LIVER TRANSPLANT HANDBOOK

CONTENTS

Introduction

1. LIVER
Liver Disease

2. LIVER TRANSPLANTATION
a. Cadaver Liver Transplantation
b. Living-Related Donor Liver Transplantation

Important Information for Liver Donors

Examinations for Liver Donors
Getting Ready for the Hospital
Getting Ready for the Surgery
Surgery Procedures
T-Tube Insertion and Bile Drainage
After the Surgery
Liver Biopsies
Policlinic Procedures after the Hospital

3. POST-HOSPITAL CARE
Surgical Incision Wound Management
T-Tube Management
Monitoring Fever
Blood Pressure and Pulses
Teeth Care
General Body Care
Skin and Hair Care
Growing of Undesired Hairs
Exposure to Sunlight

4. LIFE AFTER THE TRANSPLANTATION

Going Back Home
Diet and Nutrition
Points to Consider in your Diet
Salt (Sodium)
Exercise
Driving
Alcohol
Smoking
Sexual activities
Production
Vacation

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Vaccinations
Pets and Plants
House cleaning

5. IMMUNOSUPPRESSIVE MEDICATIONS
Long-term Drugs
Rejection Treatment
Using Corticosteroids
Cyclosporine (Sandimmum / Neoral)
Prograph (Tacrolimus)
Mychophenolate (CELLCEPT, MY FORTIC)
Immuran (Azatioprin)
Rapamune (Sirolimus)
Using ALG or ATG
OKT3 (Muromonab- CD3)

6. MEDICATION CONTROL LIST

7. POST-SURGERY COMPLICATIONS

Refusal (Rejection)
Rejection Treatment
Infection
Infection Prevention
Infection Symptoms
Abnormal Kidney Functions
Diabetes
High Blood Pressure (Hypertension)
Cancer
Neurological Complications
Psychiatric Problems
Life Quality
Communication with your Transplantation Team

8. GLOSSARY

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 INTRODUCTION

It is possible that you may not have ever come across the term liver transplantation in
your life before you had a opportunity to read this handbook. When your doctor told you
that you could not possibly lead a life with your old liver anymore and you needed a new
liver, you may even have become a little worried. But today the best-known treatment in
the world for patients with liver failure is liver transplantation. Every day a great many
people all around the world are getting a second chance of returning to their healthy,
active lives owing to liver transplantation surgeries. Recently, the success rate of liver
transplantation surgeries has increased tremendously. Moreover, new medications and
recent progress in surgical techniques have ameliorated post-operational quality of
patients’ lives and success rates of surgeries.

This handbook is designed to give you and your immediate family information about
cadaver liver transplantation and living donor liver transplantation. It will allow you to
find answers to many of the questions in your mind about issues arising either during
surgery or after the procedure. Everything that your new life may require and that you
should take into account are described in detail.

We would like you all to be fully equipped with all the information you need about your
new liver. Having this information will better facilitate your adjustment to your new life
and recovery process.

I wish you happiness in your new lives.

Prof. Yaman TOKAT

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1. LIVER

The liver is the largest organ of our bodies. The liver lies on the upper-right side of your
abdominal cavity, behind the lower ribs, and beneath the diaphragm. The liver has many
functions. Some of them are:

• Breaking down food and turning it into energy (For instance, starch is broken
down to glucose, and it produces urea for the digestion of fats);
• Producing blood clotting factors, enzymes and other proteins;
• Storing iron, vitamins and other energy sources (e.g. fats and glucose); and
• Filtering harmful substances from the blood such as alcohol and drugs.

Liver Diseases

The liver has an outstanding capacity for renewing itself even after many diseases. Yet, in
some occasions, the liver may be subject to irreversible damages. These damages may
occur as a result of some genetic abnormalities, excessive alcohol and drug consumption,
cancer or infectious viruses that may lead to hepatitis. The disease, which appears when
the liver shrinks by getting tense and various sizes of lumps appear on it, is called
cirrhosis. Liver cirrhosis may result in morbidity and some of its complications are
bleeding, jaundice, collection of fluid in the abdomen (ascites), infection, and coma by
accumulation of toxins. At this point, the only option for survival is removing the
diseased liver and transplanting a new one. The patient can only survive by such an organ
transplantation surgery.

The most distinctive complication of the liver disease is jaundice (yellowing of the eyes
and skin). The cause for jaundice is excessive accumulation of urinary products.

BE AWARE!!!

• Dark urine;
• Confusion or coma;
• Vomiting blood;
• Easy bruising and bleeding tendencies;
• Grey or clay color excrements;
• Development of fluid in the abdomen (ascites);
• Extreme fatigue; and
• Shivering in sleeping tendencies

are some of the symptoms of a liver disease.

A liver disease progresses with symptoms such as:

1. Hepatitis;

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2. Development of fluid in the abdomen;
3. Bleeding; and
4. Confusion-coma.

2. LIVER TRANSPLANTATION
There are two options after you are told that you or your child need a liver
transplantation.

1. Cadaver Liver Transplantation

2. Living-Related Donor Liver Transplantation

1. Cadaver Liver Transplantation: The transplantation surgery may become possible

after the organ donation by the family of a person whose brain death has occurred
following a traffic accident, bleeding in the brain, brain tumor or heart attack.
Examinations should confirm that the donor does not have any kind of infectious
diseases, cancer or liver diseases. Within 24 hours at most, the liver removed from the
deceased person and kept in a special protection liquid should be transplanted under
proper conditions. Unfortunately, as cadaver liver transplantation is so uncommon in our
country, there are long waiting lists.

If you are on a waiting list of cadaver liver transplantation, you should always keep your
phone (preferably cell phone) with you 24 hours a day in order to be reached. Moreover,
you should always keep a list of the people who will donate blood for your surgery.

2. Living-Related Donor Liver Transplantation: This is the kind of surgery where

pieces of livers are removed from the relatives of people who suffer from liver diseases
and are in need of organ transplants.

Mothers, fathers, brothers/sisters, wives or other close relatives should volunteer for liver
transplantation. All the examinations done on this person should prove that this donor is
eligible for liver transplantation. There are basically two sets of tests:

The first set includes examination of all systems so that the donor is not subject to any
harm. These examinations are related to all organs such as the heart, liver, digestive
system, and psychiatric conditions.

The second set comprises examinations related specifically to the liver. Within these
examinations, all structural features of livers, which may also be described as liver maps,
arterial, venous, and biliary systems are checked.

If all the examination results are fine, it is decided that the candidate donor may proceed
in organ donation. Usually, for young children patients, the donor’s left part of the liver
should be removed; whereas, for adults or older patients, the donor’s right part of the
liver should be taken out.

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Important Information for Liver Donors
It is a unique feeling to do a favor for someone you love, to give him/her a second chance
to live and survive from his/her disease. Furthermore, doing it by giving a piece of your
organ makes it an even more incomparable pleasure. Despite these sensational feelings,
you may still have lingering doubts about donating a piece of your liver. You may be
worried about long-run effects of the donation on your health in the future.

Please keep in mind that the donor’s liver will immediately start growing back after the
surgery, and within approximately three months it will regenerate to its previous size
before the surgery. In the same manner, the part transplanted in the recipient will also
grow back in three months and regenerate to the normal liver size of the patient.

