as evidenced by facial expressions and pain scale
readings.
Planning: Assess the pain level, intensity and location.
 Provide comfortable position to patient.
 Provide cool and calm environment.
 Provide diversional therapies to divert the mind of patient.
 Give analgesics as per order.
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Expected outcomes: Pain level will be reduced to some extend as evidenced by facial expressions and
pain scale reading.

3) Risk for infection related to suppressed immune system due to disease condition.
Planning: Assess the general condition of patient.
 Monitor vitals regularly.
 Use strict aseptic techniques while providing care to patient.
 Limit no. of visitors to decrease risk of infection.
 Perform hand washing before and after procedure.
Expected outcome: Risk of infection will be reduced to some extent.

HEALTH EDUCATION:
1. Diet:
 Advice patient to avoid grapefruit and grapefruit juice because of its effects on immunosuppressive
medication. Grapefruit juice can interact with some transplant medications, in particular raising the
levels of immunosuppressants in the blood.
 Never let child drink unpasteurized milk products or untreated water as they can have infections that
may be more harmful to child because their immune system is decreased.
Low in Sugar
 Limit juice, soda and other high-sugar drinks to less than 8 ounces a day.
 Limit candy and dessert-type foods to one serving or less a day.
Low in Fat
 Limit butter, margarine, red meat, fried foods, poultry skin, bacon, sausage, full-fat dairy products,
eggs, mayonnaise and junk food.
 Choose skinless poultry and fish more often than red meat.
High in Fiber
 Serve fiber-rich foods such as fruits, vegetables, whole grains, legumes and lentils.
 Serve two to four pieces of fruit a day. Choose fruit instead of juice.
 Provide whole grains every day.

Adequate in Calcium
Great sources of calcium include milk, yogurt, cheese and calcium-fortified beverages such as soy milk
and orange juice — each has about 300 milligrams per serving. (A serving is equal to 8 ounces of milk or
yogurtr 1 ounce of cheese.) Dark green vegetables, such as spinach and broccoli, are also good sources of
calcium.
The recommended daily intake of calcium varies by age:
1 to 3 years old — 400 to 600 milligrams
4 to 8 years old — 800 to 1,000 milligrams
9 to 18 years old — 1,300 to 1,500 milligrams

Special Nutrients
Some patients have low levels of potassium, phosphorus and magnesium in their blood. These patients
often need supplements to raise blood levels of these minerals. In addition to supplements, child should
eat foods rich in these minerals.
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Potassium-Rich Foods
 Fruits — Bananas, cantaloupe, dates, dried apricots, honeydew melon, kiwi, mango, nectarine,
oranges, papaya, prunes, raisins
 Protein-Rich Foods — Chicken, flank steak (lean), halibut, peanuts, peanut butter, red snapper,
salmon, sole, trout, tempeh, tofu, turkey
 Cereals — All Bran cereal, bran flakes
 Vegetables — Artichoke, avocado, cabbage, spinach, tomato, tomato juice, vegetable juice
 Starchy Vegetables — Potato with or without skin, sweet potato, yam, winter squash
 Beans and Legumes — Black-eyed peas, kidney beans, lentils, lima beans, refried beans, pinto beans
 Dairy Products — Milk, yogurt

Phosphorus-Rich Foods
 Dairy Products — Cheese, custard, frozen yogurt, ice cream, milk, pudding, yogurt
 Protein-Rich Foods — Beans, chicken, eggs, fish, lentils, nuts and peanut butter, red meat, pork,
turkey
 Other Foods — Caramel and chocolate (limit portion and frequency because of their sugar content)

Controlling Weight Gain

Patients taking glucocorticoids (prednisone) after kidney transplantation often have very large appetites
and can feel hungry all day. This can lead to eating larger portions and eating more often than usual,
causing weight gain.
Although children who are still growing should continue to gain weight, they should avoid gaining too
much weight too fast.
To control weight gain:
 Follow all the healthy diet guidelines outlined above.
 Monitor portion sizes. Portion sizes vary from child to child and are somewhat dependent on age.
Work with your child's dietitian to determine appropriate amounts for your child, but in general:
 Keep meat, chicken and fish to 3 to 4 ounces cooked or less — the size of a deck of cards or a
woman's palm.
 Keep servings of starches such as pasta, rice, oatmeal, cereal, bread or tortillas to about two
servings per meal. One serving is equal to 1/2 cup pasta, rice or oatmeal; 3/4 to 1 cup dry cereal;
1 slice of bread; or 1 6-inch tortilla.
 Offer lots of vegetables. Vegetables are very low in calories but high in fiber, which helps you feel
full.

2. Exercise:
 Educate for regular exercise to boost energy level and increase strength.
 Regular exercise helps to prevent post-operative complications such s high blood pressure and
cholesterol levels.

3. Immunization:
 “Live Vaccines”: In general child should not have “live vaccines” after transplant as they may cause
disease in someone taking immunosuppressive medications.
 This is why whenever possible vaccinations should be updated BEFORE transplantation.
 Common live vaccines are: Chickenpox (varicella) • Smallpox • Oral polio • Rotavirus •
Measles/mumps/rubella (MMR) • Influenza drops into the nose (influenza nasal mist, FluMist).
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 Immunizations child should receive (depending on age) are the following killed (non-live) vaccines:
• Injectable polio • Hepatitis B • Tetanus/diphtheria or Tetanus/diphtheria/acellular pertussis • Flu
shot • Pneumococcal (both Pneumovax or Prevnar) • Hepatitis A • Meningococcal Vaccine • HIB
Vaccine • HPV Vaccine.

4. Dental Care:
The mouth has a large number of bacteria in it. The use of transplant medications after transplantation
makes it harder for the body to fight infection. A bad dental cavity may turn into a tooth abscess if the
immune system is low. Some of the drugs used after transplant, such as Neoral (cyclosporine) and some
of the antihypertensive medications (amlodipine, isradipine, nifedipine, verapamil), may cause gum
swelling and overgrowth. This, in turn can lead to gum disease. It is important for child to be seen by a
dentist before transplant. Have child’s teeth cleaned and all cavities filled. Following transplant, twice-
yearly dental visits with cleanings are recommended. It is generally recommended to wait until 3 months
after transplant to begin seeing the dentist again.

5. Ophthalmologic (Eye) Care:

Many children are prescribed prednisone after transplant as part of their immune-suppression regimen.
Because of the risk of side effects affecting the eyes (steroids cause change in aqueous fluid outflow
system resulting in increased eye pressure), recommendation are given for monitoring eye health for
cataracts and glaucoma by a professional. It is recommended that all children should have dilated eye
examinations once a year while they are on prednisone to monitor for the development of cataracts and/or
glaucoma.

6. Skin Care:
Transplant patients have a higher risk of developing skin cancer. The transplant immune-suppression
medications that allow child’s liver to work and survive also increase the risk of skin cancer.
Prevention of skin cancer means daily use of a sunscreen with a sun protection factor (SPF) of 30 or
more. Clothing with long sleeves and a tight fabric weave should be worn outdoors, as well as a broad-
brimmed hat. Stay out of the direct sun between 10 a.m. and 2 p.m. as much as possible.

BIBLIOGRAPHY
1) Chintamani, Lewis, “ Medical Surgical Nursing”, edition 2013, published by Elsevier, page no.
1223-1226
2) Suddarth’s and Brunner, : Text book of Medical Surgical Nursing, 12 th edition, published by Wolters
Kluwer, page no1336-1339