1. Liver Transplantation: When is it Recommended?
2. What is Hepatitis C and chance for transplant?
3. Are people with liver cancer considered for transplantation?
4. Are people with alcohol-related liver disease considered for transplantation ?
5. At what stage of liver disease is transplantation considered ?
6. What risks are involved ?

1. Liver Transplantation: When is it Recommended?

A liver transplant is the only treatment available for most forms of "end stage liver disease" (ESLD). The decision to treat liver disease with transplant is one that should be made by persons expert in liver diseases and liver transplantation. A transplant is not reversible once it is done, therefore it is crucial that only patients that will benefit from transplant be transplanted.
The liver does thousands of things to maintain normal life. It is also very able to carry on when it is diseased and therefore most people with liver disease do not require a transplant. However, once the liver has reached the point of "end stage" the progression from normal health can be rapid in some cases. No specific criteria for who should and should not be transplanted have been agreed upon. Instead, the decision must be made by an experienced team at a liver transplant center. No single piece of data can be interpreted in the absence of the overall picture of a person's health.

General criteria for assessing the severity of liver disease are:

• Jaundice (caused by an elevated bilirubin )
• Fluid retention (called ascites or edema)
• Fatigue
• Blood clotting studies (Prothrombin time)
• Indications of portal hypertension
• Muscular wasting
• Bleeding from the esophagus or stomach

These criteria are weighed together with the clinical history of the disease (how long has each symptom been present, are the symptoms getting progressively worse, is it certain that the symptoms are due to the liver disease), the overall health of the patient, and the cause of the liver disease in order to determine if transplant should be considered.

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2. What is Hepatitis C and chance for transplant?

What is Hepatitis C?
Hepatitis C is a liver disease caused by the hepatitis C virus (HCV) which was discovered in 1989. The virus is composed of RNA (ribonucleic acid) surrounded by an envelope of carbohydrate and protein. Prior to 1989 many patients were diagnosed with "non-A, non-B hepatitis" since they had hepatitis that could not be characterized. We now know that ninety percent of patients with "non-A non-B" hepatitis actually had hepatitis C.

How is the diagnosis of Hepatitis C made?
The diagnosis is most commonly made after finding abnormal liver function by detecting an antibody to a portion of HCV in the blood. This indicates that the person was exposed to the virus and that their immune system made an antibody. The test can show false positive reactions and therefore confirmation is necessary by finding evidence that the Hepatitis C virus is actually in the blood using the polymerase chain reaction (PCR), an extremely sensitive test for viral RNA.

How did I get Hepatitis C?
Most people with hepatitis C contracted it either through a blood transfusion that was contaminated with hepatitis C, or by sharing needles with intravenous drug users that were infected with hepatitis C. Prior to 1990 blood could not be screened for HCV but surrogate tests had been used for the previous several years. These reduced the percentage of HCV contaminated and therefore infectious units of blood from about 7% to 3-4%. Thanks to HCV testing with modern sensitive methods, the risk of acquiring hepatitis C from blood transfusion is less than 1%. The other means of acquiring hepatitis C include health care and laboratory workers that may get stuck with an infected needle or instrument, and people that had tattoos that were performed with poorly sterilized equipment. Infected mothers can pass the virus to the fetus in utero but this occurs less than 1% of the time. It may occur more readily if the mother is also infected with the human immunodeficiency virus (HIV) that causes AIDS.

I never shot drugs or had a blood transfusion. How did I get hepatitis C?
Cases of hepatitis C with no evidence of exposure through blood transfusions, needle sticks or needle sharing are called "sporadic". How these individuals became infected is unknown.

Can I give hepatitis C to others?
The blood from an individual that has hepatitis C is infectious. Therefore, people with hepatitis C should not donate blood or plasma. It is not known how likely one is to contract hepatitis C from sexual contact with an infected individual. Some studies have shown no risk of passing hepatitis C on to a sexual partner, others have shown only a low risk. The United States Centers for Disease Control and Prevention (CDC) do not recommend a change in sexual practices for those engaged in a long-term relationship with one sexual partner.

Does everyone with hepatitis C get liver failure?
No, but current studies indicate that most (80%) people infected with hepatitis C will develop a chronic state of infection. About 30% those with chronic infection will go on to develop cirrhosis of the liver. The disease appears to progress slowly, symptoms often do not appear for ten or twenty years.

What are the symptoms of hepatitis C?
Soon after contracting the infection many people have a flu-like illness with fatigue, fever, muscular aches and pain, nausea and vomiting. About 10% of patients become jaundiced (their skin turns yellow). Generally these symptoms resolve and the patient has no symptoms of liver disease for many years.

What are the symptoms of chronic infection and cirrhosis?
Generally there are no symptoms of chronic infection, although gradually progressive fatigue and lack of energy may occur over several years. The symptoms of cirrhosis include progressive fatigue, jaundice (yellow skin), icterus (yellow eyes), dark urine (the color of cola), abdominal swelling, muscle wasting, itching, disorientation and confusion, loss of appetite, and easy bruisability.