When you decide to donate a piece of your liver, detailed examinations will first be done
in order to protect your health condition. During these examinations, if any kind of
doubts should arise, then you will not be considered as a donor candidate and you and
your relative will be notified. After that, a new donor will be looked for.

Examinations on the Liver Donor

1. Complete blood and urinary tests;

2. Tumor markers (indicators);
3. Liver tests;
4. Viral hepatitis tests;
5. Infectious diseases (HIV, etc.) tests;
6. Pulmonary function test;
7. Cardiograph, echocardiography, if needed;
8. Abdominal ultrasound;
9. Doppler ultrasound for liver veins;
10. Spiral tomography for liver volume;
11. Magnetic resonance cholangiography for biliary tracts; and
12. Angiography for liver veins (if needed).

The minimal age limit is 18 and the upper age limit is 60 for donating a liver. Even
though there is no definite evidence regarding whether people over sixty may donate or
not, problems that are likely to occur in people over 60 constitute problems for this kind
of surgery. The first requirement for the liver transplantation is blood group
compatibility. The table below summarizes this requirement.

blood group can receive blood from can give blood to

0 0 0-A-B-AB
A 0-A A-AB
B 0-B B-AB
AB 0-A-B-AB AB

*Rh factor does not have any effect on organ transplantation

*In some circumstances and with small babies, liver transplantation surgeries may

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 be performed without the requirement of blood compatibility

Getting Ready for the Hospital

It is a good idea to have a pre-prepared bag at home for the hospital; in this way, you will
not lose any time in going to the hospital. In your bag, you should have the personal
items and clothes listed below:
• Pajamas;
• Slippers;
• Nightgowns;
• Several changes of underwear;
• Sportive clothes, t-shirts and socks;
• Toiletry bag (shaving tools, tooth brush, etc.);
• Books;
• A fork, knife, and glass; and
• Paper towels and napkins.

While waiting for the donor organ, it may be useful to go see a dentist. Thus your
diseased teeth may be treated. This also helps reduce possible sources of post-surgery
infections. If you are receiving a piece of liver from one of your relatives, both the donor
and the recipient will be hospitalized a few days prior to the surgery. The personal items
listed above are required for each of you separately.

Getting Ready for the Surgery

When you arrive at the hospital, they will run some tests on you. This is a common
preparation procedure for the surgery and these tests aim at detecting any kinds of
infections that may not be apparent at that time. You will undergo a general physical
examination and you will be asked to give urinary and blood samples. A chest X-ray and
electrocardiogram will be ordered. Lastly, you will need to wash all your body with an
antiseptic soap and the nurse will shave the surgery area of your body.

A transplantation surgeon and an anesthetist will meet you to inform about the surgery
process and the risks you may encounter. They will ask you to sign a form having your
surgery approval on it.

When you are admitted to the hospital, you will undergo a series of tests.
Starting from the time when the organ transplant team calls you, you:

• Must not eat or drink anything;

• Must inform your relatives;
• Must not smoke;
• Must head immediately to the hospital; and
• Must stay calm!

Surgery Procedures

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The fundamentals of cadaver liver transplantation technique go back 25 to 30 years.
Surgical techniques have gradually improved, their success rates have increased, and
complications have decreased. Yet, it is still a very difficult surgery and it lasts between 6
and 12 hours on average.

The diseased liver is completely removed and a healthy liver is transplanted. Although it
seems quite easy, this surgery, in which considerable bleeding may also occur, requires
usually 1 or 2 surgeons, 3 surgical assistants, 3 nurses and 2 anesthesia specialists
together with assistants, nurses and technicians.

The diseased liver should be cut through four main blood vessels; the cylinder that carries
blood from the liver to intestines and known as the bile duct should be separated from the
intestines. Then the donor liver is put in place and attached to the patient’s main blood
vessels and bile duct in order to complete the surgery.

Living donor liver transplantation has recently become more common and for the last 10
years, it has increased more rapidly. During this surgery, two teams – one removing the
liver and the other transplanting the liver – usually work together simultaneously. The
piece of liver removed from a relative is transplanted in the place of the diseased liver by
preserving the recipient’s inferior vena cava. In terms of surgical techniques, it is a more
difficult technique compared to the technique used in cadaver liver transplantation. It also
requires a more crowded team: at least 2 surgeons, 4 surgical assistants, 3 nurses, 2
anesthesia specialists, 2 anesthesia assistants, 4 anesthesia nurses and technicians all
work together during the surgery. Additionally, micro-surgeons for stitching the very tiny
artery, and radiologist specialists for ultrasound examinations performed during the
surgery are also required. While a transplantation surgery from a living donor lasts for 8
to 16 hours, the length of the donor operation is between 4 to 6 hours.

Even at this last stage, the surgery may be cancelled or postponed due to donor organ
incompatibilities or other complications. The surgery is a very demanding one and may
last between 6 to 18 hours.

T-Tube Insertion and Bile Drainage

During liver-transplant surgery, the surgeon may find it necessary to place a small tube,
called a T-tube, into the bile duct. The T-tube allows bile to drain out of the patient's
body into a small pouch, known as a bile bag. In this way, the amount of bile, which
varies in color from deep gold to dark green, can then be measured. If a T-tube is put in
place, it may remain attached to a bile bag between a week to ten days or possibly longer.
If there is no narrowing or bile leaks on the T-tube X-ray (T-tube cholangiography)
screened (usually) on the tenth day, the T-tube will be tied or capped. It may remain in
place for (usually) 3 to 6 months, sometimes longer, so that the wound can heal and it can
be used for special testing.

The T-tube is attached to the skin with a stitch and the dressing around the tube should be
changed if it becomes unclean or moist. The transplant nurse will show you how to

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change the dressing around the tube before you are discharged or this procedure will be
done in the hospital during your visits.

After surgery
After surgery, you will be transferred to the intensive care unit and attached to a
ventilator (a machine for respiration). If everything goes well, the ventilator may
gradually be removed within 24 to 48 hours; however, you may also need the ventilator
for a longer period of time. In addition to the T-tube, you may also have other drainage
tubes in your abdomen during this post-surgery period. These tubes are used to drain
fluids around your liver and they are generally removed before you are discharged.

After staying for a few days in the intensive care unit, you will probably experience a
recovery period of two or three weeks in the transplantation unit before you are
discharged from the hospital. During this period, you will be monitored in terms of any
organ rejection signs of your body such as high fever, pain, jaundice, fluid collection,
side effects of medications, and increasing liver functions. This post-surgery recovery
period covers intensive physical and mental rehabilitation and all your efforts during this
period will have an effect on your gaining back your strength as soon as possible.

Liver Biopsies
If necessary, your liver transplantation team may collect samples of tissues from your
new liver in order to monitor your recovery process. This procedure is called biopsy, and
it is generally practiced to control organ rejection, jaundice, infection, and other possible
problems. Biopsies may be done either as an inpatient at the hospital or in the polyclinic.
Before the biopsy, an anesthetic drug (local anesthetic) will be applied first in the right
part of your abdomen. After that, a small sample will be removed by a special needle
(Hepafix) from the tissue of the liver in order to examine it under a microscope.
Following this procedure, you are supposed to lie on your side for at least an hour and
stay in bed for almost 4 hours.

