Definition:
A liver transplant is an operation to remove a diseased liver and replace it with a healthy liver from a donor.
Signs:
Signs can be divided into:
Signs related to the transplant procedure:
- Mercedes Benz scar, although not all patients have the classic Mercedes Benz scar
- Transplant should not be palpable underneath
Signs of previous chronic liver disease may be present such as:
- Palmar erythema
- Dupuytrens contracture
- Leuconychia
- Spider naevi
- Gynaecomastia
Complications/side effects of immunosuppressants:
- Cushingoid: thin skin, bruising, fingerprick marks on the fingers from diabetes which all suggest steroid use
- Skin malignancy, hypertension, diabetes and tremor due to tacrolimus
- Hypertension, hirsutism and gum hypertrophy associated with ciclosporin
Comment on transplant function:
- Presence of jaundice, ascites or encephalopathy indicates the liver transplant may not be functioning.
It is highly unlikely for the patient to have any of these signs in the exam. The absence of them indicates that the transplant is likely to be functioning well and you should mention this to the examiner
Lastly, search for signs indicating the aetiology of the liver transplant:
- Tattoos, piercings, previous injection sites – hepatitis
- Obesity – Non-alcoholic fatty liver disease
- Dupuytrens contracture –may suggest alcoholic liver disease
- Middle aged woman may have had autoimmune hepatitis or primary biliary cirrhosis
Symptoms:
If the transplant is functioning and the patient is tolerating the immunosuppressant medications there should be no symptoms
Symptoms indicating a failing transplant include increasing drowsiness suggesting encephalopathy, jaundice, ascites, abdominal pain, or fever.
Causes:
Cirrhosis of the liver (from any cause but most commonly alcohol in the UK)
Acute hepatic failure – most common reasons are viral hepatitis or paracetamol
overdose
Hepatic malignancy
Investigations:
Investigations prior to liver transplant include:
Full liver screen to determine aetiology of liver disease (see chronic liver disease document)
Up to date FBC/U+E/LFT/clotting
Viral serologies – HIV/Hep B/C and CMV
G+S and cross match
Tissue typing
ECG
CXR
Echo
Pulmonary function tests
Up to date cervical smear – women
Up to date dental checkup
Management:
Patients are reviewed routinely at specialist centre
Regular blood tests checking U+E/FBC/LFT/coagulation screen
Assessment for transplant function as well as for side effects and complications of immunosuppressant medications:
Women need regular cervical smear
Patients are instructed to wear a medic alert bracelet/necklace
Advice to contact doctor if fever or prolonged illness
Annual influenza vaccination
Advice regarding smoking cessation and weight loss
Top tips:
Try to work out and suggest a possible underlying cause for the liver transplant.
Written by Jo Corrado
Resources used to write this document are listed in the references section of this webpage