Liver Transplantation
Jebatharani1, Mercy Ezhil Rani2
1Staff Nurse, Kauvery Hospital, Hosur, Tamil Nadu
2Clinical Educator, Kauvery hospital, Hosur, Tamil Nadu
Abstract
Liver transplantation is a life-saving surgical procedure performed to replace a diseased or failing liver with a healthy liver from a donor. It is primarily indicated for patients with end-stage liver disease, acute liver failure, or certain liver cancers.
Advancements in surgical techniques, immunosuppressive therapies, and postoperative care have significantly improved patient survival and graft outcomes. Post-transplant patients require lifelong immunosuppression and close monitoring to prevent rejection, infections, and complications such as hepatic artery thrombosis or biliary strictures.
Introduction
Liver transplantation is a complex and live saving surgical procedure performed to replace a severely diseased or non-functioning liver with a healthy liver from a Donor. The first successful human liver transplant was performed in 1967 and since then, this procedure has evolved with advancements in surgical techniques, anaesthesia, immunosuppressive therapy and post-operative care.
Case Presentation
A 29-year young patient presented with the complaints of Wilson disease for the past 14 years and bilateral lower limb swelling for the past one week. There was no known history of diabetes or thyroid disorder.
Physical examination
LOC: Alert and Oriented
Orientation: Person, place, time
Vitals
Blood Pressure: 100/60mmhg, Pulse Rate :78/min
Respiratory Rate: 20/min,
Temperature: 97°F,
SpO2: 100% on RA
Present illness
Admitted for Liver transplant procedure.
History of bilateral leg swelling.
No fever, syncope, chest pain and shortness of breath.
History of past illness
A known case of Wilson disease since the age of 14 years.
Status post left FESS surgery 2 years ago.
Examination
Cardiovascular sound: S1S2 +
Respiratory sound: B/L AE+
Per Abdomen: Soft
Central Nervous System: No Deficit
On examination he was afebrile, conscious, alert and oriented.
Investigations
| Investigations | Pre-Op | Day 1 | Day 12 |
|---|---|---|---|
| Hemoglobin | 11.6 g/dl | 12.8 g/dl | 10.4 g/dl |
| PCV | 35.2 % | 39.3 % | 32.3 % |
| WBC | 2440 cells/µL | 10680 cells/µL | 4520 cells/µL |
| Platelet count | 40,000 cells/µL | 33,000 cells/µL | 67,000 cells/µL |
| Neutrophil | 56.7 % | 92.5 % | 85.2 % |
| Lymphocyte | 26.2 % | 5.4 % | 7.3 % |
| Monocyte | 10.2 % | 2.0 % | 7.5 % |
| Basophil | 1.6 % | 0.0 % | 0.0 % |
| Urea | 21.1 mg/dl | 29.1 mg/dl | 81.3 mg/dl |
| Creatinine | 1.0 mg/dl | 1.4 mg/dl | 1.0 mg/dl |
| Sodium | 137 mmol/L | 137 mmol/L | 141 mmol/L |
| Potassium | 4.0 mmol/ L | 4.3 mmol/ L | 4.3 mmol/ L |
| Chloride | 110mmol/L | 109 mmol/L | 112 mmol/L |
| Bilirubin – Total | 2.7 mg/dl | 5.8 mg/dl | 1.1 mg/dl |
| Bilirubin – Direct | 0.9 mg/dl | 2.5 mg/dl | 0.4 mg/dl |
| Bilirubin – Indirect | 1.7 mg/dl | 1.7 mg/dl | 0.7 mg/dl |
| SGOT | 72 U/L | 364 U/L | 87 U/L |
| SGPT | 58 U/L | 236 U/L | 170 U/L |
| Total Protein | 7.4 g/dl | 5.7 g/dl | 5.1 g/dl |
| Globulin | 4.5 g/dl | 2.5 g/dl | 3.0 g/dl |
| Albumin | 2.9 g/dl | 2.5 g/dl | 3.0 g/dl |
| Calcium | 8.1 mg/dl | - | - |
| Phosphorus | 3.6 mg/dl | 4.2 mg/dl | 3.3 mg/dl |
| Magnesium | 2.1 mg/dl | 2.9 mg/dl | 2.2 mg/dl |
| PT – T | 22.3 sec | 25.4 sec | 16.3 sec |
| PT- C | 11.4 sec | 11.4 sec | 11.4 sec |
| INR | 1.99 | 2.27 | 1.44 |
| Blood Group | O positive | - | - |
| Ph | - | 7.38 | 7.43 |
| PCo2 | - | 40 mmHg | 36 mmHg |
| PO2 | - | 102 mmHg | 44 mmHg |
| HCo3 | - | 23.7 mmol/L | 24.5 mmol/L |
| Lac | - | 1.8 mmol/L | 0.7 mmol/L |
Diagnosis: Wilson’s Disease need Liver Transplantation
Wilson’s Disease
Definition
Wilson’s disease is a rare autosomal recessive genetic disorder of copper metabolism caused by mutations in the ATP7B gene, leading to excessive accumulation of copper in the liver, brain, cornea, kidneys, and other tissues.
