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Liver transplant candidates must undergo detailed physical, laboratory and psychological evaluations to ensure proper selection and therapy. Tests are done to confirm the diagnosis of end-stage liver disease, to rule out other potential treatments and to assess the candidate's ability to tolerate surgery. The typical evaluation takes seven to 10 days and generally follows the course outlined below.
The candidate will be scheduled for an initial consultation with a transplant hepatologist. Once a patient has been identified as a transplant candidate, the patient is assigned a nurse coordinator to guide him or her through the evaluation process. The nurse coordinator also will schedule the candidate's next series of tests. Coordinators should be used as resources during the pre-transplant period.
The pre-transplant workup is extensive.
Tests include:
At the end of the pre-transplant workup, the candidate will meet with a transplant surgeon. The surgeon will assess the candidate's surgical risk as well as discuss the transplant procedure, including organ acquisition and post-transplant recovery.
During this consultation, the surgeon also will review possible complications and outcomes. It is important that the candidate and family members be comfortable with the journey they are about to take. Asking questions is encouraged.
The patient will then be scheduled to meet with a variety of medical specialists and allied health personnel, including social workers, nutrition specialists and anesthesiologists.
This exam is conducted by a transplant anesthesiologist, who will review the patient's heart-function tests, including EKG, echocardiogram and pulmonary function test. The physician will provide a detailed explanation of transplant anesthesia, including line placement. This is the patient's opportunity to ask questions. The goal is to make the patient as comfortable with the operation as possible.
The social services consultation is valuable for the candidate and family members. Issues such as housing and transportation during can be addressed. A candidate's support system, coping ability and family dynamics will be assessed. An operational plan for the family to use during and after the transplant will be created. When warranted, social services will assess and evaluate substance abuse history and issues. If necessary, the patient will be referred to the Department of Psychology for further evaluation.
The liver transplant dietitian will complete a nutritional assessment. The dietitian will help the patient develop an eating plan that provides a balanced diet and appropriate calories. The goal is to create a practical plan that fits the patient's lifestyle and helps him or her live a healthy life.
At this point, the candidate has had all the necessary diagnostic tests to determine if they are a candidate for liver transplantation.
Specialists in hepatology, infectious disease, anesthesiology, social services, along with the transplant surgeons, meet to review a patient's candidacy for transplant. This process is known as the selection conference. The group determines whether a candidate is suitable for a transplant. If accepted, the patient is placed on the UNOS (United Network for Organ Sharing) waiting list. A MELD score is calculated for each patient to determine where on the list the patient stands.
Physicians will have discussed the long-term implications of liver transplantation with the patient and family. Transplantation requires a lifelong commitment by the patient and family. This commitment includes taking medications daily, visiting a physician regularly, eating a proper diet, maintaining an exercise program and avoiding infections. Even though the patient is on the waiting list for transplantation, the disease process continues and must be dealt with every day. A waiting period of anywhere from a few days to many months can be expected. Throughout the waiting period, checkups at Mayo Clinic will be scheduled. Hepatologists order laboratory tests and cultures at these checkups and may adjust medications. The transplant coordinator is the main contact during this period.
Once a potential donor is found, a transplant surgeon or designated team member will contact the patient by phone or pager advising him or her to come to Mayo Clinic as soon as possible. It is important that the patient organize travel plans ahead of time to hasten arrival at the hospital. If the patient lives more than five hours from Mayo Clinic, the patient may need to stay near the clinic during the waiting period or arrange for air transportation. The transplant liaison can help make arrangements for quick transportation to Mayo when a donor is located.
Upon arrival at the hospital, the patient will have a brief examination. Blood tests, urine samples, cultures, an electrocardiogram and a chest X-ray will be taken.
While the patient is in transit and then undergoing a last-minute checkup, the organ procurement team is recovering the donor liver. The team consists of one transplant surgeon, a surgical technician or surgical resident/fellow and an organ procurement coordinator. The time it takes to recover the organ depends largely on where the donor is located. In some cases, the team must travel by aircraft. The donor and recipient must match in blood type. In addition, the donor must be assessed carefully to be sure the liver is healthy. Once the liver is determined to be a good match, it is removed from the donor and is flushed with a preservative solution. It is then placed in an ice-filled cooler for transport to Mayo Clinic.
If the donor liver is to be found unacceptable after a final assessment, the operation will be canceled, and the patient will be discharged from the hospital. In most cases the liver is brought back and the opertaion proceeds. The average operation takes from three to five hours, but may take longer. The diseased liver is removed and the new liver is placed in position. When the procedure is completed, the transplant surgeon will discuss the operation and the patient's condition with family members.
Following surgery, liver transplant patients typically spend one to two days in the Intensive Care Unit and remain hospitalized for five to 10 days. Patient education begins in the early postoperative period and continues after hospital discharge.
When recipients leave the hospital, they are assigned a post-transplant nurse coordinator and given a supply of medication, instructions and phone numbers to call with questions or for emergencies. In the early post-transplant period, patients are sen frequently in the outpatient clinic.
If the patient does not live nearby, he or she must arrange temporary housing near Mayo Clinic for an observation period, usually the first two to four weeks after leaving the hospital.
Once at home, the patient maintains regular contact with the post-transplant nurse coordinator. The patient must have lab work completed weekly for the first four months post-transplant and then twice a month for the first year. Lab work can be done by the patient's local physician or a community lab. Results are sent to the nurse coordinator for review with a physician. The coordinator can assist the patient with home care issues, medication questions and refills, as well as respond to general questions and concerns. Patients must return to Mayo periodically for follow-up exams.
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