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  • Writer's pictureDoç.Dr.Mutlu Ünver

Things to Know About Liver Transplantation – Liver Transplant Surgery - Assoc. Prof. Dr. Mutlu Unver – Izmir, Turkey

Updated: Mar 2

Pre-Liver Transplant Evaluation


Liver transplantation can be a life-saving intervention, but it requires careful evaluation before this serious operation. The transplant team determines risk factors for each patient after a detailed examination and laboratory tests.


It should be remembered that transplantation can be performed except in cases of cancer and infectious diseases with no prospect of recovery, refusal of treatment or psychiatric illness.


Table of Contents


Liver Transplant Assessment Steps:


Liver Transplant; Determination of Physiological Age:

Biological age for the patient is not only the age determined by the date of birth, but also a concept determined by taking into account body health and organ functions. Since the increase in diabetes, especially in recent years, increases the susceptibility to cardiovascular complications, it is vital to make a detailed assessment in this regard.


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Liver Transplant; Reasonable Life Expectancy:

Transplant candidates should have a life expectancy that can tolerate the surgery as well as the recovery process afterwards. The ability to tolerate surgical interventions and a sufficient physical reserve capacity to compensate for the adverse effects of drugs that affect the immune system are required. Age is an important factor, but the general state of health is more decisive than age.



Liver Transplant; Investigation of Diseases and Complications:

It is important that transplant candidates undergo a detailed evaluation in terms of cardiovascular system, renal function and other critical organ systems. The presence or risk of any disease or complication in these organ systems should be determined before the transplant operation.


These assessment steps are critical both to determine whether patients are suitable candidates and to achieve the best post-transplant outcomes. A detailed pre-transplant evaluation provides the basis for a successful transplantation process by ensuring the best preparation of patients.


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Diseases to be Evaluated in the Recipient Before Liver Transplantation and Evaluation for Infection

Liver transplantation requires careful assessment of the general health status of prospective recipients. Important information about critical illnesses and infection assessment that should be considered before the transplant operation:


Coronary Artery Disease:

Coronary artery disease is a critical factor in cardiovascular health. Angiography should be performed in symptomatic patients, and non-invasive cardiac tests should be performed in patients who are not symptomatic but in the high-risk group. Candidates with coronary artery disease can be made suitable candidates by performing "by-pass" surgery before transplantation



Chronic Lung Disease:

It is important that lung function is suitable for surgery. Since the risk of postoperative lung infection is high, necessary precautions should be taken and patients in this condition should be meticulously evaluated.


Malignancies (Cancers):

In case of malignant disease before transplantation, the patient must be completely cured. Waiting times differ for different types of cancer. For example, a 2-year waiting period is sufficient for some cancer types, while a 5-year waiting period is recommended for others.


Assessment for Infection:

Infection is contraindicated for transplantation in case of an active infection. Therefore, all recipient candidates should be evaluated for infections such as HIV, tuberculosis, cytomegalovirus (CMV). Recently, with the increase in antiretroviral therapies, HIV (+) patients have started to be considered as transplant candidates.


These assessment steps are vital in determining the suitability of patients for transplantation and managing infection risks. Comprehensive evaluation of patients before transplantation can increase the chances of success after transplantation and reduce the risk of complications.


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Laboratory Investigations Before Liver Transplantation

Detailed laboratory examinations of prospective liver transplant recipients before liver transplantation play a critical role in determining their general health status and potential risk factors.


Blood and Urine Tests:


  • Haematological tests, renal function tests and liver function tests are performed.

  • Hepatitis markers are analysed.

  • Viral serology is studied for childhood diseases and infections such as CMV and EBV.

  • Tumour markers, fasting blood glucose, uric acid, calcium and phosphate levels are investigated.

  • Urinalysis is also performed.


ECG and Echocardiography:


  • Cardiology consultation is performed together with these examinations.

  • If there are signs of coronary artery disease, coronary angiography may be performed.

  • All cultures of the patients are taken and the risk of infection is evaluated.


Radiological Investigations:


  • Chest radiography is performed and evaluated with blood gases when necessary.

  • Endoscopic examinations for oesophagus, stomach, duodenum and colon may be requested when necessary.


Other investigations:


  • Computed tomography (CT) is definitely requested.

