Choosing the Medical Center that is Right for the Liver Transplant Patient

Choosing the medical center that is right for the liver transplant patient.  Fortunately, the liver transplant operation is quite commonplace, thus leaving a host of medical centers in many states that perform this procedure, and perform it well.  How do you find a medical center that may be right for you?  How about word of mouth, our good friend Google, your family doctor, newspapers, and many more ways to find a suitable medical center that are limited only by the imagination.  What are some of the characteristics of a good medical center.  The first ones that come to mind, are liver transplantation success rate and patient care and follow up.  In today’s complicated, competitive medical environment, you would be hard pressed to find a medical center with a low liver transplant success rate.  And patient care rests at the top of most good medical centers too.  A hospital that is lax in its’ given success rates and patient care is soon to be a facility whose days are numbered.  There are also sources on the internet that provide ratings.  (Google seems to be everywhere.)  One other important issue in finding a good medical center is distance from your home.  Distance means time and money, especially at today’s gas prices.   

Liver Transplant Operation – What to Expect

This section is about what to expect before during and after the liver transplant operation.  Since, I have not undergone this procedure, I will be describing it from third party information, such as from other web sites, the attending physicians, and individuals.  After you have qualified for the liver transplant, in addition to packing your bags in preparation for a quick trip to the hospital, you will be waiting and waiting.  Sometimes the wait is short, while many times the wait can be a year or longer.  And this occurs only if your MELD score is around 20 or above.  My MELD score is around 14, so the active process for my liver transplant has not even started.  However, if and when the liver procurement process begins, events go pretty fast. There are no further major batteries of tests to be done, so all you have to do is accept the transplant when you get the call and head to the hospital.  I understand there is about a 3 hour window from liver procurement to the operation.  The operation itself lasts approximately 6 to 12 hours and has a high success rate in the 90% or higher range.  Five year survivability is very good too, being somewhere around the mid to upper 80% range.  I am not quite sure where the greater than 5 year survivability statistics went.  Maybe, they figure no more statistics are needed if you make it 5 years. I have talked with a liver transplant patient, who has survived over 15 years and is leading a normal life. When the liver transplant operation is completed, the first 48 hours is the most critical time.  The medical staff will be monitoring for excessive bleeding, clotting and infection. There also will be tubes and machines hooked up the liver transplant patient for the first 2 to 3 days. You can expect your stay in the hospital to last about 10 days to 2 weeks.  I have talked to patients that told me they felt much better when they woke up from the liver transplant operation.  The medications you will be taking are mainly anti-rejection and immune-suppressant drugs.  I understand they are quite expensive.  The most expensive part of the liver transplant patient is the transplant itself, however, which runs around $300,000, give or take.  When the liver transplant patient leaves the hospital, a fairly normal life can be lead with proper care and absolutely no alcohol use.  There will be follow up visits, which will be gradually decreasing in frequency as long as the liver transplant patient continues to recover normally.     

Insurance and Payment Considerations for the Liver Transplant Candidate

Insurance and payment considerations for the liver transplant candidate are an important factor in the liver transplant process.  The hospital I am presently working with, which is the Ohio State University Medical Center in Columbus, Ohio, has been very helpful in answering these cost issues.  The ideal situation is to have medical insurance covering any and all costs.  Many times the ideal situation is not always the case.  However, there are answers that can help almost any liver transplant candidate.  If a limited medical policy exists, or no policy at all, there is still help.  And, to debunk a myth, hospitals will not always turn you away because you cannot pay for the services rendered.  All they ask for is a good faith effort to try to pay what you can on a regular schedule.  There are also state and federal agencies, such as the state job and family services agency or social security.  There is also our old friend Google that will provide a wealth of information.  

The Liver Transplant Candidate Makes it on the Transplant List and Gets to meet the Transplant Team.

The liver transplant candidate makes it on the transplant list and gets to meet the transplant team.  Finally, in 6 to 8 months, after all the diagnostic testing, meetings, therapy sessions, state board approval, and the like the liver transplant candidate is on the transplant list, and you get to meet with the transplant team.  Shortly after approval, you will be sent a brochure that explains all about liver transplants, the surgical procedure, and all kind of details about the liver transplant surgery.  Soon after you receive your brochure, a meeting will be set up for you and your family to talk with the transplant team and have any questions that you might have.  Although approval is an important step, there is waiting, follow up testing, and insurance approval.  How long is the wait?  Anywhere from 1 to 4 years.  What is the reason for this waiting process?  Unfortunately, there are not enough donor livers to satisfy the demand, which keeps growing. Currently the ratio of liver donors to livers needed  is around 1 in 8 or so.  So this is a major reason for the wait.  Then cell matching must be accomplished, and also your MELD score needs to be generally at 20 or above to receive a new liver.  So should the liver transplant candidate be discouraged?  Not really – there is always hope.  Also, in the vast amount of cases involving cirrhosis, the condition progresses very slowly, if the liver transplant candidate takes proper care of himself and absolutely abstains from any alcohol.  In my case, my MELD score is 14.  My doctor has told me I may never need a transplant.  He has seen many liver transplant candidates with the same or similar MELD scores live over 20 years until a transplant is necessary.   

