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Libby John & the Liver Transplant Unit
Libby
John has been a nurse for many years, and recently completed her
Masters of Nursing (Nurse Practitioner) in liver transplantation. She
has long specialised in this area, having been involved with the Liver
Transplant Unit when it started at the Flinders Medical Centre back in
1992, and working with liver transplant units in the UK. She has been
the co-ordinator of the Liver Transplant Unit for 12 years. The Hepatitis C Community News interviewed her at Flinders about the unit’s work and history.
The Liver Transplant Unit
“We’re
the only liver transplant unit in SA, so patients from the other
hospitals, like the RAH and the Queen Elizabeth, come here. We also
have doctors from each of the hospitals come here as part of the
unit—we’ve got liver transplant physicians at the Queen Elizabeth and
the RAH who can refer patients here. They come to our weekly meetings
here, and they also consult in our liver clinic here once a week.
“We
follow patients all the way through the process. There are some who are
referred to us for transplants, and some who we work up through the
process for transplants. Then there’s the transplant operation itself,
and after that they continue to see us here for monitoring for the rest
of their lives. We usually have around 150 patients, pre- and
post-transplant, at any one time.
“The first successful
liver transplant was done in 1963, in Denver in the US, and then in
1968 in the UK, at Cambridge. In Australia the first successful liver
transplant was in 1985, in Brisbane. State-based liver transplant units
started soon after that—Melbourne in 1988, us in 1992, and Perth in
1993. There’s now one in each State, with SA covering the NT, and
Victoria covering Tasmania.”
The Waiting List
“The
waiting list is slowly getting longer, compared to what it was about 10
years ago. We always have about 15 patients on the waiting list, and we
do 15 transplants or so a year, depending on donor liver availability.
Around Australia there are probably about 180 liver transplants each
year, with NSW doing the most.
“The waiting time is
getting longer, too. There’s a significant shortage of organ donors,
although SA has the highest per capita organ donor rate in Australia.
There are only about 20 or 30 South Australian donors per year, but not
all of those donate their livers, or have livers suitable for donation.
People have to die in certain circumstances—be clinically dead, but the
organs still receive oxygen via a ventilator, and the person with no
medical history that would be a problem.
“The waiting
time is usually a minimum of six months, sometimes less, but it depends
on blood group—you have to receive a liver from someone of the same
blood group as yourself. Unfortunately, some people do die on the
waiting list before an appropriate liver is available.
‘We’re
probably not getting referred everyone we could be at the moment, but
we get about 50 referrals a year, perhaps, and only 50% of those would
be transplantable. We could easily do 20 transplants a year if we had
the donor livers.
“The growing list is probably from
more people being referred or identified. And, of course, not everybody
referred to us is suitable for transplant—they may have other
contraindicated medical or psychosocial conditions. One of the main
things that we’re finding, though, is the growing incidence of
hepatitis C-related cirrhosis. Certainly in Australia, and SA, the main
reason for transplantation is hepatitis C. There’s particularly a
growing incidence of liver cancer in people with viral hepatitis.”
Transplantation
“There’s
a lot of variation in liver size—the liver actually adjusts to the size
of the person it’s in, so a large man will have a larger liver than a
50kg female, for example. A smaller transplanted liver will grow to
accommodate a larger body size. They can shrink a little bit, too, as
long as they fit into the abdominal cavity in the first place.
“It
is possible to transplant half a liver, which will then grow to the
size of a whole liver in a couple of months. It’s one of the few
regenerative organs. As long as you have a certain minimum mass, which
can perform the functions the liver needs to perform, and that mass is
based on your body size. For example, with children, there aren’t
enough child livers for transplant, but you can cut down an adult
liver, as long as you calculate that you have enough to regrow and do
the job. The liver is an amazing thing.”
After Transplant Surgery
“The
stay in hospital after transplant can be from two weeks to two months,
depending on complications. On average, though, it’s two to three
weeks. If all goes well, two days are usually in intensive care, and
then the rest of the time is on the ward. There we teach transplant
recipients about medications and monitor them closely. Then, once they
go home, they come back in three times a week for the first month or so
to have blood tests and check medication levels. Later on, though,
people might only come in every three to six months or so, for
monitoring.
