Donor Evaluation Process

• Risk of death - about three to five in 1,000 liver donations.
• Potential organ failure and the need for a future organ transplant for the donor.
• Risk of wound infection and other minor complications.
• Heart complications, stroke, blood clot formation in the legs or lungs.
• Bile leakage - which happens in about five to 15 percent of the patients. Most bile leaks resolve without the need for surgery. Occasionally, T-tubes or stents may need to be placed to help in the healing process. In rare cases, surgery may be needed to correct the bile leak.
• Risk of a bile duct being damaged. There could also be damage to surrounding organs and tissues, such as the spleen or bowel. In such cases, follow-up surgery may be needed to repair the injury.
• Incisional hernia - a hernia is the protrusion of an organ through the wall that normally contains it.
• This could be due to thinning or stretching of scar tissue that forms after surgery. This weakened scar tissue then creates a weakness in the abdominal wall, allowing part of the abdominal contents to protrude.
• Allergic reactions to anaesthesia.
• Hyperbilirubinemia or jaundice – it is a condition in which there is too much bilirubin in the blood, causing the yellowing of the eyes and skin.
• Small bowel obstruction, pancreatitis, bleeding duodenal ulcer and renal failure.
• Portal vein thrombosis.
• Pulmonary embolism – a condition that occurs when an artery in your lung becomes blocked by blood clots that may have travelled to the lungs from another part of your body.
• Intra-abdominal bleeding.
• Pleural effusion – abnormal accumulation of fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs.
• Gastric perforation, gastric outlet obstruction.
• Surgical scars, pain, fatigue, abdominal or bowel symptoms such as bloating and nausea.

You and your donor will be assessed by our transplant team to confirm your suitability to undergo a liver transplant surgery. For foreigners, your blood and other imaging tests will be repeated in Singapore to confirm your disease condition.

Your donor will also undergo stringent medical evaluation. He/she will be asked to complete a questionnaire and have his/her blood tests done to assess suitability. This is also to rule out chronic conditions such as Hepatitis B and C. Further stringent blood, radiological and psychosocial examinations will be carried out.

Your donor will also be assessed by independent physicians, cardiac, infectious disease physicians, psychiatrist, dentist and nephrologist for suitability. The transplant coordinator will inquire about his/her family, social and financial history to gather the necessary information for the ethics committee. At times, personal questions may be asked.

The purpose of the extensive donor evaluation process is to minimise the risk to both the donor and the recipient. It ascertains that the donor is in good mental and physical health, and that the portion of the liver to be retrieved is suitable for the recipient.

During this period, the donor may be put on iron medication and injected with Epogen, a red blood cell stimulant.

For foreigners, verification of passports may be required. This can be done at the recipient and donor's local embassies in Singapore. Assessment by an independent psychiatrist and physician will be carried out. The donor will be reviewed by a team of independent doctors to confirm the donor's medical suitability to donate his/her liver as well as to make a legal declaration before the Commissioner of Oath to fulfill the legal requirements for the transplantation.

The Transplant Ethics Committee (TEC) team comprises:

• A medical practitioner employed or connected with the hospital
• A medical practitioner not employed or otherwise connected with the hospital (from the National Team)
• A layperson (from the National Team)

The TEC members are independent, and they are governed under the Human Organ Transplant Act (HOTA) in Singapore.

The transplant surgery will be performed a week after the date of approval by the Transplant Ethics Committee. Depending on your condition, the surgery date can be brought forward with written consent from the relevant parties.

You will also be given financial counselling by our Business Office. A deposit will be collected one week prior to your admission to the hospital.

If you are on dialysis, you will continue with it while waiting for the transplantation.

From the time of arrival in Singapore with your donor, the entire evaluation (including the ethics committee approval process) will take about four to six weeks.

On the day before the transplant surgery, you and your donor will be admitted and will be required to undergo a series of blood tests, chest X-ray, electrocardiogram (ECG), and a final assessment by the surgeons and the anaesthetists. This is to ensure both of you are medically fit to undergo the surgery and are clear of infection.

Both of you will receive an enema to clear your bowels and prevent constipation after surgery. The chest and abdomen area will be shaved clean to prevent infection. No food, drink or water will be allowed from midnight before the operation.

