Liver Transplant

Doctors use liver transplant to treat children with severe liver disease. Transplant provides excellent outcomes for liver failure and chronic liver diseases such as biliary atresia and fulminant hepatic failure. The procedure is typically very successful and offers hope to children with severe conditions of the liver. Sometimes, a child may be placed on the liver transplant list if they have an inherited metabolic condition such as Wilson's disease, alpha-1 antitrypsin deficiency or a urea cycle defect.

The transplant surgeons with IU Health Transplant at Riley Children's Health carefully consider if a liver transplant will improve your child's quality of life before placing him or her on the liver transplant list. Your child’s doctor will perform an extensive medical evaluation to ensure liver transplant is the best treatment option. This evaluation includes:

Blood tests. The doctor will conduct blood tests to assess liver function, rule out other causes of liver disease and find out if your child has a virus that may complicate a liver transplant. Some of the blood tests that may be performed during a transplant evaluation include:

Albumin blood test. The amount of albumin protein in the blood tells how well the liver makes protein.
Bilirubin panel. Elevated levels of bilirubin in the blood show that the liver is not working well or that bile flow from the liver is blocked.
Coagulation tests. A blood-clotting study measures the liver’s ability to make the proteins that help the blood to clot. It can also indicate a vitamin K deficiency, which can be caused by liver disease.
Liver enzyme test. Elevated levels of liver enzymes in the blood indicate injury to liver cells and can also reflect problems with the bile ducts.
Autoimmune liver disease blood tests. The doctor can perform numerous blood tests to check for specific antibodies associated with a variety of autoimmune liver diseases.
Metabolic liver disease blood tests. Various blood tests can measure the levels of proteins, fatty acids and minerals in the blood to check for specific metabolic malfunctions.
Viral hepatitis blood tests. The physician can check for the presence of different viruses, antibodies and infections related to hepatitis A, hepatitis B and hepatitis C.

Medical history and physical exam. Your child’s doctor will obtain a full medical history and perform a physical exam to learn everything about your child's overall health.
Ultrasound. An abdominal ultrasound may be performed to evaluate the liver and connecting blood vessels.
X-ray. An X-ray may also be performed to evaluate the liver and connecting blood vessels. The size and position of the lungs are also noted to help ensure the donated liver is properly sized.
Echocardiogram. An echocardiogram (a test that uses sound waves to produce images of the heart) may be performed to evaluate the heart’s function and strength prior to transplant surgery.

If the medical evaluation shows liver transplant to be the best treatment option, your child will be placed on the liver transplant list. This list contains the name, weight and blood type for all patients who need a transplant in a particular region of the country. Every patient is listed by his or her size and pediatric end-stage liver disease (PELD) score. Size is important because the new liver must match your child's size. The PELD score is based on levels of bilirubin and albumin in the blood, your child’s age and other factors of liver function. A higher PELD score suggests worse liver function and gives a patient a higher priority on the list.

When a potential donor becomes available, the local and national organizations for organ sharing are informed. A computer then prints up a list of patients who are the most sick (using PELD scores) and matches the blood type and size of the donor. The new liver must fit into the body in the same way as the diseased liver so that blood vessels can be more easily connected. The person on the top of the list—if that person remains a good candidate—is called in for the transplant.

Waiting for a donated organ to become available can be stressful. While your child is waiting for a donated liver, your family will meet with the liver transplant team to learn about every aspect of the transplant process. The team will:

Explain the surgery and recovery in detail
Educate your family about your child's nutrition requirements before and after a liver transplant
Assist you in accessing additional services such as financial assistance and home care
Coordinate your child's recovery

When a liver that is a match for your child becomes available, you will be notified to come to the hospital right away. Donated livers work best if transplanted within 12 hours.

Our liver transplant team includes pediatric specialists in transplant, surgery, gastroenterology, hepatology, radiology, pathology and social work. If needed, oncologists and metabolism doctors are also available. Your child's transplant team also will include a transplant coordinator and a dietitian.

