Patients with liver disease are dealing with a very serious medical condition, and may develop further complications. Patients and their families need to recognize the warning signs and what to do if complications occur. Signs and symptoms may include:

• Jaundice (yellowing of the skin and eyes)
• Itching
• Ascites (an abnormal accumulation of fluid in the abdomen)
• Forgetfulness, confusion
• Dark, tea-colored urine
• Gray or clay-colored bowel movements
• Vomiting of blood
• Tendency to bleed
• Muscle wasting

If you are experiencing any of these symptoms, please speak with your primary care physician before contacting us.

You or your primary care physician must contact our office to begin the referral process. Our Patient Referral Coordinator will then work on getting the necessary insurance clearance so you can start your evaluation here at Mount Sinai. It is important that you bring a copy of your medical records with you or ask your physician to fax it to us before your visit.

• Referrals to Adult Liver Transplantation
  Phone: (212) 659-8042
  Fax: (212) 289-4106
• Referrals to the Division of Liver Diseases
  Phone: (212) 241-0034
  Fax: (212) 289-7738
• Referrals to Surgical Oncology
  Phone: (212) 241-9049
  Fax: (212) 996-9688
• Referrals to Mount Sinai at Monmouth Medical Center and Englewood Hospital, New Jersey
  Phone: (212) 241-0034
  Fax: (212) 289-7738
• Patients living outside of the United States
  Contact our Senior Transplant Liaison, Sharyn Kreitzer, MSW, to arrange an evaluation or a consultation.
  Phone: (212) 659-8027 (Kidney Prgm Info)
  Phone: (212) 659-8042 (Liver Prgm Info)
  Email: Sharyn.kreitzer@mountsinai.org

Evaluation for liver transplantation is an ongoing process and continues even after you have been accepted onto the waiting list. The evaluation process determines whether you have liver disease for which transplantation is the best treatment and if you can safely undergo the transplant surgery.

During your visit, you will meet with our Transplant Hepatologist, Transplant Clinical Coordinator and Transplant Social Worker. We will take a complete medical history from you, conduct a physical exam, and review earlier records, tests and consultations. The Social Worker will conduct a full evaluation of your current environment, including an assessment of your personal support system such as your friends and family. The Clinical Coordinator will further explain the evaluation, selection and listing processes. Based on the urgency of your condition, you may also be given information about the transplant procedure, immediate post-operative care, medication and follow-up care.

It is important to remember that you will remain in the care of your primary care physician even after you are accepted as a transplant candidate. The transplant team will function as consultants. If you do not have a primary care physician, you should select one at this time. After the surgery (approximately three months) you will be returned to the care of your primary physician.

Testing During the Transplant Evaluation Process

1. Cardiology: You will have an echocardiogram to evaluate the heart valves as well as a stress test to exclude coronary artery disease, both of which could complicate your transplant
2. Chest X-Ray: This allows us to check for possible pulmonary complications
3. Abdominal CT / MRI: This is a computerized imaging study of the liver and allows us to determine the size of the liver and identify any abnormalities that may interfere with the success of your transplant
4. Blood Tests: It is important that we have your blood type, blood count, blood chemistries and viral studies in addition to other specific blood tests
5. Dental Clearance: You will be given a form to be filled out by your regular dentist describing the health of your teeth and gums
6. GYN: All female patients 18 and older will be given a form to be completed by your gynecologist and must be returned to our office
7. Mammogram: This test is required for all female patients 40 and older
8. Colonoscopy: This procedure is required for all patients over the age of 50 years

Depending on your specific condition, additional testing such as a bone scan, chest CT and upper endoscopy may also be performed.

Every potential liver transplant patient is seen by the social worker as part of the initial transplant evaluation. The social worker will be available to assist you with any psychosocial issues that may impede your candidacy for transplant.

As part of the evaluation, we explore various areas such as alcohol/substance use and/or mental heath issues that may require attention and assistance. The team determines whether further treatment will be required and if necessary, will assist in locating an appropriate program to meet your needs. In addition, the evaluation assesses if you have adequate social supports since they play a vital role during the transplantation process. You should discuss the transplantation process with your family and friends and bring someone with you on the first visit.

Social workers also provide individual and short-term family counseling related to the transplant process. They will advise you about various entitlements and resources and assist in referrals to appropriate agencies. The liver transplant process can be stressful at times; patients and family members are encouraged to contact their social worker at anytime for help.

All new referrals into our liver transplant program are handled by financial coordinators. They will obtain your demographic and insurance information to begin processing clearance from your medical insurance carrier. Some private insurance carriers or HMOs require prior authorization and may take longer to process. In some cases, a patient's insurance carrier may not participate with Mount Sinai, but we will work diligently with the insurance company to obtain approval.

