Our ProgramThe Liver Transplant Program at the USC Transplant Institute complements Keck Medicine of USC’s outstanding medical and surgical services with pioneering advancements in transplantation services in order to safely serve more patients and achieve high-quality outcomes.
Our liver transplant program is one of the pioneering centers in the country for live donor liver transplant, in which a donor donates a portion of his or her own liver. The program successfully performed the first live donor transplant between adults in Southern California. Our team also performed the world’s first adult-to-adult live donor transplantation without a blood transfusion. Few centers in the country perform this procedure, but the liver transplant team at Keck Medical Center of USC in Los Angeles performs several such procedures every year.
Our renowned team of experts provides patients with a comprehensive approach to transplant patient care. Our physicians are involved in all aspects of treatment from the pre-transplant evaluation through the transplant procedure and into post-transplant immunosuppression management and long-term care. Our transplant programs are members of the United Network of Organ Sharing (UNOS), the central agency that coordinates the nation’s organ transplant system.
Patients who are determined to be in need of a liver transplant are those diagnosed with end-stage liver disease. This disorder is characterized by reduced liver function, muscle loss, fatigue, encephalopathy (brain inflammation), signs of portal hypertension, poor blood clotting and jaundice. Several liver diseases can lead to end-stage liver disease. Liver disease is either caused by a virus (hepatitis B or hepatitis C), alcohol-related damage, or by problems in the bile duct leading to primary biliary cirrhosis or primary sclerosing cholangitis. Other more rare disorders also can cause end-stage liver disease. Before being accepted for transplantation, a multidisciplinary transplant team evaluates each patient. The team will look for the extent of liver disease as well as the patient’s ability to withstand surgery and manage health post-transplant.
Pre-transplantation tests help identify potential problems before they occur and help determine whether transplantation is truly the best option. This increases the likelihood of success.
If a patient is positively evaluated for transplantation, he/she is placed on the liver transplant waiting list with the national United Network for Organ Sharing (UNOS), which matches living or cadaveric donors with potential transplant patients.
Receiving a TransplantThe USC Transplant Institute offers the following types of liver transplants:
A bloodless transplant is a transplantation that is performed without a blood transfusion. This technique has long been applied to patients who have specific spiritual beliefs, but it is now experiencing widespread popularity with other patients due to the lessened risk of infection and immunologic complications. Our transplant team performed the world’s first adult-to-adult live donor transplant without a blood transfusion. We use a multidisciplinary approach to eliminate the need for the transfusion of blood and blood products. The strategy is to build up the body’s own reserve of blood components prior to an operation and perform all surgeries in a fashion that minimizes blood loss.
A cadaveric donor transplant is a transplant from a person who has been diagnosed as “brain dead” but whose other organs are functioning properly. These procedures make up the majority of liver transplant surgeries. A potential transplant recipient, once evaluated, is placed on a transplant waiting list maintained by the United Network for Organ Sharing (UNOS). Once a donor is found that matches the patient, the transplantation takes place, often within hours of learning about the match.
A live donor transplant is a procedure in which a living person donates a portion of his or her liver to another. The donor’s liver and the portion given to the patient regenerates to full size within a few weeks. Our transplant team has performed these procedures at Children’s Hospital Los Angeles with excellent results. We performed the first adult-to-adult live donor transplant in Southern California.
What to Expect
If you will be receiving part of a liver from a living donor, your surgery can be scheduled for a specific date. However, for a cadaveric donor transplant, it may take days or even weeks for the United Network for Organ Sharing (UNOS) to locate the right liver for a specific patient. While waiting to hear of a match, you should prepare as much as possible and take steps to deal with the stresses of waiting, always staying focused on reaching the goal of transplant.
Your telephone is your lifeline
When a donor liver becomes available, the coordinator will call you to get ready. Since this call could come at any time, the transplant team must be able to reach you whether you are at home, at school, at work or on vacation.
Be sure to provide the transplant team with the phone numbers of family members and close friends as well and do everything you can to make sure that you can be contacted immediately.
When the phone call comes
When a liver becomes available, there is a time limit! When the transplant team calls you, everything will move very quickly. Stop all eating and drinking. The transplant coordinator will advise you when to arrive at the USC Transplant Institute. You must get to the institute without delay.
Make a list. Pack ahead of time
Pack an overnight bag in advance as soon as your name is put on the UNOS waiting list. Make a list of items you will need in the hospital after surgery such as medications, as well as a list of people to be contacted when the liver becomes available. Give this list ahead of time to a trusted family member or friend to pack any last-minute items and make the calls while you are on your way to the transplant center.