Polyclinic Procedures after the Hospital

You must come to the transplantation unit once or twice a week for polyclinic check-ups
during the first months after you are discharged from the hospital. The aim of these
polyclinic check-ups is to monitor your recovery process and diagnose any possible
complications. During each of your visits, your liver function will be closely evaluated,
and you will be fully examined. In this way, if there is any infection, it will be
determined.

You will also be asked to give a blood sample; hence your Tacrolimus (Prograph) or
Cyclosporine (Neoral) levels in your blood will be measured, and your medications will
be prescribed accordingly. Medication intakes in excessive doses may lead to higher
levels of immunosuppression and greater risk of infection; whereas medications taken in
excessively low doses may result in the rejection of the transplanted liver. As the

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infection and organ rejection risks decrease, the frequency of your polyclinic check-ups
will also decrease.

The aim of these check-up visits is to monitor your recovery, and determine any possible
complications.

• Do not take Prograph and Sandimmun medications just before the blood test,
because they will affect your results;
• For each of your check-up visits, always bring your medication list and this
handbook with you; in this way, you can take notes about any important
information.

3. POST-HOSPITAL CARE
You have been under the meticulous care of the medical team in the transplantation unit
until now, but the time to leave the hospital has come. From now on, you will be the one
who is mostly responsible for your further care, although you should keep in mind that
the transplantation team is always there to offer you assistance whenever you encounter a
problem.

Surgical Incision Wound Management

Keep the surgical wound clean by using an antiseptic soap. If you observe any redness,
swelling or fluid collection, inform your doctor immediately about it.

T-Tube Management
If you have a T-tube inserted for bile drainage, it is possible that the skin gets infected in
the area where the T-tube is inserted.

What you need to do is:

• Clean the area around the tube with an antiseptic soap;
• Avoid vigorous actions that may do harm to the wound or may dislocate the tube.

Monitoring Fever
If you feel that you have fever, you tremble, feel any kind of discomfort, feel pain or if
any parts of your body hurt, please check your temperature. This may be the first
indication of an infection or rejection process. If your fever is above 38°C for more than a
day, contact your transplantation team or doctor immediately. Do not take any
medications without your doctor’s approval.

Do not take any medications without your doctor’s approval.

Blood Pressure and Pulses

Your nurse will teach you how to take your blood pressure and pulses. It is important for
you to know your regular blood pressure and pulses. In this way, if you ever recognize a
difference in values, you may inform your doctor.

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If you recognize any of the symptoms listed below, please call your doctor or
transplantation team immediately:

• Redness in skin around the T-tube;

• Warmness in T-tube area;
• Leaking in this area;
• Coming apart of the stitches attached to the T-tube; or
• A change in the visible length of the T-tube.

Teeth Care
You should use a soft toothbrush so that you do no harm to your gums during this time.
After each meal, brush your teeth right away and rinse your mouth with an antiseptic
mouthwash.

If you have false teeth, you should clean them thoroughly after every meal.

It is important to see a dentist regularly every six months for a general check-up in order
to prevent infections and decay. If you are experiencing serious problems related to your
teeth, you should not see a dentist following the first six months of your surgery. No
matter how long ago you had your liver transplantation surgery, before any kind of teeth
operation you will need to take antibiotics, starting from 24 hours before the surgery and
lasting for 48 hours after the surgery. This kind of treatment is called prophylaxis (a
protective measure) and your doctor will inform you about which antibiotics you should
be taking.

It is necessary to go to a dentist regularly to prevent infections and decay.

General Body Care

It is extremely important to maintain a new personal cleaning standard to help in keeping
infection risk low. Please pay attention to these points listed below:

• Wash yourself regularly and prefer taking showers to having baths;

• Use liquid soap instead of soap bars while washing your hands;
• Change your hand and face towels daily;
• Always wash your hands before meals and after toilet;
• Clean your nails thoroughly with a nailbrush; and
• Women must change their hygienic pads and tampons regularly on their
menstruation days. It will be enough to clean this area with a soft soap and water.

As blood presents an ideal environment for bacteria, women in their menstrual periods
should change their hygienic pads and tampons regularly. Avoid using hygienic cleaning
substances. These substances involve disinfectants that increase the risk of infection by
killing microorganisms, which exist in vaginal area under normal conditions. It is enough
to wash regularly with a soft soap and water.

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Skin and Hair Care
Cortisone may lead to acne on your face, chest, shoulders, and back. If acne starts to
show up, wash that area three times a day with a soft antibacterial soap and make sure
that you rinse the soap off your skin thoroughly. Avoid scrubbing the effected area and
do not use medicated cosmetics to cover acne, because wearing make-up will prevent
acne from healing. Keep in mind that severe and infected acne must be treated by a
dermatologist. If your acne problem persists, please contact your doctor or a member of
your transplantation team for recommendations.

Remember that severe and infected acne must be treated by a dermatologist.

If your skin gets extremely dry, stop washing the infected area temporarily so that the
skin gets back its natural moisture. Use a soft soap and apply body cream after bathing.
Cortisone will probably affect your hair. Permanent hair colors, highlights, gels, and hair
bleaching products may cause your hair to get thin and weak. Be careful while applying
these chemicals. Using a good conditioner may help your hair grow stronger.

Growing of Undesired Hairs

One of the side effects of some immunosuppressive medications (especially
Cyclosporine) is that hairs on face grow fast and increase. In women and children, this
situation may be disappointing but you must never stop taking immunosuppressive
medications in any case. Use some hair removing cream (depilatory) or a special solution
to bleach hairs. Removal of excessive hairs, depilation and electrolysis may also work. If
growth of undesired hairs becomes vigorous, contact your doctor for recommendation.

Exposure to Sunlight
Excessive exposure to sun is dangerous for everyone. Ultra violet rays in sunshine lead to
early aging, sunburn and skin cancer. Transplantation patients are more subject to skin
cancer because their immune systems cannot cope entirely with the damage of ultraviolet
rays absorbed by the skin. In brief, you must always protect your skin by applying these
basic rules listed below:

• Avoid sun in midday when sunrays are felt strongly (from 10 a.m. to 15 p.m.).
Try to stay in the shade as much as you can; and
• As long as you stay outside and when you do not put on any kind of sun
protective cream, wear a hat, long sleeves and light pants.

During spring and summer, use a high-quality sun cream with at least a 15 factor of sun
protection. Apply it to all parts exposed to sun, especially on your face, neck and hands.
Sun cream dissolves in water. If you tend to sweat a lot, re-apply sun cream regularly,
especially after you swim.

Keep in mind that sunrays may be harmful even on cloudy days. Ultraviolet rays
reflecting from the sea, sand, snow and concrete may lead to sunburns. Never use
artificial tanning facilities (including a solarium). Be aware of your moles. If you notice
that one of your moles changes in color or takes an irregular shape, contact your doctor

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immediately. As the immune system is suppressed, it is also more likely that moles will
be more susceptible to cancer in transplantation patients. Protect your skin from the sun
at all times.

