- Center for Liver Disease and Transplantation
- How long will my liver transplant last?
- What can I expect my quality of life to be after liver transplantation?
- Will my liver disease come back after a transplant?
- How much pain is typical after the surgery?
- How large is the scar?
- How long is the recuperation period?
- Will I need to take medications after my liver transplant?
- What side effects can be expected from the medications prescribed after transplant?
- Can I return to work after my transplant?
- Can I drink alcoholic beverages after my transplant?
- Can I have sex after my liver transplant?
- Will I be able to have children after my transplant?
- How can I get in touch with the family of my donor?
- Liver Transplant – The Surgery, Recovery and Quality of Life [Transcript]
- Describe liver transplant surgery.
- Explain the recovery from surgery.
- What kind of scar will be present afterwards?
- What quality of life can a patient expect after a liver transplant?
- How does transplant research affect patient care?
- What is the most rewarding thing about your work?
- What makes the Hopkins program unique?
- When a Transplant Fails
- Fluid Collection
- Side Effect of Medicines
- Donor Kidney Problems
- Non Adherence (aka Non-Compliance)
- Recurrent Disease
- Acute Rejection
- Chronic Rejection
- Reactions to Transplant Failure
- 10 Things Your Doctor Won’t Tell You About Organ Transplants
- Younger Patients More Likely to Live a Decade or Longer After Heart Transplant – 02/27/2012
- Who is a Liver Transplant Candidate?
- Liver Transplant Eligibility: Referral Criteria and Requirements
- Causes of Liver Failure
- Excluding Criteria for Liver Transplant
- Living-Donor Liver Transplant Criteria
- Patient Survival Rates
- Facts and Myths
- Myths About Deceased Donation
Center for Liver Disease and Transplantation
How long will my liver transplant last?
Liver transplant can have excellent outcomes. Recipients have been known to live a normal life over 30 years after the operation.
According to the most recent year computed UNOS/OPTN (2004) national average one-year graft survival at 83%, and patient survival at 87% for patients receiving a deceased donor liver and 92% for those transplanted with an organ from a living donor. Five-year graft and patient survivals are 67% (deceased/2000) 62% (living/2000) and 76% (deceased/2000) 81% (living/2000), respectively. During 2006 at New York Presbyterian, our one-year graft and patient survival rates are 82% and 88%.
It is important to remember that many factors come into play with these statistics. They represent ALL patients transplanted, including the very old and the very young, those who were critically ill and those with less severe liver problems at the time of transplant.
Transplant recipients directly contribute to the success of their transplant. Failure to comply with the immunosuppression medical regimen is the number one cause of organ failure. Close follow-up with your transplant team and primary-care physician can help ensure a good outcome. Careful attention to medication schedules, lifestyle changes, infection-avoidance techniques are all important ways to prolong one’s life after transplantation.
What can I expect my quality of life to be after liver transplantation?
The first three months following transplantation are the most difficult. The body is adjusting to the “new” liver and all the medications needed to maintain its health. By the time of discharge from the hospital patients are able to care for themselves, with some minor restrictions. The transplant team carefully prepares each patient for discharge. Most patients can return to work within 3 to 6 months after a transplant. Playing sports and getting healthy exercise, socializing, and traveling for business and pleasure are all possible. The Center’s expectation is that people who undergo liver transplantation can and do go on to lead “normal” lives.
Will my liver disease come back after a transplant?
Certain liver diseases can reappear in the new liver. One example is hepatitis C. The transplant team can advise you on the incidence of recurrence of specific liver ailments. In cases where there is a risk of recurrence the transplant team will monitor you very closely to help prevent recurrence.
How much pain is typical after the surgery?
There is pain after liver transplant surgery, however it is generally not as severe as with other abdominal surgeries. This is because nerves are severed during the initial abdominal incision causing numbness of the skin around the abdomen. These nerves regenerate over the following six months and sensation returns. More common post-transplant discomfort is back pain associated with the length of time on the operating table. The team prescribes the appropriate pain medicine for each patient.
How large is the scar?
The standard incision used for the liver transplant is called a “chevron incision.” It starts at the right side of the midsection just under the ribs and extends to the left edge of the abdomen. There is also a short incision starting under the sternum (breastbone) which extends to meet the horizontal incision.
How long is the recuperation period?
Most patients are hospitalized for 7 to 10 days after liver transplant. Afterwards, they generally recuperate at home and typically return to work or school after about 3 months.
Will I need to take medications after my liver transplant?
Patients must take many medications after a liver transplant: some to prevent rejection (immunosuppressants), some to fight infection, and others to treat the side effects of the immunosuppressants. Patients returning home after transplantation will be taking approximately 7 to 10 different type of medicines. As the patient heals and recovers health with the help of their new liver, dosages and number of medications are reduced over time. By six months, it is common to be down to 1 or 2 medications. However, patients will be taking immunosuppression medications for the rest of their lives in virtually all cases. It is vital that these medications are taken as prescribed, in the proper amounts and at the specified times. Missing medication doses or discontinuing them on one’s own can lead to rejection and organ failure.
What side effects can be expected from the medications prescribed after transplant?
Many medications have side effects. Side effects typical with post-transplant medications include: elevated blood pressure, changes in mood, hair loss or hair growth, elevated blood sugar, bone and muscle weakness, kidney dysfunction, nausea, vomiting, diarrhea, and headache. Most patients will experience side effects initially, but these often diminish over time as dosages are reduced.
Although side effects can be troublesome, medications should never be discontinued without the knowledge and agreement of the transplant team. When side effects are severe, the array of medicines can often be adjusted to improve their tolerance.
Can I return to work after my transplant?
