performing “live donor” organ transplants, in which part of the liver from a matched donor is removed and transplanted. The surgery is possible because healthy livers can regenerate themselves. Within a year, the part of the liver removed from a donor has fully grown back.
Transplant patients typically spend a few days in an intensive care unit after surgery, where their condition can be carefully monitored. Then they are moved to a regular hospital room for a stay of two to three weeks, on average. Patients who are critically ill at the time of the transplant may need to remain in intensive care and in the hospital longer, up to three months. Once patients leave intensive care, they begin to resume normal diets and are encouraged to get out of bed and walk.
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The paradox of rejection
The most dangerous risk for transplantation patients is rejection. This occurs when the body’s immune system attacks and destroys the transplanted organ.
Why does the immune system, which is there to protect us, try to reject the life-saving transplant? Rejection occurs because the immune system’s job is to target and destroy foreign cells that pose a risk. Immune cells identify foreign cells by looking at unique molecular fingerprints on their surfaces and comparing them to the body’s own unique molecular fingerprints. In this way, the immune system distinguishes between “self” and “non-self.” A donor organ comes from someone whose cells have a different molecular fingerprint. Unfortunately, the immune system reacts as if the body has been invaded. It unleashes its destructive power to get rid of the foreign cells that it has mistakenly perceived as a threat. If not suppressed, the immune system can destroy a transplanted liver within days.
Several drugs have been developed that stop or slow the rejection process. Anti-rejection drugs may be given by injection during the first several weeks and later in pill form.
All anti-rejection drugs work by suppressing the immune system. As a result, they make patients more susceptible to infections. Other side effects include elevated blood pressure, fluid retention, puffiness, and bone loss. Over time, as the body begins to tolerate the new organ, patients require less anti-rejection medicine. Still, it’s likely that all transplant patients will have to take the drugs for the rest of their lives. Because of the potentially serious side effects, doctors typically try to lower the dosage to the smallest amount required to prevent rejection. To prevent serious infections, transplant patients are often given antibiotics in pill form.
Liver transplantation doesn’t always succeed. In some cases, the transplanted organ may fail to function. Clots forming in the blood vessels that supply the transplanted organ may cut off blood supply, starving the new liver. Sometimes doctors are unable to stop the rejection process. If the liver begins to fail, a second transplant may be necessary.
In rare cases, the hepatitis C infection comes back. However, new direct-acting agents can cure it, according to research reported by the American Gastroenterological Association. Some have had success with a combination of ledipasvir, sofosbuvir, and ribavirin, while another researchers used a combination of sofosbuvir and simeprevir to get rid of the infection.
For most patients, however, liver transplants are nothing short of a miracle. People who were seriously ill have been able to return to full, active lives.
New advances ahead
For HCV-positive patients, a liver transplant doesn’t offer a cure. Because HCV is circulating in the bloodstream, the transplanted liver inevitably becomes infected with the virus. Over time, the infection can begin to injure the new liver.
Fortunately, advances in treating hepatitis C promise to slow that process dramatically. The higher the viral load at the time of surgery, studies have shown, the more quickly symptoms of hepatitis C infection recur in transplant patients. That finding led scientists to wonder if anti-viral treatments given before surgery could lower viral levels and protect the new liver from damage. To find out, experts at Loyola University Medical Center in Illinois have begun aggressively treating HCV patients with high doses of alpha interferon. Early results suggest that the treatment may help delay recurrence of the disease.
The use of “live donor” liver transplants, meanwhile, could significantly increase the availability of donor organs. Because this technique poses some risk to the healthy donor, however, it remains controversial. In 2002, the National Institutes of Health launched a seven-year study to assess the technique and identify the safest ways to perform the procedure.
Another new advance could help buy time for patients awaiting donor livers. The Mayo Clinic laboratory is developing a bioartificial liver, which operates outside the body like hemodialysis but contains live, functioning liver cells. This new form of therapy is intended not only for patients prior to transplantation but also for those in need of chronic supportive therapy.