Liver transplantation which was performed by Thomas Starzl in 1963 in Denver U.S.A for the first time, improved greatly during the 80’s and is nowadays the only option in the treatment of liver failure.
In the 1990s, a number of new liver transplant centers were opened in different countries and a rapid increase occurred in the count of operations performed.
Liver transplantation techniques have reached outstanding levels as a result of studies since 1963. While one-year survival rate after liver transplantation was below 50% before 1980, today this rate is around 80-90%. In the past, liver transplantation used to be considered as the last remedy to save patient’s life, in contrary, in our age it’s a radical therapy applied in order to increase patient’s quality of life in the early stage of liver failure.
One year life expectancy for the patients who are in the last stage of liver failure is around 50% and emerging complications may reduce this rate even to a lower level. It has been shown that as the condition of the patient at the time of operation worsens, the life expectancy reduces and the costs of treatment increase. Therefore, appropriate timing and proper patient selection are gaining more importance.
While transplantation operations are gradually increasing, number of liver donors stayed relatively constant. One of the methods to compensate lack of available organs is taking cadaver’s liver, splitting into two parts (split-liver transplantation) and planting them into two receivers. Another method is getting a piece of the liver from living donor and planting it to the receiver patient. In our country, especially in recent years, transplantations from living donors stand out.
When doctors tell you that you or your child needs liver transplantation, there are two options in front of you:
1-) Cadaveric Liver Transplantation
2 -) Liver Transplantation with Living Related Donors
1 -) Cadaveric Liver Transplantation: Organs of persons who are declared brain dead as a result of traffic accident, brain hemorrhage, brain tumor or heart attack can be donated with the consent of the family. Examinations must show that the donor has no infectious disease, cancer or liver disease. The liver that is taken under appropriate conditions and preserved in special protection solutions must be transplanted within 24 hours after removal from cadaver. Unfortunately there are long waiting lists for cadaveric organ transplantation in Turkey as rates of organ donation are very low.
If you are on the waiting list for cadaveric organ transplantation, you should have a phone with you at all times (preferably your mobile phone) from which you will be accessible during 24 hours a day. In addition, you should have a list of people who will be able to give blood when necessary for the surgery.
2 -) Liver Transplantation with Living-related Donors: This is the type of operation where partial liver is transplanted from living relatives of the patient who has liver disease and is in need of organ transplantation. Mother, father, siblings, spouse or other relatives or friends must volunteer for this. It is necessary that all tests on this voluntary person verify there will be no harm on him/her as a result of partial liver donation.
These tests have two aspects:
First; Investigations of all systems in order to ensure that there will be no harm done to the donor. Heart, lungs, digestive system, as well as all the organs and mental condition are checked.
Secondly; Investigations of the liver. In these tests, all the structural properties of the liver which can be denoted as the “map of the liver”, arteries, vents and biliary tract are examined.
Provided all tests reveal appropriate results, it is decided that there is no obstacle to organ donation by the volunteering person. For minor patients, usually the left side lobe of the donated liver should be transplanted whereas for adults or elderly patients, the right side lobe of the liver should be taken.
Background information for liver donors
It is a very nice emotion to be able to do a favor to a loved one and offer him/her a chance to pull through the illness and bring him/her back to life. On top of that, nothing compares to the feeling of happiness when you make his happen by offering a part of your own organ.
Despite this beautiful feeling, the thought of donating a piece of your liver may be unsettling at first. You may begin to worry about what kind of consequences this may have on your future health.
Please keep in mind that donor's liver starts to grow rapidly immediately after the operation and reaches the pre-op size approximately three months later. Likewise, the piece of liver transplanted to the receiver patient grows to reach the normal size within three months.
When you decide to donate a part of your liver, very detailed assessments will be performed to ensure the safety of your health. If the slightest doubt arises regarding the safety of your health during these studies, your donation request will be rejected and you and your relative will be informed about this decision. The next step that should be taken in this case would be to find a new voluntary donor.