  • For certain diseases, PET scintigraphy, scintigraphy and tests for thrombosis tendency may be requested.

  • In addition, consultations with pulmonology, cardiology, anaesthesia, dental, psychiatry, gastroenterology, neurology, neurology, infection, urology and obstetrics are carried out and additional tests requested by these departments are also performed.


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All these laboratory examinations and investigations are important to comprehensively assess the health status of the prospective recipients and to identify potential risks prior to transplantation. These examinations will help to ensure the success of the transplantation process and to prepare patients for the transplant operation in a healthy way.


Preparation Before Liver Transplant Surgery

A detailed preparation process is followed before liver transplantation surgery. Here are the topics to be considered in this process:


Blood Group Compatibility:


  • Blood group compatibility is important and transplants between AB0 compatible groups are more successful.

  • According to the blood group, 2 units of blood should be prepared.


Hospitalization and Examination of the Donor:


  • After all examinations are completed, the donor is hospitalised 2-3 days before the operation.

  • A detailed history is taken, a physical examination is performed and a systemic examination is performed without neglecting any system.


Special Examination and Consultations:


  • If there are conditions that require special examination and evaluation during the physical examination, consultation is made in the relevant branches.

  • Examinations such as otorhinolaryngology, dentistry, gynaecology, cardiology and pulmonology should be performed especially.


Re-evaluation of Examinations:


  • Previously performed tests are repeated: complete blood count, urinalysis, ECG, chest X-ray, blood biochemistry.

  • Cytomegalovirus titration is rechecked.


Liver Donor Preparation:


  • The donor is fasted for 10-12 hours before the operation.

  • During this period, 1000 ml Lactated Ringer's infusion is administered.

  • Elastic bandage is applied to the lower extremities.


Consent Form:


  • The donor must sign the consent document before the operation.


Blood Preparation:


  • 2 units of blood are prepared according to the blood group.


All these preparation steps are of great importance for a successful and safe operation. Acting meticulously at these stages ensures that the patient is prepared in the best way before the operation and minimises the factors affecting the success of the operation.


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Laboratory Tests Performed on the Donor for Liver Transplantation

A series of detailed laboratory tests are performed to determine whether a donor candidate for liver transplantation is a healthy and suitable candidate:


Blood Tests:


  • Haemogram and peripheral smear

  • Bleeding profile

  • Thrombosis profile

  • Routine biochemistry

  • Hepatitis markers

  • Tumour markers


Urine tests


  • Urinalysis and culture

  • Creatinine clearance (24-Hour urine)


Other Investigations:


  • Chest, cardiology, psychiatry and other necessary consultations

  • Viral serology

  • Electrocardiogram (ECG)

  • Chest X-ray

  • Whole abdomen tomography and CT angiography

  • MR cholangiography


According to the results of these examinations, it is evaluated whether the donor candidate has any pathological findings. In candidates without pathological findings, liver volumes are calculated and vascular structures and biliary anatomy are evaluated preoperatively.


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The living liver donor candidate must meet certain criteria:


  • 18 years of age

  • Having a healthy body structure

  • Absence of systemic diseases (e.g. hypertension, diabetes, heart disease, kidney disease)

  • Normal lung function tests (in smokers)

  • Negative HIV antibody test in blood tests

  • Not being a carrier of hepatitis B and hepatitis C


While 65 years of age is accepted for age limit in some centres, there is no upper age limit in many centres. These examinations are important to determine whether the donor candidate is a healthy and suitable candidate and to perform the transplant procedure safely.


In addition, hepatitis B and hepatitis C carriage should be checked to reduce the risk of disease transmission to the recipient.


Liver Transplant Assessment

When end-stage liver disease is diagnosed, patients undergo a recipient assessment, which takes approximately 5-7 days. This evaluation is carried out in three stages:


Definitive Diagnosis:


  • A definitive diagnosis of the patient's condition and liver disease is made.

  • Other systems (heart, lungs, kidneys, blood counts) are tested and the presence of infection is ruled out.


Determination of Severity of Liver Disease and Urgency of Transplantation:


  • The severity of liver disease is assessed and transplant urgency is determined.


Determining the Patient's Suitability for Transplantation:


  • The liver specialist decides how successful the surgery will be depending on the patient's condition, the cause and severity of the disease.