4. LIFE AFTER TRANSPLANTATION

Organ transplanted patients think of themselves as reborn and feel that they are beginning
a fresh life. Most patients celebrate their surgery day as “Transplant Birth Day”.
Depending upon how successful your transplantation is, a better life compared to your
previous one will probably be awaiting you.

Going Back Home

Going back home after transplantation is generally a very happy and emotional incident;
however, during the first weeks, concerns and even mild depression may also accompany
your state of happiness. It is of great importance that you understand the recovery process
that will last for weeks. It takes time to adapt to this new lifestyle, both for you and for
your family. Living with organ transplantation is a learning process that takes time. Most
people cope well with this process of getting over an especially long rehabilitation period
provided that they are active and determined.

Almost all liver transplanted patients return to their previous and pre-diseased lives by
the end of the first critical stage, which lasts nearly three months. Despite the possible
problems that may affect people with transplanted organs, most patients get a second
chance for a normal lifestyle. They work, become a family, bring up children and take
active roles in society.

The recovery period may take weeks. It depends on you to keep this period shorter.

Diet and Nutrition

You were probably exposed to a long period of being sick before transplantation and
most probably lost a lot of weight. For that reason, eating regularly is a crucial part in
your recovery period. A healthy and balanced diet will help you regain your strength.
Unfortunately, one of the side effects of cortisone intake is that there is a certain increase
in almost all patients’ appetite. Therefore, putting on weight is a long-term problem for a
lot of transplantation patients and in order to control your weight and blood sugar, you
may need a diet with less fat and sugar. Contact a dietician to help you put together an
eating-drinking plan that will provide you a well-balanced diet that meets your needs.

Your diet should include these items:

• Fruits;
• Vegetables;
• Grains, cereals, and bread;
• Low fat milk and milk products or other calcium sources; and
• Fat free meat, fish, poultry or other protein sources.

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Points to pay attention in your diet:

Weigh yourself every day.

• Avoid snacks like pies and biscuits between meals;

• When you feel hungry, have some fruit or vegetables (in low calories);
• Try to take almost two liters of liquid every day. This will be good for your
kidneys. Liquid also helps in removal of waste products from your body. Bottled
water, herbal tea, low fat pasteurized milk and fruit juice are good choices;
• Always wash and peel fresh fruit;
• Always peel vegetables that grow in soil (such as potatoes) and boil them;
• Cooking vegetables in a pressure cooker will help preserve vitamins they contain
and is a good way to save time and energy;
• Do not eat raw vegetables like lettuce;
• Do not eat cheese made of unpasteurized milk. Avoid eating spoiled cheese; and
• Buy milk, cheese, butter and yogurt in small quantities each time, as in this way
you can eat them fresh.

You may need a low-fat and a low sugar diet in order to control your weight and
blood sugar.

Salt (Sodium)
Another side effect of cortisones is that they lead your body to store salt. This may cause
the body to retain water and bring high blood pressure. You should limit your salt intake.
For that reason:

• Use little salt when you cook;

• Try not to add salt to cooked food;
• Avoid eating salty foods such as potato chips; and
• Avoid canned food (these kinds of food generally contain a lot of salt).

Corticosteroids lead the body to store salt.

Exercise
Physical activities freshen up not only bodies but also spirits. Patients exercising
regularly indicate that exercises reinforce generally the state of feeling good and that they
have more energy for work, entertainment and personal relations. Exercise burns the
calories you take and therefore helps in controlling your weight.

It is really important to exercise daily to strengthen your muscles, which may be

weakened after a long period of sickness. Your exercise program should gradually get
harder and it should allow your exercise level to increase slowly. In this way, you will
benefit fully from the exercise program without getting hurt or without a serious injury.
The best exercise is walking, especially walks in clean and fresh air; these will help you

14
sleep better and your intestines will work properly. Climbing stairs is also a good way of
starting exercises, but avoid doing it excessively and rest as soon as you feel tired. You
will soon notice that you get your strength back in a very short time and you can try other
ways of exercises. Cycling, swimming and walking are very useful exercises to increase
your general muscle strength, and if everything goes well, you may try other exercises
like tennis and jogging in a short time, most likely three months after surgery. Moreover,
by exercising you can also cope with osteolysis, which is another side effect of
medications. Do not forget to consult your doctor or transplantation team before starting
any exercise program.

WARNING
If you observe any symptoms listed below, stop your exercises or postpone them until
your doctor recommends you to do so.

• Pain or pressure in your chest, neck or chin;

• Excessive fatigue not associated with insomnia;
• Difficulty in breathing;
• Dizziness during or after exercises, confusion; or
• Constant rapid or irregular pulses occurred as a result of transplantation surgery
during or after exercises.

Driving
Driving is not allowed within the first four weeks following transplantation.

Alcohol
Avoid taking alcohol as it may lead to liver damage because alcohol is broken down by
the liver.

Smoking
Absolutely, quit smoking! Smoking is not only harmful for you but also for everyone. If
you need help in quitting smoking, consult your doctor. He/she will introduce you to the
team who will help you in this subject matter.

Sexual Activity
A few months after a successful transplantation, you can go on with your sexual activities
when you start feeling good enough. Most men regain their sexual strength and women
observe that their menstruation cycles return to normal. Some medications, however, may
reduce some sexual functions. If you experience any problems, you can ask for assistance
either from your doctor or the transplantation team.

Kissing someone, unless he has cold or infection such as herpes, will not create any
problems. It is recommended that both partners wash themselves with water and soap
thoroughly before and after sexual intercourse.

It is recommended that you do not take any immunosuppressive medications as they may
reduce the effectiveness of birth control pills. It is also better not to use intrauterine

15
devices such as a spiral due to the increasing risk of infection. Condoms are the best way
to prevent both infection and undesired pregnancies. Diaphragms are also other
alternatives. Patients can consult their gynecologists to learn about more alternatives.

Reproduction
Many men have children after transplantation, and a lot of women give birth to healthy
children. Women should discuss their desires to have children with their doctors or a
member of transplantation team.

You should wait for at least a year or two before you get pregnant. Before you get
pregnant, it is necessary that you have a good functioning liver, that you do not have any
illnesses that may be a threat to the baby, and that you are being treated with a low dose
immunosuppressive medication.

Vacation
There is no reason why you cannot travel to any parts of the country or the world, but use
your common sense and avoid filthy places where food and water are not hygienic and
where there are insufficient health care conditions. Discuss your travel plans with your
doctor before going on vacation. Do not forget to take a sufficient number of pills that
you will need during your whole trip and inform doctors about your correspondence
address.

Take enough pills with you during your trip.

Vaccination
You should never get any live virus or attenuated (low virulence) vaccination (such as
oral polio vaccination, measles). You can get dead or inactive viral vaccinations such as
tetanus, but before getting any shots you should definitely inform your doctor or
transplantation team.

Pets and Plants

Having pets is not recommended due to the increasing risk of infection; however, for
many people, petting an animal and taking care of it is an important factor that
accelerates recovery process. Fish, reptiles, and rodents carry the least risk of infection.
Dogs are also another option, and taking care of a short-haired kind of a dog is easier in
terms of maintaining hygiene. You should avoid cats due to toxoplasmosis infection, and
birds are not recommended as they carry staphylococcus bacteria.