Yes, patients are encouraged to return to work after transplantation. It customarily takes around 3 months before returning to work is feasible. Certain patients will require light-duty assignments temporarily as they reacclimate to the workplace. Unless there are complications, disability is usually not granted for more than six months after a liver transplant, because the disabling disease has been treated. From the start of the transplant process, patients should consider their long-term employment goals so that they can rejoin the workforce in a timely manner and avoid lapse in health insurance coverage.
Can I drink alcoholic beverages after my transplant?
No. Not only is alcohol toxic to the liver, it can also interfere with the metabolization of certain medications. Be aware that many “non-alcoholic” beers do contain some alcohol.
Can I have sex after my liver transplant?
Yes. Sexual activity can resume early after discharge from the hospital. Because of illness, many patients experience impotence or lack of desire prior to the transplant. This usually reverses itself after transplant, but a patient’s libido tends to return slowly. Immunosuppressed individuals are at greater risk of contracting sexually transmitted diseases, therefore protective barriers such as condoms should be used (unless in a long-term monogamous relationship).
Because of their chronic illness, many people are unable to conceive prior to transplant, but this may not be the case afterwards. Birth-control methods should be discussed with your transplant team and implemented when sexual activity resumes.
Will I be able to have children after my transplant?
Many couples are able to have children after liver transplantation with minimal risk to the mother and baby. Women are advised to wait at least one year following transplantation before trying to conceive. It is important to discuss such plans with the transplant team. They will need to carefully evaluate the health and medication regimen of women seeking to become pregnant. Often, changes in medications are recommended. Women becoming pregnant will need to be closely followed by their obstetrician and the transplant team. It is common to require monthly lab testing for pregnant transplant recipients. Babies born to immunosuppressed mothers tend to have lower birth weights than average, but are generally healthy. Planning the pregnancy and receiving close follow-up care throughout are key.
How can I get in touch with the family of my donor?
Transplant recipients often want to thank the donor’s family for the liver they received. This can only be done anonymously through the organ procurement agency. To communicate with the donor’s family, write a letter without signing it and give it to the team’s social worker at the transplant center. They send it to the organ procurement agency who in turn forwards it to the donor’s family. Often the donor’s family will respond via another anonymous letter. However, not everyone receives a response, but this does not mean your gratitude wasn’t appreciated by the donor’s family.
Liver Transplant – The Surgery, Recovery and Quality of Life [Transcript]
Watch the video.
Dr. Andrew Cameron talks about heart-lung transplants at Johns Hopkins. Watch the video
Featuring Andrew Cameron, MD, Assistant Professor of Surgery, Surgical Director of Liver Transplantation
Describe liver transplant surgery.
The liver transplant procedure generally takes between four and eight hours. The patient will come to the hospital, often the night before, then go down to the operating room, often for about two hours of anesthesia before the surgery even begins. They then undergo a procedure in which their old liver is removed and the new one is sewn into place in the exact same position. After that, they are taken to the intensive care unit, often with the breathing tube still in place.
Explain the recovery from surgery.
After the liver transplant, patients will be in the intensive care unit for two days. After that, they are in the regular part of the hospital for about eight to ten days. They then go home, though they may not feel all the way better for up to three months. After that, they tell me they feel their normal state of good health.
What kind of scar will be present afterwards?
Patients that undergo liver transplantation end up with a large incision that resembles a Mercedes car emblem. It goes beneath the rib cage on both sides and extends upwards. It’s a large incision.
What quality of life can a patient expect after a liver transplant?
Patients are restored to their normal, healthy quality of life after liver transplant – the way they were, before they got sick. Patients can go out to dinner; they can wear normal clothes. Some patients have even played in the Olympics after liver transplant.
How does transplant research affect patient care?
Here at Johns Hopkins in our scientific laboratories, we are studying novel ways to treat Hepatitis C. Hepatitis C is one of our most challenging problems before and after transplant and we are studying new drugs that will help us treat patients after transplant.
We are also studying novel drug therapies which will enable patients to become tolerant of their new organ and thus stop taking their medicines. The medicines, though they are life-saving, have many complications and it’s the holy grail of transplant to be able to stop them at some point after transplant.
What is the most rewarding thing about your work?
The most rewarding part of the experience is seeing how sick the patients are before transplant and then watching them become completely normal after their transplant. I ask them or their family, “What do you like to do?” and they may say, “Go fishing” or “Watch the Ravens game” and I tell them, “You’re going to go fishing again.”
What makes the Hopkins program unique?
The Johns Hopkins liver transplant program is successful because all the team members work together. There’s lots of experts at Johns Hopkins and we take advantage of all of them. There may be a hepatologist, a dietician, a pharmacist – we all work together to give the patient the best possible care.
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When a Transplant Fails
Everyone talks about the success rates of kidney transplants. Rarely do we talk about what happens when transplants fail. People will quote the official statistics that 97% of kidney transplants are working at the end of a month; 93% are working at the end of a year; and 83% are working at the end of 3 years*. Those are some pretty good odds.
In the transplant evaluation process, transplant programs talk about the success rates and risks, including that the kidney may never work or won’t work for long, but everyone thinks they will be one of the successes.
We rarely talk about the 7% of people whose transplant failed within a year or the 17% of people who have lost their transplants within 3 years. It’s hard to find any guides or brochures for patients and families about how to deal with a failed transplant—for the nearly 3,000 people who lose their kidney transplants in the first year or the over 6,000 people who lose their transplants within 3 years. At 10 years, 54% of transplant kidneys are still working. In fact, over 20% of kidney transplants every year are re-transplants.
There are many reasons why a kidney transplant can fail:
This is usually when the blood vessels to the transplanted kidney clot, so the kidney has no blood flow. This seems most likely to happen shortly after the surgery.
If there is fluid collection around the kidney, there can be damage to the kidney from the pressure if it is not treated.
Having an infection in the kidney can cause permanent problems with the kidney, especially if it is not found and treated early.