“Liver transplantation
restores quality of life, but sometimes we exchange one set of problems
for another. Liver transplantation is a high-risk procedure, and the
anti-rejection medications that we have to give people for the rest of
their lives can have side-effects. They suppress the immune system so
that the body doesn’t reject the new liver, but this means that the
body can’t fight bacteria and virus the way it used to, so you’re
susceptible to infectious diseases, cancers…
And the
other thing is that transplantation doesn’t cure someone of hepatitis
C, because the virus is still in their body—unless they’ve been
successfully treated—so there’s a risk of the virus infecting the new
liver, and that does occur in the majority of cases. But the extent to
which the virus damages the new liver can vary—for many people that new
liver will last for many, many years. You could argue that it took 20
years for the virus to damage your first liver, so it might take
another 20 to damage the new one, although with a suppressed immune
system, the virus can be more aggressive, and damage the liver faster.
“We
can remove the problems associated with end-stage liver disease—the
jaundice, the fluid retention around the tummy, the lethargy, the
encephalopathy, the itching, the bleeding, all of those things—but
after a transplant you may get infections because of the anti-rejection
drugs. We try to keep the drug levels to a minimum, but it’s a
balancing act. We titrate drug levels very carefully, and adjust
dosages very carefully for each patient on an ongoing basis.
“The
chance of surviving a year after a liver transplant here in SA is about
95%. So you have a 5% chance of not getting off the table—perhaps the
new liver just doesn’t work, or there’s too much bleeding, they might
have a heart attack on the table—but there’s a risk associated with any
surgery, even having an ingrown toenail removed. Then there’s a 5-year
survival rate of 80%--and not every person is that 20% dies of anything
to do with their liver. They might have a heart attack years after the
operation, for example, or develop cancer.”
Multiple transplants
“People
do have more than one liver transplant, for various reasons. It depends
on the reason why their first transplanted liver has failed. If it’s
for a technical reason—perhaps an artery supplying blood to the liver
has blocked off—then we will redo it, because that’s a technical
problem we can solve with a new transplant. If somebody has a failure
of their transplanted liver because they started drinking alcohol
again, they won’t get another liver.
“The
issue of whether someone gets a second transplant because the hepatitis
C virus has severely damaged their new liver is a tricky one, because
that’s through no fault of anybody; it just happens. So, in theory, we
should re-transplant that person. But what we have to look at is if the
virus has attacked that first liver very quickly, then it will do so
again to any other liver we put in. The survival rate for each
successive transplant reduces. So if we’re looking at a 5-year survival
rate of 80% for a first transplant, it’s only 60% for a second, and so
on. We have to weigh that up—does someone want to go through the
transplant again, do we have enough livers, and so on. Fortunately we
haven’t had to do re-transplantation much in SA.”
Rejection
“For
the rest of your life there’s a risk of rejection. If somebody stops
taking their medication 10 years down the track because they feel fine,
they will still get rejection. Pretty much everybody gets a small
degree of rejection, but these days it’s pretty rare to lose a
transplant from rejection, because the medications we have now are very
good. There are some cases which are difficult to treat, but that’s
quite rare.
“It’s common to have some acute rejection
in the first three months after transplant, which is why we monitor
people very closely for those first few months, so that we can pick it
up early and give extra anti-rejection medication, and it’s usually
pretty easy to treat.”
Education
“Education
about liver transplantation is important, not just in the general
public but in the medical community as well. We’ve done a lot of
education, and we say that when in doubt it’s better to refer people to
us, and we can say yes or no, but it’s better to do it that way.
Sometimes, for example, people will be referred to us when it’s too
late—when they’re too sick for transplant. It’s better to refer people
earlier in their disease so that we’re aware of them and they’re
assessed by us, even if they don’t need to consider transplantation at
that time.’
James Morrison
AHCS would like to thank the Hepatitis C Council SA for this article in the Community Newsletter. http://www.hepccouncilsa.asn.au/hccn/hccn_no35.html
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