During the first visit, our financial coordinator will meet with you and your family to discuss insurance coverage and financial obligations for both the evaluation and transplant. Financial clearance for transplant also involves coverage for outpatient medications and these matters must be addressed before a patient can be listed for transplant. Our financial coordinator and social workers will work closely with you and your family to resolve these issues. Please inform our financial staff of any insurance changes as this can affect your eligibility for transplant-related services. Patient insurance matters are closely monitored from referral until after the transplant.

Patients with liver disease who may need a liver transplant are dealing with a very complex medical condition. It is important that you and your family have a good understanding of all aspects of the pre-transplant process, transplant surgery and how to recognize and handle any complications that may develop before and after surgery.

We use manuals, regular classes, and inpatient video systems to provide our patients with a very thorough education. The manuals provide comprehensive information about the transplant process such as pre-operative care, waiting on the list, the transplant surgery, post-operative recovery and potential complications. Our Patient Education Video Program is available on our hospital TV system and includes 200 interactive videos.

Organs for transplantation are usually obtained from deceased donors. Unfortunately, there are not enough deceased donor organs available for everyone who needs one. As a result, more and more patients are being added to the transplant waiting list. The shortage of organs has caused many patients to succumb to their illnesses while waiting for a liver, or become too sick to undergo a transplant. However, if a patient receives a piece of liver from a living relative or compatible friend, he or she does not have to wait for a deceased organ. Thus, living donor liver transplantation can be an important alternative for many patients. In living donor liver transplantation, a piece of liver is surgically removed from a living person and transplanted into the waiting recipient.

Living donor liver transplantation is possible because the liver—unlike any other organ in the body—has the ability to regenerate, or grow. Regeneration of the liver happens over a very short period—possibly days to weeks, and certainly within six to eight weeks. Therefore, when surgeons remove a piece of the living donor's liver, the part that remains in the donor quickly grows back to its original size.

More than a decade ago, surgeons around the world began to perform these procedures using adult donors for children who needed transplants. In addition, surgeons gained experience in splitting a single deceased liver into two pieces, for transplantation into two recipients. Mount Sinai surgeons have been at the forefront of these surgical advances. They have also pioneered the use of living donor liver transplants in adult recipients, safely removing the larger right lobe of the donor's liver.

There are many benefits to living donor liver transplantation, including a lower risk of rejection and the ability to schedule surgery electively, rather than on an emergency basis, when a deceased donor liver becomes available. There is also an important emotional benefit that comes from knowing that a loved one has made a "gift of life." Mount Sinai has developed an independent donor advocacy team to ensure that the highest standards of safety and ethics are always in place. This team consists of an independent gastroenterologist, independent transplant surgeon, a liver transplant coordinator, social worker, psychiatrist and ethicist. For more information, please contact our Living Donor Coordinator at (212) 241-2892.

To learn more about becoming a living donor, please visit the following websites:

Transplant Living

After the evaluation, your case will be presented before our Recipient Review Committee. This group includes our Transplant Hepatologists, Surgeons, Clinical Transplant Coordinators, Social Workers, and various clinicians from other departments who are involved with the transplant team.

After you are accepted for transplantation, you will be put on the "candidate waiting list," and the search for a suitable donor begins. All patients are entered onto the national transplant waiting list maintained by The United Network for Organ Sharing (UNOS), a national organization that works 24 hours a day, 365 days a year to match donors to recipients. In order to fairly and efficiently distribute this scarce resource, the country is divided into regions, so most of the organs that come to Mount Sinai are from donors in New York State.

The amount of time you spend on the waiting list is determined by many factors including blood type and the urgency of your condition. Unfortunately, due to the shortage of donor organs, the waiting time can be long. It is very important that during this time you do your best to maintain good health.

The United Network for Organ Sharing (UNOS) is a non-profit organization that regulates and maintains the nation’s organ transplant waiting list. The Organ Procurement and Transplantation Network (OPTN) was established by Congress to ensure that donated organs are fairly distributed regardless of an individual's age, sex, ethnicity, religion, lifestyle, or social status through UNOS. Both UNOS and OPTN are regulated by the U.S. Department of Health and Human Services. On February 27, 2002, UNOS implemented the Model for End-Stage Liver Disease (MELD) scoring system for donor liver allocation. UNOS mandates that all transplant centers in the United States use this new policy.

The Model for End-Stage Liver Disease (MELD) scoring system was developed as a way to predict the likelihood of death within three months for people with advanced liver disease. One of the major responsibilities of the OPTN is to develop and implement new policies that will ensure that scarce donor organs are allocated to the patients that are medically in greatest need of a liver transplant. The idea behind MELD is that organs will be allocated more fairly because medical urgency is emphasized, while waiting time becomes less important.

How will a MELD score be assigned?

