FAQs

Nonalcoholic Fatty Liver Disease & NASH

Definition & Facts

Nonalcoholic fatty liver disease (NAFLD) is a condition in which fat builds up in your liver. Nonalcoholic steatohepatitis (NASH) is a type of NAFLD. If you have NASH, you have inflammation and liver cell damage, along with fat in your liver.

Symptoms & Causes

Usually, nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) cause few or no symptoms. Certain health conditions—including obesity, metabolic syndrome, and type 2 diabetes—make you more likely to develop NAFLD and NASH.

Diagnosis

Doctors use your medical history, a physical exam, and tests to diagnose nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH). Tests may include blood tests, imaging tests, and sometimes liver biopsy.

Treatment

Doctors recommend weight loss to treat nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH). Weight loss can reduce fat in the liver, inflammation, and fibrosis. No medicines have been approved to treat NAFLD and NASH.

Eating, Diet, & Nutrition

You may be able to prevent nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis fatty liver disease (NASH) by eating a healthy diet and maintaining a healthy weight. If you have NAFLD and NASH, your doctor may recommend weight loss and diet changes.

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

Definition & Facts for Cirrhosis

What is cirrhosis?

Cirrhosis is a condition in which your liver is scarred and permanently damaged. Scar tissue replaces healthy liver tissue and prevents your liver from working normally. Scar tissue also partly blocks the flow of blood through your liver. As cirrhosis gets worse, your liver begins to fail.

Many people are not aware that they have cirrhosis, since they may not have signs or symptoms until their liver is badly damaged.

A healthy liver (left) and liver with cirrhosis (right).

How common is cirrhosis?

Researchers estimate that about 1 in 400 adults in the United States has cirrhosis. Cirrhosis is more common in adults ages 45 to 54. About 1 in 200 adults ages 45 to 54 in the United States has cirrhosis. Researchers believe the actual numbers may be higher because many people with cirrhosis are not diagnosed.1

Who is more likely to get cirrhosis?

People are more likely to get cirrhosis if they have certain health conditions. People are also more likely to get cirrhosis if they1

  • have abused alcohol  for a long time
  • have type 2 diabetes
  • are men
  • are older than age 50

What are the complications of cirrhosis?

As the liver fails, complications may develop. In some people, complications may be the first sign of the disease. Complications of cirrhosis may include the following.

Portal hypertension

Portal hypertension is the most common serious complication of cirrhosis.2 Portal hypertension is a condition that occurs when scar tissue partly blocks and slows the normal flow of blood through your liver, which causes high blood pressure in the portal vein. Portal hypertension and its treatments may lead to other complications, including

  • enlarged veins—called varices—in your esophagus, stomach, or intestines, which can lead to internal bleeding if the veins burst
  • swelling in your legs, ankles, or feet, called edema
  • buildup of fluid in your abdomen—called ascites—which can lead to a serious infection in the space that surrounds your liver and intestines
  • confusion or difficulties thinking caused by the buildup of toxins in your brain, called hepatic encephalopathy

Infections

Cirrhosis increases your chance of getting bacterial infections , such as urinary tract infections and pneumonia .

Liver cancer

Cirrhosis increases your chance of getting liver cancer .3 Most people who develop liver cancer already have cirrhosis.4

Liver failure

Cirrhosis may eventually lead to liver failure. With liver failure, your liver is badly damaged and stops working. Liver failure is also called end-stage liver disease. This may require a liver transplant.

Other complications

Other complications of cirrhosis may include

  • bone diseases, such as osteoporosis 
  • gallstones
  • problems with the bile ducts—the tubes that carry bile out of the liver
  • malabsorption and malnutrition
  • bruising and bleeding easily
  • sensitivity to medicines
  • insulin resistance and type 2 diabetes

Symptoms & Causes of Cirrhosis

What are the symptoms of cirrhosis?

You may have no signs or symptoms of cirrhosis until your liver is badly damaged.

Early symptoms of cirrhosis may include

  • feeling tired or weak
  • poor appetite
  • losing weight without trying
  • nausea and vomiting
  • mild pain or discomfort in the upper right side of your abdomen

As liver function gets worse, you may have other symptoms, including

  • bruising and bleeding easily
  • confusion, difficulties thinking, memory loss, personality changes, or sleep disorders
  • swelling in your lower legs, ankles, or feet, called edema
  • bloating from buildup of fluid in your abdomen, called ascites
  • severe itchy skin
  • darkening of the color of your urine
  • yellowish tint to the whites of your eyes and skin, called jaundice

What causes cirrhosis?

Cirrhosis has different causes. Some people with cirrhosis have more than one cause of liver damage.

Most common causes

The most common causes of cirrhosis are

  • alcoholic liver disease—damage to the liver and its function due to alcohol abuse 
  • nonalcoholic fatty liver disease
  • chronic hepatitis C
  • chronic hepatitis B

Less common causes

Some of the less common causes of cirrhosis include

  • autoimmune hepatitis
  • diseases that damage, destroy, or block bile ducts, such as primary biliary cholangitis and primary sclerosing cholangitis
  • inherited liver diseases—diseases passed from parents to children through genes—that affect how the liver works, such as Wilson disease, hemochromatosis, and alpha-1-antitrypsin deficiency 
  • long-term use of certain medicines 
  • chronic heart failure  with liver congestion, a condition in which blood flow out of the liver is slowed

Diagnosis of Cirrhosis

How do doctors diagnose cirrhosis?

Doctors diagnose cirrhosis based on your medical history, a physical exam, and the results of tests.

Medical history

Your doctor will ask about your symptoms. He or she will also ask if you have a history of health conditions that make you more likely to develop cirrhosis.

Your doctor will ask about your use of alcohol and over-the-counter and prescription medicines.

Your doctor will ask about your history of health conditions.

Physical exam

Your doctor will examine your body, use a stethoscope to listen to sounds in your abdomen, and tap or press on specific areas of your abdomen. He or she will check to see if your liver is larger than it should be. Your doctor will also check for tenderness or pain in your abdomen.

What tests do doctors use to diagnose cirrhosis?

Blood tests

Your doctor may recommend the following blood tests

  • liver tests  that can show abnormal liver enzyme levels, which may be a sign of liver damage. Your doctor may suspect cirrhosis if you have
    • increased levels of the liver enzymes alanine transaminase (ALT), aspartate transaminase (AST), and alkaline phosphatase (ALP)
    • increased levels of bilirubin
    • decreased levels of blood proteins
  • complete blood count , which can show signs of infection and anemia that may be caused by internal bleeding
  • tests for viral infections to see if you have hepatitis B or hepatitis C
  • blood tests for autoimmune liver conditions, which include the antinuclear antibody (ANA), anti-smooth muscle antibody (SMA), and anti-mitochondrial antibody (AMA) tests

Based on the blood test results, your doctor may be able diagnose certain causes of cirrhosis.