Side Effect of Medicines
Some medicines can be harmful to kidneys.
Donor Kidney Problems
Transplant surgeons will only offer you a kidney that they believe will work, but sometimes there are problems with the donor kidney that are not expected and the kidney never works well. If the kidney never works well, it is not likely to last long.
Non Adherence (aka Non-Compliance)
Some people stop taking their anti-rejection medicines or miss doses. The anti-rejection medicine prevents your body from recognizing the kidney as a “foreign object.” Without enough of the medicine in your blood, your body “sees” the kidney and begins to attack it. Eventually you will damage enough of your kidney that you have to go back on dialysis. Non-Adherence can also cause problems if a person misses their appointments, lab tests, or other treatments.
Although it is not very common, it is possible for the disease that damaged your original kidneys to come back and damage the transplanted kidney.
The type of acute rejection that happens right after the transplant surgery is pretty rare now, but this can happen at any time.
This is the most common reason that kidney transplants fail. It is the long term damage done by the body’s immune system for a lot of different reasons.
I think it is important to say that transplant patients have NO CONTROL over most of these causes of transplant failure. Transplant patients do HAVE CONTROL over taking their medicines and following treatments as prescribed, calling their transplant care provider when they are not feeling well, and otherwise staying as healthy as possible. Most people take good care of their kidney, but it can fail anyway.
Reactions to Transplant Failure
There are a lot of reactions that people have when their transplanted kidney fails. Since every situation is different, it’s impossible to determine the “usual” response.
When the transplant stops working shortly after the transplant, often the most common responses are shock and disappointment. In my experience, the most common cause of an immediate transplant failure is a clot in the blood vessels to the kidney. The surgeons will see if they can remove the clot and save the kidney, but if it cannot be saved, the kidney will be removed. So, you’ve had two surgeries with the accompanying pain and have no working kidney! Some people say that they feel abandoned by the transplant team when this happens. They are in a kind of grey zone (not a transplant recipient and not back in the community of their dialysis unit). Although signing up for another surgery is the last thing people are thinking about, the transplant center can request for the person to get their wait time back if the transplant kidney has failed within 90 days.
There is another group of people who are relieved when their transplant has failed. In my experience, this happens when there have been many complications with the transplant. This can mean multiple hospitalizations and treatments or symptoms of kidney failure on top of the side effects of the medicines. If you feel better on dialysis then after the transplant, sometimes it is a relief to stop the anti-rejection medicines and return to dialysis.
For a lot of people, it seems that there is a theme of frustration and sadness when they have to go back on dialysis. No matter how long the kidney worked, it is discouraging to be told that you will need to go back on dialysis, and some people consider it devastating news.
Some of the struggles people have when they first learn of kidney disease are also experienced by people who are returning to dialysis after transplant. They wonder what they did wrong and why they have to go through this again. They sometimes consider not returning to dialysis and are angry and sad all the time. Some people aren’t ready to deal with the reality of having to return to dialysis.
As the kidney is failing, many people start the process to get back on the waiting list and begin talking to potential living donors before restarting dialysis. This can help give back a sense of control in a situation where many things are out of your hands. In fact, I think that focusing on the things that will help you move toward a positive future is one of the most helpful ways to deal with the disappointments related to a failed transplant.
*The transplant statistics are the most recent overall numbers from the Scientific Registry of Transplant Recipients at www.srtr.org. The results are different for deceased donors and living donors. You can check the results from a particular transplant program on this site.
Lara is a social worker at the Rush University Transplant Program in Chicago.
10 Things Your Doctor Won’t Tell You About Organ Transplants
Here are 10 facts your doctor might not tell you about organ transplants and donations:
1. Transplanted organs don’t last forever.
While transplanting a healthy organ to replace a diseased or failed organ can prolong life, transplants have limits. A transplanted pancreas keeps working for five years in only 57 percent of patients, meaning nearly half of patients will need a second transplant. A transplanted liver will function for five years or more in 70 percent of recipients, and even longer if the organ came from a living donor. After a heart transplant, the five-year survival rate for the organ is about 76 percent. However, a transplanted lung continues to work for five years or more in only about 52 percent of patients, according to the Scientific Registry of Transplant Recipients.
2. A transplanted organ can carry a hidden disease along with it.
Before transplant, organs are screened for common infections and diseases. This is to exclude any potentially dangerous contamination. Still, one or two people out of every 100 who receive an organ transplant — up to 560 people in the United States each year — contract a hidden infection or disease along with it, data from the U.S. Centers for Disease Control and Prevention shows. Infectious diseases linked to transplants include viral, bacterial, fungal, and even parasitic illnesses. A few examples are West Nile virus and rabies virus, as well as undetected hepatitis B and hepatitis C viruses missed during screening. Rare cases of cancer from transplants have also been reported.
3. The cost of donating an organ as a living donor may be too high for you.
Offering to donate a kidney or part of your liver as a living donor can be life-saving, but the process may come with surprisingly high costs. Donating an organ could mean lost pay from time away from work, travel costs for surgery, medical care after the procedure, and time off to recover. Current estimates are that living kidney donors in the United States bear out-of-pocket, transplant-related costs of $5,000 to $20,000. The number of people willing to be living kidney donors has been going down, and this may be in part because of the high financial burden. Lower-income people are much less likely to donate a kidney, according to a 2013 analysis of more than 50,000 donors.
4. Being a living organ donor could cost you your life insurance.
An unexpected consequence of donating an organ as a living donor is a change in your eligibility for insurance coverage. The Affordable Care Act ensures that you can’t be denied health insurance. But a 2014 survey of people who were living kidney donors found that, in many cases, they were turned down for life insurance coverage. Other donors were surprised to find they were charged higher health and life insurance premiums after donating.