The final stage involves psychological and mental preparation of the patient. The patient and his/her family are informed about the procedure, the duration of hospital stay, the possible course after surgery, follow-up and post-operative care.


After the assessment, the patient is placed on the waiting list for cadaveric transplantation or, if a relative with a suitable blood group is willing to donate, the person is evaluated for donation and transplantation is planned.


The patient waiting for a cadaveric transplant is monitored by the transplant team until a suitable liver is found.


If the patient's condition worsens, it is usually recommended that the family consider living donor donation. These assessments are vital for directing patients to the most appropriate treatment and transplantation process.


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Things to Know About Liver Transplant Operation

Left half of the liver:


  • The ligaments holding the liver are cut and cholecystectomy is performed.

  • A film is taken to determine the anatomy of the bile ducts.

  • The veins and bile duct leading to the left lobe are identified and suspended.

  • The structures leading to the right side of the liver are carefully preserved.

  • The liver tissue begins to separate and the vascular structures are controlled.

  • The bile ducts are isolated, cut and carefully sutured.

  • The left portal vein, left hepatic artery and left hepatic vein are cut and the left lobe is completely or partially removed depending on the amount of liver to be removed.


Right Half of the Liver:


  • A similar procedure is performed for the right lobe.

  • It is advantageous that the graft (segments 5-6-7-8) fits the cavity on the right side.

  • Disadvantages are large cross-sectional surface, anomalies in vessels and bile ducts.

  • The right hepatic artery is a large artery unless there is an accessory artery.

  • Venous drainage requires special attention and a wide anastomosis is performed to ensure adequate hepatic drainage.

  • Biliary ducts can be anastomosed to the intestine or to the recipient's own bile ducts.

  • Although an adequate minimum graft volume cannot be determined, the graft/body weight ratio and estimated graft weight are important to indicate whether the transplant will be adequate.

  • Liver dysfunction may be more common in the donor because 2/3 of the liver is removed in this procedure.


This information describes the basic principles of the surgical procedures used in liver transplantation and how the liver is prepared. Each surgical procedure has certain advantages and disadvantages and this information plays an important role in the decision making of the surgical team.


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Cadaveric Liver Transplantation -DDLT Liver Transplant Procedure


Utilisation of the Left Half of the Liver:


  • Good results have been obtained with the use of the left lobe in children, and it is thought that this practice may be applicable to the right lobe in adults.

  • The left lobe graft (segments 5-6-7-8) fits exactly into the cavity on the right side and usually the right hepatic artery is a large artery.

  • Venous drainage requires special attention and a wide anastomosis is required to ensure adequate hepatic drainage.


Applications in the Presence of a Second Hepatic Vein:


  • If there is a large second hepatic vein (inferior right hepatic vein), two separate anastomoses should be performed or the mouths of these veins should be joined with artificial or specially preserved veins.


Anastomoses for Bile Ducts:


  • Bile ducts may require one or more anastomoses to the intestine or to the recipient's own bile ducts, depending on the number of ducts.


Graft Volume and Risks:


  • An important problem in liver transplantation to adults is to determine the maximum amount of graft that can be harvested without putting the donor at risk and the minimum graft volume required for the recipient to survive.

  • Although the adequate minimum graft volume is not known exactly, it is thought that a graft/body weight ratio of 1% or more or transplantation of 50%-60% of the estimated graft weight will be sufficient.


Extended Right Lobe Use:


  • Extended right lobe, which includes the middle hepatic vein but not the entire segment 4, reduces the risk of graft failure for the recipient.

  • However, since 2/3 of the liver is removed in this major surgical procedure, liver dysfunction is more common in the donor.


This information describes the different graft options used in cadaveric liver transplantation and their advantages and risks. In all cases, careful evaluation and surgical planning is required to determine the most appropriate graft option.


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Back - Table (Preparation of the Liver for Transplantation)


The liver taken from the donor (cadaver or living) is removed together with the surrounding tissues in a sterile and cold environment, cleaned from excess tissues and prepared for transplantation is called "Back - Table". This procedure is performed on a completely sterile operating table.


Sterile Preparation:


  • The bag with the liver is placed in a container filled with broken sterile ice and cold serum with special solutions. This prevents other liquids and ice from entering the liver. The liver is prepared in this cold liquid environment.