Your doctor can use blood tests to tell how serious your cirrhosis is.

1Your doctor can use blood tests to tell how serious your cirrhosis is.

Imaging tests

Imaging tests can show the size, shape, texture, and stiffness of your liver. Measuring the stiffness of the liver can show scarring. Your doctor can use stiffness measures to see if the scarring is getting better or worse. Imaging tests can also show how much fat is in the liver. Your doctor may use one or more of the following imaging tests

  • magnetic resonance imaging (MRI) 
  • ultrasound 
  • x-rays such as computerized tomography (CT) scans
  • transient elastography, a special ultrasound that measures the stiffness of your liver and can measure liver fat

Liver biopsy

Your doctor may perform a liver biopsy to see how much scarring in is your liver. A liver biopsy can diagnose cirrhosis when the results of other tests are uncertain. The biopsy may show the cause of cirrhosis. Sometimes your doctor may find that something other than cirrhosis has caused your liver to become damaged or enlarged. Your doctor can also diagnose liver cancer  based on liver biopsy results.

Treatment for Cirrhosis

How do doctors treat cirrhosis?

Doctors do not have specific treatments that can cure cirrhosis. However, they can treat many of the diseases that cause cirrhosis. Some of the diseases that cause cirrhosis can be cured. Treating the underlying causes of cirrhosis may keep your cirrhosis from getting worse and help prevent liver failure. Successful treatment may slowly improve some of your liver scarring.

How do doctors treat the causes of cirrhosis?

Doctors most often treat the causes of cirrhosis with medicines. Your doctor will recommend that you stop activities such as drinking alcohol and taking certain medicines  that may have caused cirrhosis or may make cirrhosis worse.

Alcoholic liver disease

If you have alcoholic liver disease, your doctor will recommend that you completely stop drinking alcohol. He or she may refer you for alcohol treatment .

Nonalcoholic fatty liver disease

If you have nonalcoholic fatty liver disease, your doctor may recommend losing weight. Weight loss through healthy eating and regular physical activity can reduce fat in the liver, inflammation, and scarring.

Chronic hepatitis C

If you have chronic hepatitis C, your doctor may prescribe one or more medicines that have been approved to treat hepatitis C since 2013. Studies have shown that these medicines can cure chronic hepatitis C in 80 to 95 percent of people with this disease.5

Chronic hepatitis B

For chronic hepatitis B, your doctor may prescribe antiviral medicines that slow or stop the virus from further damaging your liver.

Autoimmune hepatitis

Doctors treat autoimmune hepatitis with medicines that suppress, or decrease the activity of, your immune system.

Diseases that damage, destroy, or block bile ducts

Doctors usually treat diseases that damage, destroy, or block bile ducts with medicines such as ursodiol  (Actigall, Urso). Doctors may use surgical procedures to open bile ducts that are narrowed or blocked. Diseases that damage, destroy, or block bile ducts include primary biliary cholangitis and primary sclerosing cholangitis.

Inherited liver diseases

Treatment of inherited liver diseases depends on the disease. Treatment most often focuses on managing symptoms and complications.

Long-term use of certain medicines

The only specific treatment for most cases of cirrhosis caused by certain medicines is to stop taking the medicine that caused the problem. Talk with your doctor before you stop taking any medicines.

How do doctors treat the complications of cirrhosis?

Treatments for the complications of cirrhosis include the following.

Portal hypertension

Doctors treat portal hypertension with medicines to lower high blood pressure in the portal vein. Treatments for the complications of portal hypertension include

  • Enlarged veins in your esophagus or stomach, called varices. Your doctor may prescribe medicines to lower the pressure in the veins of your esophagus or stomach. This lowers the chance that the veins become enlarged and burst, causing internal bleeding. If you vomit blood or have black or bloody stools go to a hospital right away. Doctors may perform procedures during upper GI endoscopy or use surgical procedures to stop the internal bleeding.
  • Swelling in your legs, ankles, or feet, called edema. Your doctor may prescribe medicines that remove fluid from your body. Your doctor will recommend limiting the amount of salt in your diet.
  • Buildup of fluid in your abdomen, called ascites. Your doctor may prescribe medicines that remove fluid from your body. Your doctor will recommend limiting the amount of salt in your diet. If you have large amounts of fluid in your abdomen, your doctor may use a needle or tube to drain the fluid. He or she will check the fluid for signs of infection. Your doctor may prescribe medicines to treat infection or prevent infection.
  • Confusion, difficulties thinking, memory loss, personality changes, or sleep disorders, called hepatic encephalopathy. Your doctor may prescribe medicines that help lower the levels of toxins in your brain and improve brain function.

Infections

If you have a bacterial infection , your doctor will prescribe an antibiotic.

Liver cancer

Your doctor may treat liver cancer  with the medical procedures that remove or destroy cancer cells, such as surgery, radiation therapy , and chemotherapy . Doctors also treat liver cancer with a liver transplant.

Liver failure

Liver failure, also called end-stage liver disease, happens when the liver stops working. The only treatment for liver failure is a liver transplant.

Other Complications

Your doctor may treat other complications through changes in medicines, diet, or physical activity. Your doctor may also recommend surgery.

What can I do to help keep my cirrhosis from getting worse?

To help keep your cirrhosis from getting worse, you can do the following

  • Do not drink alcohol or use illegal drugs.
  • Talk with your doctor before taking
    • prescription medicines
    • prescription and over-the-counter sleep aids
    • over-the-counter medicines, including nonsteroidal anti-inflammatory drugs (NSAIDS) and acetaminophen 
    • dietary supplements , including herbal supplements.
  • Take your medicines as directed.
  • Get a vaccine for hepatitis A, hepatitis B, flu , pneumonia  caused by certain bacteria , and shingles .
  • Get a screening blood test for hepatitis C.
  • Eat a healthy, well-balanced diet.
  • Avoid raw or undercooked shellfish, fish, and meat.
  • Try to keep a healthy body weight .

Talk with your doctor about your risk for getting liver cancer and how often you should be checked.

When do doctors consider a liver transplant for cirrhosis?

Your doctor will consider a liver transplant when cirrhosis leads to liver failure. Doctors consider liver transplants only after they have ruled out all other treatment options. Talk with your doctor about whether a liver transplant is right for you.

Talk with your doctor about whether a liver transplant is right for you.

Eating, Diet, & Nutrition for Cirrhosis

What should I eat if I have cirrhosis?

If you have cirrhosis, you should eat a healthy, well-balanced diet . Talk with your doctor, a dietitian, or a nutritionist about healthy eating.

What should I avoid eating and drinking if I have cirrhosis?

You should avoid eating raw or undercooked shellfish, fish, and meat. Bacteria or viruses from these foods may cause severe infections in people with cirrhosis.

Your doctor may recommend limiting salt in your diet and limiting your intake of fats or protein.

You should completely stop drinking alcohol because it can cause more liver damage.