The tests to be performed during medical examination of the donor:
All blood and urinanalysis tests
Tumour markers (markers)
Viral hepatitis tests
Infectious diseases (such as AIDS, etc ...) tests
Echocardiography, cardiac X-ray if necessary
Abdominal ultrasound examination
Doppler ultrasound examination of liver veins
Computed tomography for liver volume determination
Hepatic veins angiography (if necessary)
Magnetic resonance cholangiography for bile duct (if necessary)
Liver biopsy (if necessary)
For liver donation, the lower and upper age limits are 18 and 60, respectively. Although it is not a certainty in this regard, health problems encountered above the age of 60 may pose an obstacle to transplantation surgery. Blood type compatibility (haemocompatibility) is the first prerequisite for liver transplantation. The following table summarizes the situation:
The blood type of the patient. The blood type that can donate the liver
A A 0
B B, 0
AB O, A, B, AB
Getting ready for the hospital
It is a good idea to pack a bag containing your daily needs before you go to hospital; this way, you wouldn't waste any time before leaving for the hospital. It is also good to have your teeth examined by a dentist while waiting for the donor organ so that your unhealthy teeth can be treated. This will help reduce any potential sources of post-operative infection. If you are getting a liver part from a relative, both the donor and the receiver will be hospitalized a few days before the transplantation. The materials mentioned above are separately necessary for both donor and receiver.
Getting ready for surgery
There will be some tests to be done upon your arrival at the hospital. They are part of the usual preparation for surgery and aimed at detecting any non-obvious infections. You will undergo a general physical examination and will be required to give urine and blood samples. A chest X-ray and electrocardiogram of your heart will be taken. Lastly, you will be required to wash your whole body with antiseptic soap and a nurse will shave the area of operation.
The transplantation surgeon and the anesthetist will meet with you to explain the process and the risks you may encounter. You will be asked to sign a form to give consent for surgery. You will pass a series of tests upon arrival at the hospital.
From the moment on the transplant team calls you:
Do not eat or drink anything
Notify your relatives
Do not smoke
Go to the hospital immediately
The process of surgery
The principles of liver transplantation from cadaver date back to 25-30 years ago. Since then, the surgical technique has been greatly improved and success rates have increased while the complications have shown a decrease. Nevertheless, liver transplantation is still a quite difficult surgery which lasts 6-12 hours on average. The whole diseased liver of the patient is replaced with the healthy liver. Although it seems like a simple operation, excessive bleeding may occur and usually one or two surgeons, three surgery assistants, three nurses and two anesthetists as well as assistants, nurses and technicians are necessary. The ill liver must be cut from the four main blood vessels; the tube that carries bile to the intestines from the liver (known as the bile duct) must be separated from the intestines. The new liver is then placed in its position and veins and bile duct are connected again in order to complete the operation.
As for the living liver transplantation surgery, it was started to be implemented in recent years and has rapidly become a widespread operation in the last 10 years. In this surgery, two teams, one that takes the liver and one that transplants the liver, work together at the same time. Liver taken from the relative is replaced with the diseased liver whose main abdominal vein (vena cava) is preserved. As a surgical technique it is much more difficult than the cadaver surgery. It requires a larger team. At least two surgeons, six surgical assistant, six nurses, two anesthetists, 4 anesthesia assistants, 4 anesthesia nurses and technicians work during the surgery. In addition, for the very small arteries that need to be stitched, micro-surgeons and for ultrasound examinations made during surgery, expert radiologists are needed. Living liver surgery lasts between 8-18 hours. The duration of donor surgery is 4 -6 hours.
Placement of the T-Tube and Biliary Drainage
Your surgeon may find it necessary to connect a small tube called the "T-tube" to your biliary tract. The T-tube enables the bile to be drained out of your body into a small bag called the "bile bag". Thus, the amount of bile with colors ranging from dark green to dark gold can be measured. The T-tube may stay connected to the bile bag after its placement for a period of one week/ten days or even longer. Unless there is a biliary stricture or leakage on the T-tube image (T-cholangiography) that is taken on the tenth day of operation, the T-tube is tied and closed. It may remain in place for weeks, in general for 3-6 months and sometimes for longer time in order to let the wound heal and to perform special tests. The T-tube is stitched to the skin and if the tamp around the tube gets dirty or wet, it needs to be replaced. You will be instructed on how to replace the tamp around the tube before you leave our hospital or this will be done when you come back for follow-up controls.
You will be taken to the intensive-care unit after the surgery and depending on the state of your lungs, you might be connected to a respirator (a breathing apparatus). If everything goes well, the respirator may gradually be disabled. Other drainage tubes as well as the T-tube may remain in your abdomen in the post-operative period. These tubes are used to empty any fluids around your liver, and are usually removed before you go home. Patients are often taken to the regular care unit after their stay at the intensive care unit for 1-2 days and may be discharged from the hospital after approximately 7-10 days of stay here. During this time, you will be monitored in terms of any signs of organ rejection such as high fever, pain, jaundice, fluid accumulation, drug side effects and decreased liver functions. This post-operative recovery period covers intensive physical and mental rehabilitation and the effort you will show in this period will be decisive for a quick recovery process.