Prevalence:
- Globally: about 1 in 30,000–40,000 people.
- Carrier frequency: 1 in 90–100 in the general population.
- The prevalence may be higher in regions with consanguinity (intra-family marriages).
- Onset: Usually between 5 – 35 years but can occur earlier or later.
Pathophysiology
The pathogenesis starts when the liver is unable to appropriately excrete excess copper into bile and incorporate it into the transport protein ceruloplasmin due to a malfunctioning (ATP7B) protein. This results in a poisonous buildup of copper in the liver cells, which damages the cells and causes inflammation, which can lead to cirrhosis and fibrosis. The poisonous, unbound copper enters the bloodstream and is deposited in other organs such as the kidneys, eyes, and brain after the liver’s storage capacity is exceeded. In addition to the formation of Kayser-Fleischer rings in the cornea, the disease’s hallmark hepatic (liver failure) and neuropsychiatric (movement disorders, psychiatric symptoms) manifestations are brought on by the copper-induced generation of free radicals, which causes oxidative stress and tissue damage.
- Normally, copper is incorporated into ceruloplasmin, and excess copper is excreted in bile.
- Normal copper intake : 1 mg / day
- Impaired copper excretion
- Copper accumulates in hepatocytes
- Leakage of free copper into blood
- Deposits in extrahepatic tissues.
Treatment
- Chelation therapy
- Zinc therapy
- Supportive treatment
- Liver Transplantation
Surgical procedure
The donor liver was prepped in standard fashion, including mobilization of the suprahepatic and infrahepatic IVC, ligation of the adrenal vein, and flushing of the hepatic artery, portal vein, and IVC with UW solution. The bile duct was probed and irrigated, ensuring no obstruction. Multiple simple cysts were noted on the donor liver.
The recipient procedure involved reverse L incision, removal of 3 litres of ascitic fluid, and extensive hilar dissection. Recipient hepatectomy was completed after careful ligation and division of the hepatic artery, bile duct, portal vein, and IVC tributaries. The donor liver was brought to the operative field and flushed with saline.
Anastomoses included
- Side-to-side cavo-cavostomy with continuous 4-0 prolene.
- End-to-end portal vein anastomosis with continuous 5-0 prolene.
- Anastomosis of the graft’s common hepatic artery to the recipient’s aorta using continuous 7-0 prolene.
- Choledocho-choledochostomy with continuous 5-0 PDS.
Secondary warm ischemia time was 42 min, anhepatic phase lasted 2 hours, and cold ischemia time was 7 hr. Estimated blood loss was 0.75 litres. Post-reperfusion, the liver appeared uniformly perfused, and Doppler confirmed good flow in hepatic artery (HA), portal vein (PV), and hepatic vein (HV).
Post-operative period: The patient was extubated on the table and shifted to the transplant ICU. Post-operative management included Intravenous fluids, antibiotics, antifungals, aAlbumin,hhparin, hepatoprotectives, and immunosuppressants (Methylprednisolone and Tacrolimus). Regular monitoring of liver function tests (LFTs), PT/INR, and ABG was performed, showing an improving trend.
On post-operative day (POD)-3, Doppler revealed absent hepatic artery visualization. ABG showed increased lactate levels, and liver enzymes began rising. CT imaging confirmed hepatic artery thrombosis with an abrupt cutoff of the hepatic artery. After obtaining high-risk consent, the patient underwent emergency re-exploration and thrombosis evacuation on 17/06/2025.
Intra operative period
- Graft liver adequately perfused.
- Thrombosis in the common Iliac artery conduit extending to the graft hepatic artery anastomosis.
- No pulsation in graft hepatic artery.
- Perihepatic collection of approximately 300 ml.
- Dilated bowel loops.
The patient was extubated on the table and shifted to the ICU. Post-operative management included chest physiotherapy, incentive spirometry, nebulization, and gradual reintroduction of oral feeds. Doppler study showed good flow, and LFTs improved.