March 2018

Definition & Facts of Liver Transplant

What is a liver transplant?

A liver transplant is surgery to remove your diseased or injured liver and replace it with a healthy liver from another person, called a donor. If your liver stops working properly, called liver failure, a liver transplant can save your life.

A liver transplant removes your diseased or injured liver (right) and replaces it with a healthy liver (left).

How common are liver transplants?

In 2015, about 7,100 liver transplants were performed in the United States. Of these, almost 600 were performed in patients 17 years of age and younger.1

When do people need a liver transplant?

People need a liver transplant when their liver fails due to disease or injury.

For adults in the United States, the most common reasons for needing a liver transplant in 2016 were1

  • alcoholic liver disease 
  • cancers that start in the liver  combined with cirrhosis
  • fatty liver disease (nonalcoholic steatohepatitis)
  • cirrhosis caused by chronic hepatitis C

Biliary atresia is the most common reason children need a liver transplant.1

Doctors may consider a liver transplant to treat rare disorders such as urea cycle disorders and familial hypercholesterolemia .

People may also need a liver transplant due to acute liver failure. Acute liver failure is an uncommon condition most often caused by taking too much acetaminophen .2 Other causes of acute liver failure include

  • bad reactions to prescription medicines, illegal drugs, and herbal medicines 
  • viral hepatitis
  • toxin1s 
  • blockage of the blood vessels to the liver
  • autoimmune diseases
  • genetic disorders

What are the types of liver transplant?

Deceased donor transplants

Most livers for transplants come from people who have just died, called deceased donors. During a deceased donor transplant, surgeons remove your diseased or injured liver and replace it with the deceased donor’s liver. Adults typically receive the entire liver from a deceased donor. However, surgeons may split a deceased donor’s liver into two parts. The larger part may go to an adult, and the smaller part may go to a smaller adult or child.

Living donor transplants

Sometimes a healthy living person will donate part of his or her liver, most often to a family member who is recommended for a liver transplant. This type of donor is called a living donor. During a living donor transplant, surgeons remove a part of the living donor’s healthy liver. Surgeons remove your diseased or injured liver and replace it with the part from the living donor. The living donor’s liver grows back to normal size soon after the surgery. The part of the liver that you receive also grows to normal size. Living donor transplants are less common than deceased donor transplants.

What are the survival rates after a liver transplant?

For patients receiving liver transplants from deceased donors, the survival rates are1

  • 86 percent at 1 year
  • 78 percent at 3 years
  • 72 percent at 5 years

The 20-year survival rate is about 53 percent.3

Your chances of a successful liver transplant and long-term survival depend on your personal situation.

The Liver Transplant Process

The liver transplant process has many steps, including talking with your doctor, visiting a transplant center, and getting evaluated.

Talk with your doctor about a liver transplant

The first step is to talk with your doctor to find out whether you are a candidate for a transplant. Doctors consider liver transplants only after they have ruled out all other treatment options. However, a liver transplant is not for everyone. Your doctor may tell you that you are not healthy enough for surgery. You may have a medical condition that would make a transplant unlikely to succeed. If you and your doctor think a liver transplant is right for you, your doctor will refer you to a transplant center.

Talk with your doctor to find out whether a liver transplant is right for you.

Visit a transplant center

During your first visit to a transplant center, health professionals will provide information about

  • the evaluation and approval process
  • placement on the national waiting list
  • reasons for being removed from the national waiting list
  • the waiting period
  • how people are selected for liver transplants
  • surgery and recovery
  • the long-term demands of living with a liver transplant, such as taking medicines for the rest of your life

Get evaluated for a liver transplant

You will go through a series of evaluations at the transplant center, where you will meet members of your transplant team. You may need to visit the transplant center several times over the course of a few weeks or even months.

Your transplant team

Your transplant team has many members. The team will include all or some of the following people:

  • transplant coordinator—a specially trained nurse who will be your point of contact, arrange appointments, and provide information and education before and after your transplant.
  • transplant surgeons—specially trained doctors who perform the surgery and provide care before and after your transplant.
  • hepatologist—a doctor who specializes in liver disease and may provide care before and after your surgery.
  • insurance case manager—a person who will help you with your insurance coverage.
  • financial coordinator—a person who helps with financial matters.
  • social worker—a person who can help solve problems in your daily life and coordinate care needs after your transplant.
  • psychiatrist—a doctor who determines whether you are mentally and emotionally healthy and prepared for caring for a new liver.
  • dietitian—an expert in food and nutrition. A dietitian can teach you about the foods you should eat and how to plan healthy meals before and after your transplant.

Your team will ask you about your medical history and perform medical tests. These tests may include

  • a physical exam
  • blood and urine tests
  • tests that provide pictures of organs inside your body, called imaging tests
  • tests to see how well your heart, lungs, and kidneys are working

The team will use the results of these tests to tell them

  • how likely you are to survive transplant surgery
  • what other diseases and conditions you have
  • the cause and severity of your liver disease

Your team will find out if you are healthy enough for surgery. Some medical conditions or illnesses can make a liver transplant less likely to succeed. You may not be able to have a transplant if you have

  • a severe infection
  • alcohol or drug abuse problems
  • cancer outside the liver
  • serious heart or lung disease

Also, the transplant team will

  • find out whether you or your caregivers are able to understand and follow your doctor’s instructions for care after your transplant. They need to be sure you are mentally prepared for caring for a new liver.
  • find out whether you have a good support system of family members or friends to help care for you before and after the transplant.
  • review your medical insurance and other financial resources. Many financial assistance programs  are available to people receiving a liver transplant and their families to help with the cost of the surgery, medicines, and care.

Get approved for a liver transplant

The transplant center’s selection committee will review the results of your evaluation. Each transplant center has its own guidelines about who can get a liver transplant. Transplant centers often post their guidelines on their websites. The centers also follow national guidelines.

Keep in mind that you may choose not to have a transplant even though you have been approved.

Get placed on the national waiting list

If you are approved for a transplant and do not have a living donor, the transplant center will submit your name to be placed on the national waiting list for a liver from a deceased donor. If you have a living donor, the transplant center will not place you on the national waiting list.

The Organ Procurement and Transplantation Network  (OPTN) has a computer network linking all regional organ-gathering organizations—known as organ procurement organizations—and transplant centers. The United Network for Organ Sharing  (UNOS), a nonprofit organization, runs the OPTN under a contract with the Federal Government. When UNOS officially adds you to the national waiting list, UNOS will notify you and your transplant center.

UNOS policies let you register with more than one transplant center to increase your chances of receiving a liver. Each transplant center may require a separate medical evaluation.

Wait for a match

The waiting period for a deceased donor transplant can range from less than 30 days to more than 5 years.4 How long you will wait depends on how badly you need a new liver. Other factors—such your age, where you live, your blood type  and body size, your overall health, and the availability of a matching liver—may make your wait time longer or shorter. The UNOS computer matches a deceased donor’s liver based on your blood type and body size.