More A Patient’s View of Blood Tests and What They Mean for the Liver Transplant Candidate

Red blood cells are the most numerous blood cell, about 5,000,000 per microliter.  Red blood cells make up about 40% of our total blood volume, a measure called the hematocrit.  Their color is caused by hemoglobin, which accounts for nearly all of the red cell volume.  Hemoglobin is the critical protein that transports oxygen from our lungs to the tissues.  Red cells are normally shaped as round, biconcave discs.  With microscopic examination, they look like a red or orange tire with a thin, almost transparent center.  Their function is to carry oxygen throughout the body to organs and the like. They are produced in the bone marrow.

White blood cells are the largest of the blood cells but also the fewest.  There are only 5000 to 10,000 white blood cells per microliter.  There are several different types of white cells but all are related to immunity and fighting infection. 

Eosinophils - EOS

There are many disorders where the eosinophils have been found elevated either in the blood or in different tissues. The experts in the Cincinnati Center for Eosinophilic Disorder at Cincinnati Children's Hospital Medical Center provide a list of general categories of diseases with some examples included.

Allergic Disorders: Allergic disorders are classically characterized by presence of eosinophils. Allergic rhinoconjunctivitis (hay fever) has increased levels of eosinophils in the nasal mucosa. Asthma, after an exacerbation, shows increased eosinophils in the lung.

Drug Reactions: Any drug/medicine can precipitate a reaction. Some of these reactions are allergic in nature and eosinophils might be elevated in blood or in tissues where the drug is concentrated.

Infectious Diseases: Parasitic infections (Helminthiasis-worms), fungal infections and some other types of infections are associated with increased eosinophils.

Blood Disorders: A few examples of hematologic disorders with increased esoinophils include the hypereosinophilic syndrome, leukemias, lymphomas, tumors, mastocytosis and atheroembolic disease.

Immunologic Disorders and Reactions: Hyper-IgE syndrome, Ommen's syndrome, thymomas, transplant rejections are only a few types of conditions with increased eosinophils.

Endocrine Disorders: Hypoadrenalism has been associated with blood eosinophilia.

Specific Organ Involvement: Below are certain conditions organized by the organs/tissues that are affected where eosinophils have been found to be increased or pathologically present.

Skin and subcutaneous disorders	Atopic dermatitis (eczema), bullous pemphigoid, pemphigus vulgaris, dermatitis herpetiformis, drug-induced lesions, urticaria, eosinophilic panniculitis, angioedema with eosinophilia, Kimura's disease, Shulman's syndrome, Well's syndrome, eosinophilic ulcer of the oral mucosa, eosinophilic pustular folliculitis and recurrent cutaneous necrotizing eosinophilic vaculitis.
Pulmonary conditions	Drug/Toxin-induced eosinophilic lung disease, Loeffler's syndrome, allergic bronchopulmonary aspergillosis, eosinophilic pneumonia, Churg-Strauss syndrome, eosinophilic granuloma, pleural eosinophilia.
Gastrointestinal diseases	Gastroesophageal reflux, parasitic infections, fungal infections, Helicobacter pylori infections, inflammatory bowel disease (ulcerative colitis and Crohn's disease), food allergic disorders, protein-induced enteropathy and protein-induced enterocolitis, allergic colitis, celiac disease, primary eosinophilic esophagitis, gastroenteritis and colitis. Rare tumors (leiomyomatosis), connective tissue disorders and vasculitic disorders.
Neurologic disorders	Organizing chronic subdural hematoma membranes, central nervous system infections, ventriculoperitoneal shunts, drug-induced adverse reactions.
Rheumatologic illnesses	Eosinophilic synovitis, eosinophilia-myalgia syndrome, vaculitic disorders such as the Churg-Strauss Syndrome.
Cardiac conditions	Heart damage has been reported secondary to systemic disorders such as the hypereosinophilic syndrome or the Churg-Strauss syndrome. Certain congenital heart conditions (septal defects, aortic stenosis) are associated with blood esoinophilia.
Renal diseases	Eosinophiluria (eosinophils in the urine) associated with infections or interstitial nephritis and eosinophilic cystitis.