5. Transplant tourism may be risky for your health and unfair for organ donors.
U.S. law prohibits paying people to donate organs, but the practice is not banned globally. People who travel to other countries to have organ transplants may not realize that their donor could be an unwilling participant — a prisoner, refugee, or illiterate person — notes an international declaration on organ trafficking. A study of transplant patients in California found that those who went to China, Iran, and the Philippines for the surgery usually received organs from living but unrelated people in those countries. They also took a risk with their health by having a transplant in another country. Thirty percent of transplant tourists lost the organ due to rejection versus 12 percent in the United States. In addition, 52 percent of transplant tourists in the study returned home with severe infections.
6. A liver transplant won’t cure an infection like hepatitis C.
Each year, 6,000 Americans out of the 17,000 who need one have liver transplants, according to the American Liver Foundation. The leading cause of liver failure in the United States is hepatitis C viral infection. But if you get a liver transplant, the new, healthy liver can become infected with hepatitis C once inside your body. This is because the hep C virus can continue to circulate in your blood throughout your body, including your liver.
7. A kidney transplant may be a real option for you if you have kidney failure.
If your kidneys are failing, your doctor should discuss the option of kidney transplant with you before you start on dialysis, as part of informed consent. This discussion is even required on provider claims for Medicare and Medicaid reimbursement. But one-third of dialysis patients surveyed said they didn’t know about the transplant option, found a Johns Hopkins University study published in August 2014. As far as the patients recalled, that mandated kidney transplant discussion never happened. Because the study showed that people informed about a transplant option are three times as likely to have one, be sure to ask about all your options, including transplant.
8. Women aren’t as likely to be evaluated for kidney transplants, or get living-donor transplants.
Most women on dialysis who need a kidney transplant get offers from family and friends willing to donate a kidney. But fewer women than men go through with it, a 2014 survey of dialysis patients in Philadelphia showed. The reasons are unclear, but only about half as many women as men were ever evaluated by their healthcare providers to get the organ transplant process going. Researchers also found that women felt less willing to go through with a living-donor transplant, compared to a transplant from a deceased donor.
9. You could be too obese to have a transplant.
The American Society of Transplantation advises patients to get their weight down before a transplant, to a BMI of 30 or less. This corresponds to less than 203 pounds for a person who is 5-feet 9-inches tall. When you are obese, you may have more health problems after a transplant than someone who weighs less, a review of studies found. Obese people are more likely to have infections at the wound site of a transplanted kidney, and the new organ fails to function more often as well. People who are obese are also at greater risk of developing heart disease after a transplant compared to people who weigh less.
10. Where you live may determine how long you have to wait.
Your wait time for an organ may be from days to years, and doctors cannot predict the timing for any individual case. It depends on when an organ becomes available and whether it is the right fit for your blood type and body. Wait time can also be affected by where you live, data show. In the United States, people living in the Southeast have the highest rates of kidney failure and the longest waits for kidney transplants, found a 2014 national analysis by Emory University in Atlanta. The study reported that people living in New England have the shortest wait times.
Whether it’s a heart, lung, kidney or liver, many people assume that transplantation is a last resort in treating a failing organ.
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But in the case of kidney disease, transplantation is actually the first line of treatment for patients who are candidates to receive a new kidney.
“A kidney transplant is not a last resort; it’s a first resort,” says nephrologist Emilio Poggio, MD, an expert in kidney transplantation. “For people who meet the requirements for kidney transplantation, it’s the best option for treatment.”
But the scarcity of kidneys for transplantation makes the alternatives — hemodialysis and peritoneal dialysis — much more common.
Dialysis vs. kidney transplant
Dialysis artificially does what healthy kidneys do. It pumps blood out of your body, cleans it and returns it to your body. Treatments are usually for three or four hours, three times a week.
“Transplantation is the way to go, and the sooner the better,” says nephrologist Robert Heyka, MD, Chair of Nephrology in the Department of Hypertension and Nephrology. “But the reality is most people will still need to be on dialysis.”
According to the Centers for Disease Control and Prevention, more than 10 percent of American adults – about 20 million people — have chronic kidney disease. Dr. Poggio says 600,000 are on dialysis and 100,000 are on the waiting list for a kidney transplant. Yet only 16,000 transplants are done each year.
What you need to know
Experts say you should know these four facts:
1. Dialysis has both positives and negatives. Some of Dr. Heyka’s patients put off going on dialysis, but when they try it, they may find themselves pleasantly surprised.
“People often say that they didn’t realize how bad they’d been feeling until they got treatment,” he says. “Within the first few months, their appetite is back, they’re gaining weight and they have more energy.”
But the time commitment of dialysis treatments can limit a person’s independence and quality of life.
2. Benefits of transplant outweigh the side effects. “There’s plenty of data that, despite the negatives of transplantation, the short-term and long-term outcomes are much better than those on dialysis,” says Dr. Poggio. “Their quality of life improves, they live better and longer.”
In fact, a landmark 1999 study compared the health outcomes of patients on dialysis waiting for a transplant to those who had already received a new kidney. The study found the long-term mortality rate of transplant recipients was 48 to 82 percent lower than for those on dialysis.
Of the 16,000 kidney transplants conducted in the U.S. every year, 30 to 40 percent come from living donors. Those transplants have greater success than transplants from cadavers.
3. Not everyone can receive a transplant. Dr. Poggio considers many factors in deciding who is a candidate for a new kidney, including other medical conditions like diabetes and heart failure. But there are ways you can improve your candidacy.
“Stay healthy and active,” he says. “Manage your conditions that might complicate a transplant — like smoking — and remain compliant with your medical therapies.”
4. Choose your care wisely. Living well on dialysis depends on choosing the right location for your care. Social workers should provide support. Good communication among your healthcare providers is a key factor. And a positive atmosphere with social interaction among patients is also important.