Preparation Stages:


  • The vessels and bile ducts of the liver in the bag are prepared.

  • They are cleaned from the surrounding tissues and possible holes and injuries in the vessels are detected.

  • If necessary, patches are applied to these areas and repairs are carried out.


These preparatory stages are meticulously carried out in order to properly prepare the liver and make it suitable for transplantation. Hygiene and care are of great importance in this process and are critical to the success of the transplant operation.


Transplantation of the Liver to the Recipient


In liver transplantation operation, the following steps are followed in the process of liver implantation to the recipient:


Surgical Incisions and Liver Removal:


The recipient's abdomen is entered under the ribs through incisions called mercedes incisions extending both to the right and left and extending to the midline. The entire liver is removed over the large vein, preserving the hepatic vascular and biliary stumps.


Preparation of the Operation Area:


Before the liver is brought to the operation field, it is made sure that the vascular stumps and the surgical field are ready.


Vascular Anastomoses:


The liver is first sutured to the main vein. The infrahepatic vena cava is brought to the liver area with two rows of sutures and sutured to the junction of the suprahepatic vena cava - hepatic veins.


The veins bringing blood into the liver are sutured to the veins of the recipient. At the end of the anastomosis, the clamps on the veins are removed. If there is a problem with the veins, vein grafts can be used.



Artery Anastomoses:


Arterial anastomoses are made between similar arteries in both the donor and the recipient. Spleen artery can also be used. If there is a problem in the recipient artery, the hepatic artery can be connected to the main artery with veins or synthetic veins taken from the recipient or donor.


Bile Duct Connection:


The bile duct can be sutured to the recipient's bile duct or intestine. A stent or T-tube may be used.


Drainage and Bleeding Control:


After bleeding control, the abdomen is closed by placing drains.

Precision, care and surgical expertise are of paramount importance in this process. Successful attachment of the liver to the recipient is the key to a successful transplant operation.


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Conditions for Cadaver and Living Donor Liver Transplantation


Liver transplant operations can be donor-derived (cadaveric and living donor). Here is information about these two types of liver transplantation:


Cadaveric Liver Transplantation:


This type of transplantation is performed from people who are brain dead. After the patient's death (brain death) is definitively determined, his/her family is interviewed and after obtaining permission for organ donation, some of the donor's organs and the entire liver can be used for transplantation to other patients. The liver is stored in special preservation solutions for a certain period of time and the most suitable recipients are identified and sent to the relevant centre.


Living Donor Liver Transplantation:


In this type of transplantation, a part of the liver is removed from a healthy individual and transplanted to the recipient. The recipient and donor must be related by blood and kinship up to the 4th degree. In addition, in cases where there is no kinship, the approval of the ethics committee should be obtained in case of long-term acquaintance and friendship. Nowadays, with the developing technology and better understanding of liver anatomy, donor operation can be performed safely.


Thanks to the large reserve of the liver, the metabolic needs of the donor can be met. After the operation, the liver regenerates rapidly in both donor and recipient and reaches almost normal size within a few weeks.


In both types of transplantation, it is important to identify a suitable recipient, surgical skill and appropriate organ storage. The ethical, legal and medically appropriate principles of organ donation and living donor transplantation should be carefully followed.


Living Donor Liver Donation Conditions are as follows:


  • Free Will: The donor must make the donation of his/her own free will.

  • Age Limit: The donor must be over 18 years of age.

  • Degree of Kinship: The donor and the recipient must be related up to the 4th degree.

  • Blood Group Compatibility: The blood groups of the donor and recipient must be compatible.

  • Health Conditions: The donor liver structure and function and other systems must be normal. The anatomy of the donor liver must be suitable for the recipient and itself.


These conditions and other technical details are determined by the Transplant Team during the Pre-Transplant Donor Evaluation, which usually takes 2-3 days. During this evaluation process, the suitability of the donor is examined in detail and the most suitable candidate for transplantation is determined.


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Frequently Asked Questions About Liver Transplantation


1. How long a person can live after liver transplant?


Life expectancy after liver transplantation may vary depending on a number of factors. In general, however, the survival rate of liver transplant patients is very good.


Approximately 88 per cent of patients live at least one year after transplantation and 73 per cent live at least 5 years. These rates may vary depending on factors such as selection of suitable transplant candidates, quality of post-transplant care, recipient and donor compatibility.