Post-discharge Outpatient clinic Controls
You will need to come to the transplantation unit once or twice a week for outpatient clinic monitoring in the first months after you leave the hospital. The purpose of these outpatient clinic controls is to monitor your recovery and to identify any potential complications. Your liver functions will be carefully evaluated and you will undergo a medical examination; in this way, any potentially existing infections will be detected. You will be required to give a blood sample so that your blood Tacrolimus (Prograf) or
Ciclosporin (Sandimmun - Neoral) levels can be measured and your medications can be determined. Overdose medication may lead to a high repression of the immune system and a high risk of infection whereas underdose medication may lead to the rejection of the liver. As the risk of infection and transplant rejection reduces, so will the frequency of your outpatient clinic visits.
Do not take your Prograf and Sandimmun (Neoral) medication immediately before the blood test, as these may interfere with the results.
Bring your medication list and this booklet with you each time you come for check-up so that you can make a note of any important information
Life After Transplantation
Organ transplant patients describe themselves as they were born again and think they have started a brand new life. Most of them celebrate the day of operation as the "Transplant Birthday". Following the success of your transplantation, a life much better than before awaits you.
Returning home following the transplantation is a happy and emotional event, however some anxiety and even a mild depression may accompany this feeling of happiness in the first weeks. It is of great importance to understand that recovery is a process lasting several weeks. For both you and your family, it takes some time to get used to a new way of life: living with an organ transplant is a learning process that requires some time. Most people handle this situation better provided that they are active and in particular show a real commitment to overcome the long process of rehabilitation. With the end of the first sensitive phase of recovery which lasts about three months, almost all liver transplant patients return to their previous healthy lives. Despite the potential problems that affect the individuals who live with a transplanted organ, the majority of patients restore their normal lifestyles. They go to work, have families, raise children and play useful roles in the society. The recovery period can last for weeks. It is in your hands to shorten this period.
Diet and Nutrition
Before the transplantation, you have been sick for a long time and you probably have lost a lot of weight as well. For this reason, eating on a regular basis forms an important part of your recovery period. A healthy and balanced diet will help you get up on your feet again. Unfortunately, one of the side-effects in almost all of the patients taking up cortisone is a significant increase in the appetite. Thus, weight gain is a serious long-term problem in many transplant patients and you may need a low-fat and low-sugar diet in order to keep your weight and blood sugar levels under control. Consult a nutrition specialist for help in creating a balanced eating diet that meets your needs.
Your diet should include the following:
Grain cereals and breads
Low-fat milk and milk products or other calcium sources
Lean meat, fish, poultry or other protein sources
Points to consider in your nutrition
Weigh yourself every day
Avoid sugary junk food such as cakes and biscuits between meals.
When you feel hungry, eat some fruit or low calorie vegetables.
Try to take about two liters of fluid every day. This is good for your kidneys and helps to take waste away from your body.
(Bottled water, herbal teas, juices, low-fat pasteurized milk are appropriate options)
Always wash and peel fresh fruits.
Soil-growing vegetables such as potatoes should be peeled all the time and boiled in boiling water.
Using pressure cooker to cook vegetables protects vitamins and it is also a good way to save on electricity and time.
Do not eat raw vegetables, such as lettuce.
Avoid cheeses made from non-pasteurized milk, avoid moldy cheese.
Buy products such as milk, cheese, butter and yogurt in small amounts at a time, so you can eat them while they are still fresh.
To keep your weight and blood sugar under control, you may need low fat and low sugar diet.
Another side effect of cortisones is that they cause your body to store salt. This can cause your body to retain water and can lead to high blood pressure. You should limit salt intake.
For this purpose;
Use less salt when cooking.
Try not to add salt to cooked meal.
Avoid salty foods such as potato chips.
Avoid canned foods (they usually contain a lot of salt)
Corticosteroids cause your body to store salt.
Physical activity rejuvenates the body as well as the soul. The patients who exercise regularly say the exercise reinforces the sense of general well-being and it gives them more energy for work, having fun and personal relationships. Exercise burns the weight you gained, so that will help you keep your weight under control. It is important to make daily exercise to strengthen the weakened muscles after a long period of illness. Exercise program should increase your level of exercise gradually. In this way, your body will get all the benefits of exercise without causing injury or severe disability . The best exercise is walking. Especially walks in nice and clean weather would help you sleep better and also help your bowel work better. Walking up the stairs is also a good way to start exercise, but be careful not to overdo it and take a rest as soon as you feel tired. You will feel that your strength is back again and you can try other forms of exercise. Cycling, swimming and walking are very useful to increase overall muscle strength, and if everything goes well, in three months after the operation, you can do other hobbies such as jogging and tennis. In addition, by exercise, you can cope with osteoporosis which is one of the side effects of medication. Before you begin any exercise program, consult your doctor or transplant team.