“Don’t be afraid to ask, ‘How often will I see my doctor? What are your rates for hospitalization? Will I see a nurse practitioner?’” says Dr. Heyka. “If you are in the right unit, you’ll get lots of support.”
If you have kidney disease and currently on dialysis, don’t hesitate to talk to your doctor about a kidney transplant. Depending upon your individual situation, it could offer many benefits.
Younger Patients More Likely to Live a Decade or Longer After Heart Transplant – 02/27/2012
Heart transplant patients who receive new organs before the age of 55 and get them at hospitals that perform at least nine heart transplants a year are significantly more likely than other people to survive at least 10 years after their operations, new Johns Hopkins research suggests.
Examining data from the more than 22,000 American adults who got new hearts between 1987 and 1999, researchers found that roughly half were still alive a decade after being transplanted and further analysis identified factors that appear to predict at least 10 years of life after the operations.
“There are 2,000 to 2,500 heart transplants a year in the U.S. and many people die waiting,” says Arman Kilic, M.D., a surgical resident at The Johns Hopkins Hospital and leader of the study published in The Annals of Thoracic Surgery. “We have to be very smart about how to allocate scarce organs, and our research suggests we can predict which patients will live longer with a new heart.”
Kilic and his colleagues used information collected by the United Network of Organ Sharing (UNOS) and compared the 9,404 heart transplant recipients who survived for 10 or more years with the 10,373 who did not. Some 3,000 were lost to follow-up.
The researchers found that patients 55 and younger had a 24 percent greater chance of 10-year survival than older patients; those treated at hospitals performing nine or more heart transplants a year had a 31 percent greater chance of 10-year survival than those at lower volume centers; and white patients were 35 percent more likely to survive a decade than minority patients.
Kilic says that nearly half of heart transplant recipients in the study were over 55 and there is debate over how old is too old to undergo the surgery. “After the age of 55, we see the biggest difference in long-term survival,” he says. “The chance of surviving for 10 years drops precipitously.”
Patients at high-volume centers do better not only because their surgeons likely have more experience with heart transplants, but also because the staff and facilities are likely better equipped to manage the complex post-operative care of these patients and promote good outcomes, Kilic says.
The researchers noted that patients who were on ventilators before their transplants were 47 percent more likely to die within 10 years of surgery. People who require breathing machines before surgery are much sicker than those who do not, so it makes sense that those patients would do poorly, Kilic says. In addition, diabetics were one-third more likely to die within 10 years of transplant.
The study results also show the impact on long-term survival of ischemic time, or how long the heart is out of the body as it travels from donor to recipient. For every hour ischemic time was reduced, the researchers found an 11 percent increase in the chance that the recipient would survive for a decade or more.
The age of the donor was also significant. For every decade younger the donor was, the recipient was 10 percent more likely to survive long term, Kilic says.
Under current regulations and policies, UNOS gives available hearts to the sickest patients on its national waiting list, typically those whose doctors predict they will not survive a month without a new organ. Kilic agrees with the policies, but suggests it may be useful to give priority within this sickest group to patients who — using his data — would likely survive the longest.
“These data could be used for both prognosis and allocation purposes,” Kilic says. “They help predict which patients have the best chance to derive the longest and most sustainable benefit from the limited number of hearts that become available each year. It also identifies areas that need further research, such as why racial disparities exist in long-term survival following heart transplant.”
More than five million Americans suffer from heart failure and, while the majority of these patients can be managed with lifestyle modifications and medication, for those who suffer from severe, end-stage heart failure, transplantation remains the gold standard treatment.
Advances in the medical and surgical treatment of heart failure in recent decades include the use of new drugs, cardiac resynchronization therapy-defibrillators, and ventricular assist devices; however, heart transplantation continues to be the treatment of choice for refractory cases.1–3 The enthusiasm shown when the first transplantation was performed by Christiaan Barnard in 1967 rapidly waned because of the common postoperative complications and the high early mortality associated with rejection and infection. The introduction of cyclosporin and other advances in the 1980s radically improved the prognosis of these patients and led to prolonged survival and widespread use of the technique.4 International and Spanish registries show that the median survival of transplanted patients is currently somewhat higher at 10 years, and about 14 years for those who survive the first year, which is the year with the highest incidence of complications.5,6
In the oldest transplantation programs, the group of transplanted patients with follow-up exceeding 20 years is now becoming numerous.7 However, no large series to date have described any transplantation recipients with more than 20 years of follow-up. There is only a small cohort,8 and therefore the clinical characteristics associated with prolonged survival are not well understood. Functional status, quality of life, comorbidities, and the incidence and causes of death in this period are also not well known, even though these are important aspects in patients who have received immunosuppressant medication for 20 years. This patient subgroup was the objective of our study.
A retrospective review was carried out using the databases, medical histories, and anatomic pathology reports related to patients who received a heart transplant at our hospital from September 1984 to May 2012. For parameters related to the follow-up of these patients, the patient’s current status was confirmed by phone.
The patients in our study received transplants between September 1984 and May 1992. For this study, survival was defined as time to death or retransplantation due to graft failure. Our study excluded any patients who received a simultaneous heart and lung transplant as well as patients with heart retransplantation, shown in other studies to have a significantly different morbidity and mortality from that of de novo heart transplantation. All patients were classified into 3 groups according to clinical progress: patients who died within 1 year (group A), usually due to causes related to surgery and acute rejection or infectious complications, patients who survived the first year but did not survive 20 years (group B), and patients who survived more than 20 years with no need for retransplantation (group C). The last group was the subject of our study, and its characteristics are described in detail. A comparison with group B was established to identify the characteristics associated with long-term survival. The comparison group for patients from group A did not include patients who died in the early post-transplantation stage because the factors associated with early mortality have been investigated in numerous studies and are not of interest in identifying the factors associated with very long survival in surgical survivors.3,4
Immunosuppressive therapy in all patients started as triple therapy with cyclosporin, azathioprine, and prednisone. Most patients received induction therapy with muromonab (OKT3), 2 weeks initially and 1 week after 1987. Routine protocols for the withdrawal of steroids or other immunosuppressants were not used at our hospital, although a low threshold for the withdrawal of drugs causing significant adverse effects was maintained after the first year.
