Liver Transplantation

Liver Transplantation

Liver transplantation is used to treat life-threatening, end-stage liver disease for which no other form of treatment is available. The transplantation procedure involves total removal of the dis-eased liver and its replacement with a healthy liver in the same anatomic location (orthotopic liver transplantation [OLT]). Removal of the liver leaves a space for the new liver and permits anatomic reconstruction of the hepatic vasculature and biliary tract as close to normal as possible.

The success of liver transplantation depends on successful immunosuppression. Immunosuppressants currently in use in-clude cyclosporine (Neoral), corticosteroids, azathioprine (Imuran), mycophenolate mofetil (CellCept), OKT3 (a monoclonal anti-body), tacrolimus (FK506, Prograf), sirolimus (formerly known as rapamycin [Rapamune]), and antithymocyte globulin. Studies are underway to find the most effective combination of immuno-suppressive agents and to identify new agents with fewer side effects (Hebert et al., 1999; Watson, Friend & Jamieson, 1999).

Despite the success of immunosuppression in reducing the incidence of rejection of transplanted organs, liver transplan-tation is not a routine procedure and may be accompanied by complications related to the lengthy surgical procedure, immunosuppressive therapy, infection, and the technical diffi-culties encountered in reconstructing the blood vessels and bil-iary tract. Long-standing systemic problems resulting from the primary liver disease may complicate the preoperative and postoperative course. Previous surgery of the abdomen, in-cluding procedures to treat complications of advanced liver disease (ie, shunt procedures used to treat portal hypertension and esophageal varices) increase the complexity of the trans-plantation procedure.

The indications for liver transplantation are not as limited today as they were when the procedure was first introduced, due to advances in immunosuppressive therapy, improvements in bil-iary tract reconstruction, and in some cases the use of venovenous bypass. General indications for liver transplantation include irre-versible advanced chronic liver disease, fulminant hepatic failure, metabolic liver diseases, and some hepatic malignancies. Exam-ples of disorders that are indications for liver transplantation in-clude hepatocellular liver disease (eg, viral hepatitis, drug- and alcohol-induced liver disease, and Wilson’s disease) and cholesta-tic diseases (primary biliary cirrhosis, sclerosing cholangitis, and biliary atresia).

The patient being considered for liver transplantation fre-quently has many systemic problems that influence preopera-tive and postoperative care. Because transplantation is more difficult when the patient has developed severe GI bleeding and hepatic coma, efforts are made to perform the procedure before this stage.

Liver transplantation is now recognized as an established ther-apeutic modality rather than an experimental procedure to treat these disorders. As a result, the number of centers where liver transplantation is performed is increasing. Patients requiring transplantation are often referred from distant hospitals to these sites. To prepare the patient and family for liver transplantation, nurses in all settings must understand the processes and proce-dures of liver transplantation.

SURGICAL PROCEDURE

The donor liver is freed from other structures, the bile is flushed from the gallbladder to prevent damage to the walls of the bil-iary tract, and the liver is perfused with a preservative andcooled. Before the donor liver is placed in the recipient, it is flushed with cold lactated Ringer’s solution to remove potas-sium and air bubbles.

Anastomoses (connections) of the blood vessels and bile duct are performed between the donor liver and the recipient liver. Bil-iary reconstruction is performed with an end-to-end anastomosis of the donor and recipient common bile ducts; a stented T-tube is inserted for external drainage of bile. If an end-to-end anastomosis is not possible because of diseased or absent bile ducts, an end-to-side anastomosis is made between the common bile duct of the graft and a loop (Roux-en-Y portion) of jejunum (Fig. 39-15A); in this case, bile drainage will be internal and a T-tube will not be in-serted (Maddrey et al., 2001). Figure 39-15B and C illustrates the final appearance of the grafted liver and final closure and drain placement.

Liver transplantation is a long surgical procedure, partly be-cause the patient with liver failure often has portal hypertension and subsequently many venous collateral vessels that must be ligated. Blood loss during the surgical procedure may be exten-sive. If the patient has adhesions from previous abdominal surgery, lysis of adhesions is often necessary. If a shunt proce-dure was performed previously, it must be surgically reversed to permit adequate portal venous blood supply to the new liver. During the lengthy surgery, providing regular updates to the family about the progress of the operation and the patient’s sta-tus is helpful.