UNOS policies rank people with the most urgent need for a new liver to prevent death at the top of the national waiting list.

When a matching liver from a deceased donor is found, your transplant team coordinator will call you right away, tell you what you need to do before going to the hospital, and ask you to come to the hospital right away.

Confirm living donor match if you choose this type of liver transplant

If a family member, spouse, or friend wants to be a living donor, the transplant team will determine whether you and the person have blood types that work together and a similar body size. The transplant team will

  • ask the potential donor about his or her medical history
  • perform medical tests to make sure the person is in good general health, with no major medical or mental illnesses

The potential donor must be able to understand and follow instructions before and after surgery, be between the ages of 18 and 60, and have an emotional tie to the person receiving the liver transplant.

The OPTN and UNOS provide detailed information on the organ transplant process.

Liver Transplant Surgery

How do I prepare for liver transplant surgery?

How you prepare for liver transplant surgery depends on the type of liver transplant you are having.

  • Deceased donor transplant. If you are on the national waiting list for a deceased donor liver, your transplant team coordinator will call you as soon as a matching liver is found. You must go to the hospital right away. Your transplant team coordinator will tell you what you need to do before going to the hospital.
  • Living donor transplant. If you are receiving a liver from a living donor, you will schedule your surgery 4 to 6 weeks in advance. Your transplant team coordinator will tell you and the donor what you need to do before going to the hospital for the operations.

How do doctors perform liver transplant surgery?

Doctors perform liver transplant surgery by removing your diseased or injured liver and replacing it with the donor’s liver. Liver transplant surgery can take up to 12 hours or longer. During the surgery, the surgical team will

  • give you general anesthesia 
  • put intravenous (IV) and other types of lines into your body so you receive medicines and fluids
  • monitor your heart and blood pressure

If you are getting a liver from a deceased donor, your surgery will start when the donor liver arrives at the transplant center. If you are getting a liver from a living donor, the surgical team will operate on you and your donor at the same time.

For liver transplant surgery, surgeons remove your diseased or injured liver and replace it with the donor’s liver.

What are the possible problems of liver transplant surgery?

Possible problems of liver transplant surgery should be discussed with your surgeon. Some possible problems include

  • bleeding
  • blood clots  in your liver’s blood vessels
  • damage to the bile ducts
  • failure of the donated liver
  • infection
  • rejection of the donated liver

What happens after liver transplant surgery?

After your surgery, you will stay in an intensive care unit (ICU). Specially trained doctors and nurses will watch you closely while you’re in the ICU. You’ll begin taking medicines called immunosuppressants to prevent problems with your new liver. The doctors and nurses will perform

  • blood tests often to make sure your new liver is working properly
  • medical tests to make sure your heart, lungs, and kidneys are also working properly

When your doctors feel you are ready, you will move from the ICU to a regular room in the hospital.

Your transplant team will teach you how to take care of yourself before you get home. Transplant team members will give you information on follow-up medical care, the things you need to do to care for your new liver, and possible problems you may have with your new liver.

After a living donor’s surgery, the donor will stay in a recovery room for a few hours and spend his or her first night in an ICU. Specially trained doctors and nurses will watch the donor closely in the ICU. The day after surgery, the donor will usually move to a hospital room. The doctors and nurses will encourage the donor to get out of bed and sit in a chair the day after surgery and to walk short distances as soon as he or she is able.

When can I go home after liver transplant surgery?

You can likely go home about 2 weeks after your transplant surgery. A living donor can typically go home about 1 week after surgery.

When can I go back to my normal activities?

Your doctor will let you know when you can go back to your normal activities. You can likely return to your normal activities after a few months. Most people are able to return to work, be physically active, and have a normal sex life. You will continue to have regular medical checkups to make sure that your liver is working properly and you have no other health problems. Doctors often recommend that women wait at least a year after their transplant before getting pregnant.

Although recovery times vary, most living donors can often return to their normal activities 1 month after surgery and can return to work within 4 to 6 weeks.

Living with a Liver Transplant

After a liver transplant, you will need to see your doctor often to make sure your new liver is working properly. You will have regular blood tests to check for signs of organ rejection and other problems that may damage your new liver.

What is organ rejection?

Organ rejection occurs when your immune system sees your transplanted liver as “foreign” and tries to destroy it. You have the highest chance of organ rejection in the first 3 to 6 months after your transplant.5

What are the signs and symptoms of organ rejection?

Abnormal liver blood test  results may be the first sign of organ rejection. Rejection does not always cause symptoms you may notice. When symptoms of rejection are present, they may include

  • feeling tired
  • pain or tenderness in your abdomen
  • fever
  • yellowing of the skin and the whites of your eyes
  • dark-colored urine
  • light-colored stools

You should talk with your doctor right away if you have symptoms of organ rejection. Your doctor will often perform a liver biopsy to see if your body is rejecting the new liver.

How can I prevent organ rejection?

To help keep your body from rejecting the new liver, you will need to take medicines called immunosuppressants. These medicines prevent and treat organ rejection by reducing your immune system’s response to your new liver. You may have to take two or more immunosuppressants. You will need to take these medicines for the rest of your life.

You will need to take medicines called immunosuppressants for the rest of your life.

Rejection can occur any time the immunosuppressive medicines fail to control your immune system’s response to your new liver. If your transplanted liver fails as a result of rejection, your transplant team will decide whether another transplant is possible.

What are the side effects of immunosuppressants?

Immunosuppressants can have many serious side effects. You can get infections more easily because these medicines weaken your immune system. Other possible side effects include

  • brittle bones
  • diabetes
  • high blood pressure
  • high levels of cholesterol and triglycerides in the blood
  • kidney damage
  • weight gain

Long-term use of these medicines can increase your chance of developing cancers of the skin and other areas of your body.

Prescription medicines, over-the-counter medicines, vitamins, and dietary supplements can affect how well immunosuppressants work. Tell your doctor if you are prescribed any new medicines. Talk with your doctor before using over-the-counter medicines, vitamins, dietary supplements , or any complementary or alternative  medicines or medical practices.

How do I help care for my new liver?

Do the following to help take care of your new liver.

  • Take medicines exactly as your doctor tells you to take them.
  • Talk with your doctor before taking any other medicines, including prescription and over-the-counter medicines, vitamins, and dietary supplements.
  • Keep all medical appointments and scheduled blood draws.
  • Stay away from people who are sick.
  • Tell your doctor when you are sick.
  • Learn to recognize the symptoms of rejection.
  • Have cancer screenings  as recommended by your doctor.
  • Keep up to date with vaccinations; however, “live” vaccines should not be used.
  • Talk to your doctor, both before and after your liver transplant, about the use of contraceptives and the risks and outcomes of pregnancy.

Learn how to recognize the symptoms of infection. Symptoms of infection may include:

  • fever
  • chills
  • a stuffy nose
  • sore throat
  • cough
  • diarrhea
  • vomiting

Talk with your doctor right away if you have symptoms of infection.