We analyzed 62 variables related to the recipients, donors, procedures, and events during follow-up, which are the same variables used in the Spanish registry.6
In the descriptive analysis of the variables, parameters with a normal distribution were described as the mean standard deviation and those with a non-normal distribution were described as the median (range). For the comparisons of quantitative variables, the Student t test was used in variables with normal distribution, and nonparametric tests if otherwise. All qualitative variables were compared by the χ2 test, and all survival rates were described using Kaplan-Meier curves.
In order to identify the characteristics associated with survival>20 years, a bivariate analysis that included characteristics of the recipient, donor, and surgery was performed. All variables associated with survival >20 years with a significance level of P<.1 were included in multivariate logistic regression models to identify predictive factors of very long survival. Statistical significance was defined as P<.05. All data were analyzed using SPSS 15.0 (Chicago, Illinois, United States).
From the first heart transplantation in 1984 until May 2012 at our hospital, 761 heart transplantations have been carried out in 736 patients, including 25 retransplantations and 30 heart-lung transplants. A total of 706 patients were included in the de novo heart transplantation survival curve at our hospital. The overall survival curve of our series is shown in Figure 1. The actuarial survival rates were 75% at 1 year, 64% at 5 years, 53% at 10 years, 40% at 15 years, and 26% at 20 years.
Actuarial survival curve of heart transplant patients from 1984.
Of 183 transplants performed before May 1992, 39 patients survived and are the main focus of our study (Fig. 2). The general characteristics are shown in Table 1 and are compared to those of the control group, which included 90 patients who survived the first year but died before they completed 20 years of follow-up.
Flow chart for the study population.
(0.17MB). Table 1.
Characteristics of Patients Surviving >20 or <20 Years
BMI, body mass index; TBI, traumatic brain injury.
Unless otherwise indicated, values are expressed as no. (%) or mean±standard deviation.
In the comparison of the two groups, the following variables showed a statistically significant association with survival >20 years: lower age and lower body mass index of the recipient, dilated cardiomyopathy as pretransplantation diagnosis, history of extracorporeal circulation, and lower time of ischemia during surgery. The following variables showed some trends but did not achieve statistical significance: weight disproportion>20% (if the donor was younger than the recipient) and mechanical ventilation. Other variables that were included, such as older donor age, history of diabetes mellitus, risk of cytomegalovirus (negative recipient and positive donor), and number of rejections in the first year post-transplantation were not associated with lower survival in our series.
Variables with P<.1 were included in the logistic regression model to identify those independently associated with prolonged survival (Table 2). Specifically, the model identified 2 variables: recipient age<45 years (4-fold probability of survival in excess of 20 years post-transplantation compared to the other age bracket) and idiopathic dilated cardiomyopathy as the reason for transplantation (3-fold probability of prolonged survival compared to other etiologies).
|Age>45 years||66 (51)||3.9 (1.6-9.7)||.002|
|Idiopathic cardiomyopathy||47 (36)||3.3 (1.4-7.8)||.012|
95%CI, 95% confidence interval; OR, odds ratio.
During a mean follow-up of 30 months, 6 of 39 recipients with very long survival died, which represents a survival of 84% and an average annual mortality of 6%. Only 1 patient was lost to follow-up. The actuarial survival curve at 20 years post-transplantation is shown in Figure 2. Of the deaths, 3 were due to infectious complications (pneumonia, septic shock due to peritonitis secondary to colon perforation, and sepsis of unknown origin), 2 to neoplasms (lung and tongue cancer), and 1 to heart failure associated with allograft vasculopathy.
In the case of patient autonomy to perform daily activities, most (82%) of the 33 patients who survived at the time of the study were completely autonomous, whereas 6% were partially dependent and 12% were completely dependent. The functional limitations were attributed to osteomuscular diseases in half the cases, whereas the others were due to vascular and neurologic causes.
The incidence of common complications in transplanted patients was recorded during follow-up. In terms of infectious complications, 8 patients (20%) had hospitalizations for bacterial infections during the follow-up period, mainly respiratory, urinary, and soft tissues, and another 10 (26%) experienced major viral infections (4 due to cytomegalovirus, 1 herpetic encephalitis caused by herpes simplex virus 2, 3 cases of chicken pox zoster, 1 hepatitis B infection, and 2 hepatitis C infections, of which 1 had cirrhosis of the liver as a complication that required liver transplantation, which was successful).
In all, 38% of the survivors have had some kind of malignancy, mainly benign skin tumors (60%), followed by solid-organ neoplasms (tongue, lung, and liver), and only 1 presented a blood cancer.
After 20 years of transplantation, most (84%) patients presented with chronic kidney disease, with a mean estimated glomerular filtration rate of 59 mL/min. A total of 36% had stage 2 renal insufficiency, 48% had stage 3, and 15% had stage 4. At the time of writing, none had required definitive renal replacement therapy. Cardiovascular risk factors were very prevalent: 94% had hypertension, 87% had hyperlipidemia, and 15% had diabetes mellitus.
Patients underwent coronary angiography every 3 years according to our local protocol for the detection of allograft vasculopathy; this was often accompanied by intravascular ultrasound. A total of 35 (89%) patients presented some degree of allograft vasculopathy, although most (72%) had no significant coronary lesions. In the case of patients with an intravascular ultrasound study, 27% were classified as Stanford class II, 11% as Stanford class III, and 58% as Stanford class IV. To date, 3 of these recipients have required percutaneous revascularization (which failed in 1 case). Two of them had systolic graft dysfunction, with 40% left ventricular ejection fraction.