It is possible for a planned transplant to be cancelled. This is especially so for liver cancer patients. In some situations, after the surgeon opens up the abdominal cavity, the surroundings of the organs and the liver ducts will be assessed before proceeding with the surgery

You and your donor will be operated on simultaneously and attended by two teams of surgeons, anaesthetists, nursing assistants and technicians in two different operating rooms. Both of you will be taken to a pre-operative holding area, where your medications will be administered. In the operating room, general anaesthesia is administered and you will be intubated. A breathing tube, connected to a ventilator, is inserted down your throat into your lungs to help you to breath during the operation. The transplant physician will explain the drugs used prior to your surgery. You will also be connected to other machines (that will monitor your blood pressure and your heart), drips and blood transfusion tubes.

The human liver comprises eight segments, each with its individual blood supply and bile drainage. Individual segments or a combination of segments (the right or left lobe) are retrieved from the live donor and transplanted into the recipient. The remaining liver in the donor will regenerate and replace its size and function in about four to six weeks. Similarly, the transplanted liver segments in the recipient will regenerate rapidly.

Recipient

You will be wheeled into the operating room where an intra-operative ultrasound is carried out to ensure that the tumour(s) have not spread outside of the liver organ. In some instances where cancer has spread or tumour involving the portal vein, the transplant may be aborted. The surgical team will proceed with the transplantation after assessing your condition at the operating table. The team will remove the diseased liver, leaving portions of the major blood vessels clamped and in place.

The donor's liver will then be placed into the abdominal cavity. Implantation involves anastomosis (connections) of the inferior vena cava, portal vein and hepatic artery. Once anastomosis is completed, an intra-operative ultrasound is carried out by the radiologist to ensure blood flow in your new liver. The surgeon then closes the wound using dissolvable sutures or staples covered by a dressing, which will remain in place for a few days following the surgery. To help with the bile drainage, a T-tube will also be inserted in the bile duct during surgery.

You will be attached to a cardiac monitor, intravenous lines, tubes and drains. Immunosuppressant drugs will be given immediately after the transplant operation. This is to ensure that your body will not reject the liver once it has been transplanted. The whole transplant surgery normally lasts between eight to 12 hours.

Donor

Surgery for the donor begins with an incision on top of the breast bone and extending down to the right and left of the bottom of the rib cage. The incision is like an inverted "Y". The surgeon will also remove the gallbladder since it is located under the part of the liver. The liver is then split into two according to the lobes. The surgeon will remove about 40 to 60 percent of the donor's liver, depending if the recipient is an adult or child. If the recipient is an adult, the right lobe is removed; if the recipient is a child, a portion of the left lobe is taken.

The hepatic artery supplies the liver with blood that is rich in oxygen. The portal vein carries nutrient-rich blood from the intestines to the liver. The veins, bile ducts and arteries of the donated lobe are clamped and cut. The portion of liver meant for the recipient is removed, flushed with preservative solutions, and cooled on ice. The time between removing the portion of the donor's liver and transplanting it into the recipient is known as ischaemic time. The liver graft is quickly transplanted to the recipient, keeping the time the liver graft is without circulating blood to a minimum. This also allows a higher chance that the liver graft will function well after transplantation. Drain tubes are inserted into the surgical area to drain fluid and bile during the surgery and are left in place for a few days after the surgery. The incision is then closed with either self-absorbing sutures or staples which will be removed during follow-up visits. The entire donor operation takes six to eight hours to complete, from the first cut to the close of the incision.

After a liver transplantation, there are three types of graft rejection that may occur. They include:

• Hyperacute rejection - which is caused by preformed anti-donor antibodies. It is characterised by the binding of these antibodies to antigens on vascular endothelial cells.
• Acute rejection - which is the most common and the primary target of immunosuppressive agents. Acute rejection is usually seen within days or weeks after the transplant.
• Chronic rejection - which is the presence of any sign or symptom of rejection after one year. The cause of chronic rejection is still unknown but an acute rejection is a strong predictor of chronic rejections.

Liver rejection may happen any time after the transplant. Laboratory findings of a liver rejection include abnormal SGPT, SGOT, SGGT and liver function values such as prothrombin time, ammonia level, bilirubin level, albumin concentration, and blood glucose.