They will propose the best exercise program for you. Walking is the best exercise.
If you experience any of the following symptoms, stop or postpone your exercise until your doctor's advice:
Chest, neck, or jaw pain, or pressure
Extreme fatigue that is not related with insomnia.
Unusual shortness of breath
Dizziness, light-headedness during or after exercise,
Sustained rapid or irregular heart rate during or after exercise not experienced before transplantation.
Driving: You are not allowed to drive within the first four weeks following transplantation.
Alcohol: Since alcohol is broken down by the liver, all kinds of alcoholic drinks can lead to liver damage, so you should avoid all kinds of alcohol. Since the transplanted liver is much more sensitive to the effects of alcohol than the normal organ, even very small amount of alcohol can make serious damage.
Smoking: Quit smoking definitely! Smoking is harmful for everyone, not just for you. If you need assistance, contact your doctor, s/he will introduce you to the team that will give you the help you need. Cigarette can block the vessels of the new organ and blockages can lead to the loss of the organ.
Sexual Activity: Usually after a few months following a successful transplantation and when you feel good enough, you may continue your sexual activity. Most men regain their potency and most women notice that their menstrual periods return back to normal in a few months after the surgery. However, some drugs might reduce sexual function. If you encounter problems, you can seek help from your doctor or your transplant team. Kissing someone is alright unless he/she has a cold or an infection like herpes. It is recommended for both sides to wash their bodies well with water and soap before the sexual intercourse. Since some immunosuppressive medications reduce the effectiveness of oral contraceptives such pills are not recommended. Intrauterine devices such as spirals are generally not recommended as they increase the risk of infection. Condoms are the best way to prevent both infection and unwanted pregnancies. Diaphragms are another option. Some women may choose to consult their gynecologists about this choice. You may continue your sexual activity when you feel good enough.
Reproduction: After surgery, many men were able to have children and many women were able to give birth to healthy children as well. Women should discuss their desire of having a family with their doctors or a member of the transplant team. You should normally wait for at least a year or two before getting pregnant. Moreover, you need to have good liver functions, be free of any disease that could threaten your or your baby's health and must receive a low-dose immunosuppressive treatment.
Vacation: There is no reason preventing you from travelling to different places of the country or around the world, however, use your common-sense and avoid places where the water or food may be contaminated and health conditions may be poor. Before taking any vacations, get advice from your doctor regarding your travel plans. Do not forget to take enough medication for the duration of your travel and leave an address where you can be reached. Take adequate amount of medication with you for the trip.
Vaccinations: You must not be vaccinated with any live or attenuated (weakened) vaccines (e.g. administration through oral route against polio or rubeola) You may be vaccinated with a dead or inactive viruses (e.g. against tetanus) but you must definitely notify your doctor or your transplant team before you get vaccinated.
Pet Animals and Home Plants: Having pets at home is normally not recommended since they increase the risk of infection. However, for many people, caressing a pet and taking care of it is an important factor that speeds up the process of recovery. Fish, reptiles and small rodents have the lowest risk of infection. Dogs are another option and short-haired species are rather easier to keep clean. Cats should be avoided because of the danger of toxoplasmosis infection and birds are not recommended either for they carry Staphylococcus bacteria. If you have a pet, you must avoid making physical contact with its faeces and wear plastic gloves while cleaning its cage. It's best to ask someone else to do this job. Do not let your pet lick your hand or face, but if that accidentally happens, you must wash the area immediately with soap and water. The pet's utilities such as artificial bones, toys and food cans must be kept clean and away from your belongings.
Pot plants are not recommended because of the danger of infection caused by soil microorganisms. Due to the high risk of infection, you must not do any gardening, farming and soil work. You may later work in garden little by little; however avoid works such as planting or picking up leaves and wear your gloves at all times.
House Cleaning: You must clean the bathroom and kitchen -especially the refrigerator. No special disinfectants are necessary. Normal household detergents and liquid scrubbing soaps are good enough. The other rooms must be cleaned as usual as well and bed sheets must be changed once a week. We do not recommend having any pets. Avoid pot plants.