Nine patients presented significant arrhythmias. One of them required ablation for ventricular tachycardia, and 8 (20%) required pacemaker implantation for symptomatic bradyarrhythmia at some time during the course of their clinical progress.
Figure 3 shows the prevalence of the main complications in the long-term survival group.
Complications during follow-up 20 years after heart transplantation.
AV, allograft vasculopathy.
In terms of immunosuppression, 1 or more components of the initial triple therapy had been withdrawn in most patients, such that 76% were being treated with 2 drugs at the time of the study. The most common combination was cyclosporin and corticosteroid (13 patients ), followed by cyclosporin and azathioprine (5 patients ), cyclosporin and mycophenolate mofetil (3 patients ), cyclosporin plus everolimus (2 patients ), and everolimus plus prednisone (3 patients ). One patient received a combination of tacrolimus and mycophenolate and another, everolimus with mycophenolate.
Cyclosporin was usually switched due to renal dysfunction, azathioprine because of blood count abnormalities (leukocytopenia), and corticosteroids because of recurrent infections or metabolic disorders such as hard-to-control diabetes mellitus or osteoporosis. Patients with rare infections or malignancies with considerable repercussions eventually were switched to monotherapy.
Advances implemented in recent decades in the management and follow-up of patients with heart transplantation have allowed prolonged survival rates to be obtained.4–6 At present, 20-year survival rates in the national and international registries are >20%, similar to the 26% reported in our series.5,6 As in the case of international registries, the initial mortality observed in our curve is high for the current standards due to the relative weight of the procedures carried out at the start of the series in the 1980s and early 1990s, but decreases when only recent surgical patients are taken into account. This is influenced not only by the learning curve, but also by advances in immunosuppression, prophylaxis of infectious diseases, and monitoring and management of the various types of rejection.
From the quantitative point of view, mortality after the first year becomes more stable and the mortality rate remains steady. Annual mortality was 2.5% in our series, 2.6% in the Spanish Heart Transplantation Registry, and 3.5% in the Registry of the International Society for Heart and Lung Transplantation (ISHLT).5,6 In comparison, the mortality of the general population between 55 and 60 years of age in Spain is approximately 0.5%.7 In comparison to these figures, recipients who have reached 20 years post-transplantation in our series showed a mortality rate of 6% per year of follow-up; however, this figure should be viewed with caution, due to the low numbers of patients and of deaths during follow-up.
Although several articles on the long-term follow-up of transplant patients have been published in recent years, most of these studies had a follow-up period of the first 15 years8–13 and only a few lasted as long as 20 years.14,15 In various studies, particularly in those published more recently, the factors associated with longer survival were consistent with those identified in our series. These included low recipient age,11,13 lower body mass index at the time of transplantation,11,12 nonischemic diagnosis prior to transplantation,11–13 and lower graft ischemia time.11,12
In contrast, other factors identified in these series, such as low donor age,13 serologic group at risk of cytomegalovirus infection,14 smoking,14 and history of diabetes mellitus,14 which have been found to be predictors, were not associated with survival>20 years in our series. Several reasons that might explain this discrepancy in our series include donor age, which was much lower in all cases, in keeping with the practice at that time. Nonetheless, the low percentage of patients with acknowledged smoking, diabetes mellitus, and serologic group at risk of cytomegalovirus infection in our series prevented an appropriate assessment of their influence in our study.
An analysis of the late causes of death after heart transplantation show that allograft vasculopathy and neoplasms predominate after the first year. In patients who survive the first decade, when allograft vasculopathy is more prevalent, cancer appears to be the main cause of death. Large series with 15 years of follow-up report malignancies as the leading cause of death (35.8%), followed by allograft vasculopathy (24.7%) and infections caused by microorganisms other than cytomegalovirus (8.6%). In our patients, there were few deaths. However, the same causes of death, with slightly different prevalences, were observed after 20 years of the transplantation; predominance of infections was observed, followed by neoplasms, and allograft vasculopathy in 1 case.14
The progress of these patients is characterized by the usual complications associated with transplantation and chronic immunosuppression, such as recurrent bacterial and viral infections, chronic kidney disease, hypertension, diabetes mellitus, hyperlipidemia, and neoplasms. In our series, most patients (84%) presented some degree of renal dysfunction after 20 years of transplantation, a figure that appears to be consistent with the rate of kidney disease (65%) reported by the ISHLT registry at 10 years of follow-up; it is very likely that prolonging follow-up in these patients to 20 years would show figures highly consistent with ours. In the ISHLT registry, 4% of patients were receiving renal replacement therapy at 10 years post-transplantation. None of our 39 patients are in the dialysis program, although 15% presented creatinine clearance<30mL/min, which means that, over time, some might require replacement therapy. Similar to international experience, in our hospital’s cohort of transplant patients before 1992 who died within 20 years, 4% required hemodialysis before they died.
In terms of the prevalence of cardiovascular risk factors, we have no data beyond 5 years in the ISHLT registry for comparison. However, the figures from this registry seem consistent with ours, as most patients already present hypertension and hyperlipidemia at 5 years, similar to the patients in our series.
Among osteomuscular complications, osteoporosis is the most common and is associated with significant functional limitation in many cases. This frequency is probably due to prolonged exposure to corticosteroids, and was the cause of corticosteroid discontinuation in many cases.
Despite all these complications, the quality of life of patients in our series appears to very acceptable, as 82% of subjects were independent for activities of daily living. In international registries, this parameter has been similarly assessed, but data are only shown for the first 5 years of follow-up, with figures for complete autonomy of around 90%. This is the first time the parameter has been assessed after more than 2 decades of immunosuppression.