If you have a pet, you should avoid touching its stool and should wear rubber gloves
while cleaning its cage. The best thing is to ask someone to do it for you. Do not let your
pet lick your hand or face, but if it happens by accident, then wash that area immediately
with water and soap. Keep your pet’s items, such as calcium bones, toys, and feeding
bowl clean and away from your personal items.

Keeping potted home plants is not recommended due to the risk of infection originating
from microbes in their soil. During the first year of your transplantation, you should not

16
do any gardening, farming or any works related to soil due to the high risk of infection.
After a while, you can start working on your garden little by little, yet avoid work such as
planting or raking leaves and always wear gloves.

House Cleaning
You should regularly clean bathrooms and kitchens, particularly your refrigerators. You
do not necessarily need special disinfecting agents. Regular house detergents and liquid
soaps are enough. Other rooms should also be cleaned as usual, and bed sheets be
changed once a week.

5. IMMUNOSUPPRESSIVE MEDICATIONS
Your body recognizes the liver tissue as a foreign object, and your immune system starts
attacking this intruder. Immunosuppressive medications help in the prevention of
rejection of the liver transplanted by attenuating the response of your immune system.
Immunosuppressive medications also increase your susceptibility to more infection at the
same time. Therefore, a balance is required among the conflicting needs in order to
prevent rejection and maintain sufficient protection against infection.

Fortunately, the amount of immunosuppressive medications needed to protect a

transplanted organ decreases following the first months of the surgery. Yet,
immunosuppressive medications are necessary for many years after the transplantation,
and you must never change the dose and the amount of your medication without your
doctor’s approval.

All immunosuppressive medications may lead to some side effects. Doctors have
determined that while a combination of immunosuppressive medications reduces side
effects of each medication, they may also help in maintaining an ideal
immunosuppressive level. In conclusion, your treatment will probably involve a
combination of several immunosuppressive medications.

Your body will detect that the liver tissue is a foreign object.

You will take immunosuppressive medications for all your life after transplantation
surgery.

As patients may react differently to these medications, each immunosuppressive diet is

determined according to the patient’s individual needs. Do not worry if other patients are
taking different kinds or amounts of medications.

You will find a general summary of the most common immunosuppressive medications
below. The information provided here does not cover all aspects of each medication and
if you have further questions, please consult your doctor or transplantation team. Do not
forget that most people do not experience all the effects mentioned below, and you may
be exposed less to these side effects as the dose of your medication will gradually taper
off in time.

17
While some immunosuppressive medications are administered all life long, some are
used only for treatment of rejection periods.

Long-term Used Medications

Rejection Treatment
• Metilprednisolane;
• Antilenphosit Globulin;
• Antitimosit Globulin;
• Orthoclone OKT3; and
• Corticosteroids (Prednisolone).

Corticosteroids may be used life-long in order to prevent organ rejection. They are also
administered in short-term and high dose rejection treatment. Corticosteroids are
produced naturally in the adrenal cortex and they are crucial for regular functioning of
most tissues. The body produces corticosteroids in a 24-hour rhythm, and following the
highest concentration during the early hours of the day, a constant decrease in
concentration is observed later within the day. For this reason, you must take your
corticosteroid medications first early in the morning, in this way you can keep up with
your body’s natural rhythm. While some patients take cortisones in the morning at a
single dose, some may take them twice a day, mainly in the morning and at night.
Corticosteroids are generally administered together with Cyclosporine or Tacrolimus.
You must take your corticosteroid medications first in the morning.

Using Corticosteroids
Your corticosteroid dosage will be determined according to your weight, medical
condition and the length of time passed after your transplantation. Take the tablets with
meals. If you take the tablets once a day, you must take them in the mornings when you
have breakfast.

Side Effects
Short-term side effects of corticosteroids are as follows:

• Increased susceptibility to infection, slowed healing of wounds; and

• Suppressing fever and other symptoms of infection.

Increased Blood Sugar (*)

Mood swings from happiness to agitation and confusion

Depression in Some Cases (*)

Side effects of long-term corticosteroids tend to be related with total treatment dosage
needed. Depending on dosage, corticosteroids may lead to the side effects listed below:

• Anomalies in body-fat distribution (e.g. thickening in the neck, swollen cheeks,

hunchback);

18
 • Bones getting thinner and weaker, muscle weakness;
• High blood pressure;
• Thinning of the skin and susceptibility to injuries;
• Diabetes;
• Cataracts in eyes;
• Increase in acne or facial hairs;
• Increased appetite and weight gain; and
• Gastrointestinal side effects, ulcer or chest burn.

Even though the side effect list seems quite frightening, it should be emphasized that side
effects have reduced significantly today compared to the side effects in the past owing to
the use of corticosteroids at low doses in order to prevent organ rejection. When
compared to other immunosuppressive medications, corticosteroids have some
advantages. They do not suppress bone marrow, can be used in combination with other
medications and do not have direct toxic effects on transplanted organ.

Measures
If you are pregnant or breast feeding, the advantages of these medications should be
compared with the potential damages they may do to your fetus or baby. If you think you
are pregnant, consult your doctor or transplantation team right away.

Cyclosporine (Sandimmum / Neoral)

Following steroids, Cyclosporine has become the most important drug group used in
organ transplantation. Organ rejection rates have decreased significantly after
Cyclosporine started to appear in immunosuppression protocols since the 1980s.
Cyclosporine functions by preventing the activities of T-cells (a kind of white blood cell).
It is generally taken orally in combination with corticosteroids and other medications.

The most distinctive feature of Cyclosporine is that as soon as it is taken orally, its effect
is quickly observed as it is easily transmitted to blood after being absorbed in the
intestines. Today, the use of Neural preparate instead of Sandimmum preparate
eliminates this problem to some extent. Cyclosporine blood levels may get quickly
affected as it has the feature of dissolving in fat, especially in cases where dysfunction of
livers and increased serum bilirubin levels occur or where a biliary tube exists due to
enterohepatic circulation. Besides, the rate of Cyclosporine removal from blood may also
vary depending on age. Child patients may remove Cyclosporine more quickly compared
to adults.

The most preferred form of Cyclosporine is the oral preparate. General dosage of use is
between 10-20 mgr./kg. Cyclosporine must be administered regularly once every 12
hours. Measuring the effects of Cyclosporine on the blood level is extremely important. If
it is taken at high doses, it may do severe harm to your kidneys. It may cause tingling of
the hands and trembling. However, if it is taken at low doses, then it may result in organ
rejection. The best time to measure your blood level of Cyclosporine is two hours after
taking the medicine. In order to have reliable calculations in blood level of Cyclosporine,
it is necessary that you make sure to take the medication at the scheduled time the

19
previous night, and you do the calculation of blood level exactly two hours after taking
the medication in the morning. It is crucial that you do not make any timing mistakes, not
even a five-minute delay, during this calculation process. Your dosage will be determined
according to your weight, blood levels, medical condition, laboratory test results and any
other side effects. Serum levels must be checked twice a week during the first month after
the operation. This monitoring process gradually decreases, and six months later a level
monitoring check-up only once a month will be enough.

