Liver Transplant And Hepatitis C

Word Count: 1822 |

The liver is one of the most important organs in the human body. It is

intimately Involved in almost every part of the body’s processes, and it has

four crucial functions: Fuel Management, Nitrogen Excretion, Water

Balance, and Detoxification. Being the central role of the body systems,

when liver diseases or viruses like Hepatitis C strikeat the core, it can be

life threatening.

You cannot survive without your liver. Over 80-90% of Hepatitis C (HCV)

infections become chronic and lead to liver disease, including cirrhosis

and liver failure.HCV infection is typically mild in its early stages, and it is

rarely recognized until it has caused significant damage to the liver. The

cycle of the disease from infection to significant liver damage can take

twenty years or more. This was the case for my best friend’s father, J.N., at

Kaiser Oakland. J.N. is a fifty-three year old man who has lived with HCV for

over fifteen years. His liver could no longer withstand the virus and began

to shut down. J.N. was on a liver transplant list since December of 2000,

and on December 31, 2006 his prayers were answered. He got the phone

call transplant seekers dream of. The hospital had found a donor.

J.N.’s life as a young adult was composed mostly of partying, drugs,

and alcohol. He began using drugs at the age of thirteen, and didn’t stop

until his early thirties. His love for getting “high” and seeking different levels

of euphoria led him to the use of needles. His heroine use led to his crack

use. He said, “I couldn’t afford heroine anymore, so I started buying crack. It

was a good high, not as clean, didn’t last long, but it was good enough”

(J.N., personal communication, January 31, 2007).

J.N. didn’t find out he had contracted HCV through the use of sharing

dirty syringes until six years later. As J.N. began to clean up his act, he got

remarried, and was becoming closer to his daughter, but J.N. felt tired all

the time and was constantly getting sick. He had a good job at this point,

with full medical coverage, so he went for routine blood tests and HCV was

detected by his doctor. “I felt like I hit a brick wall. All my fun days of partying

where over, but now they were going to follow me for the rest of my life,

which wouldn’t be much longer according to my doctor” (J.N., personal

communication, January 31, 2007).

J.N. didn’t anticipate that the severe damage HCV was causing his

liver and it was a shock when the rest of his body started to shut down. By

the time he was put on the waiting list for a liver transplant in December of

2000, his liver disease was forbidding him from working, exercising, or

carrying out any of his other daily activities. Being that the liver was

responsible for critical portions of his metabolism, it had become

overwhelmed with the HCV, and a number of essential metabolic

processes were compromised. J.N.’s body was losing the ability to store

and synthesize glucose. This was affecting his CNS function and mental

process. His body wasn’t able to manage amino acid metabolism and the

removeal nitrogen, which decreased his ability to synthesize glucose

leading to CNS dysfunction and cause accumulation of nitrogen waste,

resulting in toxicity to many surrounding tissues (Huether, S.E. & McCance

p. 1044).

The overall ability of his body to manage and use fuels diminished

drastically leading to fatigue and general sense of “not feeling well”. HCV

was causing disturbances in water distribution, which made J.N. feel

“swollen all over”. The edema and generalized alteration of cell function

was causing muscle and joint pain, and malaise (

J.N. felt like he was going to die very soon. He tried numerous drug

therapies to try to slow down the progression of the disease. However, J.N.

admits to not being very active in his health care. After the diagnoses of

HCV, he felt doomed, and did not do any extra research on the disease that

could eventually take his life. J.N.’s doctor started his treatment with peg

interferon alfa-2a in summer 2005. Research has shown over the last

ten years that peg interferon alfa-2a alone produces significantly higher

sustained virology responses than treatment with interferon alfa-2a alone

in patients with chronic hepatitis C virus (HCV) infection


J.N. received his new liver on January 01, 2007. Walking into J.N.’s

private room at Kaiser Oakland was shocking at first. He looked extremely

sick. It had barely been a month since his transplant. He looked lifeless in

his bed. His face was sunk in and his skin was jaundice. He was receiving

supplemental oxygen via a nasal cannula at all times, and he looked like

he was going to die. He said he didn’t feel much better since the

transplant, but he knew it was the result of all the drugs he was getting to

lower his immune system.