Your body recognizes the transplanted liver tissue as a "foreigner" and your immune system launches a counterattack against this "invader". Immunosuppressive drugs weaken the response of your immune system and prevent the rejection of the transplanted liver. Nevertheless, at the same time, immunosuppressive drugs may leave you more susceptible to infections. For this reason, a balance is needed between the conflicting needs of preventing the transplant rejection and maintaining an efficient defense against infection. Fortunately, the amount of immunosuppressive drugs needed to protect a transplanted organ reduces after the first months following the surgery. Still, immunosuppressive drugs are necessary for many years after transplantation and you must never skip doses and reduce the amount taken without the approval of your doctor. All immunosuppressive drugs can cause some side effects. Doctors have determined that a level of immunosupression close to the ideal can be maintained while lowering the side effects of each of the drugs in an immunosuppressive drug combination. As a result, your treatment will probably contain a mixture of several immunosuppressive drugs. Your body would recognize the liver tissue as foreign.
Immunosuppressive drugs are used for life-time after transplantation. Because every patient responds differently to these drugs, the treatment with each of the immunosuppressive drugs is customized according to the specific needs of the patient. Do not worry if other patients receive more or less drug pills or different medication than what you are taking. You will find an overview of the most commonly used immunosuppressive drugs below. This information does not cover all aspects of each drug, and if you have any further questions you should consult your doctor or transplant team. Keep in mind that most people do not experience all of the side effects and will experience less of them as the dose is reduced gradually in time.
Some immunosuppressive drugs are used for the rest of the life whereas some are only used in the treatment of rejection periods.
Long-term Usage Drugs
Mophetil Mycophenolate (Cellcept)
Cyclosporine (Sandimmun, Neoral)
Mycophenolic acid (Myfortic)
Corticosteroids (prednisolone and metilprednisolone)
Corticosteroids (cortisone) may be used for lifetime to prevent organ rejection or they may be discontinued within the six months following the surgery in appropriate cases. Short-terms and higher doses are used to treat acute rejection. Corticosteroids are produced naturally in the adrenal glands and are required for the normal function of most tissues. The body synthesizes corticosteroids within a 24-hour rhythm; the peak concentrations occurring in the early hours of the morning are followed by a decline throughout the day. That is why you need to take your corticosteroid pills first thing in the morning so that you can get in sync with the natural rhythm of your body. Some patients may take a single dose of cortisone in the morning and some may take twice, one in the morning and one in the evening. Corticosteroids are often used in combination with cyclosporine or tacrolimus.
Using corticosteroids: Your corticosteroid dosage will be calculated according to your weight, your medical conditions and the time passed since the transplantation.
Take the pills with meals. If you take the pills once a day, take them at breakfast.
Side Effects: Short-term side-effects of corticosteroids include the following:
Increased susceptibility to infection, wound healing disturbances
Suppression of fever and other signs of infection
Increase in blood sugar
Changes in the mood ranging from a state of happiness to agitation and confusion.
In some cases, depression
Long-term side effects of corticosteroids tend to correlate with the total dosage amount needed for treatment. Depending on the dosage, corticosteroids can cause the following:
A shift in the distribution of body fat (increase in neck fat - bulging cheeks, hunched back)
Thinning and weakening of bones, muscle weakness
The growing tendency towards high blood pressure
Reduction in skin thickness and susceptibility to bruise easily, Diabetes
A slight increase in the growth of acne or facial hair
Weight gain as a result of increased appetite
Gastrointestinal side effects, ulcers, or chest burning
While this side-effects list may seem pretty scary, it should be emphasized that, with the low-dose usage of corticosteroids for organ rejection, these bad side-effects are nowadays observed far less frequently than before. Compared to other immunosuppressive drugs, corticosteroids have some advantages : they do not suppress bone marrow, can be used in combination with other drugs, and there are no direct toxic effects on the transplanted organ.
Precautions: If you are pregnant or in the breastfeeding period, the benefits of taking this drug should be checked against any potential damages that can be done to your fetus or baby. If you think you are pregnant, consult your doctor or transplant team immediately. Corticosteroids may be used in combination with other drugs.
Imuran (Azathioprine): Azathioprine shows its effect via blocking the ability of cells to divide. It is always given in combination with other immunosuppressives, for example cyclosporine or tacrolimus. Azatioprines are also useful alternatives in cases when a new combination of immunosuppressive drugs is needed due to negative side-effects of another drug. Not all transplant patients receive Azathioprine, so do not worry if it is not among the immunosuppressive drugs you are taking.