In a paediatric living donor liver transplant, about 40 percent of the left lateral portion of the liver of an adult donor is used. Such a procedure is effective and safe as it reduces the number of children who die while awaiting for cadaveric liver transplant. Children who undergo liver transplantation with living donor liver transplant graft have better survival rates than with deceased donor organ transplant.

After the surgery, you and your donor will be transferred to the Liver ICU after the anaesthesia wears off.

Recipient

A transplant therapist and our nursing team will help in your recovery. You will expect:

• Some pain and discomfort, which will be relieved by medications.
• A tube nasogastric will be inserted through your nose. This tube will run down your throat and into the stomach, keeping your stomach empty and helping to prevent nausea and vomiting.
• A tube may be inserted into your throat to help you get enough oxygen. It will be connected to a breathing machine called a ventilator. You should try to relax and let the machine breathe for you. You will not be able to talk with this tube. You will only need it for a few days until you are able to breathe independently. Your throat may feel sore or itchy for a few days.
• You will be asked to cough periodically to keep your lungs clear. With the help of a therapist, you will undergo a breathing exercise to help your lungs to breathe on its own.
• You will have an intravenous line in your arm or neck under the collarbone, which will be used to give fluids and medications for the first few days after the surgery.
• For several days after surgery, you will have a catheter in your bladder to drain urine. You may feel uncomfortable, and may have the urge to urinate constantly, but this is only temporary.
• Several drains will be placed in or near the incision during the surgery. These drains will be removed five to ten days after the surgery.
• On day three after your transplant, you will undergo rehabilitation for breathing to slowly regain your physical activity.

The length of your hospital stay will depend on your recovery progress. You are encouraged to talk to our transplant team at any time if you feel uneasy or uncomfortable.

On average, you will stay in the ICU for about five to seven days. Once your breathing tube is removed, you will be transferred to the Liver Ward for recuperation and monitoring. Our team will continue to assess and review your condition every day to determine plans for ongoing care and check how well your new liver is functioning.

You will continue to receive fluids, medications and nutrition intravenously, but will be eventually changed to a normal diet. Blood samples will be sent to the laboratory every day. X-rays and scans are ordered by the team when necessary. You will be asked to cough regularly and do breathing exercises in order to expand your lungs and prevent pneumonia.

During the recovery period, you will feel better on some days than on others. Your body is adjusting to the medications and the new liver. Different patients have different recovery periods, with complications playing a major role in the recuperation rate. The degree of weakness you experience will depend on your physical condition prior to surgery.

Our physiotherapist will help you work on your muscles to prevent formation of blood clots in your legs. Start with walking short distances to help regain strength and mobility. An exercise programme will be planned out for you to continue after your discharge. Learning to care for yourself after your discharge from the hospital is very important. To prepare you and your family/caregiver, our nurses will guide you to read and record your blood tests, and prepare a transplant flow sheet in a post-transplant file for you.

You will also be taught to care for your T-tube and the incision area, and provided with medication advice before discharging from the hospital.

Donor

Once your condition is stabilised, you will be transferred out of the ICU to the Liver Ward. You will continue with pain medications and fluid via intravenous drip for a short period before beginning to eat and drink. You will stay in the hospital for about seven days after surgery, with one day in the ICU. You can expect to experience pain and discomfort from four to six weeks after surgery.

A therapist will work with you to:

• Exercise, flex and relax your leg muscles to help prevent the formation of blood clots
• Provide training in taking deep breaths and coughing periodically to prevent pneumonia Before you discharge from the hospital, the transplant coordinator will schedule your medical follow-ups (every three months for one year after surgery) with the transplant physician for liver ultrasound and blood tests.

How will my body cope with the new liver?

The immune system is your body's natural defence mechanism. It is programmed to recognise and destroy anything unfamiliar. This includes the cells of a transplanted liver as well as the bacteria and organisms that cause infection.

Following a liver transplant, specific drugs are needed to prevent the immune system from rejecting the new liver. These are called immunosuppressants and you will have to take them every day for the rest of your life.

A combination of immunosuppressant drugs will be prescribed. These drugs will increase your risk of infection. During the first few months after transplantation, the need for immunosuppressant is at its highest. This is the time when you are at most risk of infection. The risk decreases when the doses are reduced after several months but it will always remain sensible to avoid close contact with people who have infections. You should also avoid eating any form of raw food. You will be monitored closely for signs of infection and treated if necessary.