Make healthy choices and protect yourself.

  • Eat healthy foods, exercise, and don’t smoke cigarettes
  • Don’t drink alcoholic beverages or use alcohol in cooking if you have a history of alcohol use disorder.
  • Protect yourself from soil exposure by wearing shoes, socks, long-sleeve shirts, and long pants.
  • Avoid pets such as rodents, reptiles, and birds.
  • Protect yourself against organisms that can transmit diseases, such as ticks and mosquitoes, by
    • using insect repellent
    • wearing shoes, socks, long-sleeve shirts, and long pants
    • not going outdoors at times when organisms are most likely to be active, such as at dawn and dusk
  • If you are planning on traveling, especially to developing countries, talk with your transplant team at least 2 months before leaving to determine the best ways to reduce travel-related risks.

What should I eat after my liver transplant?

You should eat a healthy, well-balanced diet after your liver transplant to help you recover and keep you healthy. A dietitian or nutritionist can help you create a healthy eating plan that meets your nutrition and diet needs.

What should I avoid eating after my liver transplant?

Grapefruit and grapefruit juice can affect how well some immunosuppressants work. To help prevent problems with some of these medicines, avoid eating grapefruit and drinking grapefruit juice.

If you have a history of alcohol use disorder, do not drink alcoholic beverages or use alcohol in cooking.

You should avoid consuming the following:

  • water from lakes and rivers
  • unpasteurized milk products
  • raw or undercooked
    • eggs
    • meats, particularly pork and poultry
    • fish and other seafood

Your dietitian or nutritionist may recommend that you limit your intake of

  • salt
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Clinical Trials for Liver Transplant

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you .

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov

CIRRHOSIS: advanced liver disease 
 
 
  INTRODUCTION:
 
Cirrhosis is a chronic liver disease often associated with alcoholism. After heart disease and cancer, cirrhosis is the third most common cause of death in people aged 45-65 years. Cirrhosis is a general term for end-stage liver disease, which can have many causes and which disrupts normal liver tissue. Cirrhosis has no cure, but removing the ultimate cause can slow the disease. 
 
Findings from several studies, however, have shown interferon alone or interferon plus ribavirin can be effective for some individuals in slowing, stopping, and perhaps reversing fibrosis and activity (inflammation & necrosis of the liver) both for individuals with sustained viral response to therapy and for some individuals who are non-responders. Patients with a sustained response were more successful. Here are links to 3 such studies presented at the AALSD annual liver conference in November 2001 and a published article. These findings are encouraging but we need more studies to confirm these findings, to better understand these study results, and to study the clinical outcomes for the patients. 
 
EFFECT OF INTERFERON AND RIBAVIRIN ON PROGRESSION OF LIVER FIBROSIS IN PATIENTS WITH SEVERE CHRONIC HEPATITIS C
  
Impact of Pegylated Interferon alfa-2b (Peg-Intron) and Ribavirin on Progression of Liver Fibrosis in patients with Chronic Hepatitis C
 
 
In this study Thierry Poynard examined 3000 patients and 5000 paired biopsies 20 months apart from 10 studies using interferon, PegIntron and ribavirin. Non-responders and responders improved or stabilized their activity score their Metavir fibrosis score by at least 1 stage. Poynard reported that some patients with stage 2, 3, and 4 fibrosis stage who were non-responders stopped disease progression and some sustained responders experienced a dramatic decrease or reversal in fibrosis rate. In what Poynard called surprising, he found half of the patients with cirrhosis who had paired biopsies reversed fibrosis: 33% of sustained responders & 15% of nonresponders.
 
Can Cirrhotics Achieve a Histologic Response?
 
In this study Jenny Heathcote did paired biopsies of cirrhotic patients who received Pegasys monotherapy, and used the Histologic Activity Index which combines both inflammation and fibrosis into one score to evaluate improvements in histology. A high percentage of sustained responders achieved a histologic response and 35% receiving Pegasys alone had a histologic improvement.
 
In cirrhosis, the liver responds to cell injury and death by producing strands of scar tissue that surround islands (nodules) of healing cells, making the liver knobby. The liver may be injured by a single event (acute hepatitis), over months or years (biliary tract blockage or chronic hepatitis), or continuously (alcohol abuse). The knobs, or nodules, and scar tissue can compress veins within the liver, resulting in high liver blood pressure (portal hypertension).
 
The scar tissue hinders the liver’s ability to perform its normal functions, such as clearing toxins, forming proteins, and storing energy. Other problems may result.
 
Portal hypertension: High pressures within blood vessels of the liver occur in 60% of people who have cirrhosis. Cirrhosis is the most common cause of portal hypertension in the United States. You may suffer from bleeding into the intestines and fluid accumulation throughout your body.
 
Hepatic encephalopathy: In this condition, toxins build up in your bloodstream because your scarred liver is unable to rid them from your body. The toxins can cause you to behave bizarrely, to become confused, and to no longer be able to take care of yourself or others.
 
Gastrointestinal bleeding: Portal hypertension causes bleeding from varicose veins in your esophagus, which can be life threatening.
 
Infection: Fluid can accumulate in your abdomen and become infected. If you have cirrhosis, you are at risk for many infections because your liver cannot form the proteins needed to fight off infection.
 
Fluid (ascites): High pressures (portal hypertension) force fluid out of blood vessels in your liver, pooling it in your abdomen. Several liters of blood can pool in your abdomen, causing pain, swelling, difficulty breathing, and dehydration.
 
Fluid retention: As fluid pools in your abdomen, your kidneys will try to hold onto more water, because they think your body is dehydrated. The excess fluid collects in your lungs, legs, and abdomen.
 
CAUSES:
 
Cirrhosis can be caused by a number of conditions, including long-standing inflammation, poisons, infections, and heart disease. In the US, alcoholism most often causes the disease, followed by hepatitis, usually a viral infection of the liver. However, for 30-50% of cirrhosis cases, no cause can be found.
 
Alcoholic cirrhosis: Alcohol can poison all living cells and cause your liver cells to become inflamed and die. Their death leads your body to form scar tissue around veins of your liver. Healing liver cells (nodules) also form and press on the liver veins. This scarring process occurs in 10-20% of alcoholics and is the most common form of cirrhosis in the US. The process depends on how much you drink and how long you have been abusing alcohol. Some families may have more risk of this type of cirrhosis than others.
 
Postnecrotic cirrhosis: Hepatitis, a viral infection of the liver, usually causes this disease, although poisonous substances may also cause it. Two types of hepatitis, hepatitis B or hepatitis C, cause 25-75% of these cases. Large areas of scar tissue mix with large areas of healing nodules.
 
Biliary cirrhosis: When small tubes that help you digest food become blocked, your body mistakenly turns on itself and reacts against these bile tubes. Gallstones often block tubes and cause this type of cirrhosis. The disease usually affects women aged 35-60 years.
 