Some factors affecting survival after liver transplantation are as follows


  • Pre-transplant health status and severity of the disease

  • Finding and matching a suitable donor for transplantation

  • Successful realisation of the operation

  • Quality of post-transplant care and appropriate drug therapy

  • Healthy lifestyle monitored by the buyer

  • Possible complications and their treatment


Careful follow-up and regular use of medication after liver transplantation can positively affect the life expectancy of the recipient. There may be certain risks and complications after transplantation, but these risks can be minimised with appropriate treatment and follow-up.


Regular medical check-ups and co-operation with a specialist healthcare team are important for a successful post-transplant process. It is recommended to contact the nearest health institution or doctor for detailed information.


2. What is the Survival Rate for Liver Transplant Patients?


Liver transplantation carries certain risks as it is a medical procedure, but modern surgical techniques and medications are used to minimise these risks. The risks involve the person receiving the transplant (the recipient) as well as the donor, who receives the liver from the donor.


The main risks for liver transplantation are as follows:


  • General Surgical Risks: Liver transplantation is a surgical intervention and involves general surgical risks. There are risks such as infection, bleeding, reactions due to anaesthesia.

  • Complications: Complications may occur after liver transplantation. These complications include infections, biliary tract complications, vascular occlusion and allograft rejection.

  • Immunosuppression: The recipient receives drugs to suppress the immune system after transplantation. This reduces the risk of the body rejecting the transplanted liver tissue, but can also make it more susceptible to infections and other health problems.

  • Donor Risks: Donor liver donation also requires a surgical intervention and is associated with some risks. However, modern surgical techniques and assessment processes help to minimize these risks. Possible risks to the donor include infection, bleeding, complications and recovery after surgery.

  • Long-term complications: Long-term complications after liver transplantation can include health problems such as hypertension, kidney failure, diabetes, bone loss and heart disease.

Comprehensive evaluation and follow-up of the donor and recipient before and after liver transplantation is critical to minimize risks. All risks and benefits should be assessed according to the individual situation and health history. A thorough consultation and evaluation process before liver transplantation will help to understand and accept these risks.

 

3. How long does a liver transplant take?


Liver transplantation is a highly complex surgical procedure and is performed carefully and over a long period of time by surgical teams. On average, it can take between 6 and 12 hours. This time includes procedures such as removing the liver, preparing it, placing it in the recipient's abdomen and transplanting it. During this time, appropriate vascular and biliary connections are made for the donor and recipient, and the organ is properly positioned.


Liver transplantation requires careful planning and coordination by a specialized surgical team. It is also important to closely monitor the patient and provide appropriate care in the postoperative period. This procedure can significantly improve the lives of liver patients and improve the quality of life in the long term. However, as with any surgical procedure, this operation has risks and complications and therefore requires careful evaluation and preparation.


4. How long does it take a liver donor to recover?


The person who donated the liver (donor) undergoes a recovery period after the liver transplant operation. This recovery process may vary depending on factors such as the complexity of the surgical intervention and the reactions of the organism. Here is the recovery process of the liver donor in general:


  • Hospitalization (7-10 days): After the operation, the donor is monitored in the hospital for about 7 to 10 days, during which time his/her condition is closely monitored by the specialized medical team.

  • Home Rest (3-4 weeks): After discharge from the hospital, it is important for the donor to rest at home and continue the healing process. Heavy physical activities should be avoided during this period.

  • Return to Normal Activities (Approximately 6 weeks): After the rest and recovery period, the donor can return to normal activities. He/she can return to his/her daily activities except for heavy physical exercises.

  • Return to Work (Approximately 6 weeks): Approximately 6 weeks after the operation, the donor can return to work and resume normal daily life.


The recovery process may vary depending on individual factors and each donor's condition may be different. Therefore, compliance with the doctor's recommendations and follow-up plan is very important. Postoperative monitoring and check-ups are important to ensure that the donor has a healthy recovery.


5.Who is not eligible for liver transplant?


People who are not eligible for liver transplantation:


  • Under 18 years of age: To be accepted as a donor for liver transplantation, you must be over 18 years of age.

