Liver transplantation in Turkey is a specific surgical treatment for patients with end-stage liver disease and patients with acute liver failure that improves liver function and survival after transplantation, liver transplantation is a final solution to many liver issues, as this operation saves the lives of patients with acute liver failure and the harms of liver transplantation can be avoided with the advancement of medicine in Turkey.
What is a liver transplant?
Liver transplantation is a surgical procedure in which a damaged liver is replaced with a healthy liver from a deceased or living donor. This operation is used to treat acute or chronic liver failure when other treatments have failed. Due to the importance of the liver in metabolizing drugs, purifying blood and producing vital proteins, liver transplantation is considered life-saving, and thanks to its ability to regenerate, part of a living donor’s liver can be used as it grows back to normal size. The success of a liver transplant depends on careful evaluation of the case, selection of a suitable donor, and post-operative follow-up.
Liver transplant conditions in Turkey
There are three basic principles for determining which patients should be referred and potentially receive a liver transplant:
- The patient must have acute or chronic liver disease that cannot be treated by conventional medical means and is expected to result in death without a transplant.
- The patient’s general state of health should be sufficient to withstand the surgery and recovery period.
- After the transplant, the patient is expected to have a high survival rate and an acceptable quality of life that justifies the risks associated with the procedure.
What are the reasons for a liver transplant?
- Acute liver failure: The most common cause is acetaminophen overdose (approximately 39%).
- Hepatic artery thrombosis: An early transplant complication that can occur within the first 14 days and requires re-transplantation.
- Decompensated liver cirrhosis: Associated with complications such as esophageal variceal bleeding, encephalopathy, ascites, hepatopulmonary syndrome, and portal pulmonary hypertension.
- Primary liver tumors: Hepatocellular carcinoma and metastatic cholangiocarcinoma (under certain conditions).
- Hereditary metabolic diseases: Such as cystic fibrosis, primary hyperoxaluria, or familial amyloid neuropathy, especially when multiple complications are present.
Contraindications to liver transplantation in Turkey
Definite contraindications for a liver transplant include:
- Extrahepatic malignancies, if active or metastatic, are an absolute contraindication
- Intrahepatic Cholangiocarcinoma is an absolute contraindication in most centers unless it is under special research protocols
- Hepatocellular carcinoma beyond the Milan criteria or metastatic HCC is considered ineligible for transplant if it exceeds the Milan criteria or has spread beyond the liver
- Severe cardiac or pulmonary disease (Severe Cardiopulmonary Disease) is intolerant of anesthesia and surgery and is an absolute contraindication unless corrected
- Uncontrolled Infections such as sepsis or severe pneumonia
- Active Substance Abuse usually requires proof of abstinence for a period of time (6 months or more) before the patient can be included
- Uncontrolled AIDS with a high viral load or very low CD4 count
- Uncorrectable Anatomic or Technical Barriers, such as a complex blood effusion, severe abdominal fibrosis, or vascular anomalies that do not allow for a safe transplant
Possible contraindications to a liver transplant include:
- Advanced Age: There is no strict upper age limit, but age >70 years is a risk factor and requires careful assessment of functional ability and general condition, not a contraindication in itself.
- Portal Vein Thrombosis: May complicate surgery but is no longer an absolute contraindication in most centers, especially with revascularization techniques or living donor transplantation.
- HIV Infection: No longer an absolute contraindication, provided the infection is controlled (undetectable viral load, CD4 count > 100-200/μL) and immune status is stable.
- Morbid Obesity – BMI ≥ 40: Associated with higher surgical and anesthetic complications and considered a relative contraindication in some centers. The patient may be required to lose weight before inclusion.
- Poor medical adherence or lack of social support: A relative contraindication if psychosocial assessments show that the patient is unable to maintain long-term adherence to immunosuppressive therapy or medical follow-up.
- Uncontrolled Psychiatric Illness: Such as psychosis or severe untreated depression. Psychiatric conditions must be controlled before transplantation to ensure compliance after the procedure.
Assessing the recipient’s condition prior to liver transplantation
Liver transplantation is a major surgical procedure that requires a thorough and careful evaluation of the patient before being placed on the waiting list. The purpose of the pre-liver transplant evaluation is to ensure that the patient can tolerate the surgery, commit to long-term care, and ensure the best chance of success after the procedure.
Liver transplant candidate evaluation goals
The evaluation focuses on the following aspects:
- Ensure that the patient has liver disease that cannot be treated by other means and is at risk of dying without a transplant
- Ensure that the physical condition of the heart, lungs, kidneys, etc. can withstand the surgery and the post-transplant period
- Ensure that there is effective medical adherence and adequate psychosocial support after the procedure
Tests required before a liver transplant
Laboratory tests
Basic lab tests include the following:
- Blood type (ABO and Rh) to match the donor
- Liver and kidney function
- Complete blood count
- Liver enzymes and clotting factors
- Calcium, Vitamin D
- Urinalysis and urine drug screening
- Serologic tests for viruses: Hepatitis A, B, C, HIV, CMV, EBV, varicella zoster (VZV), and tuberculosis (TB)
Radiographic examinations
Radiologic imaging is an essential part of a patient’s evaluation prior to liver transplantation and includes:
- Three-phase computed tomography or gadolinium-enhanced magnetic resonance imaging to evaluate
:Polylang placeholder do not modify
- If CT or MRI is not available, hepatic echo-Doppler can be relied upon initially.