COMPLICATIONS

The postoperative complication rate is high, primarily because of technical complications or infection. Immediate postoperative complications may include bleeding, infection, and rejection. Disruption, infection, or obstruction of the biliary anastomosis and impaired biliary drainage may occur. Vascular thrombosis and stenosis are other potential complications.

Bleeding

Bleeding is common in the postoperative period and may result from coagulopathy, portal hypertension, and fibrinolysis caused by ischemic injury to the donor liver. Hypotension may occur in this phase secondary to blood loss. Administration of platelets, fresh-frozen plasma, and other blood products may be necessary. Hypertension is more common, but its cause is uncertain. Blood pressure elevation that is significant or sustained is treated.

Infection

Infection is the leading cause of death after liver transplantation. Pulmonary and fungal infections are common; susceptibility to in-fection is increased by the immunosuppression needed to prevent rejection (Maddrey et al., 2001). Therefore, precautions must be taken to prevent nosocomial infections by strict asepsis when ma-nipulating arterial lines and urine, bile, and other drainage sys-tems; obtaining specimens; and changing dressings. Meticulous hand hygiene is crucial.

Rejection

Rejection is a key concern. A transplanted liver is perceived by the immune system as a foreign antigen. This triggers an im-mune response, leading to the activation of T lymphocytes that attack and destroy the transplanted liver. Immunosuppressive agents are used long term to prevent this response and rejection of the transplanted liver. These agents inhibit the activation of immunocompetent T lymphocytes to prevent the production of effector T cells.

Although the 1- and 5-year survival rates have increased dra-matically with the use of new immunosuppressive therapies, these advances are not without major side effects. A major side effect of cyclosporine, which is widely used in transplantation, is nephrotoxicity; this problem seems to be dose-related, and renal dysfunction can be reversed if the dose of cyclosporine is appropriately decreased or if its use is not initiated immediately. Cyclosporine-related side effects have caused many centers to use tacrolimus as first-line therapy because of its efficacy and lower side effect profile.

Corticosteroids, azathioprine, mycophenolate mofetil, rapa-mycin, antithymocyte globulin, and OKT3 are also elements of the various regimens of immunosuppression and may be used as the initial therapy to prevent rejection, or later to treat rejection. Liver biopsy and ultrasound may be required to evaluate sus-pected episodes of rejection.

Retransplantation is usually attempted if the transplanted liver fails, but the success rate of retransplantation does not approach that of initial transplantation.

Nursing Management

The patient considering transplantation and the family have diffi-cult decisions to make about treatment, use of financial resources, and relocation to another area to be closer to the medical center. They also must cope with the patient’s long-standing health prob-lems and perhaps social and family problems associated with be-haviors that may be responsible for the patient’s liver failure. Therefore, the time during which the patient and family are con-sidering liver transplantation and awaiting the news that a liver is available is often stressful. The nurse must be aware of these issues and attuned to the emotional and psychological status of the pa-tient and family. Referral of the patient and family to a psychiatric liaison nurse, psychologist, psychiatrist, or spiritual advisor may be helpful to them as they deal with the stressors associated with end-stage liver disease and liver transplantation.

PREOPERATIVE NURSING INTERVENTIONS

If irreversible, severe liver dysfunction has been diagnosed, the pa-tient may be a candidate for transplantation. An extensive diag-nostic evaluation will be carried out to determine whether the patient is a candidate. The nurse and other health care team members provide the patient and family with full explanations about the procedure, the chances of success, and the risks, in-cluding the side effects of long-term immunosuppression. The need for close follow-up and lifelong compliance with the thera-peutic regimen, including immunosuppression, is explained to the patient and family.

Once accepted as a candidate, the patient is placed on a wait-ing list at the transplant center and patient information is entered into the United Network for Organ Sharing (UNOS) computer system so that candidates may be matched with appropriate or-gans as they become available.

Unless the patient is having a segmental liver transplanta-tion from a living donor (Chart 39-12), a liver becomes avail-able for transplantation only with the death of another individual, who is usually healthy except for severe brain injury and brain death. Thus, the patient and family undergo a stress-ful waiting period, and the nurse is often the major source of support. The patient must be accessible at all times in case an appropriate liver becomes available. During this time, liver function may deteriorate further and the patient may experi-ence other complications from the primary liver disease. Be-cause of the current shortage of donor organs, many patients die awaiting transplantation.