This blog ends the section on some of the major blood tests.  For additional information good old Google will help.

More A Patient’s View of Blood Tests and What They Mean for the Liver Transplant Candidate

Platelets are only about 20% of the diameter of red blood cells, and they are the most numerous cell of the blood. The normal platelet count is 150,000-350,000 per microliter of blood, but since platelets are so small, they make up just a tiny fraction of the blood volume. The principal function of platelets is to prevent bleeding. Platelets are produced in the bone marrow, the same as the red cells and most of the white blood cells. Platelets are produced from very large bone marrow cells called megakaryocytes. As megakaryocytes develop into giant cells, they undergo a process of fragmentation that results in the release of over 1,000 platelets per megakaryocyte. The dominant hormone controlling megakaryocyte development is thrombopoietin (often abbreviated as TPO), which comes from the liver. Low platelets happen to occur in people with chronic liver disease because the liver is damaged and scarred. The liver cannot produce enough of a substance called thrombopoietin, which is important in creating platelets.

Platelets are not only the smallest blood cell, they are the lightest. Therefore they are pushed out from the center of flowing blood to the wall of the blood vessel. There they roll along the surface of the vessel wall, which is lined by cells called endothelium. The endothelium is a very special surface, like Teflon, that prevents anything from sticking to it. However when there is an injury or cut, and the endothelial layer is broken, the tough fibers that surround a blood vessel are exposed to the liquid flowing blood. It is the platelets that react first to injury. The tough fibers surrounding the vessel wall, like an envelop, attract platelets like a magnet, stimulate the shape change that is shown in the pictures above, and platelets then clump onto these fibers, providing the initial seal to prevent bleeding, the leak of red blood cells and plasma through the vessel injury.

Having low platelets can get in the way of your taking medicines and having diagnostic procedures, such as a liver biopsy. Why? Because your blood does not have enough platelets and you are at risk for bleeding. The liver transplant candidate most times also bruises easily.

Red blood cells are the most numerous blood cell, about 5,000,000 per microliter. Red blood cells make up about 40% of our total blood volume, a measure called the hematocrit. Their color is caused by hemoglobin, which accounts for nearly all of the red cell volume. Hemoglobin is the critical protein that transports oxygen from our lungs to the tissues. Red cells are normally shaped as round, biconcave discs. With microscopic examination, they look like a red or orange tire with a thin, almost transparent center. Their function is to carry oxygen throughout the body to organs and the like. They are produced in the bone marrow.

More A Patient’s View of Blood Tests and What They Mean for the Liver Transplant Candidate

What do elevated liver tests (AST and ALT) mean?

AST (SGOT) and ALT (SGPT) are sensitive indicators of liver damage or injury from different types of disease. But it must be emphasized that higher-than-normal levels of these liver enzymes should not be automatically equated with liver disease. They may mean liver problems or they may not. For example, elevations of these enzymes can occur with muscle damage. The interpretation of elevated AST and ALT levels depends upon the entire clinical evaluation of an individual, and so it is best done by physicians experienced in evaluating liver disease and muscle disease.

Moreover, the precise levels of these enzymes do not correlate well with the extent of liver damage or the prognosis (outlook). Thus, the exact levels of AST (SGOT) and ALT (SGPT) cannot be used to determine the degree of liver disease or predict the future. For example, individuals with acute viral hepatitis A may develop very high AST and ALT levels (sometimes in the thousands of units/liter range). But most people with acute viral hepatitis A recover fully without residual liver disease. To the contrary, people with chronic hepatitis C infection typically have only a little elevation in their AST and ALT levels. Some of these individuals may have quietly developed chronic liver disease such as chronic hepatitis and cirrhosis (advanced scarring of the liver).

It is, therefore, worth mentioning that these liver enzymes do not give an indication of the function of the liver. Sometimes they are mistakenly referred to as “liver function tests” or LFTs, but it is a misnomer commonly used even by most physicians.

Another blood test is the measurement of albumin in the blood. It is basically an indicator of how your system treats fluid retention or elimination in the body. Human serum albumin is the most abundant protein that is found in human blood plasma. This protein is produced in the liver and comprises around half of the blood serum protein. This protein has a serum half life of around twenty days. If you have too much fluid retention then you bloat up, especially around the feet, ankles, legs (called edema), and the abdominal area (called ascites).

Anion Gap, another blood test is basically the difference between Sodium + Potassium minus Bicarbonate + Chloride. Anion Gap measurements are generally lower in patients with lower albumin levels that have cirrhosis. These lower measurements mean the blood is less acidic, which I have no idea of what that means.

The best I could conclude is that lower anion gap levels that are associated with lower albumin levels are strongly associated with cirrhosis.