Liver Failure and Liver Transplantation
Liver failure has also been discussed under 'Cirrhosis'. When end-stage liver failure occurs in a patient who otherwise has a reasonable life expectancy, and when other treatment options have failed, often the only remaining treatment for these patients is liver transplantation. In fact, liver transplantation is usually done well before the patient reaches an advanced stage of liver failure, since the outcome is likely to be better.
Some manifestations of end-stage liver disease (these alone are not necessarily reasons for liver transplantation) include: yellowing of skin, eyes etc. (progressive jaundice); fluid in the abdomen (severe ascites) and fluid retention; brain dysfunction due to liver failure (encephalopathy); itch (intractable pruritus); bleeding from oesophageal varices (enlarged, swollen veins at lower end of oesophagus); bleeding due to coagulation disorder; infection in the ascitic fluid (spontaneous bacterial peritonitis); and severe malnutrition.
Treatment of liver failure is largely supportive, with maintenance of a diet that is adequate in essential nutrients, avoiding excessive protein intake that may precipitate hepatic encephalopathy. Treatment of ascites, early treatment of infections, and management of gastrointestinal bleeding is also important. The underlying cause of liver failure should be treated where this is possible and patients with liver failure should avoid medications that have the potential to cause liver damage, which may be poorly tolerated in patients with compromised liver function.
In general, there are three groups of patients who may benefit from liver transplantation:
1. those with advanced chronic liver disease
2. patients with severe acute (fulminant) liver failure, and
3. patients with inherited metabolic liver diseases.
Typical indications for liver transplantation are primary biliary cirrhosis, sclerosing cholangitis, biliary atresia, autoimmune chronic hepatitis, advanced haemochromatosis, alcoholic liver disease (provided the patient has ceased alcohol for 12 months), chronic hepatitis C and B infection with cirrhosis.
Patients with primary liver cancer are sometimes also suitable for liver transplantation.
Liver transplantation has had a dramatic impact on the treatment of a number of previously fatal liver diseases, and is now an established therapy in selected patients.
Typical indications to refer a patient for transplantation include the following (not all these need be present):
-Presence of irreversible liver disease and a life expectancy of less than 1 year, with no effective alternatives to transplantation
-Chronic liver disease that has progressed to the point of significant interference with the patient's quality of life or ability to work
-Progression of liver disease with complications of liver failure that will predictably result in a survival rate less than that of transplantation (typically 85% one-year patient survival and 70% five-year survival)
Patients who may benefit from liver transplantation should be referred as early as possible, because the waiting time for a liver transplant may be one to three years. Also, it is important for the patient to have time to adjust to the idea of liver transplantation, to allow time for a thorough medical and psychological assessment and for all other therapies to be explored.
Liver transplantation is not usually carried out for: HIV infection; cancer outside the liver; cancer of the bile duct (cholangiocarcinoma); severe infection; severe heart or lung disease; active alcoholism or substance abuse.