Living donor liver transplantation is a not a simple operation but needs pre-operative careful evaluations for healthy live donors and sick recipients, delicate donor and recipient operations and complicated post-operative cares. The live donor operation is to harvest 60-70 % of liver (right liver) for an adult recipient or 15-40% liver (left liver) for a child recipient. The donor should be blood relatives or relatives in law.
Indications to living donor liver transplantation:
(1) End stage liver cirrhosis: In adult, the causes include chronic hepatitis, alcoholism, Wilson’s disease and autoimmune disease etc. In children, the main cause is biliary atresia.
(2) Metabolic liver disease: when the condition cannot be well controlled by special formula and drugs.
(3) Liver cancers: hepatocellular carcinoma (meet UCSF criteria) and hepatoblastoma resistant to chemotherapy and unrespectable.
(4) Other liver associated diseases which can be treated by replacement of a new liver.
The liver transplantation is to replace patient’s native liver with a healthy whole or partial liver (living donor is partial liver). Under regular immune-suppressive medications, the implanted liver will function well and perform the functions of normal liver. This operation is a life-saving procedure.
Donor and recipient operations are performed simultaneously in two operation rooms. There are two operative and anesthetic teams. The donor’s operation includes laparoscopic dissection of ligamentous attachment of donated part liver, midline incision to dissect portal hilum and dissection of liver parenchyma. The graft is taken out according to the recipient’s operation, which means at the time of diseased liver already removed. The graft is cold flushed and then taken to recipient’s operation room. The recipient’s operation includes a Benz incision, total hepatectomy and then implantation of the donor graft. The usual time for donor and recipient operations is 8 hours and 12 hours respectively.
- Minor complications: bile leakage: 1-2%, post-operative bleeding needs reoperation: 0.5%, right pleural effusion needs aspiration of pleural fluid: 1-2%, post-operative intestinal ileus: 1-2%. Dyspepsia: 5-10%
- Major complications: biliary stricture: 0.5% thrombosis of inflow or outflow of residual liver: 0.5%.
- Surgical mortality: 0.1-0.3% for donation to adult patients, 0.1% for donation to children.
- Minor complications: bile leakage: 5%, post-operative bleeding needs reoperation: 5-10%, pleural effusion needs aspiration of pleural fluid: 10%, post-operative intestinal ileus: 5-10%, biliary anastomosis stricture: 20-30%.
- Major complications: thrombosis or stenosis of inflow or outflow of graft liver: 3-5%, sepsis: 3-5%, others: 5%.
- Surgical mortality: 3% non-acute liver failure patients, 10-20% for acute liver failure patients.
Living Kidney Transplantation
Kidney Transplantation Living Donor
The requirements of being a living kidney donor
1.The donor has to be at least 20 years old, healthy, and related by blood within 5 generations to the recipient, or to be the spouse of the recipient. According to the law, the donor needs to be in the marriage with the recipient for at least 2 years, having children with the recipient, or married to the recipient a year before the recipient is diagnosed having the need of kidney transplant.
2.Both kidneys function normally.
3.The donor does not have the following diseases: diabetes, high blood pressure and tuberculosis. The donor does not have history of malignant tumors or infectious diseases which are forbidden by law such as AIDS.
4.The donor donates his/her kidney of his/her own free will and pure motivations.
5.The blood type requirements of the donors
The same or compatible blood types of the donor and the recipient is the first priority. For instance, a blood type O donor can donate his/her kidney to the recipient of any blood types; a blood type O recipient can only receive the kidney from a blood type o donor; a blood type AB recipient can receive the kidney from the donor of any blood types. Under some special circumstances, it is allowed to have kidney transplant surgery with incompatible blood types. However, the survival rate of the transplanted kidney is lower, and the chance of rejection is higher.
Blood type-incompatible kidney transplantation
Treatments before ABO-incompatible kidney transplantation
1.Reducing the remaining blood type antibody: plasmapheresis and giving IVIG
2.Reducing the active of B cell: giving rituximab 375 mg/m2 7-10 days before the surgery
3.Reducing the active of T cell: giving tacrolimus, mycophenolate mofetil; with/without corticosteroid, basiliximab, alemtuzumab, antithymocyte globlin. And proper antibiotics to prevent infection
After these medicine treatments, according to the researches, ABO-incompatible kidney transplantation can lead to the similar results as ABO-compatible cases, including survival of the patient, the function of the graft, the change of rejection and infection. However, for those whose blood type antibody titer is higher than 1:512, the allograft rejection rate is still higher than ABO-compatible transplant. It indicates that they have higher incidence of chronic rejection. Therefore, the patient whose blood type antibody is higher needs to take the medicine and follow up more carefully to have the best result.