Cardiac cirrhosis: Your heart is a pump that pushes blood throughout your body. When your heart doesn’t pump well, blood “backs up” into the liver. This congestion causes damage to your liver. It may become swollen and painful. Later it becomes hard and less painful. The cause of the heart failure may be from heart valve problems, smoking, or infection of the heart muscle or the sac around the heart.
 
SIGNS AND SYMPTOMS:
 
Your doctor may ask you about alcohol abuse, hepatitis, poisonous exposures, blood transfusions, or IV drug abuse.
 
You may complain of nausea, weight loss or gain, fluid overload, feeling weak and tired, and loss of sex drive.
 
Your skin and eyes may turn yellow (a condition called jaundice).
 
You might have fever, abdominal swelling or pain, difficulty breathing, vomiting, diarrhea, bleeding from gums or nose, blood in your vomit or feces, and abnormal menstrual periods.
 
Other symptoms include loss of muscle mass, ankle swelling, confusion (hepatic encephalopathy), and hemorrhoids. Men might notice enlargement of the breasts (gynecomastia), scrotal swelling, or small testes.
 
HOME CARE:
 
You must stop drinking alcohol. If you stop all alcohol intake, you may slow the disease and feel better.
 
Ask your doctor what medications you should avoid that may be harmful to your liver.
 
Begin a low-sodium diet if you are having problems with fluid retention.
 
Eat a balanced diet with adequate calories and protein. You also may want to take a daily multivitamin if your doctor agrees.
 
If you ever have developed any brain disorder caused by your liver (hepatic encephalopathy), you should decrease your protein intake.
 
WHEN TO CALL THE DOCTOR;
 
Sudden weight changes
 
Increasing water retention
 
Yellow skin (jaundice)
 
WHEN TO GO TO THE HOSPITAL:
 
Blood in your vomit or stool
 
Difficulty breathing
 
Abdominal pain
 
Confusion or bizarre behavior
 
Repeated vomiting
 
Fever
 
PHYSCIAN DIAGNOSIS:
 
Your doctor may suspect cirrhosis if you have a history of alcohol abuse, IV drug use, or hepatitis, or if you have bleeding, jaundice, ascites (water building up in your abdomen), or any brain disorder.
 
You may be diagnosed with cirrhosis after its complications develop. Usually your doctor can make a diagnosis based on your history and physical exam alone. But taking a biopsy removing tissue from the liver and studying it under a microscope remains the only way diagnosis can be 100% certain.
 
The doctor may collect blood to look for problems with your electrolytes, blood count, clotting ability, or your liver and kidney function. Often routine blood tests may appear normal, however. 
 
PHYSCIAN TREATMENT:
 
Many medicines have been studied, such as steroids penicillamine (Cuprimine, Depen) and an anti-inflammatory agent (colchicine), but they have not been shown to improve survival. Most treatment for cirrhosis is directed toward relief of complications.
 
Various surgeries can be performed to redirect liver blood flow into the circulatory system, reducing liver blood pressures. However, surgery may worsen hepatic encephalopathy or ascites. No surgery has been proven to improve long-term survival.
 
Intestinal bleeding requires hospitalization because you are at high risk of bleeding to death. You have a 1 in 2 chance of dying during that hospital stay if you suffer from bleeding varicose veins in your esophagus.
 
If you have significant blood loss, you will need oxygen, close monitoring, and 2 large IV lines to restore lost fluids.
 
You may need blood transfusions.
 
Doctors diagnose ongoing bleeding from the esophagus by inserting a tube down your nose into your stomach to suck out any pooled blood. Once they recognize bleeding, various methods can control it.
 
Balloon inflation to compress the vein
 
Medications that decrease blood flow into the liver
 
Tying off the bleeding vein
 
Ascites, the build-up of water in your abdomen, will be treated.
 
Your doctor may prescribe diuretics (water pills)‹medicines that make you urinate more often.
 
Your doctor may insert a needle into your abdomen to directly remove large amounts of fluid. However, the fluid usually collects again.
 
If the fluid becomes infected, you will be hospitalized and given IV antibiotics.
 
If you have significant hepatic encephalopathy, you will be hos pitalized, particularly if you have become so confused you cannot care for yourself.
 
You will be given lactulose, a drink that reduces the amounts of toxins absorbed into your intestinal tract.
 
You may be started on a low-protein diet.
 
Combining these 2 treatments improves symptoms in 75% of cases.
 
You might be sent home and instructed to take lactulose every day and change to a low protein diet, but to return if symptoms come back.
 
Clotting disorders: Adequate protein intake and vitamin supplements can help to correct clotting disorders caused by the inability of your liver to form clotting factors.
 
Hepatorenal syndrome: For unknown reasons, liver failure sometimes leads to kidney failure. Without a liver transplant, kidney failure usually is fatal, often causing several organs throughout the body to fail.
 
Cancer: People often develop liver cancer before they develop cirrhosis. You may die within 3-6 months after diagnosis if the cancer remains untreated. Even with treatment, people rarely survive beyond 5 years.
 
Surgery is the only chance for a cure, but usually the cancer has progressed too far by the time surgery is performed.
 
Liver transplantation may also be considered.
 
Researchers are studying various experimental treatments, such as chemoembolization, alcohol ablation, cryoablation, immunotherapy, and gene therapy.
 
PROGNOSIS:
 
Your recovery depends on the type of cirrhosis you have and if you stop drinking. Only 50% of people with severe alcoholic cirrhosis survive 2 years, and only 35% survive 5 years. Recovery rate worsens after the onset of complications (such as gastrointestinal bleeding, ascites, encephalopathy). As discussed at the beginning of the article interferon plus ribavirin therapy has been shown to be effective for some patients with HCV-related cirrhosis. Liver transplantation remains the best treatment, but livers are available for very few people. 
 
PREVENTION:
 
Avoid risky behaviors such as alcohol abuse, IV drug use, and unprotected sexual intercourse.
 
Hepatitis B immunizations are available to health care workers and others at high risk of contacting the disease.
 
Immunization of all American children against hepatitis B, now required, will reduce the incidence of cirrhosis in the future.
 
No effective hepatitis C vaccination is available.
 
FOLLOW UP:
 
You must be hospitalized for further work-up and treatment if you are diagnosed with cirrhosis after having a major complication.
 
If you have liver disease but no major complications, you may undergo a work-up as an outpatient if the following criteria are met:
 
You have no signs or symptoms of infection.
 
Your blood still has the ability to form clots adequately.
 
You have close follow-up arranged (within 2 days) with your doctor.
 
You are able to hold down foods and liquids.
 
You will be in the company of an adult who can recognize complications and seek help should you become confused and unable to care for yourself.