What to Expect

You can expect the following on the day of your child’s liver transplant operation:

If your child is receiving tube or parenteral feedings, follow the doctor’s instructions.
When you arrive at the hospital, your child’s surgeon will explain the transplant procedure to you and answer any remaining questions.
You will be asked to read and sign a consent form for your child’s surgery. Be sure to review this document carefully and ask any questions you may have about the form.
Your child will change into a hospital gown in a private room.
After your child has changed, the surgery team will prepare him or her for surgery. A sedative may be given to help your child relax.
Your child will have an IV line inserted into his or her arm or hand. Additional catheters may be placed in your child’s neck and wrist to monitor heart and blood pressure.
Just before surgery, an anesthesiologist will administer surgical anesthesia. You may stay with your child until right before he or she is taken into the operating room.
A tube will be inserted through the mouth and into your child’s lungs to help him or her breath with the help of a ventilator during surgery.
A catheter is inserted into the bladder to monitor urine output.
The anesthesiologist will constantly monitor your child’s heart rate, blood pressure, breathing and blood oxygen level during the surgery.
The surgical team will sanitize the incision site with an antiseptic solution.
An incision is made in the right upper portion of the abdomen, and the entire diseased liver is removed. This part of the operation can take several hours.
Once the new liver is placed into the abdomen, new connections to blood vessels and bile ducts are made. Connections must also be made between the bile ducts and gastrointestinal tract.
Most transplanted livers immediately begin to maintain metabolism, create proteins and produce and drain bile.
After all vascular and bile duct connections are made, tubes may be inserted to drain fluid from the surgical site.
The incision is stitched closed, and the wound is covered with a sterile dressing.

You can expect the following immediately after surgery:

After surgery, your child will be moved to a recovery room in the pediatric intensive care unit (PICU).
Your child’s vital signs will be closely monitored.
Pain medicine will be given to keep your child comfortable.
Immunosuppression (anti-rejection) medicines are given in large doses at the time of surgery to prevent rejection of the transplanted liver. These medicines include:
- Calcineurin inhibitors, such as tacrolimus and cyclosporine, which stop the action of the protein calcineurin which activates T cells in the immune system
- Intravenous corticosteroids, such as methylprednisolone, which prevent inflammation and graft-versus-host disease
- IV antibodies to initially suppress the immune system (“induction”)
Your child will likely remain on a ventilator for one to two days.
Your child will stay in the PICU for a few days or longer depending on how sick he or she is after the transplant.
Blood will be drawn frequently to check on liver function, and sometimes ultrasounds will be done to check the blood vessels.
Your child will remain in the hospital for two weeks or more.
The transplant team will evaluate your child’s condition every day to make sure the new liver is functioning correctly. Your child will be monitored for signs of complications such as transplant rejection, infection, bleeding, high or low blood pressure and problems with kidney function.
Typically, after a week your child can begin eating normally.
Your child will be encouraged to walk around his or her room if he or she is able—sometimes as soon as a few days after surgery.
A nurse may perform coughing and deep breathing exercises with your child to prevent fluid buildup in the lungs.
Your child's care team will provide follow-up care instructions prior to discharge, including medicine instructions and proper exercise and nutrition routines. The team will also provide information on how to recognize the symptoms of transplant rejection. It is important that you follow these instructions and contact the doctor if there are any signs of transplant rejection.

Returning Home

Below are some additional guidelines for when you return home:

Encourage your child to walk; the activity can help restore strength and maintain lung function.
Your child will likely take anti-rejection and immunosuppressive medicines for life.
Eating a healthy diet will give your child needed calories for recovery and health.
Frequent follow-up visits are required to monitor the function of the new liver and check for any complications.
Over time, the frequency of follow-up visits will decrease.

Key Points to Remember

Liver transplant is performed in serious cases of liver conditions. It offers excellent outcomes for liver failure and chronic liver diseases.
An extensive medical evaluation of your child is performed by the transplant team with IU Health Transplant at Riley Children's Health to ensure that liver transplant is the best treatment option.
Patients on the liver transplant list are ranked by their pediatric end-stage liver disease (PELD) score. A higher PELD score indicates worse liver function.
After transplant surgery, your child will remain in the hospital for two weeks or more.
The liver transplant procedure is very successful, and children enjoy excellent quality of life after their transplants.

Locations

In addition to our primary hospital location at the Academic Health Center in Indianapolis, IN, we have convenient locations to better serve our communities throughout the state.