Liver transplantation is the removal of a diseased or damaged liver and is replaced by all or part of a donor’s liver. Gradual liver damage from viruses, alcohol, metabolic and genetic conditions, auto-immune liver disease and paracetamol overdose can result in liver failure. Liver transplant is undertaken when the liver is damaged and can no longer perform its normal functions. It is also performed for liver cancer and in conditions where the symptoms of a condition interfere significantly with quality of life such, as intractable itching in PBC, diuretic resistant ascites, polycystic liver disease, and hepato-pulmonary syndrome.
The decision to transplant is based on two main conditions:
A scoring system is also used. The United Kingdom Model for End- Stage Liver Disease or *UKELD calculates a score which looks at sodium, bilirubin and creatinine. UKELD is a medical scoring system used to predict prognosis and determine the need for liver transplant and is used throughout the assessment process.
*A UKELD score of 49 indicates a 9% one-year risk of mortality, and is the minimum score required to be added to the liver transplant waiting list in the U.K. A UKELD score of 60 indicates a 50% chance of one-year survival.
The transplant benefit score (TBS) is also used. This is a way of matching livers from deceased donors to adult patients on the liver transplant waiting list. The new scheme will match livers on a national, rather than a regional, basis and will help to place the organ with the patient most likely to benefit from it. It looks at the characteristics of the donor and the liver patient, to match the donated liver to the patient in a more specific way; helping to make sure the liver is allocated to the patient who will receive the most benefit from it.
The Royal Liverpool & Broadgreen University Hospital (RLBUH) transplant clinic was set up 10 years ago. Initially all transplant patients were followed up in the general liver clinics, but for 9 years there has been a separate clinic. The unit has aspirations to be a liver transplant centre in its own right and submitted a bid to become a new transplant centre in 2020.
The service is currently in the process of working with our colleagues from Aintree Hospital Trust in setting up a Pan- Mersey liver transplant service, this will ensure that access to transplant assessment, referral and post-transplant care are equitable across the Merseyside area. The team already has a joint MDT and is hoping to align consultant clinics by Spring 2022 and integrate nurse lead clinics from Autumn 2022.
Our current transplant team pon the RLUH site, consists of 3 Hepatologists, 1 national training number registrar (NTN), 1 Specialist Nurse and 1 dietician and runs once a week. The number of clinicians will increase when we have successfully combined the transplant clinics currently being run at the two separate sites. All patients have access to the Specialist Nurse for advice and support before and after transplantation.
As well as referring and managing our own patients we act as a referral centre for other hospitals in the Cheshire & Merseyside area. All RLBUH hepatology Consultants have extensive transplant experience and are able to assess and advize on the suitability of a patient for liver transplant. These patients will be offered an urgent appointment and we aim to see them in 2-3 weeks of receipt of referral. Basic blood forms will be sent out and part of the initial investigations will be arranged at this point. We also request all relevant investigation results are sent to us from the referring hospital.
For RLBUH patients the process is the same. Any patient who has deteriorated clinically or has an indication for transplant will be referred internally to the transplant clinic, a Consultant review will take place, initial investigations arranged and a decision to refer is made. On some occasions patients will not be suitable for transplantation for a variety of reasons but also because their clinical condition will have improved, if this is the case we adopt a watch and wait approach or alternatively they are discharged back to the general liver clinic or back to the original referrer.
Once a decision the team at RLUH will arrange any other necessary investigations such as cardiorespiratory, gastrointestinal, and other tests deemed necessary. If these are satisfactory and do not completely rule out suitability for transplantation we will refer to the transplant centre formally by letter which can be sent by email via the Liverpool QE email account.
There are 6 transplant centres in England; St James’ Hospital in Leeds, Addenbrookes in Cambridge, Edinburgh Royal Infirmary, Freeman Hospital in Newcastle Upon Tyne, Kings College Hospital & Royal Free both in London and finally Queen Elizabeth Hospital in Birmingham in Birmingham. The Royal Liverpool University Hospital refers all patients to The Queen Elizabeth Hospital Birmingham but on occasion we will ask for a second opinion from The Royal Free Hospital London.
In the past we had the benefit of a visiting Consultant from the Queen Elizabeth Hospital (QEH) transplant centre. They visited every 6 weeks to meet new patients who need a liver transplant either from our Trust or through a tertiary referral. If a patient fulfilled the criteria for liver transplantation following Consultant review a further clinic review is arranged for part one assessment at the QEH. Since the COVID pandemic this process of consultant review has ceased and direct referrals are made. The lead nurse has a QE email and so can access results and communicates with the Birmingham team once to twice per week to provide links between the two sites to communicate information about patients. The team has transplant assessment protocols from the QE team and is in the process of setting up a service level agreement (SLA) to commence part 1 assessments in Liverpool from 2022.
If the pat8ient passes the phase one assessment the second phase of the assessment takes place, this involves further investigation and education for patients and relatives and culminates in a decision to list or not. Sometimes the decision is deferred to another date pending further assessment/ investigation/ work-up ie with addiction or psychology services.
Patients who placed on the transplant list will be followed up at the QEH alternating with follow-up by RLBUH every 4-6 weeks. This involves ongoing management of any problems and continued chronic disease management such as HCC surveillance etc. and regular updating of UKELD.
Following liver transplantation the initial follow up is done in the QEH by the surgical team for the first 3 months post-transplant and then there is a phased hand-over to the Liverpool transplant team. After 12 months, the majority of care is delivered in Liverpool unless there is a specific issue that needs to be addressed by the QE team.. If progressing well and no major/ significant problems then patients will be handed back for ongoing follow- up at RLBUH. Routine follow-up is 3 monthly but will be heightened if there are any concerns regarding the patient’s health or the graft. The patient pathway is shown in Figure 1.
At the clinic review patients will be weighed and have a BP check, review of blood tests, including drug levels, medication review and discussion regarding any side effects of medication. Prescriptions for immunosuppression will be issued following review in a newly created immunosuppression clinic run by the Nurse Specialist and Pharmacist. All patients will be offered a yearly health-check with an experienced nurse. A physical review will be undertaken and any further relevant or necessary investigations will be arranged. Patients will be given lifestyle advice and advice on how to stay well and live healthily following a liver transplant. Any other help or referral to other agencies will be facilitated through the Specialist Nurse who helps run the transplant service.