When does a liver transplant need to be done?
This is a very complex issue and must be answered on a case by case basis. Anyone with hepatitis C should be followed by a physician regularly. If signs of progressive disease appear, the person needs to be referred to a gastroenterologist (specialist in digestive diseases and liver diseases). Since hepatitis C is known to progress very slowly, it is not necessary to have a liver transplant until the disease has reached "end stage". Factors to be assessed include the rate of progression of the disease, whether or not complications of liver failure have occurred and laboratory value including albumin, bilirubin, and prothrombin time.

What are the complications of liver failure?
When liver disease progresses to end-stage, many different things can start to go wrong. In children, growth may cease. In children and adults, fluid may accumulate in the abdomen ("ascites"). Ascites can cause difficulty breathing and it can become spontaneously infected. Thinking may become impaired ("encephalopathy"). Encephalopathy begins as slight disorientation, progresses to drowsiness and can reach complete unresponsiveness (coma). Bleeding from the intestinal tract can occur because of "portal hypertension". In early liver disease each of these problems is often controllable with medications. As the disease progresses the medications no longer help and a liver transplant may be necessary.

What are my chances with a liver transplant?
The survival rate after liver transplant overall is approximately 80% at one year, and 70% at five years. The odds for hepatitis C are approximately the same as for the average liver transplant for another reason.

How long will a new liver last?
No one knows how long a transplanted liver can last. The longest reported survivor is 25 years. Ten year survival is commonplace. Hopefully improvements in techniques and medications that are continually occurring will allow most patients receiving liver transplants today to have long productive lives.

Can anything be done for hepatitis C short of transplantation?
Yes. Several medications are being tried. The only drug that has been approved in the United States Food and Drug Administration is interferon. Studies have shown that about a third of patients with hepatitis C will show improvements in laboratory values after 6 months of treatment. However, it is not yet known if these improvements do anything to change the progression of the disease. No treatment studied to date has reversed the disease once it has reached end stage.

Will the hepatitis C be cured by a liver transplant?
No. Hepatitis C can live in cells other than in the liver. Once the old liver is removed and the new one is connected the hepatitis spreads back into the liver within the first weeks to months after the transplant. This is the bad news: at present we have no way to make the hepatitis C go away completely. The good news is that overall results with hepatitis C after liver transplantation is good. Although the disease comes back it does not seem to greatly damage the liver in the majority of cases. It is possible for the hepatitis to return so severely that the new liver fails, but this is uncommon. Long term results (ten years) are difficult to interpret since we have only been able to diagnose hepatitis C since 1990. Many people that were transplanted in the 1980's may have gotten hepatitis C at the time of transplant, since the blood supply was contaminated then. These people may have different chances compared to those that had transplant because of hepatitis C. Realistically it is likely that hepatitis C will be a long term problem in liver transplant recipients that harbor the virus. We do not yet know how bad a problem this will be.

What can be done for hepatitis C that comes back in a transplanted liver?
No treatment has been shown to change the course of the disease. Interferon alpha is being tried in experimental settings without much success.

Are there any diseases associated with hepatitis C?
Yes, hepatitis C is associated with some cases of thyroid disease, as well as a kidney disease termed glomerulonephritis caused by increased cold sensitivity of blood proteins called cryoglobuluremia..

I have hepatitis B and hepatitis C. Can a transplant still be done?
Yes, although great precaution need to be taken for these patients.

Is there anything that makes hepatitis C progress more quickly?
Alcohol is thought to magnify the progression of hepatitis C and vice versa. No one knows if there is a safe amount of alcohol to consume if you have hepatitis C. Certainly heavy intake (more than 3 drinks a day) should be avoided. The safest course of action is not to drink alcohol at all if you are known to have hepatitis C. Whether one or two drinks a day increases the rate of progression of liver disease is not currently known.

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3. Are people with liver cancer considered for transplantation?

Most cancers of the liver begin elsewhere in the body and are spread to the liver. These cancers are not curable through liver transplantation. Tumours that originate in the liver are usually detected in an advanced stage; thus, they are also rarely cured by liver transplantation. If the cancer is specifically confined to the liver, a transplantation may be considered.

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4. Are people with alcohol-related liver disease considered for transplantation ?

Most people who develop cirrhosis of the liver due to excessive use of alcohol do not require a liver transplant. Abstinence from alcohol and medication will usually treat cirrhosis by giving the liver time to regenerate. For those in whom prolonged abstinence and medical treatment fails to restore health, transplantation will be considered. Patients that continue to drink alcohol despite medical advice are not considered for transplantation in Canada.

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5. At what stage of liver disease is transplantation considered ?

If medical treatment is effective, transplantation would be reserved for the future. However, it is ideally undertaken before the very terminal stages of the disease. At this stage, the person may not be able to withstand major surgery, or might not survive long enough to allow a suitable donor liver to be found.
The actual time for placement on an active transplant waiting list is a medical decision made in consultation with all individuals involved in the patient's care, including the patient and/or family.

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6. What risks are involved ?

Severe complications arising from liver disease may jeopardise the patient's survival during transplant surgery.

The technical difficulties in removing the diseased liver and getting the donor liver "hooked up", major bleeding, shock and metabolic consequences of briefly being without liver function are also surgical risks. However, the risks after surgery are common to all forms of major surgery.

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