PROGNOSIS: Your recovery depends on the type of cirrhosis you have and if you stop drinking. Only 50% of people with severe alcoholic cirrhosis survive 2 years, and only 35% survive 5 years. Recovery rate worsens after the onset of complications (such as gastrointestinal bleeding, ascites, encephalopathy).

It is calculated according to the following formulaMELD = 3.78×ln[serum bilirubin (mg/dL)] + 11.2×ln[INR] + 9.57×ln[serum creatinine (mg/dL)] + 6.43. MELD scoresare reported as whole numbers, so the result of the equation above is rounded.

The Model for End-Stage Liver Disease, or MELD, is a scoring system for assessing the severity of chronic river disease. It was initially developed to predict mortality within three months of surgery in patients who had undergone a trans jugular intrahepatic portosystemic shunt (TIPS) procedure, and was subsequently found to be useful in determining prognosis and prioritizing for receipt of a liver transplant. This score is now used by the United Network for Organ Sharing (UNOS) and Euro transplant for prioritizing allocation of liver transplants instead of the older Child-Pugh score.

MELD uses the patient’s values for serum bilirubin, serum creatinine, and the international normalized ratio for prothrombin time (INR) to predict survival. It is calculated according to the following formula:[3]

MELD = 3.78×ln[serum bilirubin (mg/dL)] + 11.2×ln[INR] + 9.57×ln[serum creatinine (mg/dL)] + 6.43

MELD scores are reported as whole numbers, so the result of the equation above is rounded.

UNOS has made the following modifications to the score:[5]

  • If the patient has been dialyzed twice within the last 7 days, then the value for serum creatinine used should be 4.0 mg/dL
  • Any value less than one is given a value of 1 (i.e. if bilirubin is 0.8 a value of 1.0 is used) to prevent subtraction from any of the three factors, since the natural logarithm of a positive number below 1 (greater than 0 and less than 1) yields a negative value.

The etiology of liver disease was subsequently removed from the model because it posed difficulties such as how to categorize patients with multiple causes of liver disease. Modification of the MELD score by excluding etiology of liver disease did not significantly affect the model’s accuracy in predicting three-month survival.

Patients with a diagnosis of liver cancer will be assigned a MELD score based on how advanced the cancer is.

Interpretation

In interpreting the MELD Score in hospitalized patients, the 3 month observed mortality (considering 3437 adult liver transplant candidates with chronic liver disease who were added to the OPTN waiting list at 2A or 2B status between November, 1999, and December, 2001) is:[6]

  • 40 or more — 71.3% observed mortality
  • 30–39 — 52.6% observed mortality
  • 20–29 — 19.6% observed mortality
  • 10–19 — 6.0% observed mortality
  • <9 — 1.9% observed mortality

Applications of MELD score:

  • The best outcomes with TIPS occur among patients with a MELD score less than 14.
  • Patients with MELD scores greater than 24 who are reasonable liver transplant candidates are probably best served by foregoing TIPS placement.

Once you have cirrhosis, treatment focuses on keeping the condition from worsening. It may be possible to stop or slow the damage. Symptoms of end-stage liver disease may include: Easy bleeding or bruising.

End-stage hepatitis C means the liver has been severely damaged by the hepatitis C virus. The hepatitis C virus slowly damages the liver over many years, often progressing from inflammation to permanent, irreversible scarring (cirrhosis). Often, people have no signs or symptoms of liver disease or have only mild symptoms for years or even decades until they have cirrhosis.

Once you have cirrhosis, treatment focuses on keeping the condition from worsening. It may be possible to stop or slow the damage.

Symptoms of end-stage liver disease may include:

  • Easy bleeding or bruising
  • Persistent or recurring yellowing of your skin and eyes (jaundice)
  • Intense itching
  • Loss of appetite
  • Nausea
  • Swelling due to fluid buildup in your abdomen and legs
  • Problems with concentration and memory

Cirrhosis usually progresses to the point where the liver loses most or all of its function — liver failure. In addition, people with cirrhosis may develop:

  • Bleeding of the digestive (gastrointestinal) tract due to enlarged veins in the tube that connects the throat and stomach (esophagus), a condition known as esophageal varices
  • Brain and nervous system damage due to the buildup of toxins in the bloodstream (hepatic encephalopathy)

Cirrhosis also increases your risk of liver cancer.

The only effective treatment for people with end-stage liver disease is a liver transplant. Chronic hepatitis C virus is the most frequent cause of liver transplantation in the United States. Most people who receive a liver transplant for hepatitis C survive for at least five years after their transplant, but almost always the hepatitis C virus returns.

If you’re diagnosed with hepatitis C or end-stage liver disease, see a doctor who specializes in gastrointestinal diseases or liver diseases (hepatologist). Newer, more-effective hepatitis C treatments can eliminate the virus in many people, reducing the risk of end-stage liver disease.

The average wait time for liver transplant candidates with type O blood, the longest wait list blood type, was 457 days or 1.25 years from 2003-2004. This has decreased significantly from 1999-2000 which the average wait time was 1314 daysor 3.6 years.

As of 2014, the liver transplant wait list had 15,323 candidates and only 6,729 liver transplants were done nationwide, according to Organ Procurement and Transplantation Network (OPTN). Candidates are moved up and down the wait list based on a calculated score called Model For End Stage Liver Disease (MELD), which determines how sick a candidate is. A MELD of 30-39 has a 52.6% of mortality and 40 or more has 71.3% chances of mortality (Weisner et al., 2003). A candidate with the higher MELD is offered a liver first within a geographic region based on a local, regional, national algorithm. This often results in the sickest candidate not receiving an organ first because of geographical constraints (The Advisory Board Company, 2014).    

The OPTN data stated that in 2013, on average 8 people die each day while waiting for a liver transplant resulting in 1,523 deaths and 1,552 candidates taken off the wait list because they were too ill. The average wait time for liver transplant candidates with type O blood, the longest wait list blood type, was 457 days or 1.25 years from 2003-2004. This has decreased significantly from 1999-2000 which the average wait time was 1314 days or 3.6 years.    

Having worked as a registered nurse on a liver transplant unit at the UCSF Medical Center, liver transplant patients are a high acuity patient population, meaning they are incredibly sick patients. The common symptoms of a patient with end stage liver disease are yellow skin, swollen legs, stomach distension to the point of shortness of breath at rest, and malnourishment with muscle wasting to the point of becoming bed bound. The brain swells due to increased ammonia levels in the body that causes patients to become confused and sometimes agitated, called hepatic encephalopathy. Lactulose is a medication used to resolve hepatic encephalopathy by excreting the ammonia through its laxative effects. Patients often have skin breakdown from constant incontinence care and often embarrassed because they cannot get to the restroom in time. Many patients with liver disease are extremely fatigued and depressed often wanting to give up hope while waiting to get a liver transplant.        