Getting to the transplant center
If the USC Transplant Institute is nearby, plan to have a designated driver – if possible – who will be standing by when the phone call comes. This person should be available at all times and reachable by phone. If the USC Transplant Institute is farther away, the transplant coordinator can assist with transportation arrangements.
Preparing for Surgery
When that important phone call comes, bring the following to the hospital:
- a list of all the medications you are taking
- a list of drug allergies, if any
- your health insurance information
IMPORTANT: As soon as a liver is available, stop all eating and drinking immediately. Your stomach must be empty when you are taken into the operating room. Talk to your transplant coordinator about continuing or discontinuing any medications.
At the Hospital
After admission to Keck Hospital, you will have a thorough physical examination, including more blood work, a chest X-ray, an EKG and possibly other tests.
Surgery may be postponed in some cases. You will be sent home if you have an infection or developed any other medical problem that would interfere with surgery or recovery, or if the donor liver shows signs of deterioration or poor function. If surgery is postponed, the transplant team can help you through the disappointment. This is only a temporary setback, and the search for a new liver will resume once you have recovered from any medical problem or a new donor is found.
Preparing for Transplant
You may receive an enema to clean out your intestines and prevent constipation after surgery. Your chest and abdomen will be shaved clean to prevent infection and an intravenous (IV) line will be inserted to give medication and keep you from getting dehydrated. You will also be given a sedative to help you relax and feel sleepy before going to the operating room.
You will be under general anesthesia during the transplant surgery. In the case of a live donor transplant, a team will operate on the donor to remove part of his or her liver, and your team will replace your diseased liver with the donated organ.
IMPORTANT: Because transplantation is a major surgical procedure, you may need a blood transfusion. Today, all blood is screened very carefully and the likelihood of contracting a disease is very small. Any concerns you have regarding the source of blood should be relayed to the transplant team during the waiting period before getting to the hospital. Most hospitals offer the option of “autotransfusion,” which is when a patient donates his or her own blood in advance well before surgery. The blood is stored and then used during transplantation.
After the surgery is completed, the patient will wake up in the intensive care unit (ICU) after the anesthesia wears off. The length of a hospital stay will depend on the patient’s progress. Most patients can expect to be in the hospital between 12 and 30 days.
- You will probably feel some pain and discomfort, which medication will help to relieve.
- A tube will have been inserted through your nose, running down your throat and into your stomach. This tube will keep your stomach empty and help prevent nausea and vomiting.
- A tube may have been inserted into your throat to help you get enough oxygen. It will be connected to a breathing machine called a ventilator. Relax and let the machine breathe for you. You will not be able to talk with this tube in place, but you will only need it for a few days. Nurses will do everything they can to help you communicate. Your throat may feel sore or scratchy for a few days after its removal.
- You will be asked to cough periodically to keep your lungs clear. If it hurts to cough, ask someone to support your abdomen.
- You will still have an intravenous line in your arm or neck under the collarbone in order to receive fluids and medication for the first few days after surgery.
- For several days after surgery, you will have a catheter in your bladder to drain urine. You may feel uncomfortable and feel a need to urinate constantly, but the feeling is only temporary.
During liver-transplant surgery, the surgeon may find it necessary to place a small tube, called a T-tube, into the bile duct. The T-tube allows bile to drain out of the patient’s body into a small external pouch, known as a bile bag. When the bile bag is removed, the T-tube will be tied or capped. It will remain in place for several months so that it can be used for special testing. The transplant nurse will show you how to change the bandages without pulling out the T-tube.
Acute Care Unit
After your medical condition has stabilized, you will be transferred from the ICU to the acute care unit. During your say here, laboratory studies, medications, nutritional status and exercise tolerance will be monitored. As soon as you are able, discharge instructions will begin to prepare you for going home.
Clinic and follow-up visits
Upon leaving the hospital, you will receive a schedule of follow-up clinic visits for lab tests and checkups. These are set up to track your progress and detect potential complications as early as possible.
At home, you will continue taking most of the medicines you began taking in the hospital after the transplantation, especially anti-rejection medications. Your immune system recognizes the new liver as foreign and will try to reject it. Therefore, your immune system must be controlled with immunosuppressive medications. You probably will have to take one or more of these drugs for the rest of your life, in addition to other medications.
Talk to your physician, pharmacist, transplant nurse and/or coordinator to understand fully:
- the name and purpose of each medication
- when to take each medication
- how to take each medication
- how long to continue taking each medication
- principal side effects of each medication
- what to do if you forget to take a dose
- when to order more medication
- how to order or obtain medications
- what to avoid while taking medications
About Your Liver
The liver is the largest organ in the body. The liver performs more than 400 functions each day to keep the body healthy. Some of its major jobs include:
- converting food into nutrients the body can use (for example, the liver produces bile to help break down fats)
- storing fats, sugars, iron and vitamins for later use by the body
- making the proteins needed for normal blood clotting
- removing or chemically changing drugs, alcohol and other substances that may be harmful or toxic to the body
The liver produces bile, which aids in the digestion and absorption of fats. Bile also aids in the absorption of substances such as vitamins A, D, E, and K and medication that patients take as an immunosuppressive agent following liver transplantation. The bile is stored in the gallbladder (located just below the liver) and then released into the intestines as needed. Together, these organs process the nutrients found in the foods we eat.