Usage of Azathioprine (Imuran): Your dosage will be calculated according to your weight, your medical conditions and the time passed since the transplantation. You may take your pills at any time of the day, but try to make a routine for yourself by taking them at the same hour every day.
Side Effects: Bone marrow cells are very sensitive to azathioprine. In patients taking Azathioprine, anemia, decrease in thrombocyte numbers, bleeding disorders and most frequently decrease in WBC (leucocyte) counts and tendency to infection may occur. For this reason, the doctor needs to count blood cells often until a steady azatiophrin dose is reached. If the blood cell count is low, you may be forced to discontinue taking this drug for some time and give time to the bone marrow to regenerate.
In addition, azathioprine can lead to the following:
Digestive system problems such as nausea.
Joint aches and pains
Impaired hepatic function
Increased risk of tumor (lymphoma)
While this list may seem worrisome, it is important to note that that the incidence of side effects is relatively low . Effects of azathioprine in the bone marrow are reversible if the drug is discontinued. Azathioprine has been used for more than 35 years in order to prevent organ rejection and low doses needed to prevent organ rejection are safe for most people. Not all transplant patients use azathioprine . Today, instead of azathioprine, mophetil mycophenolate (Cellcept) is frequently used.
If you are pregnant or in the breastfeeding period, the benefits of taking this drug should be checked against any potential damages that can be done to your fetus or baby. If you think you are pregnant, consult your doctor or transplant team immediately.
Prograf (Tacrolimus): As cyclosporine, tacrolimus also inhibits the function of T-cells and prevents them from attacking and damaging your liver. Tacrolimus is taken orally usually in combination with corticosteroids and sometimes with azathioprine or CellCept; circulating concentration of tacrolimus in your body is measured by a blood test and according to the results its dose is determined. Drug dose will be gradually reduced.
During the first few months of Tacrolimus intake, you will frequently have blood tests; so that the side effects of the drug can be observed.
Prograf (Tacrolimus) Usage (1 and 5 mg capsules): Your dose will be calculated based on your weight, blood level, medical condition, laboratory test results and the presence of any side-effects. Total daily amount should be divided into two doses and should be taken in 12 hours apart. Swallow the unpacked capsule immediately with a full glass of water. Capsules should be taken 1 hour prior to or two-three hours after meals. On the day of check-up visits, do not take tacrolimus until you give your blood sample. Please remember to bring your medication with you, so that you can take it after giving the blood sample.
Side Effects: Side effects of Tacrolimus are listed below.
Slightly elevated blood sugar levels
Numbness and tingling in hands and feet
Hand shaking (tremor)
Transplant team may change your drug from cyclosporine to tacrolimus or tacrolimus to cyclosporine. This is done in order to prevent or eliminate the side effects of ongoing tissue rejection. Never take tacrolimus and cyclosporine at the same time.
Many of these side effects can be eliminated or reduced by decreasing the dose of tacrolimus. Probably you will not experience all or at least most of these side effects at once and keep in mind that as the received dose is reduced in time, less of the side effects will occur. Tacrolimus interacts with many commonly used drugs. Before taking any new medication, always seek the approval of your doctor or transplant team. Unprescribed drugs which you can take from pharmacies are also included in those. If you are pregnant or in the breastfeeding period, the benefits of taking this drug should be checked against any potential damages that can be done to your fetus or baby. If you think you are pregnant, consult your doctor or transplant team immediately.
Cyclosporine (Sandimmune / Neoral): Cyclosporin acts by preventing the activity of T-cells (a type of white blood cell); cyclosporine is taken orally usually in combination with corticosteroids and/or azathioprine. Circulating concentration of cyclosporine in your body is measured by a blood test and according to the results its dose is determined. cyclosporine and tacrolimus are the main drugs that suppress your immune system,
Cyclosporine (Sandimmun / Neoral) usage: Your dose will be calculated based on your weight, blood level, medical condition, laboratory test results and the presence of any side-effects. If you are receiving cyclosporine twice a day, doses should be 12 hours apart. On the day of check-up visits, do not take cyclosporine until you give your blood sample. Please remember to bring your medication with you, so that you can take it after giving your blood sample. There are two formulations of cyclosporine: liquid and capsules. In addition, a new formulation of cyclosporine apart from Sandimmune is out in the market: Neoral. The absorption of Neoral is less dependent on bile compared to Sandimmune. It also provides less variable blood levels.
Liquid Dosage Form: Oral liquid form of cyclosporine requires careful preparation, because it is chemically unstable when exposed to sunlight for extended periods.