The most important side effect of Cyclosporine is its effect on kidneys. Its effect on
kidneys increases depending on serum levels. As a result of Cyclosporine intake at high
doses, a kidney failure may develop. The damage in kidneys may improve by reducing
dosage. Cyclosporine may also have toxic effects on the liver. In patients taking high
doses, there may be an increase in their liver enzymes. Apart from all these effects,
various neurological effects such as trembling of the hands, numbness, muscle weakness,
increased sensitivity to temperature changes and epilepsy may also be observed in
patients taking Cyclosporine. In order to prevent the use of Cyclosporine at extremely
high doses, it is appropriate to use it generally in combination with a few medications at
more moderate doses.

Apart from its effects on kidneys, some other side effects of Cyclosporine are as
follows:

• High blood pressure;

• Thickening of gums;
• Increase in blood fats;
• Increase in hairs;
• Trembling of the hands (tremor);
• Gastrointestinal problems such as diarrhea, vomiting, and nausea;
• Liver functioning disorders; and
• Headaches.

Most of these side effects will either reduce or disappear when the dose is lowered. Keep
in mind that you will likely not experience all these side effects at the same time, or at
least not most of them, and fewer side effects will appear as the dose is tapered off.
Cyclosporine interacts with many other medications that are frequently used. Before
administering any medications, always consult your doctor or obtain your transplantation
team’s approval.

Prograph (Tacrolimus)
Tacrolimus, like Cyclosporine, blocks the function of T-cells, and prevents the damage of
their attack on your liver. Although Tacrolimus has a different structure, it has similar
pharmacological effects as Cyclosporine. With regard to its effect, Tacrolimus is a 10 to
200 times more effective medication compared to Cyclosporine. It has been proved that
there is no significant difference between long-term use of Tacrolimus and Cyclosporine.
Yet, when Tacrolimus is used at proper doses, it has an effect on preventing acute
rejection.

20
Tacrolimus, just like Cyclosporine, must be used by measuring serum blood levels. In
this way, its side effects can be prevented, and effective serum levels will be reached.
Tacrolimus must be taken in two doses every 12 hours. Tacrolimus has tablets of 1 and 5
mg. When blood level is measured for Tacrolimus, blood must be given 12 hours after
the previous dose; in other words, it must be given exactly before taking the following
medication, which is 8 in the morning, and 8 at night. A patient taking Tacrolimus will
give his/her blood before taking the medication at 8 in the morning. Do not forget to
bring your medication with you so that when you have your blood test done, you can take
it right away. Your dosage will be determined according to your weight, blood levels,
medical condition, laboratory test results and any other side effects.

Side effects of Tacrolimus are the same as Cyclosporine’s. However, it has been
determined that there is an increase in its effect on susceptibility to diabetes. One side
effect that is observed in one patient may not be observed in the other. Side effects of
Tacrolimus may be listed as follows:

• Disorders in kidney functions;

• High blood pressure;
• Disorders in sleeping;
• Slightly increased blood sugar levels;
• Numbness and tingling of the hands and feet;
• Trembling of the hands (tremor); and
• Headaches.

Most of these side effects will either reduce or disappear when the dose is lowered. Keep
in mind that you will likely not experience all these side effects at the same time, or at
least not most of them, and fewer side effects will appear as the dose is tapered off.

Your transplant team may change your medication from Cyclosporine to Tacrolimus or
vice versa. This is done in order to prevent ongoing tissue rejection or eliminate side
effects. Never take Tacrolimus and Cyclosporine together.

Tacrolimus interacts with many other medications that are frequently used. Before
administering any medications including over-the-counter ones, always consult your
doctor or obtain your transplantation team’s approval.

Mychophenolate (CELLCEPT, MY FORTIC)

Mychophenolate is an antiprolipherative agent, which began to be used in clinics in 1995.
It has the feature of preventing cell segmentation by inhibiting an enzyme in the synthesis
of pure bases in DNA synthesis. It prevents the forming of reaction in the immune system
by exercising this action on DNA synthesis that is found in lymphocytes responsible
especially for the immune system in the body. For the activation of the immune system, it
becomes effective in preventing development of new lymphocytes. As it has far fewer
side effects and more effectiveness compared to Azathiopirin (which was commonly used
before), more successful outcomes were obtained when used with Cycloporine and

21
corticosteroids instead of Azathiopirin. Therefore, it has contributed greatly to the
prevention of organ transplant rejection. At the organ rejection stage, it prevents
development of reaction particularly in the immune system. The most important side
effect of Cellcept is observed in the gastrointestinal system (e.g. nausea, vomiting,
diarrhea, development of peptide ulcers). Moreover, it may cause an excessive decrease
in erythrocytes and thrombocytes together with lymphocytes, depending on the amount of
suppression of bone marrow. Cellcept is an agent administered without checking serum
levels, as these levels are maintained extremely steady. It is administered night and day at
a dose of 1000 mg. in adults. Cellcept may lead to development of infection by
excessively suppressing the immune system. Therefore, patients must be monitored
carefully after organ transplantation with regard to any possible infection development.

Rapamune (Sirolimus)
Rapamune is used to prevent organ rejection in recipients of liver transplantation. It
eliminates organ rejection by blocking some cells in the immune system. Rapamune may
be administered either by itself or together with Prograph (Tacrolimus) and Neoral
(Cyclosporine).

Rapamune is found in the form of 1-mg. tablets (3 or 10 blisters of 10 tablets in each) of

30 or 100 tablets in boxes, and in colorful bottles of 60 ml. of oral solution with 1 mg./ml.
concentration.

Rapamune is administered orally once a day, and it must be taken at the same time every
day to maintain a regular level of effectiveness. Tablets must be swallowed as a whole
without being chewed; whereas, oral solution must dissolve in at least 60 ml. of water or
orange juice.

Side effects of Rapamune may vary, and they are generally related to blood levels of the
medication. The most frequently observed side effects are as follows:

• Increased susceptibility to infection;

• Nausea;
• Diarrhea;
• Anemia;
• High cholesterol and triglyceride levels;
• Headaches;
• Acne;
• Arthritis; and
• Muscle cramps.

When the dose is lowered, side effects generally disappear.

While using Rapamune, you must not self-regulate the dosage or frequency of
administration recommended by your organ transplant physician. You can check the
dosage and administration time of Rapamune by calling your organ transplant center. If
you are taking Prograph or Neoral with Rapamune, you must take these medications

22
either at least 4 hours before or after Rapamune due to their effects on pharmacokinetics
of Rapamune.

Rapamune may be either administered right after organ transplantation or a few weeks
after the surgery. Initial dose is generally 2-mg. for liver transplant recipients, and
ongoing dosage is individualized according to threshold concentration in blood.

Rapamune is not used in children under 13. Dosage adjustment is not necessary in elderly
and patients with kidney failure. Rapamune dosage may be increased during rejection
attack or due to reasons such as infection or side effects.

If you forget to take your Rapamune dosage, take it as soon as you remember to do so. If
you remember to take it at a time closer to the following dosage, skip that dosage, and
starting from the next dosage you may reapply your regular dosage schedule. It will be
best if you inform about your skipping dosage by calling organ transplant center.

