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.

Comments (1)

Subscribe to this comment's feed

Title
Comment	smaller | bigger
Name
Email
Website
Write the displayed characters
I have read and agree to the Terms of Usage.
	Add Comment