Since cyclosporine is an oily liquid, it is insoluble in water and patients using this drug must follow the instructions below:
With a given pipette, carefully pipette and mix the prescribed amount of cyclosporine, then put the fluid in a glass, ceramic mug.
Do not use plastic or polystyrene cups.
Using a metal spoon, mix cyclosporine with milk, chocolate milk or apple juice thoroughly. Mixed beverage should be at room temperature.
Do not use grapefruit juice.
Drink the mixture immediately and to ensure that you receive the entire dose, rinse off the glass with some more milk or fruit juice.
Dry the outside of pipette with a soft single-use the paper and put it back in its protective pouch. Never clean the pipette with water or other cleaning products.
Take your cyclosporine medication at the same time every day.
Do not refrigerate cyclosporine. Keep your medicine in a cool and dry place.
During the first few months of Cyclosporine intake, you will frequently have blood tests; so that the side effects of the drug can be observed
Capsules: Some patients find it easier to use capsules rather than the liquid form. Patients should take the capsules with a little milk, chocolate milk or fruit juice. Never take your capsules with grapefruit juice. Capsules should be taken at the same time every day. Swallow the capsules as soon as you removed them from blister
Side Effects: Some side effects of cyclosporine are listed below.
Increase in blood lipids
Increased pilosity (hair development)
Hand shaking (Tremor)
Diarrhea, gastrointestinal problems such as vomiting and nausea.
Many of these side effects can be eliminated or reduced by decreasing the dose of cyclosporine. Probably you will not experience all or at least most of these side effects at once and keep in mind that as the received dose is reduced, less of the side effects will occur.
Cyclosporine interacts with many commonly used drugs. Before taking any new medication, always seek the approval of your doctor or transplant team. Unprescribed drugs which you can take from pharmacies are also included in those. If you are pregnant or in the breastfeeding period, the benefits of taking this drug should be checked against any potential damages that can be done to your fetus or baby. If you think you are pregnant, consult your doctor or transplant team immediately.
Drug Control List
The following rules are valid for all drugs:
Take your medicines at the same time every day
Never change or cut the dose on your own, even if you feel better
If you take more than one recommended dose accidentally, immediately notify your doctor
Please note that your medicine is only for you
Do not use any medicine after the expiration date indicated on the label
Take unused drugs back to the transplantation service
Please inform your doctor or transplant team about any new or unusual adverse effects when taking your medicine
Do not take unprescribed drugs without your doctor's permission
Keep your medicines in a cool, dark, dry place and out of reach of children
Unless your doctor or pharmacist indicates the otherwise, do not keep your medication refrigerated.
Make sure that you have enough medication before you go on holidays, long weekends or trips.
All patients undergoing major surgery may experience postoperative complications. The majority of transplant patients may experience some complications in the first few weeks after surgery, so you should not worry if you encounter some problems as well. Your transplant team will do their best to reduce complications and quickly treat any emerging ones.
Rejection: Many patients undergo a minimum of one and sometimes a few rejection episodes in the first weeks following the transplantation surgery. At first there may not be any physical rejection signs, however you may notice an unexplained slight fever or a slight change in your well-being such as a general feeling of weakness. This is often detected with abnormalities in liver function tests.
Treatment of rejection: In case of a suspected rejection, this is usually verified via liver biopsy. If you have a moderate or severe rejection, high dose cortisone treatment is initiated for three consecutive days (pulse steroid). A week later, a biopsy can be performed to see if the treatment is effective. If there is a persistent, worsening or a re-occurring case of rejection even after steroid treatment, a stronger immunosuppressive treatment is applied. Another biopsy can be performed to check whether the rejection is brought under control after a week of treatment. Fortunately, unavoidable rejection events occur rarely anymore with the use of new and strong immunosuppressive drugs.
It is necessary to suppress the immune system to prevent organ rejection. However, this also weakens the power of your body to fight infection. You will notice that you are more prone to colds and flu in the first period after the surgery.