Heart assessment
A cardiac evaluation includes a test to check for:
- Coronary artery disease.
- Valve disease or heart muscle weakness.
- If there is advanced cardiomyopathy that cannot be corrected, a liver transplant may be contraindicated.
Screening for malignant tumors
Age-appropriate cancer screening tests (colonoscopy, mammography, cervical imaging…) should be performed, as the presence of untreatable extrahepatic cancer is an absolute contraindication to transplantation.
Bone density test
Patients with advanced liver disease are prone to osteoporosis due to vitamin D deficiency, lack of physical activity, alcohol, steroids or iron overload. A DEXA scan is performed to assess the risk of fractures.
Screening for infections
The risk of infections (such as peritonitis, pneumonia, urinary or blood infections) is increased in patients with cirrhosis. Any active infection must be fully treated before proceeding with a liver transplant.
Inoculation status
It is advisable to update vaccines before planting, including:
- Hepatitis A and B vaccines (if the patient does not have immunity).
- Tetanus, diphtheria, whooping cough.
- Seasonal flu and pneumococcal vaccine.
Portal Pulmonary Hypertension
In some cases, cirrhosis is associated with the development of pulmonary hypertension (POPH). It is assessed by measuring the mean pulmonary artery pressure (mPAP).
- mPAP < 35 mmHg: Can be transplanted with relative safety.
- mPAP > 45 mmHg: Associated with higher post-transplant mortality.
Smoking
Smoking is a definite risk factor after liver transplantation, as it increases the risk of:
- Cardiovascular death.
- Hepatic artery thrombosis.
- Oral and pharyngeal cancers.
Some transplant centers require complete smoking cessation, documented by negative nicotine tests, before a patient can be included.
Steps for liver transplantation in Turkey
The liver transplantation process goes through four main surgical stages, starting with the removal of the damaged liver and ending with the bile duct anastomosis, the technical details vary according to the clinical case and the individual anatomy of the patient, but the following steps represent the standard sequence in most advanced centers in Turkey.
1. Recipient Hepatectomy
This step represents the actual beginning of the liver transplant process and may be surgically complex due to the presence of severe fibrosis, coagulopathy, or high portal vein pressure, which increases the risk of bleeding:
- Conventional Technique: The entire liver is removed along with the hepatic portion of the inferior vena cava. This may lead to interruption of the venous return to the heart, so a Venovenous Bypass is preferred during the extrahepatic phase to minimize hemodynamic compromise.
- Piggyback Technique: The liver is removed with the inferior vena cava in place, and only the hepatic tributary is removed. This method allows the venous return to continue, and is the best option if the hepatic vein is absent in the graft.
2. Vascular Anastomosis
After liver resection, major vascular anastomoses are performed:
- Inferior vena cava anastomosis: The end of the graft’s vena cava is connected to the recipient’s vein, either through a terminal or lateral anastomosis.
- Portal vein anastomosis: Blood flow is restored through the portal vein to the transplanted liver, a critical moment that may be associated with severe hypotension or bradycardia as cold fluids and inflammatory stimuli from the new liver enter the circulation
To minimize these risks, the transplanted liver is pre-washed with warm saline and then with systemic blood before re-infusion.
3. Hepatic Artery Anastomosis
Liver arterial perfusion is usually reconstructed through an end-to-end anastomosis between the recipient’s common hepatic artery at its junction with the gastroduodenal artery and the hepatic artery of the transplanted liver. The location of the anastomosis is chosen according to the available arterial branches and simple anastomoses are preferred to minimize the risk of stenosis or thrombosis. If there is a separate arterial branch (such as the right hepatic artery), the connection is made directly to the appropriate arterial trunk in the transplanted liver
4. Biliary Reconstruction
The final stage in the liver transplant process is the reconstruction of the bile ducts. This is often done using:
- Duct-to-Duct anastomosis: Between the graft and recipient’s common bile duct, this is the preferred option if the ducts are close in size and in good condition.
- Roux-en-Y Hepaticojejunostomy: Used if the patient’s bile duct is unfit (as in primary sclerosing cholangitis), or if there is an anatomical abnormality.
Liver transplant care in Turkey
Post-liver transplant care is a critical step in ensuring the success of the operation and the stabilization of the patient’s condition. It includes several critical clinical aspects that must be carefully monitored.
Blood circulation monitoring
After surgery, cardiovascular function is re-evaluated due to the reversal of circulatory changes caused by chronic liver failure, such as elevated cardiac output and decreased vascular resistance. Stabilization of the transplanted liver leads to a gradual improvement in blood pressure and vascular resistance.
Respiratory support and endotracheal intubation
Early extubation helps reduce the risk of ventilator-associated pneumonia. However, this may be delayed in patients with pulmonary disease or metabolic disorders.