It takes 4-8 weeks to complete the evaluations step by step. If the donor is in good medical, social, psychological and metal health, the surgery will be arranged after our medical ethics committee approves the application.
( 1 )the function of the kidneys and the liver, blood counting, anti-HAV, anti-HBV, anti-HCV, blood type, syphilis, AIDS, hemostasis and tissue matching
( 2 ) Image check: chest X ray, abdominal ultrasound, breast ultrasound, mammography (female)
(3)Other: electrocardiography, urinalysis and urine cytology
( 1 )Blood test: Virus antibodies, tumor indexes, thyroid function and tuberculosis
( 2 )Image check: kidney CT and comprehensive renal function test (ERPF)
( 1 )Mental status examination
( 2 )Evaluation of social workers
( 3 )Blood lymphocyte cross matching test
Review of medical ethics committee
According to the Human Organ Transplant Regulations of Taiwan, the comprehensive information both of the donor and the recipient need to be reviewed by our medical ethics committee. The surgery will be arranged with its approval.
Surgery approaches and procedures
A living kidney donation is performed under general anesthesia. Therefore, during the surgery, you will not feel anything. In order to detecting the central venous and blood pressure, a central venous catheter will be inserted in the right part of your neck, and an artery catheter will be inserted in your upper limb. The use of a foley is also necessary.
There are 2 approaches of the surgery: open surgery and laparoscopic surgery:
1.Open surgery is performed in the abdomen or the back abdomen. First step is separating the kidney artery, kidney vain and proximal ureter, at the same time, separating the kidney from the surrounding tissues. Afterwards, the doctor will remove the whole kidney and preserve it in organ preservation solution. After the kidney is completely removed and the bleeding is stopped, the doctor will stitch the incision.
2.A laparoscopic surgery offers smaller incisions, equally successful outcomes, less pain, shorter recovery time and less days staying in hospital. First, the doctor will infuse carbon dioxide in the abdomen or the back abdomen, and then make 3 small incisions. Through these incisions, the doctor can insert the instruments and a camera in the donor’s body to perform the surgery. In the end, the kidney will be removed from the incision of the lower quadrant of the abdomen.
Nursing care plans
The risks and complications of living donors
1.The remaining kidney of a healthy donor, who received a full evaluation before the surgery, performs its normal function. According to long term follow-up studies, the life expectancy or the incidence of chronic kidney diseases (uremia) of the donors is the same with people who have not had the surgeries.
2.There are 2 approaches of the surgery: open surgery and laparoscopic surgery, taking 4-6 hours each. The donor needs to stay in the hospital for 5-7 days. The wounds will be different depending on the type of the surgery. According to the statistics, the death rate of living kidney transplant is lower than 1/1,000.
3.The incidence of complications is 8%-16%, including infection (2.4%), pneumothorax (1.5%), major bleeding and in need of bleeding control (<1%), pulmonary embolism (1%) and ureter stricture and urinary incontinence (2-10%). In the long-term change of 10 years after the surgery, the glomerulus filtration of the remaining kidney shows no significant difference, but around 30% of the donor may minor proteinuria or high blood pressure
After discharged from hospital, you need to visit your doctor to follow up your condition once a week in the beginning. After stabilizing, you may visit the doctor once every 2 weeks or a month. During the visits, you will need to take blood and urine tests to measure the kidney function.
Kidney Transplantation Recipients
Kidney transplantation criteria
1.The uremia patients who are under dialysis treatments and qualified to be catastrophic illness patients (exception: living-donor transplant)
2.Excepting the kidney diseases that the patients have carried, the patients do not have other severe illness, such as cancer and active infection.
3.The patients want to have kidney transplants at their own free wills, and can fully understand the rate of successes, dangers and complications.
4.The bladders and urinary tracts of the patients perform their normal functions. If not, the patients need to have corresponding treatments.
The lives of most end stage liver failure (uremia) patients count on dialysis. They are suitable for liver transplant unless the patient has other contraindications, such as malignant tumor, whole body infection, severe cardiovascular diseases, unstable coagulation, chronic respiratory failure, cardiac failure, mental illness, severe congenital malformations of urinary system and aids.