Prevention of infection: The world around us is full of germs and while it is important to limit contact with potentially infectious organisms, you do not necessarily have to live in a "bubble”. There are simple measures that you and your family can take in order to reduce the risk of infection without severely limiting your lifestyle. These include the following:
A healthy and balanced diet
Exercising regularly and keeping your weight within acceptable limits
Avoiding busy shopping centers, theaters and cinemas during the influenza season
Limiting contact with people carrying active infections such as the common cold and flu
Washing your hands thoroughly after using the restroom and before eating
Immediately cleansing small cuts and scars and applying a plaster
Wearing gloves while working with flowers in the garden or doing other such dirty works
Symptoms of Infection: Sometimes an infection cannot be prevented. Please contact your doctor or transplant team immediately if you experience the following:
All fevers lasting longer than a day at 38 ° C (especially if it is accompanied by chills)
Diarrhea, nausea, vomiting or unexplained headache
Fatigue, loss of appetite
Difficulty in breathing, urinary burning, abdominal pain
Change in the color of your eyes or skin, skin rash, pain and difficulty in swallowing
Abnormal Renal Function
In some patients, cyclosporine (Sandimmun) and tacrolimus (Prograf) treatments may cause abnormal kidney function. Deterioration in renal functions can easily be detected via measuring urea and creatinine levels. These two waste products rise to abnormal levels when kidneys fail to function efficiently due to cyclosporine or tacrolimus toxicity. These side-effects are often related to dose and generally can be controlled by reducing the dose. Abnormal renal function may be difficult to detect, but if you urinate excessively at night, or when you notice you feel tired all the time or there is a significant decrease in the amount you urinate even though you take enough fluid, please contact your doctor or transplant team.
** These side effects are often dose related.
Diabetes is the increase in the rate of glucose in your blood. Long-term diabetes can lead to kidney failure, blindness, circulatory disorders and loss of sensation in the arms and legs. Some immunosuppressive drugs you take may lead to diabetes. If you notice any of the following, please notify your doctor or transplant team:
Increased frequency of urination
You can lower your blood sugar level by losing weight, maintaining a careful diet and regular exercise. An oral anti-diabetic drug or insulin injection may be required. If diabetes occurs, you will receive special treatment in order to help you cope with this problem.
High Blood Pressure (Hypertension)
High blood pressure and heart disease are more commonly observed as people get older. You may have a rise in your blood pressure as a side effect of certain medications you have to take. If left untreated, high blood pressure can weaken the heart and can lead to aging of blood vessels. Therefore, in order to control your blood pressure, you may have to take additional medications. In addition, to increase urine output and to remove unwanted fluids out of body, you may take a diuretic (water pill).
You may have to take additional medications to control your blood pressure. Organizing your lifestyle can also help to lower your blood pressure. Try to avoid stress, follow a low-salt diet, quit smoking and exercise regularly.
All immunosuppressive drugs may slightly increase their risk of cancer development, especially B-cells (a type of white blood cell) lymphoma. For anyone using immunosuppressive drugs, there is a risk of cancer development, albeit a small one (less than 3%).Skin cancer is more likely to occur in transplant patients. Therefore, you should take precautions to protect yourself from the sunlight.
Cyclosporine and tacrolimus can lead to sleep disorders such as insomnia, nightmares or mixed dreams. You may feel frustrated and experience sudden mood changes.
Some patients have difficulty in concentrating and remembering. You may notice your hands shaking or a tingling sensation in your hands and feet. These side effects usually occur shortly after the surgery and decreases as drug dose is reduced. You may feel angry and experience sudden mood changes.
It is not unusual to see the transplantation patients worried or depressed at the end of the first excitement of transplantation. Changes in the appearance can be disturbing for some patients, especially women and children. You may be afraid that the life after transplantation surgery will not be the same as before and you may be afraid of being disabled or changed in shape. This can cause stress or tension in the family. It can be difficult for your partner or family to understand your specific needs. There are counseling services to help you and your family adjust your life at home, and to prepare you to return to work or school. You should contact your doctor or your transplant team about these kinds of services; so that these problems can be solved or avoided.
Quality of Life
Transplanting a liver from some person to another is not like changing the engine of a car. You have to make some changes in your life, such as taking your medication every day and going to the hospital for usual outpatient clinic visits. Nevertheless, life quality of the majority of transplant patients is much better compared to the life quality before transplantation. For many people, a transplanted organ has given them a second and valuable life and it symbolizes a new beginning. The majority of transplant patients believe that they have a very good life quality.
Contacting Your Transplant Team
This is your main responsibility. When your body and the transplanted tissue are compatible with each other, the purpose of your medical care is the same as that of any healthy person: prevention of disease and successful treatment of any emerging problems The communication between you and your transplant team and other doctors is mandatory for your permanent good health. Please make sure that all the doctors you get treatment from are aware of your transplantation, medications you take and measures you have to take in order to stay healthy. Keep an accurate and up-to-date record of your medical details: blood pressure, heart rate, changes in medications or dosage, minor infections and their treatment and any new symptoms or side effects must be recorded. Get to know your body well and notify your doctor about any changes. Keep an accurate and up-to-date record of your medical details.