On POD-5, Doppler revealed absent hepatic artery visualization. CT imaging confirmed recurrent hepatic artery thrombosis. After obtaining high-risk consent, the patient underwent emergency re-exploration and thrombectomy with revision of thrombosis on 19/06/2025
Pre-operative Nursing care
Preoperative nursing care for liver transplant patient focuses on optimizing nutrition, preventing infection, controlling of bleeding risks, reducing anxiety, maintaining fluid and electrolyte balance, stabilizing the patient and preparing for surgery.
Nursing challenges
- Imbalanced nutrition: Assess weight, BMI, and daily dietary intake.
- Risk for infection related to decreased immunity and invasive procedures (catheters, IV lines, drains) : Maintain strict aseptic technique during all procedures.
- Risk for bleeding related to impaired coagulation and thrombocytopenia: Monitor coagulation profile (PT, INR), platelet count, and Hb levels.
- Anxiety related to upcoming surgery and outcome uncertainty about outcome: Encourage patient/ family to express fears and ask questions regarding the treatment. Provide clear, simple explanation about surgery and Intensive care.
Post-operative concerns
Risk for impaired gas Exchange related to major surgery, anaesthesia, and mechanical ventilation.
- Goal: Patient will maintain adequate oxygenation and ventilation
- Interventions
- Monitor SpO₂, ABG values, respiratory rate
- Maintain ventilator settings as prescribed wean gradually
- Suction secretions using sterile technique to maintain airway patency.
Risk for Infection related to immunosuppressive therapy, invasive lines, and surgical wound.
- Goal: Patient will remain free from infection during post-operatively.
- Interventions
- Maintain strict aseptic techniques during dressing and line care.
- Monitor for fever, increased WBC, and wound discharge.
- Administer prescribed antibiotics and antifungals
Acute Pain related to surgical incision and drains
- Goal: Patient will verbalize adequate pain relief and participate in recovery activities.
- Interventions
- Assess pain using numeric or visual pain scale.
- Administer analgesics
Risk for Graft Rejection related to immune response.
- Goal: Patient will maintain graft function without signs of rejection.
- Interventions:
- Monitor liver function tests (ALT, AST, bilirubin, INR).
- Observe for jaundice, abdominal pain, dark urine, fever.
- Administer immunosuppressive drugs
Post-operative Nursing Care focuses on airway & ventilation support, infection prevention , bleeding monitoring , pain management , graft function surveillance , emotional and family support to ensure smooth recovery and long-term survival after liver transplantation.
Nursing Management
Monitoring and Assessment:
- Regularly monitored vital signs, oxygen saturation, and hemodynamic stability hourly
- Conducted frequent assessments of liver function tests (LFTs), coagulation profiles (PT/INR), and arterial blood gases (ABG) and documented
- Monitored any signs of graft rejection, infection, or complications such as hepatic artery thrombosis.
Medications
- Immunosuppressants administered as per protocol
- Tacrolimus 2.5mg BD,
- Methylprednisolone 20mg OD,
- Mycophenolate mofetil 360mg BD
- Antibiotics
- Amoxicillin + Potassium Clavulanate 625mg TID
- Antifungals
- Fluconazole 150mg BD
- Anticoagulants
- Apixaban 5mg BD
Fluid and Nutrition Management
- Maintained intravenous fluids and albumin as per ordered.
- Gradually reintroduced oral feeds, starting with clear liquids and progressing to a normal diet.
Pain and Wound Care
- Ensured proper wound care and managed post-operative pain effectively.
- Educated the patient on wound care techniques and the importance of hygiene 12 .
Respiratory Care
- Encouraged chest physiotherapy, incentive spirometry, and nebulization to prevent respiratory complications .
Patient Education
- Educated the patient and family members about medication adherence, signs of complications, and follow-up care 12 .
Documentation and Reporting
- Maintained accurate records of patient care and interventions.
- Documented any deviations from the expected recovery process and notify the medical team promptly.
Condition at discharge
- Patients is conscious, oriented, and Afebrile
- Wound healthy, stoma in situ.
- Vitals are stable
- Blood Pressure: 120/80 mmHg,
- Pulse Rate:102beats/min
- Respiratory Rate: 18breaths/min,
- SpO2: 98% on RA
Conclusion
Liver transplantation is a critical and life-saving procedure for patients with end-stage liver disease or acute liver failure. It involves replacing the diseased liver with a healthy donor liver, either from a living or deceased donor. The success of liver transplantation depends on multidisciplinary teamwork, including surgeons, anaesthetist, nursing staff, and post-operative caregivers.