Liver disease can originate from viruses, alcohol or bile duct dysfunction. The symptoms of liver disease include:
- Jaundice (yellowing of eyes and skin)
- Severe itching
- Dark urine
- Mental confusion or coma
- Vomiting of blood
- Easy bruising and tendency to bleed
- Gray or clay-colored stools
- Abnormal buildup of fluid in the abdomen
It is important to discuss any symptoms with your physician and ensure that a proper diagnosis is made before determining the proper treatment of liver disease (including transplantation).
The following procedures are used to evaluate a patient’s health status:
Chest X-ray – determines the health of the patient’s lungs and lower respiratory tract.
Electrocardiogram (EKG or ECG) – determines how well the patient’s heart is working and may reveal heart damage.
Ultrasound with Doppler examination – determines the openness of the bile ducts and major vessels. It is commonly done in all liver transplant recipients before and after transplantation.
CT (CAT) scan – shows the size and shape of the patient’s liver and major blood vessels.
MRI (magnetic resonance imaging) – may be used in place of CT scan or ultrasound to see inside the patient’s body.
Total-body bone scan – ensures that if the patient has a liver tumor, the tumor has not spread to his or her bones.
Blood tests – checks for the patient’s blood count, blood and tissue type, blood chemistries and immune system function. In addition, blood tests for certain infectious diseases will be performed.
Pulmonary function test – the patient breathes into a tube attached to a measuring device, which reveals how well lungs are working and determine the blood’s capacity to carry oxygen.
Hepatic angiograph – dye is injected into the patient’s arteries will enable the transplant physician to see any abnormalities or blockages in the patient’s blood vessels.
Cholangiogram – reveals any obstructions or growths in the patient’s bile ducts.
Gallium, colloidal gold or technetium scan – gives the transplant physician a view of the patient’s liver, gallbladder and pancreas.
Peritoneoscopy – the transplant physician will see any structural changes in the liver by inserting a flexible tube through a tiny incision in the patient’s abdomen.
Upper gastrointestinal (GI) series – shows whether the patient’s esophagus and stomach are disease-free.
Lower GI series – ensures that the patient is free of intestinal abnormalities.
Kidney function studies – urine may be collected from the patient for 24 hours in order to determine if the kidneys are working correctly.
Clinical TrialsPatients have the option of taking part in clinical trials, of new medications and treatments, being conducted at Keck Medical Center of USC. Clinical trial participation provides invaluable information for future treatments and possibly a cure in the future.
For patients to be seen at the USC Transplant Institute, your insurer must have a contract in place with USC Care Inc., the group practice organization for all Keck School of Medicine of USC faculty. Contact us so we can help you determine whether pre-authorization or special testing is required in advance of your visit. You should check to make sure whether or not you are responsible for any co-payments. Please bring your insurance card with you to all your appointments.
USC Care Inc., does not accept capitation, although many plans have negotiated fees for our services. All participants in closed panel or restricted-access HMO plans must have secured an out-of-plan referral to Keck Medical Center of USC, or else you may provide cash or credit card payment at the time of your visit.
Your Transplant Team
Each skilled health care professional who makes up the transplant team takes a personal interest in answering your questions and taking care of your medical needs. Your physical, emotional and practical needs will help the team shape a personalized pre-transplant and post-transplant treatment program.
The transplant surgeon performs the actual transplantation procedure and monitors medication before, during and after surgery. He or she will assess the quality of the donor’s liver before surgery and monitor your health and liver status following transplantation. He or she will also check your medication needs and periodically check the incision to make sure it is healing properly.
A transplant physician (hematologist) monitors all non-surgical aspects of patient care for liver transplants. You will see this doctor often. The transplant physician performs examinations, checks test results and adjusts medication as needed. Don’t be shy in asking questions and alerting this physician regarding changes in the way you feel, no matter how insignificant it may seem.
The transplant coordinator, usually a registered nurse, will have two key responsibilities:
- He or she will coordinate all events leading up to and following surgery. These may include scheduling pre-transplant testing, locating a donor liver, testing for donor compatibility, contacting you once a liver has been found and making sure that you have proper follow-up care.
- Teaching you how to take care of yourself before and after transplantation, including how to take medication and when to return to the transplant center for follow-up visits. He or she can put you in touch with community services that will make life easier for you and your family.