Rapamune blood level must be monitored regularly in liver transplant recipients. As

Rapamune shares the same metabolic path with Neoral, medications affecting Neoral
level will also affect Rapamune level. Furthermore, as Neoral leads to formation of
higher blood levels by preventing Rapamune metabolism, changing Neoral dose or
stopping its intake will also have an effect on Rapamune level. When there are some dose
changes, blood level stabilizes within 5 to 7 days, and after that their threshold levels
maintain their stability for quite a long time. For this reason, the control of blood level is
done once a week.

Rapamune tablets must be kept at room temperature, but in solution form it must be kept
in a refrigerator. While using oral solution, there may be some sores in your mouth.
These wounds will heal when the dosage is lowered.

If you are considering getting pregnant, you must contact your organ transplant physician
related to the use of Rapamune.

Using ALG or ATG

Your dosage will be determined according to your weight, blood levels, medical
condition, laboratory test results and any other side effects. ALG or ATG can only be
administered intravenously, and therefore you can get the medication only in the hospital.
Infusion time is 4-6 hours. During your treatment with ALG or ATG, your
transplantation team may change the dosage of your other medications.

Side Effects
Side effects include but are not limited to, the following:

• Difficulties in breathing;
• Gastrointestinal problems such as diarrhea, vomiting, and nausea;
• Serum sickness such as fever, trembling, peeling of the skin, joint pains;
• Low count of white blood cells (leucocytes); and

23
 • Increased bleeding risk.

ATG or ALG use for longer periods or recurrent times increases the risk of lymphoma
development.

OKT3 (Muromonab- CD3)

OKT3 is a monoclonal antibody that may destroy certain cells, which cause acute organ
rejection. OKT3 is a very strong immunosuppressive, and can only be used for shorter
periods. Hence, OKT3 can sometimes be used just before or right after transplantation as
it is administered to prevent acute rejection that generally resists corticosteroid treatment.

OKT3 Use
OKT3 is administered intravenously once a day for 5-14 days. During your treatment
with OKT3, your transplantation team may change the dosage of your other medications.

Side Effects
Side Effects of OKT3 are as follows:

• Respiratory difficulties;
• Gastrointestinal problems such as diarrhea, vomiting, and nausea;
• Fever, trembling;
• Rapid heart beat; and
• Pulmonary edema (fluid accumulation in the lungs).

These side effects are often reduced by administering additional corticosteroids before
OKT3 treatment. Additionally, side effects may also be reduced by administering
medications such as antihistaminic drugs or paracetamols to patient before treatment.
Most side effects appear during the first few doses of OKT3 in a great deal of patients.

Measures
If you are pregnant or breast feeding, the advantages of these medications should be
compared with the potential damages they may do to your fetus or baby. If you think you
are pregnant, consult your doctor or transplantation team right away.

6. MEDICATION CONTROL LIST

The following rules apply to all medications:

• Take your medication every day at the same times;

• Even though you feel better, never self-regulate the dosage or stop taking it;
• If you ever accidentally take an overdose, immediately contact your doctor;
• Do not forget that the medication is prescribed only for you;
• Never take any medications if they have passed their expiration dates stamped on
their labels;
• Bring back unused medications to the transplant service;

24
 • If you ever experience any new or unusual side effects while taking the
medication, inform your doctor or transplant team about it;
• Avoid buying any unprescribed medications without your doctor’s approval;
• Keep your medications in cool, dry, dark places where children cannot reach;
• Do not keep your medications in refrigerators unless told to do so by your doctor
or pharmacist; and
• Make sure you bring enough medication with you before you go on shorter
vacations on the weekends, for longer periods or when you take long trips.

7. POST-SURGERY COMPLICATIONS
Post-surgery complications may be observed in all patients who undergo important
surgeries. Most transplantation patients may experience same complications within the
first few weeks following the surgery. For this reason, if you also experience some
problems, do not worry. Your transplantation team will do everything they can to reduce
the complications and will treat the emerging ones at once.

Refusal (Rejection)
In the first weeks after transplantation surgery, many patients experience rejection attacks
at least once and sometimes twice. At the very beginning, there may not be any physical
rejection symptoms; however, you may feel a slight change in your general health
condition such as an unexplained minor fever or a general state of fatigue.

You must also be aware of the rejection symptoms listed below:

• Tiredness, fatigue;
• Abdominal pain or sensitivity;
• Dark yellow/orange color urine;
• Glazier’s putty color excretion; and
• Disorders in liver function tests.

Rejection Treatment
When there is a suspicion of rejection, it is generally verified by a liver biopsy. If you
experience some sort of a moderate or severe rejection, cortisone treatment (pulse
steroid) at high doses is applied for three successive days. After steroid treatment, if
rejection still exists or gets worse, or reappears in a very short time, a cycle of a stronger
immunosuppressive medication such as OKT3 or ATG is applied. A week after OKT3
treatment, a biopsy can be done to check whether rejection is under control or not. Owing
to new and stronger immunosuppressive medications, rejection incidents that cannot be
prevented rarely occur.

Infection
Suppressing your immune system to prevent organ rejection is crucial. Yet this kind of
suppression weakens, at the same time, the power of our bodies to fight against infection.
You will notice that you are more susceptible to having colds and flues within the first
period following the surgery.

25
Infection Prevention
The world surrounding us is full of microbes, and even though it is important to restrict
your contact with infectious organisms, it does not require that you live in a bell jar.

There exist some basic measures you may take to reduce your and your family’s risk of
infection without restricting your lifestyle extremely. These measures include the
following:

• Take enough rest;

• Follow a healthy, and balanced diet;
• Exercise regularly, and keep your weight within acceptable limits;
• Avoid crowded shopping malls, theatres, and cinemas during flu periods;
• Avoid close contact with people who have active infection such as cold and flu;
• Wash your hands thoroughly after using the restroom, and before meals;
• Immediately wash little cuts and scratches, and cover them with band-aids;
• Wear gloves while dealing with garden, flowers or other similar gardening works
that may cause dirt; and
• Avoid smoking.

Infection Symptoms
Sometimes infection cannot be prevented. If you experience the following, immediately
contact your doctor or transplantation team:

• All sorts of fever (especially accompanied with trembling) above 38 degrees

centigrade that last for more than a day;
• Diarrhea, nausea, vomiting, or unexplained head aches;
• Tiredness, loss of appetite;
• Difficulty in breathing, burning while urinating, abdominal pain; or
• Changes in your skin or eye color, peeling of the skin, pain and difficulty in
swallowing.

Abnormal Kidney Functions

Cyclosporine (Sandimmum) and Takrolimus (Prograph) treatment may lead to abnormal
kidney functions in some patients. Deterioration in kidney functions may be measured
easily by urea and creatinin levels. These two waste products increase in abnormal levels
when kidneys begin to function poorly due to Cyclosporine or Takrolimus toxicity. These
side effects are usually related to doses and are generally controlled when doses are
tapered. Detecting impaired kidney functions may be difficult; however, if you notice that
you urinate excessively at nights or feel yourself constantly tired or even though you take
sufficient amount of liquid, there is still a significant decrease in your urine amount,
contact your doctor or transplantation team.