In series that evaluated the early progress of transplantation, acute rejection has been described as a major cause of mortality. Over the years, however, it becomes less common and even though most patients at 20 years receive significantly lower immunosuppression, in our series there were virtually no events that could be related to acute cellular rejection. We cannot rule out that this privileged subgroup of recipients may have some degree of immunologic tolerance of their respective grafts. Therefore, in our case we preferred to decrease the immunosuppressive burden considerably.
This study has several limitations. First, it is a retrospective study conducted at a single center, and therefore we cannot rule out the presence of local factors that could have affected the outcomes and/or follow-up. The relatively low number of patients in the survivor group after 20 years post-transplantation, although obviously justifiable, means that the conclusions of the statistical analysis should be viewed with caution.
Second, the quality of life data were assessed and collected by the cardiologist who performed the follow-up at the outpatient clinic, rather than by a standardized tool such as a validated questionnaire.
One fourth of all heart-transplant patients from the start of our experience achieved survival >20 years with the same graft. Predictors of this favorable outcome included recipient age<45 years and idiopathic dilated cardiomyopathy as a pretransplantation diagnosis. The complications and mortality that affect these patients are those known to be present in the late phase following heart transplantation, although with a slightly higher incidence. However, functional status is favorable in most of these recipients, which confirms the net benefit of transplantation in this subgroup.
New studies to identify recipient and donor characteristics that predict very long-term survival in large series may contribute to better allocation of the few donors currently available.
CONFLICTS OF INTEREST
Who is a Liver Transplant Candidate?
Liver Transplant Eligibility: Referral Criteria and Requirements
When you have end stage liver disease, and no longer see results with medical therapy, you may be eligible for a liver transplant at UPMC.
At the UPMC Liver Transplant Program, we consider each person referred to our program – even if other centers have said that you are not a candidate.
We’re committed to providing liver transplant services to anyone who will benefit, including those who are high-risk.
Causes of Liver Failure
A candidate for liver transplant may suffer from any of these liver conditions:
- Hepatitis C
- Hepatitis B
- Alcoholic liver disease
- Non-alcoholic steato-hepatitis or fatty liver disease
- Primary liver cancers
- Primary biliary cirrhosis
- Autoimmune hepatitis
- Primary sclerosing cholangitis
- Acute liver disease from toxins including Acetaminophen/Tylenol
- Alpha 1 Antityrpsin deficiency
- A failed prior liver transplant
- Polycystic disease
- Veno-occlusive disease
- Wilson’s disease
Excluding Criteria for Liver Transplant
The UPMC Liver Transplant team makes every attempt to ensure that people chosen for transplant evaluation are the most suitable for the surgery.
There are many requirements for liver transplant surgery. Before you can begin the liver transplant evaluation process, you must be free of:
- Cancer outside the liver
- Alcohol for at least 6 months
- Substance abuse
- Active infections
- Disabling psychiatric conditions
- Documented medical non-compliance
- Lack of adequate social support
- Lack of adequate insurance
- Other diseases or conditions
You must also be willing and able to make lifestyle changes to support the gift of life that a liver transplant provides.
Living-Donor Liver Transplant Criteria
If you’re at an earlier stage of liver failure, you may want to look into living-donor liver transplant. This surgery is a partial liver transplant, so you must have it before your liver disease is severe enough to require a full organ transplant.
The UPMC liver transplant team will work with you to help find a suitable living donor and help you both through the process.
Patient Survival Rates
The Scientific Registry of Transplant Recipients (SRTR) is a national database of transplantation statistics. Founded in 1987, the registry exists to support the ongoing evaluation of the scientific and clinical status of solid organ transplantation, including kidney, heart, liver, lung, intestine, and pancreas.
Data in the registry are collected by the Organ Procurement and Transplantation Network (OPTN) from hospitals and organ procurement organizations (OPOs) across the country. The SRTR contains current and past information about the full continuum of transplant activity, from organ donation and waiting list candidates to transplant recipients and survival statistics. This information is used to help develop evidence-based policy, to support analysis of transplant programs and OPOs, and to encourage research on issues of importance to the transplant community.
- Kidney “
- Pancreas “
- Kidney-Pancreas “
- Heart “
- Lung “
- Heart-Lung “
- Liver “
- Intestine “
Facts and Myths
Mason at Transplant Leadership Council’s (TLC) event.
Myths About Deceased Donation
There are certain things that can keep me from being an organ donor such as age, illness or physical defects.
Each person’s medical condition is evaluated at the time of their death to determine what organs and tissues are viable for donation. People living with chronic diseases or those who have a history of cancer or other serious diseases are still encouraged to join the donor registry.
If doctors know that I am registered to be an organ or tissue donor, they won’t work as hard to save my life.
The first priority of a medical professional is to save lives when sick or injured people come to the hospital. Organ and tissue donation isn’t even considered or discussed until after death is declared.
Typically, doctors and nurses involved in a person’s care before death are not involved in the recovery or transplantation of donated corneas, organs or tissues.
If you are rich or a celebrity, you can move up the waiting list more quickly.
Severity of illness, time spent waiting, blood type and match potential are the factors that determine your place on the waiting list. A patient’s income, race or social status are never taken into account in the allocation process. .
After donating an organ or tissue, a closed casket funeral is the only option.
Organ procurement organizations treat each donor with the utmost respect and dignity, allowing a donor’s body to be viewed in an open casket funeral.
My religion doesn’t support organ and tissue donation.
Most major religions support organ and tissue donation. Typically, religions view organ and tissue donation as acts of charity and goodwill. Donor Alliance urges you to discuss organ and tissue donation with your spiritual advisor if you have concerns on this issue.
My family will be charged for donating my organs.
Costs associated with recovering and processing organs and tissues for transplant are never passed on to the donor family. The family may be expected to pay for medical expenses incurred before death is declared and for expenses involving funeral arrangements.