Regular blood samples will determine the level of these drugs and the daily dosage will be changed if required by the transplant physician. If the levels are too low, the risk of rejection is greater and the doses will be increased. If the levels are too high, you may experience more side effects and the doses will be reduced. You must not change the dosage of your immunosuppressant drugs without consulting your doctor. Failure to take these medicines as prescribed can result in rejection of your new liver.

What are the possible side effects caused by immunosuppressants?

Like most medicines, immunosuppressants have some side effects.

Your immunosuppressant drugs, which are necessary to prevent rejection of your transplanted liver, will make it more difficult for your body to fight infections. Symptoms of cough or fever, which may have gone away on their own before your transplant, can be a warning sign of an infection. If you have any signs or symptoms of infection, you should call your transplant coordinator immediately. We will recommend for you to be seen immediately by a doctor to determine if you have an infection, and if so, how you should be treated.

Your transplant coordinator or the nurses will provide you with a medication timetable. Keep to it strictly and do not skip any medications without the approval of your doctor. The immunosuppressant drugs help to prevent the rejection of your new liver by your body; while other medications are meant to support your immune system which may otherwise be weakened by the immunosuppressant drugs. It is important to always check with our Transplant Centre if you are prescribed with any new drugs as there may be interactions with the immunosuppressant drugs.

What other medicines do I have to take?

For the first three to six months after transplantation, you will need to take the following medicines:

• Antibiotics - to reduce the risk of bacterial infection
• Anti-fungal liquid - to reduce the risk of fungal infection in your mouth
• Anti-acid agents - to reduce the risk of stomach ulcers and heartburn
• Any other medicines prescribed by your transplant physician, depending on your symptoms

Some prescribed medications can cause acne, dry skin, skin growth, brittle hair and unwanted hair growth. Some of these side effects can be avoided if you take precautions, whilst others may require you to see a doctor.

Do discuss your current medications with the pharmacist if you need to buy over-the-counter medicines for minor ailments (for example, paracetamol for a headache). Your General Practitioner may wish to contact your liver transplant physician before prescribing you with any new medicines.

How do I know if I am having a liver rejection?

Rejection is your body's way of recognising your donated liver as foreign and attacking it. Rejection can usually be reversed if it is diagnosed and treated early. You have to diligently take precautions and learn to watch out for signs of rejection that may require immediate medical attention.

• Elevated liver levels of enzymes - total bilirubin, SGPT (ALT), SGOT (AST), SGGT
• Fatigue
• Fever
• Abdominal pain or tenderness
• Dark or light coloured urine
• Yellow eyes and/or skin (Jaundice)
• Ascites (fluid in the abdomen)
• Itch

Increasing the chances of early detection of liver rejection:

• Have your blood and other laboratory tests as recommended by the transplant team
• Take your medications as prescribed
• Report signs of rejection immediately

Elevated laboratory results can indicate a possible rejection but only a liver biopsy can determine if you are having a rejection. Other factors can cause your liver enzymes to be elevated. For this reason, treatment of rejection should only be managed by your transplant physician.

Important facts about liver rejection:

• Elevated liver levels of enzymes - total bilirubin, SGPT (ALT), SGOT (AST), SGGT
• Having rejection does not always mean you will lose your liver
• You may feel perfectly well while having rejection
• Rejection may be acute (occurring suddenly), or chronic (occurring slowly over time)
• Rejection will get worse if it is not treated
• Rejection can occur any time

When do I need to have follow-ups and why?

Your transplant coordinator will provide you with a schedule of medical follow-ups, with laboratory tests and scans:

• Ultrasound - to make sure that all your main blood vessels leading to the liver are functioning normally and there is no collection of bile or blood;
• Percutaneous TranshepaticCholangiogram (PTC) - a dye is injected into the T-tube, which then highlights the bile ducts. It shows if there is a leak, blockage or other potential problems;
• Liver biopsy - to check for rejection of the new liver or hepatitis;
• Computed Tomography (CT) scan - it shows the liver from different angles; to detect infections and fluid collection;
• Endoscopic Retrograde Cholangiopancreatogram (ERCP) - a dye is injected through an endoscope, which is passed through the mouth to the stomach and intestine to the liver. It shows the biliary tree (the various ducts in and around the liver) as well as the ducts from the pancreas.