Diabetes

26
Diabetes is an increase in sugar rate in your blood. In the long-term, diabetes may lead to
kidney failure, blindness, circulation disorders and loss of feeling in arms and legs. Some
of your immunosuppressive medications may cause diabetes.

If you notice any of the following, inform your doctor or transplantation team:

• Increased thirst;
• Increase in frequency of urinating;
• Blurred view; or
• Confusion.

You can reduce your blood sugar level by losing weight, following a careful diet, and
exercising regularly. It may be necessary to administer an oral antidiabetic medication or
insulin injection. If you are diagnosed with diabetes, then you will be specifically treated
to cope with this problem.

High Blood Pressure (Hypertension)

High blood pressure and heart diseases are more commonly observed as people get older.
Your blood pressure may increase due to the side effects of some of your required
medications. If your high blood pressure is not treated, it may weaken your heart, and
lead to fattening of your blood veins. For this reason, you may need to take additional
medications in order to control your blood pressure. Moreover, you may also take a
diuretic (water pill) to increase the frequency of your urination, and remove unwanted
excessive fluids from your body.

You may also need to take extra medications to control your blood pressure. Adjusting
your life style may help in reducing blood pressure. Avoid stress, maintain a low-salt
diet, quit smoking and exercise regularly.

Cancer
All immunosuppressive medications may slightly increase the risk of cancer, especially
B-cell (a kind of white blood cell) lymphoma. There is the possibility of cancer for
everyone using immunosuppressive medication; however, this risk is low (lower than
3%). The possibility of skin cancer is higher in transplantation patients. Therefore, you
must take measures to protect yourself from the sun.

Neurological Complications
Cyclosporine and Takrolimus may lead to sleeping disorders such as insomnia,
nightmares or mixed dreams. You may feel yourself angry and experience sudden mood
swings. Some patients suffer from difficulties in concentrating and remembering. You
may notice that your hands tremble or there may be a feeling of tingling in your hands
and feet. These side effects generally appear a very short time after the surgery and are
reduced as the dose of medication is lowered.

You may feel yourself angry, and experience sudden mood swings.

27
Psychiatric Problems
It is not uncommon for transplantation patients to start worrying and become depressive
when the initial excitement after the surgery is over. Some changes in appearance may
disturb some patients, especially women and children. You may fear that your life will
not be the same as your previous life, and you will be disabled or exposed to distortions
in your body shape. These fears may also cause problems or tension within the family. It
may be difficult for your partner or family to understand your special needs. There exist
some consultancy services to help you and your family in adjusting your life at home, and
finally to prepare you to return to work or school. You should contact your doctor or
transplantation team to learn more about these kinds of services. In this way, these sorts
of problems may be prevented or solved.

Life Quality
Transplanting a liver to someone is not the same as changing the engine of a car. You
need to make some changes in your life such as taking your medications every day, going
to the hospital for regular polyclinic visits. Still, life quality of most of the transplantation
patients is much better than their previous lives before transplantation. For many people,
a transplanted organ has provided them the opportunity of a second and valuable life, and
symbolized a new beginning.

Most transplantation patients believe that their life quality has improved a lot more
after transplantation.

Communication with your Transplantation Team

(*) This is your primary responsibility. As soon as it is finalized that you and your liver
tissues are compatible, you become no different from any other healthy person to receive
treatment in terms of medical care goals which are: (1) to prevent diseases, (2) to treat
occurring problems with others. To keep you permanently well, it is a must to maintain
good communication between you and your transplantation team together with other
doctors. Make sure that all your doctors are aware of your transplantation process,
medications you administer, and measures you take in order to be healthy. Keep an
accurate and up-to-date record of your medical details. Blood pressure, pulse, changes in
medications or dosage, minor infections and their treatment, and any other kind of new
symptoms or side effects must absolutely be recorded.

Know your body well and inform your doctor about any changes. Keep an accurate
and up-to-date record of your medical details.

8. GLOSSARY
A
Anemia: Decrease in red blood cells in the body
Anesthetist: Medical doctor trained to administer anesthesia during surgery
Antacid: Medicine that prevents or treats the formation of ulcers by neutralizing stomach
acid in the digestive system
Antibody: Protein produced by the body to neutralize foreign objects such as bacteria

28
Antigen: Molecule that prompts the generation of antibodies and can cause an immune
response

B
Bacteria: Microscopic organisms that cause disease
Biliary Tract: Bladder connected to liver; it stores bile
Bilirubin: Dark yellow substance produced by the breakdown of red blood cells and
excreted in bile

C
Cholesterol: A kind of fat (lipid) found in all parts of the body, but a high level of
cholesterol leads to coronary heart diseases
Cortisone: A kind of immunosuppressive medication
CMV (Cytomegalovirus): Common infectious virus that may often be observed in
transplant patients
Creatinin: Substance found in body fluids, blood, and urine. If it is elevated in the blood,
it is an indicator of a problem in kidney functions

D
Diabetes: Disease associated with high blood sugar
Diuretic: Medication used to increase the amount of urine

E
Electrocardiogram: Tool to record the electrical activity of your heart
Electrolytes: Ionized substances such as sodium, potassium, chloride
Enzyme: Protein that is produced by the body, and it can convert a specific set of
reactants into specific products

F
Fetus: Human embryo in uterus

H
Hemotocrit: Measure of the proportion of red cells found in the blood
Hepatic: Related to the liver
Hepatologist: Internal medicine specialist in treating liver disease
Herpes: Infection caused by the herpes simplex virus. It leads to mouth and genital area
sores
Herpes Zoster (Shingles): Viral disease that leads to herpes
Hypertension: High blood pressure

I
Immune System: System that protects the body from the invasion of foreign objects
such as bacteria and virus, and cancer cells
Immunity: Resistance of an organism to a certain infectious disease
Intravenous: It literally means ‘into a vein’. It describes giving medications or liquid
substances directly into a vein

29
J
Jaundice: Yellowish staining of the skin and sclerae (the whites of the eyes) caused by
excessive biliary products in blood

L
Liver: Substances produced in the liver and released to blood. These are measured to
evaluate enzymes and therefore liver functions.

O
Oral: By mouth
Organ Rejection: Attempt of the immune system to refuse or attack anything that is
recognized as a foreign organism (e.g. a transplanted liver)

P
Potassium: Mineral needed for the body
Prophylaxis: Use of medications to assist in prevention of a disease (e.g. antibiotics)

R
Renal: Related to kidney

T
T-Cells: White blood cells that play a key role in rejection process
T-Tube: Tube inserted into the bile duct; it allows bile to drain out of the patient’s body
into a pouch
Thrombocyte: Blood cells essential for haemostasis, blood clotting

U
Ultrasound: This kind of examination is done to check whether all main blood vessels to
your liver work properly or not. It is also used in controlling of liquid accumulation such
as blood or bile. The procedure includes first applying a clear water-based gel to the area
of the body being studies. Then the transducer is pressed firmly on your abdomen and
swept over the area. It sends sound waves, and these waves are measured and displayed
by a computer, which in turn creates images on the monitor

V
Ventilator: Machine to assist with the patient’s breathing
Virus: A small agent (microbe) that causes infection

W
White Blood Cells (Leucocyte): Cells of the immune system defending the body against
infectious disease in blood

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