The first successful liver transplant was performed by Professor Thomas Starzl at the University of Colorado in 1967. Liver transplantation is now performed worldwide. Professor Robert Jones performed the first liver transplant at the Austin Hospital in June 1988. Since then we have performed over 700 liver transplants including approximately 100 paediatric liver transplants. In 2010, approximately 250 patients received a liver transplant in Australia and New Zealand. The number of transplants performed is limited by the availability of organ donors. Currently the demand for donor livers outweighs the supply.
Most people who need a liver transplant suffer from long-term liver disease (cirrhosis) that is advanced and irreversible. Usually the disease has progressed over months or years before symptoms occur. Not everyone with cirrhosis needs a transplant and many people can live active lives with mild forms of liver disease.
In some rare circumstances, liver disease may develop quickly following an infection with a virus or contact with toxic chemicals/drugs. Occasionally, a patient may require an urgent liver transplant when complete liver failure occurs over a few days.
In any case, once a GP or specialist decides a patient has become unwell enough to require a liver transplant a referral is made to the Liver Transplant Unit. The Victorian Liver Transplant Unit accepts referrals from Victoria, Tasmania, southern New South Wales and other states as indicated. Once a patient is considered eligible for a liver transplant they will undergo the liver transplant assessment process.
Most organs for transplant are obtained, with family consent, from people who have died following a serious brain injury. By law there is no exchange of identity between the organ donor's family and the recipient. In some cases a part of the liver may be donated from a living relative to a child.
Brain Dead Donors
The majority of our donated livers come from people who have suffered acute structural brain damage, which has resulted in brain death. Brain death is defined as the irreversible loss of brain function. These donors are usually previously well individuals who have died as a result of an accident, a brain haemorrhage or from another cause of brain injury.
Donation after Cardiac Death
Another source of donated organs comes from those who donate organs after a person’s heart has stopped beating. This is known as donation after cardiac death (DCD). Livers from DCD donors increase organ availability by approximately 10%.
Living Related Donors
Under certain circumstances it may be possible for an adult to donate a portion of their liver to a child. These donors must be either a relative to the child or someone known to the family. Some transplant units perform adult to adult living donor liver transplantation however this is not a procedure which is done by our unit.
Following the identification of a suitable donor, consent for organ donation is sought from the family. The donor would be in an Intensive Care Unit (ICU) in any hospital in Australia or New Zealand. This process is managed by organ donor co-ordinators from DonateLife. The final decision to donate rests with the family. Organs considered for donation include the heart, lungs, kidneys, pancreas, intestines and the liver. Sometimes tissue is also donated.
Once a patient with liver disease is deemed unwell enough to require a liver transplant they will undergo the liver transplant assessment process. During this time a variety of tests and consultations are performed. The assessment aims to establish a patient’s suitability for liver transplantation. This includes tests of physical health (such as heart and lung function), psychological wellbeing and social supports. All these factors are taken into account in determining whether liver transplantation is a patient’s best option. During the assessment period, patients and their families receive education about liver transplantation including the risks and responsibilities. This helps patients to make an informed decision about accepting transplantation as an option.
Once the assessment is completed and a patient is deemed suitable for a liver transplant they will be activated on our liver transplant waiting list. Patient’s details are entered onto a confidential national registry and our local transplant waiting list. The waiting period is a difficult time for most patients. It may last just a few days or stretch to many months. The average wait is 8 to 12 months.
Once donor consent has been given, the donor liver is offered to the local state liver transplant unit. If the originating state is unable to use the liver, the organ is referred on to the other transplant units in Australia on a rotational basis. A recipient is matched from our liver transplant waiting list based on blood group, size and priority. Priority is determined using the MELD score (a computer generated number calculated using blood test results) and clinical assessment of liver disease severity. Occasionally a liver will be offered interstate for a patient with severe liver failure in intensive care and requiring urgent transplantation.
The success rate of liver transplantation has improved from a 1 year survival rate in the 1970’s of approximately 30% to approximately 93% in 2009. The 5 year survival rate in 2009 was 86% as per the Australia & New Zealand Liver Transplant (ANZLT) Registry. The improvement in survival rates is due to advances in operating technique, organ procurement and preservation, immunosuppressive therapy and more appropriate patient selection.
Liver transplantation is a major medical and surgical undertaking and is associated with significant risks and complications. The risks vary for individual patients depending on a number of factors such as age and general health.
The major risks of liver transplant surgery include:
· Intra-operative bleeding
· Primary non function (rare condition which occurs when the new liver does not work)
· Hepatic artery thrombosis (formation of blood clot in the artery to the liver which may result in the liver failing)
· Kidney failure requiring temporary dialysis
· Cardiac complications
· Unexpected transmission of other diseases from the donor
· Death (1% or 1 in 100 risk of patients dying during the transplant operation)
Long term post transplant risks include:
· Acute/Chronic rejection
· Bile duct narrowing (strictures)
• Disease recurrence
There are various side effects of the immunosuppressive therapy required to prevent the body from rejecting the new liver. These most commonly include high blood pressure, diabetes, impaired kidney function, skin cancers and osteoporosis.