The purpose of the follow-ups is to track your progress and detect potential complications as early as possible. At every visit to our Transplant Centre, you will have to bring your post transplant file and medication timetable. Keep a journal and list any questions you and/or your family may have and bring it along during your follow-up visits.

As your natural immune system is weaker with the immunosuppressive medications, the following precautions will help to reduce the risk of infection:

• Maintain good personal hygiene by washing hands and taking daily showers.
• Drink only bottled or boiled water. Eat freshly cooked foods.
• Do not have visitors who are feeling unwell, or who have an infection.
• Avoid construction sites and other places with heavy air pollution.
• Do not do gardening without wearing gloves.
• Avoid handling animal waste and close contact with animals.
• Avoid vaccines that consist of live viruses (such as Sabin oral polio, measles, mumps, German measles, yellow fever, or smallpox) as these can cause infections. If you or any family members intend to receive any vaccinations, you should notify the transplant team or your local physician.
• Take good care of your teeth and visit the dentist twice a year for cleaning and check-up.

Recommendations for Recipient Care

After you have been discharged home, you will be scheduled with medical follow-ups and will be seen at our Liver Transplant Centre as an outpatient. The purpose of regular follow-up is to assess your liver function and the level of your immunosuppressant drugs.

During your follow-up, the Liver Transplant team will:

• Discuss your current health
• Check your weight and blood pressure
• Examine your wound
• Do a physical examination
• Take blood tests to check your liver function, kidney function and blood count
• Take a blood test to check your blood Tacrolimus/Cyclosporine level
• Check for any signs of side effects from your medications
• Check for any signs of rejection or infection

Do not take your morning dose of Tacrolimus/Cyclosporine before going for your follow-up at the Transplant Centre. Bring it along with you so that you can take it after your consultation with the doctor.

Outpatient Follow-ups

Schedule	Frequency of Visits
6 weeks to 3 months	Two times a week
3 to 6 months	2 to 3 times a month
6 months to 1 year	Once every two months
After 1 year	Once every 3 to 6 months

Exercise

It takes about six to eight weeks for the wound to heal, but the muscles and nerves may take longer to get back to normal. During this time, you should avoid strenuous physical activity but gentle exercise is necessary to regain your strength and muscle tone. In the longer term, you will be able to participate in any physical activity or sport that you enjoy.

Diet

Some patients have other medical conditions and may require special dietary needs. Post-transplant nutritional requirements differ from pre-transplant needs. A nutritionist/dietitian can help you develop an eating plan that would suit your needs. The goal is to achieve adequate or near balance intake to allow the surgical wound to heal and to keep up with your energy needs.

Alcohol

It is important to avoid alcohol after your transplant as it can cause liver disease. If alcohol has been the cause of your liver disease, total lifelong abstinence is necessary to safeguard your future health.

Sex

There is no medical reason that you cannot have sex when you feel well enough. However, you may find that it takes some time for your sex drive to return and this is quite normal.

Pregnancy/Contraception

Female patients of childbearing age must use appropriate birth control methods as pregnancy should be avoided for at least a year after liver transplant.

Driving

You may start to drive about six weeks after discharge from hospital unless you are still experiencing discomfort caused by the safety belt.

Returning to Work

You are likely to remain off from work for at least three months but this depends on your recovery and the nature of your job.

Travel

You may travel if you feel well enough but you will have to discuss your travel plan with your transplant physician for information on health risks, vaccinations and medications etc.

General Health Screening

It is essential to follow advice on cancer screening (for example, skin protection, cervical screening, breast or testicular self-examination).

Outpatient Follow-ups

You will need to attend your follow-ups at the Transplant Centre but the visits will become fewer as you get better. The purpose of the visit is to monitor the function of your new liver and detect any problems as soon as possible. The visits are also an opportunity for you to ask any questions that you or your family may have.

Readmission to Hospital

If you feel unwell, you may need to be readmitted for further investigations and treatment. After your outpatient follow-up, if your blood results are abnormal, we may call you to adjust the dosage of your medications or to arrange for you to be admitted to the hospital for further investigations and treatment.

Who Do I Contact If I Have Questions?

Should you have any questions or concerns about any aspects of your liver transplantation, do contact your transplant coordinator or doctors.

For more information or an appointment, please call Gleneagles Patient Assistance Centre at (65) 6575 7575 or email us atgpac@parkway.sg