Nurse practitioners are responsible for monitoring your daily status and care and will meet with you regularly during your clinic visits. They will provide patient and family education, including teaching you how to check your vital signs and identify any signs of infection. They will help you learn how and when to take your new transplant medications. They play an important role in alerting the team to any potential problems.
The floor or staff nurse will help coordinate activities with your other caregivers, as well as tending to your needs during your hospital stay and preparing you for discharge.
A physical therapist will set your exercise limits after surgery and will advise when it is safe to increase activity. Exercise will improve your circulation, make you feel stronger, help avoid excessive weight gain and increase your sense of well-being. Ask your therapist to help devise an exercise plan that will be beneficial.
A dietitian, following doctor’s orders, will create a special diet plan that will help you stay healthy and avoid excessive weight gain after surgery. Follow the diet plan prepared specifically for you. Proper nutrition can speed recovery and help a patient stay healthy.
A psychologist/psychiatrist can offer insight and support along every step of the procedure. You and your family members may find it helpful to talk about your feelings with a professional before and after surgery. Frank discussion may help you cope with the transplant experience and with the changes it will make in your life.
The social worker will link you to services and people in the community who can help with recovery after leaving the hospital. If you need transportation, help at home or a hand when going back to school or work, the social worker will help arrange it. The social worker can also advise about Medicare, Medicaid and other insurance coverage, as well as help with psychosocial and family matters.
The pharmacist will be available to educate you and your family about the medication that will become a regular part of your life before and after surgery. He or she can give advice about drugs, including the immunosuppressive medications that will help prevent the body from rejecting a new liver.
The United Network for Organ Sharing is the national organization for registering, waiting list management and matching of donors and organ recipients. UNOS is responsible for matching all organ donations in the United States, including liver transplants. Physicians register qualified patients on the list. Visit http://unos.org for more information.
USC Liver Transplant support group
The group is a place for patients to mutually support each other while awaiting a liver transplant. Post transplant patients are also welcome. Click here for more information.
USC Hepatobiliary Program
The USC Division of Hepatobiliary, Pancreas and Abdominal Organ Transplant at the Keck School of Medicine consists of health care professionals who specialize in the following hepatobiliary and pancreatic procedures in addition to liver transplants: liver surgery, pancreatic surgery, gallbladder and bile duct surgery and portal hypertension surgery.
Liver surgery includes resections for tumors, removal of stones, repair of bile duct injuries within the liver and biopsy of the liver for tumors within the liver. Gallbladder and bile duct surgery includes laparoscopic and open stone removal, surgery in pregnant females, repair for bile ducts injured during laparoscopic gallbladder removal, surgical removal of gallbladder and biliary cancers. Portal hypertension surgery includes treatments of obstruction of the mesenteric venous system, splenic vein, portal vein or of the hepatic veins.
USC Liver Cancer Program
Liver cancer is one of the most common cancers in the world. Its prevalence has been increasing in the United States, largely due to the growing number of people with cirrhosis of the liver caused by hepatitis C infections. Keck Medical Center at USC specialists are experts in diagnosing and finding treatments for liver cancer (including possible transplantation).
Donate Life California
Donate Life California is the state-authorized nonprofit organization responsible for managing the organ, eye and tissue registry. It saves lives by inspiring people to sign up with the state organ, eye and tissue donor registry. Visit http://donatelifecalifornia.org for more information.
The Liver Transplant Program at Keck Medical Center of USC in Los Angeles involves experts from several specialties and includes a partnership with Children’s Hospital Los Angeles. Specialists include surgeons, transplant specialists, liver cancer specialists, hepatologists and gastrointestinal disease specialists.
Yuri Genyk, MD, Division Chief, Hepatobiliary and Abdominal Transplant Surgery
Jeffrey Kahn, MD, Medical Director of Liver Transplant
Linda Sher, MD, Director of Clinical Research and Director of Abdominal Transplant Surgery Fellowship
Aaron Ahearn, Associate Surgical Director of Liver Transplant
Robert Rick Selby, MD
Yuri Genyk, MD
Jim Kim, MD
Linda Sher, MD
Kambiz Etesami, MD
Juliet Ann Emamaullee, MD
Navpreet Kaur, MD, Associate Director of Abdominal Transplant Surgery Fellowship
Aaron Ahearn, MD
Yong Kwon, MD
Medical Team (Hepatologists)
Jeffrey Kahn, MD
Tse-Ling Fong, MD
Saro Khemichian, MD
Hyosun Helen Han, MD, Medical Director of Living Donors (Liver)
Brian Kim, MD
Liyun Yuan, MD
John Donovan, MD
Norah Terrault, MD, MPH