Pain relief
Fentanyl is used initially and morphine is avoided due to its slow metabolism in patients with liver disease. Patient-controlled analgesia pumps may be used or oral analgesics may be substituted later. Epidural anesthesia is used with caution and is not routinely applied.
Correcting electrolyte and sugar disorders
The patient may have hyperkalemia, hypocalcemia, and blood sugar disorders where electrolytes are carefully monitored and corrected because imbalances may indicate transplanted liver failure or infections.
Coagulation disorders
Coagulation issues persist after surgery due to multiple causes such as fibrinolysis or platelet retention in the transplanted liver, and hypercoagulability may occur, requiring careful evaluation and treatment.
Immunosuppression
Steroids and other immunosuppressants are used to avoid rejection of the transplanted liver and doses are adjusted to reduce the risk of infection or tumor recurrence. Side effects include high blood pressure, diabetes, and slow wound healing.
Rehabilitation after liver transplant in Turkey
Rehabilitation after liver transplantation plays a key role in improving long-term outcomes and restoring the patient’s quality of life. Rehabilitation programs include muscle strengthening, increasing pulmonary ventilation exercises, enhancing physical activity, and reducing chronic fatigue. Physical therapists supervise the design of the treatment program according to the patient’s condition, taking into account contraindications such as: Acute rejection, electrolyte imbalances, bleeding, or severe heart disease.
A comprehensive assessment including muscle strength, respiratory capacity, level of independence, pain, and comorbidities is essential to determine the most appropriate rehabilitation program, which usually begins shortly after the operation and continues in a phased manner.
Major complications of liver transplantation
Post-liver transplant complications are common and require careful management to ensure the success of the procedure:
1. Breathing Problems
Pulmonary complications are especially common in patients who smoke or have chronic lung disease, and hypoxia caused by hepatopulmonary syndrome is a real risk after the operation.
2. Infections
Infections are the leading cause of death during the first month after transplant and include infections: Wound, lung, urine, and sepsis and prophylactic antibiotics are used to minimize this risk.
3. Renal insufficiency
It affects more than 40% of patients after transplantation. Ischemic tubular necrosis is the most prominent cause of ischemic tubular necrosis: Ischemia, diabetes, hepatitis C, and the use of nephrotoxic drugs.
4. Thrombocytopenia
Caused by retention in the xenograft or spleen, or decreased production of thrombopoietin in cirrhosis.
5. Rejection of the transplanted liver
It may be mediated by lymphocytes or antibodies and is treated with immunosuppressants such as steroids or rituximab and, in some cases, retransplantation.
Liver transplant results in Turkey
The results of liver transplantation in Turkey are continuously improving thanks to medical expertise and the development of immunologic drugs. Physiological status is taken into account more than chronological age, as some patients over 70 years old have shown acceptable results.
- 75% of patients live more than 5 years.
- 50% live more than 10 years.
- 20% live more than 20 years.
Studies show that quality of life after transplantation is generally good with an improvement in physical ability, especially in males.
Cost of liver transplant in Turkey
Turkey is one of the leading countries for liver transplants and offers high quality at a competitive cost:
| Type of hospital | Liver Transplant Cost |
|---|---|
| State hospitals | 35,000 – 45,000 dollars |
| University hospitals | 45,000 – $55,000 |
| Private hospitals | 50,000 – 80,000 dollars |
Liver transplantation is a definitive treatment option for patients with advanced liver failure or liver tumors that cannot be treated with conventional methods. With significant advances in surgical techniques and immunosuppression methods, liver transplantation is safer and more successful than ever before. The success of liver transplantation depends on accurate preoperative evaluation, adherence to the postoperative treatment plan, and long-term psychosocial support. In short, liver transplantation represents a real hope to regain a normal life and significantly improve the quality of life.
Sources:
- Bulur A and Sevmiş M. Clinical, surgical and histopathological characteristics of liver transplant recipients: An analysis of a large sample from Turkey. Gulhane Medical Journal 2022;64:60-66.
- Ionescu, V.A, Diaconu C.C, Bungau S, Jinga V, Gheorghe G. Current Approaches in the Allocation of Liver Transplantation. J. Pers. Med. 2022;12,1661.
- Mahmod N. Selection for Liver Transplantation: Indications and Evaluation. Current Hepatology Reports 2020;19:203-212.
- European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Liver transplantation. Journal of Hepatology 2016;64:433-485.
- Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alono-Coello P, et al. Evaluation for Liver Transplantation in Adults: 2013 Practice Guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. BMJ 2008;336:924-926.
- Miller C and Diago Uso T. The Liver Transplant Operation. Clinical Liver Disease 2013; 2,(4):192-196.
- Parekh K.N, et al. Postoperative Care of the Liver Transplant Recipient. Springer 2017;29:365-384.
- Yıldırım M.S., Yurdalan S.U. Physiotherapy in Liver Transplantation. InTech 2012;21:445-454.
- Zhu J.H, et al. Medical complications of liver transplantation. AME Medical Journal 2018;3:1-10.