  • Those outside the 4th degree of consanguinity: The donor must be related up to the 4th degree. After 4th degree of consanguinity, ethics committee approval must be obtained from the Provincial Health Directorate.

  • Blood Group Incompatibility: Blood groups of the recipient and donor must be compatible. If the blood groups are incompatible, transplantation cannot be performed.


These criteria have been set to regulate the selection of a suitable donor for liver transplantation and the transplantation process. Choosing a suitable donor and paying attention to these criteria during the transplantation process is extremely important for the health of both the donor and the recipient.


6. Is there an age limit for liver transplant?


Yes, there are age restrictions in liver transplantation. Here are the details on this subject:


  • 18 Years and Over: In order to be a liver donor, a person must be over 18 years of age.

  • Age Limit (Under 60): Depending on the general health of the donor and recipient, the donor must be younger than 60 years of age. This age limit is set to assess donor suitability for transplantation.


These age restrictions are one of the important factors affecting donor suitability and transplant results in the liver transplantation process. Choosing a suitable donor for liver transplantation is the basis for a successful transplantation process.


7. How long is hospitalization after liver transplant?


The length of hospital stay after liver transplantation may vary depending on the recovery and condition after transplantation. Generally, the average length of hospital stay after liver transplantation can vary between 2 and 3 weeks.


During this time, depending on the patient's condition and recovery process, discharge is made or the patient may continue to be monitored in the hospital. The patient's full recovery and return to normal life depends on the course of the healing process.


8. Does the liver regenerate if it is cut?


Yes, if a certain part of the liver is damaged or removed, this organ can regenerate itself. The ability of the liver to repair itself is quite high. For example, even if about 60% of it is removed, the liver can complete itself over time.


This regeneration process is fast and starts shortly after destruction. This makes it possible for a person to donate a certain part of the liver in cases such as liver transplants and donor eligibility.


9. How long does it take liver to regenerate?


It is difficult to give a specific time frame for the liver's regeneration, as this process can vary from person to person and depending on the degree of damage to the organism.

However, it is generally known that liver cells have the capacity to regenerate themselves and this process can take place in as little as 6 months. The liver has a high regenerative capacity and this supports the repair of damaged or removed parts.


10. Is There Pain After Liver Transplant?


Yes, there may be pain after a liver transplant. Since liver transplant surgery is a major surgical intervention, postoperative pain is normal. Postoperative pain may vary depending on the type of surgery, the person's pain threshold and the body's healing process. This pain usually decreases over time and eases as the healing process progresses.


Infections can also occur after liver transplantation and can cause symptoms such as abdominal pain. Viral infections, especially cytomegalovirus (CMV), can cause abdominal pain, fever and diarrhea. It is therefore important to consult a doctor in case of any discomfort or pain in the postoperative period. The doctor will prescribe the appropriate treatment and ensure that the patient is comfortable.


11. How many years does a liver transplant donor live?


The life expectancy of liver transplant donors depends on many factors. These factors are as follows:

  • Age of the donor: Younger donors tend to live longer than older donors.

  • General health status of the donor: Healthy donors tend to live longer than donors with health problems.

  • How much of the liver is removed: Donors who have less liver tissue removed tend to live longer than those who have more tissue removed.

  • Post-operative complications: Donors who experience postoperative complications tend to live shorter lives than those who do not.

  • Lifestyle of the donor: Donors who lead a healthy lifestyle tend to live longer than those who lead an unhealthy lifestyle.


Data from Research:


  • 10-year survival rate: The 10-year survival rate of living liver transplant donors is 90-95%.

  • 20-year survival rate: The 20-year survival rate of living liver transplant donors is 80-85%.

  • Life expectancy: Living liver transplant donors live on average 50-60 years.


Factor

Impact

Age of the donor

Young donors live longer.

General health of the donor

Healthy donors live longer.

How much of the liver is removed

Donors who receive less tissue live longer.

Postoperative complications

Donors without complications live longer.

Lifestyle of the donor

Donors who lead a healthy lifestyle live longer.


Conclusion:


Living liver transplant donors generally live a long and healthy life. The 10-year survival rate is over 90-95% and the 20-year survival rate is 80-85%. Factors such as the donor's age, general health status, amount of liver tissue harvested, postoperative complications and lifestyle may affect survival.


Sources:



Liver Transplant Surgery in İzmir, Turkey

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