The MELD score will be calculated by using a mathematical equation that involves the following laboratory data:

• Creatinine: An end product of metabolism that is used to monitor kidney function, the normal range is less than 1.2 mg/dL. The value becomes abnormally elevated with kidney dysfunction that is associated with advanced liver disease. If a patient is receiving dialysis as a result of kidney failure, they will be assigned a maximum creatinine of four mg/dL
• INR: This is a laboratory value used to help determine the liver's ability for making clotting factors and a patient's risk for bleeding. If prolonged, it is an indication that the liver disease is progressing. Normal range is less than 1.2
• Bilirubin: An indicator of the liver's ability to detoxify the blood, it's what makes a person appear jaundiced (yellowing of the skin and white of the eyes). When elevated it can cause an individual to feel itchy. Normal range for total bilirubin is 0.1-1.2mg/dL

A MELD score can range from 6 to 40 points. The higher the MELD score, the more frequently you will be required to have laboratory blood tests. Organs are now allocated to the patient with the highest MELD score versus the patient who has the longest time on the waiting list. If there are two patients with the same MELD score, then time waiting at that particular score will be used as a "tie breaker."

While on the waiting list, you will have follow-up appointments with your own physicians as well as regular appointments in our office. At this point, we will start vaccinations against certain viruses and bacteria that sometimes develop after transplant surgery when immunosuppressive medication increases the risk of infection.

When a suitable donor has been identified, you will be informed and asked to come into the hospital. This call could come at any time and often happens at night, so it is important to be prepared. Upon arrival, you will undergo a series of tests and be given immunosuppression medications and antibiotics as part of your preparation for surgery.

Your family will wait in the Surgical Family Waiting Room and be kept abreast of your progress by a member of our transplant team while you undergo surgery. The transplant surgeon will speak with your family after the surgery.

Liver transplant surgery is extremely complex and may last six to eight hours or longer, depending upon the patient's condition. Transplant surgery occurs in four stages:

1. Removal of the recipient's diseased liver
2. Placement of the new liver and creation of vascular connections between donor liver and recipient vessel
3. Removal of the vascular clamps and establishment of the blood flow into the liver (which is called "reperfusion")
4. The last step is the reconstruction of the biliary tract. This can be done either by connecting the donor's and recipient's bile ducts or creating isolated intestinal loop to connect the donor bile duct

Immediately after the surgery, you will be taken to the Surgical Intensive Care Unit (SICU) where you will be closely monitored. Equipment will monitor your heart, blood pressure and breathing, and regular tests including blood tests, electrocardiograms, and daily chest X-rays will keep the clinical staff informed on your condition. You will have several intravenous lines providing medications and fluid. The abdominal incision will be in the shape of an inverted "Y" and will be cleaned regularly. As you regain your strength, certain equipment, such as IV lines and tubes, will gradually be removed.

Your family can visit you in SICU during designated hours. However, since post-surgical patients are at a high risk for infection, visitors with a cold or infection cannot visit you during this time. The length of stay in the SICU varies from patient to patient. You will be able to leave when you are fully awake, able breathe on your own, and have a normal temperature, blood pressure, and pulse.

From the SICU, you will be moved to the general surgical unit where you will be more comfortable because continuous monitoring will no longer be required. As the nurses help you through this stage of recovery, it is important for you to become independent as soon as possible so you can take care of yourself when you leave the hospital.  You should learn how to take your medications since this is a very important aspect of your long-term care. Independence also includes slowly returning to normal activities such as eating, walking and deep breathing. An inpatient nurse coordinator will explain the various medications and discharge planning and will teach you and your family about the post transplant recovery process.

The average post transplant hospital stay is approximately 8 to 14 days. However, transplantation is a complicated process and may require re-admission to the hospital if problems occur. Please refer to our post-liver transplantation education manual.

Follow up visits are very important to your recovery. Visits will be more frequent immediately after discharge and less frequent over the course of the following months. Typically, outpatient visits are scheduled as follows:

• Two visits each week for three weeks
• One visit each week for three weeks
• One visit every other week for three months or until you are considered sufficiently stable

When you are stable, you will be referred back to your primary physician for routine follow up care. We will continue to monitor your progress through blood tests and will remain in contact with your primary physician. You should be able to return to work three to six months after the surgery.

HCV
Hepatitis support group meetings are held every third Wednesday each month from 6:00 P.M. to 7:30 P.M. Anyone who is affected by Hepatitis C, including their friends and family members, may attend. To learn more, please call (212) 241-5736.

Liver Transplant
Liver transplant support group meetings are held at Mount Sinai every Thursday from 1:00 P.M. to 2:00 P.M. in the Guggenheim Pavilion, 9C patient/family visiting room. This group consists of pre- and post- transplant patients and their families or friends.