The assessments before kidney transplant is very important. The main purpose is to reduce the complications after the surgery. We will arrange you to have the following examinations:
Blood type, functions of liver and kidney, anti-HAV, anti-HBV, anti-HCV, the virus quantity of hepatitis BC, antibody of syphilis, AIDS, tumor index, blood counting, hemostasis, thyroid function, tuberculosis, tissue matching and autoimmune system
Chest x ray and abdominal ultrasound
Breast ultrasound and mammography for female patients
3.Others: Electrocardiography and urinalysis and urine cytology
If patients are also elders or having diabetes, they need to take further cardiac examinations, such as cardiac ultrasound or systolic function. Elder women need to take breast and cervix examinations. Elder men need to take prostate examinations and bladder function examinations if having difficulty of urination. Oral health is also important. If you have cavities, you need to take treatment immediately. Otherwise, they may become the cause of transplant infection.
The surgery will be performed in the lower quadrant of the abdomen. The doctor will make an incision that looks like new moon. Then, the doctor will place the kidney at the pelvic fossa, and match the arteries and veins of the kidney and proximal ureter. The kidney may be from a decease donor, the spouse of the recipient, or the donor who is related by blood to the recipient. Whether removing the original kidney or the unsuccessful transplanted kidney is depending on different situations.
Nursing care plans
1.If there are not any rejections or complications, the patient may be discharged 10~14 days after the surgery.
2.Long-term medications is necessary after the surgery (including anti-rejection medicines and other medicines in need). Each medicine has certain side effects, and the patients’ underlying medical conditions (e.g. viral hepatitis) may be worsened and should be carefully monitored.
3.Blood transfusion–kidney failure often happens with anemia. Therefore, in order to maintain cardiopulmonary function, sometimes it is necessary to have blood transfusion during the surgery. The side effect of blood transfusion is showed in the blood transfusion consent form. If you disagree with blood transfusion, please inform the medical crew in advance.
4.Acute rejection (10-20%)–most of the acute rejections can be treated by the stronger anti-rejection medicines. Only in some rare cases (<5%), the acute rejections cause the permanent transplanted kidney function failure.
5.Sometimes the transplanted kidney will not fully function after the surgery. The incidence depends on the resources of the transplanted kidney; <10% for living-donor transplants and 30% for deceased-donor transplants. Sometimes the transplanted kidney may not function at all.
6.Hematuria might happen at different levels to the patients after the surgery. In general, this symptom will be self-improved.
7.The incidence of complications after the surgery is 5%-10%. With severe complications, the patient may need to have another surgery.
Infection or slowing healing of wounds-the wounds may have some complications due to anti-rejection medicines.
Wound bleeding Urinary leakage or incontinence Hernia of the incision
Embolism of kidney artery or kidney vain-needing to have another surgery, or blood vessel aggressive treatment
Infection-such as urinary tract infection, infection of respiratory tract and biliary tract, other virus infections and severe comprehensive infections Malignant tumors or lymphoma happening, or the treated cancer relapsing The transplanted kidney not functioning。
Cardiac or vascular diseases
Diabetes happening Death (<1%)
8.The kidney diseases that the donor had carried may occur to the transplanted kidney.
9.The side effects of certain anti-rejection medicines:
( 1 ) Cyclosporine (neural) or tacrolimus (prograf): tremor, high blood pressure, kidney function declining, constipation, diarrhea, headache, abdominal pain, sleep disorder, hypophosphatemia, hypomagnesaemia, gum thickening, hair growing, baldness, hyperkalemia and diabetes
( 2 ) Prednisolon: appetite increasing, body weight gaining, appearance changing (moon face and buffalo hump), body fluid detaining, high blood pressure, sugar tolerance decreasing, bone density decreasing (more risky having fractures), digestive disorder, cataract, glaucoma, skin thinner, easy having bruises
( 3 ) Mycophenolate mofetil (Cellcept )or Mycophenolic Acid (Myfortic): leukocyte and platelets decreasing at different levels, nausea, vomiting, diarrhea, fever throat pain, tiredness, muscle pain, tuberculosis, hepatotoxic, pancreatitis
( 4 ) Sirolimus (rapamune) and everolimus (certican): leukocyte and platelets decreasing at different levels, canker sores, diarrhea, edema or pain in lower limbs, rash and hepatotoxic
( 5 ) Basiliximab (Simulect) and antibody interleukin: the side effects are not common. Sometimes, the liver index elevates at a slight level. The symptoms will be improved after reducing the medicine dose.
After discharged from hospital, you need to visit your doctor to follow up your condition once a week in the beginning. After stabilizing, you may visit the doctor once every 2 weeks or a month. During the visits, you will need to take blood tests to measure the liver function and the drug level of the anti-rejection medication. You may also need image study (ultrasound) every 3~6 months.
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