Malnutrition, massive ascites, and fluid and electrolyte distur-bances are treated before surgery to increase the chance of a suc-cessful outcome. If the patient’s liver dysfunction has a very rapid onset, as in fulminant hepatic failure, there is little time or oppor-tunity for the patient to consider and weigh options and their con-sequences; often this patient is in a coma, and the decision to proceed with transplantation is made by the family.

The nurse coordinator is an integral member of the transplant team and plays an important role in preparing the patient for liver transplantation. The nurse serves as a patient and family advocate and assumes the important role of link between the patient and the other members of the transplant team. The nurse also serves as a resource to other nurses and health care team members involved in evaluating and caring for the patient.

POSTOPERATIVE NURSING INTERVENTIONS

The patient is maintained in an environment as free from bac-teria, viruses, and fungi as possible, because immunosuppressive medications reduce the body’s natural defenses. In the imme-diate postoperative period, cardiovascular, pulmonary, renal, neurologic, and metabolic functions are monitored continu-ously. Mean arterial and pulmonary artery pressures are moni-tored continuously. Cardiac output, central venous pressure, pulmonary capillary wedge pressure, arterial and mixed venous blood gases, oxygen saturation, oxygen demand and delivery, urine output, heart rate, and blood pressure are used to evalu-ate the patient’s hemodynamic status and intravascular fluid volume. Liver function tests, electrolyte levels, the coagulation profile, chest x-ray, electrocardiogram, and fluid output, in-cluding urine, bile, and drainage from Jackson-Pratt tubes, are monitored closely. Because the liver is responsible for the stor-age of glycogen and the synthesis of protein and clotting factors, these substances need to be monitored and replaced in the im-mediate postoperative period.

Because of the likelihood of atelectasis and an altered ventilation–perfusion ratio as a result of the insult to the dia-phragm during the surgical procedure, prolonged anesthesia, immobility, and postoperative pain, the patient will have an en-dotracheal tube in place and will require mechanical ventilation during the initial postoperative period. Suctioning is performed as required and sterile humidification is provided.

As the vital signs and condition stabilize, efforts are made to as-sist the patient to recover from the trauma of this complex surgery. After removal of the endotracheal tube, the nurse encourages the patient to use an incentive spirometer to decrease the risk for atelectasis. Once the arterial lines and the urinary catheter are removed, the patient is assisted to get out of bed, to ambulate as tolerated, and to participate in self-care to prevent the compli-cations associated with immobility. Close monitoring for signs and symptoms of liver dysfunction and rejection will continue throughout the hospital stay. Plans will be made for close follow-up after discharge as well. Teaching, initiated during the pre-operative period, continues after surgery.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care.Teaching the patient and familyabout long-term measures to promote health is crucial for success of the transplant and represents an important role of the nurse. The patient and family must understand why they should adhere continuously to the therapeutic regimen, with special emphasis on the methods of administration, rationale, and side effects of the prescribed immunosuppressive agents. The nurse provides written as well as verbal instructions about how and when to take the medications. To avoid running out of medication or skipping a dose, the patient must make sure that an adequate supply of medication is available. Instructions are also provided about the signs and symptoms that indicate problems that require consul-tation with the transplant team. The patient with a T-tube in place must be taught how to manage the tube.

Continuing Care.The nurse emphasizes the importance offollow-up blood tests and visits to the transplant team. Trough blood levels of immunosuppressive agents are obtained, along with other blood tests that assess the function of the liver and kidneys. During the first months, the patient is likely to require blood tests two or three times a week. As the patient’s condition stabilizes, blood studies and visits to the transplant team are less frequent. The importance of routine ophthalmologic examina-tions is emphasized because of the increased incidence of cataracts and glaucoma with the long-term corticosteroid therapy used with transplantation. Regular oral hygiene and follow-up dental care, with administration of prophylactic antibiotics before dental treatments, are recommended because of the immunosuppression.

The nurse reminds the patient that although a successful transplantation will not return him or her to normal, it does in-crease the chances for survival and a more normal life than before transplantation if rejection and infection can be prevented. Many patients have lived successful and productive lives after receiving a liver transplant. In fact, pregnancy can be considered 1 year after transplantation. Successful outcomes have been reported, but these pregnancies are considered high risk for mother and in-fant (Sherlock & Dooley, 2002).