Being this sick, many patients can’t survive for 1.25 years to be transplanted. The United Network for Organ Sharing (UNOS) along with the OPTN has acknowledged this and proposed in 2012 to change the current region system for liver allocation from 11 regions to either four or eight regions.  A member of UNOS stated “The overall goal of redesigning liver distribution is to decrease the variation in access to liver transplantation nationally. In some areas of the country candidates must wait much longer and become much sicker before they are able to receive a liver transplant than some other areas of the country. By broadening the boundaries in which livers are shared, candidates would have an increase in their access to donated livers. For areas that currently experience longer wait times, we anticipate by moving to a model of broader sharing, the wait times would decrease. For areas of the country that are currently transplanting less sick patients, we anticipate they may experience a slight increase in wait times as their candidates are not as critically ill.” (A. Archer-Hayes, personal communication, March 26, 2015).    

Since 2012, the OPTN/UNOS liver and intestinal organ committee has been obtaining data through the Liver Simulated Allocation Model (LSAM). It is a computer program designed to reduce the variation in the median MELD as well as decreasing wait list deaths. The data has shown to decrease deaths on the wait list by 581 people per year if the regions are reduced to four. The LSAM uses historical inputs of donors and candidates, organ offer acceptance practices, and removals for death or other reasons to create simulated outputs. Examples of these outputs are number and rate of wait list deaths, median MELD scores, average transport times, and the percentage of transplants based on demographics or MELD scores greater than 25 (OPTN/UNOS Liver and Intestinal Organ Transplantation Committee, 2014).    

Based on comments from a public forum held in September 2014, main concerns for restructuring the regional map were increased costs, organs shifting from higher performing organ procurement organizations (OPO) to lower performing OPOs, and poorer outcomes post-transplant by transplanting more critically ill candidates. The Advisory Board Company (2014) voiced the concerns of physicians in areas with high liver organ donation rates becoming an “organ farm” to areas with lower organ donation rates by reducing the number of regions from 11 to eight or four. Urban areas have higher wait lists and less organ donations while the Midwest and South have high donations with a lower number of candidates on the wait list. Physicians in high organ donation areas are concerned organs will be “farmed” out to urban areas with high liver transplant wait lists. UNOS argues that candidates on longer wait lists, such as in urban areas, become sicker and therefore have a greater need for the organ than a person who is less sick on a shorter wait list in a rural area.    

As a nurse on the liver transplant unit, I was curious if the reduced region proposal would increase the number of liver transplants done at UCSF and it’s impact on the California liver transplant wait list. Dr John Roberts, chief of transplant at UCSF, stated “the proposed four and eight regions do not dramatically effect California. Transplants may increase somewhat, but patients who can travel to other areas will benefit. California is disadvantaged because the surrounding states do not have dense populations, so that organs have to travel long distances. The proposed plan limits travel time to three hours for shared organs which means the population around California can’t support it. The cost will rise because organs that do come to California will require long travel times.”  (J. Roberts, personal communication, March 25, 2015).     

A public forum is planned to be held in the first half of 2015 by the liver subcommittees to further discuss the issues with decreasing the regions: finance, logistics and transportation, metrics of disparity, and optimization of distribution. (A. Archer-Hayes, personal communication, March 26, 2015). The OPTN/UNOS Liver and Intestinal Organ Transplantation Committee (2014) states the earliest a policy proposal will be circulated to the public is Spring of 2015.

Is It Painful To Die Of Liver Failure?

Liver is the second largest organ that is situated in the right upper quadrant of the abdomen, below the diaphragm and overlying gallbladder, parts of pancreas and stomach. Liver is a vital organ that helps support nearly every other organ. Liver has over 500 functions in the body and the major functions include digestion by the production of bile (helps in fat digestion), metabolism, detoxification, old RBCs destruction, protein synthesis, regulation of hormones, to name a few. The failure of liver to carry out its functions due to destruction/damage of its cells affects nearly all the organs.

Causes and Symptoms of Liver Failure

Liver failure is a life-threatening medical emergency and requires prompt treatment. Although, liver failure is a slow process and progresses gradually over a course of many years known as chronic liver failure; however, it can also happen over a course of very short time (within 24 to 48 hours) known as acute liver failure.

The causes of chronic liver failure includes hepatitis B, hepatitis C, chronic alcoholism, cirrhosis, malnutrition and/or hemochromatosis.

The causes of acute liver failure include paracetamol overdose, hepatitis A, B or C (mostly in children), allergy reaction to certain prescribed or herbal drugs and/or ingestion of poisonous wild mushrooms.

The symptoms of liver failure include nausea, vomiting, appetite loss, diarrhea, fatigue, jaundice, easy bruising and bleeding, painful edema (swelling)/fluid buildup of abdomen (ascites) and lower extremities, varicose veins in the lower esophagus and abdomen, splenomegaly, gallstones, hepatocellular carcinoma, hepatic encephalopathy (mental confusion and disorientation), somnolence and/or coma.

Diagnosis and Treatment

Liver failure is hard to diagnose with only the symptoms as these symptoms overlap other diseases. The definitive diagnosis of liver failure includes physical examination along with liver function tests (LFTs) through a blood sample that determine the proper functioning of the liver. LFTs include ALT (Alanine Aminotransferase), AST (Aspartate Aminotransferase), alkaline phosphatase, bilirubin, albumin and ammonia, which are usually abnormal in liver failure and will show the functional deterioration of the liver.

Other blood tests can also be done to find out the exact cause of liver failure such as hepatitis A, hepatitis B, hepatitis C, prothrombin time (PT) and partial thromboplastin time (PTT). Liver imaging is also done, which include ultrasound, CT scan, radioactive liver and spleen scan, and liver biopsy. All the above tests help in diagnosing the exact cause of liver failure.

The final treatment of liver failure is ultimately liver transplantation. However, the patient is hospitalized and given supportive care depending on the cause of liver failure, such as sometimes paracetamol poisoning can be reversed if prompt treatment is given and also in the case of viral etiology supportive care can help in recovery of liver. If supportive care is unresponsive then liver transplant is the only option.

It is better to prevent these conditions wherever possible such as abstaining from alcohol in chronic alcoholism, getting vaccinations for hepatitis, refraining from drug abuse and eating a healthy diet, to name a few.

Is It Painful To Die Of Liver Failure?

Liver is a vital organ in clearing up metabolites from the blood stream that are toxic to the body. With the loss/deterioration of liver function, these metabolites do not get eliminated from the body and lead to suppression of brain activity. Due to this the cognition and pain perception are reduced, thus leading to reduced sensitivity to pain in liver failure patients. Patients also experience itching due to elevated levels of bilirubin and causes yellowing of the skin and eyes. This is tr

eated with anti-histamines and sedatives. The failing liver is unable to metabolize these drugs too, hence the patient experiences less pain/agitation/itching. With liver failure, there is increased sedation and sleepiness; with the progression of liver failure, there is an increase in drowsiness and finally the patient slips into coma. Thus, dying of liver failure is painless for the patient as well as the relatives of the patient who do not have to see them suffer from pain.