In the long-term, HCV RNA levels are related to level of

immunosuppression and correlate with severity of liver injury. However,

despite immunosuppression, some liver transplant recipients show

HCV-specific major histocompatibility complex class II-restricted CD4.

T-cell responses and experience minimal or no histological recurrence.

Conversely, transplant recipients who lack appropriate immunologic

responses to HCV antigens may experience severe recurrence. These

processes are highly dynamic. It has been estimated that the balance

between HCV cytotoxicity, immunologic destruction of infected hepatocytes,

and hepatic regeneration may lead to complete allograft replacement

within 2 weeks. Immunosuppression tips the balance to favor accelerated

loss of the allograft. Strategies to reduce the impact of

immunosuppression on recurrent HCV have included global reduction in

total immunosuppression, discontinuation of individual agents, and use of

immunosuppressive agents with possible antiviral properties.

Immunosuppressive drugs may be classified into five groups: calcineurin

inhibitors (cyclosporine [CSA] or tacrolimus [TAC], steroids (prednisone or

methylprednisolone), inhibitors of purine biosynthesis (azathioprine [AZA]

or mycophenolate mofetil [MMF]), inhibitors of mammalian target of

rapamycin (sirolimus [rapamycin (RAPA)]), and monoclonal or polyclonal

antibodies (OKT3, antithymocyte globulin, antilymphocyte globulin [ALG],

and interleukin-2 (IL-2) receptor antibody (

Steroids often are prescribed in the early post transplantation period,

but are now commonly withdrawn after 3 months. Doses and duration of

steroid therapy vary considerably. AZA and MMF inhibit purine synthesis

and are used to enhance immunosuppression or allow dose reductions in

CSA, TAC, or steroids. Antibodies and high-dose steroids are used for

induction and to treat acute cellular rejection. The overriding goal of

maintenance immunosuppression is prevention of allograft rejection.

Current immunosuppressive agents, when administered in high dosage

or multi-drug Combinations induce global immunosuppression and

markedly reduce the risk for allograft rejection. However, excessive

immunosuppression to prevent rejection favors viral replication and

facilitates viral-mediated graft injury. Research found that the

survival of HCV-positive a transplant has decreased in recent years, and at

least one factor was the use of stronger immunosuppressive treatments.

Specific immunosuppressive calcineurin inhibitors, TAC and CSA, are

the mainstays of current immunosuppressive regimens. Their

immunosuppressive effect is through inhibition of early T-cell signal

pathways and IL-2 production and release. TAC is more potent then CSA,

and as a result, doses of TAC are typically 25 to 60 fold less than doses of

CSA. Each of the three centers used different induction

immunosuppression: CSA plus Prednisone plus AZA, CSA plus

Prednisone, and ALG followed by CSA Prednisone plus AZA. All centers

participated in the TAC primary immunosuppression trial and had a

subgroup of patients treated with TAC-based immunosuppression. They

observed no difference in either patient or reducing immunosuppression is

a balancing act between the attempt to control recurrence of HCV

and maintenance of adequate immunosuppression to prevent rejection

(Liver Transplantation, Vol. 8, No 10, Suppl.1. October, 2002: pp S19-S).

Even though my best friend’s father looked and felt like he was dying,

his chances for survival are 100 folds with his new liver. The

immunosuppressants are causing him to have very little appetite and

therefore to lose excessive amounts of weight, feel nauseous and fatigue

all the time. His body isn’t rejecting the new liver and he will continue the

immunosuppressant therapy for another three months. J.N. expresses

his deepest gratitude, and he feels anxious towards going home, “HCV

was my disease. I brought in upon myself, and now my wife and daughter

suffers from my carelessness. I wish I could take care of them the way they

have taken care of me” (J.N., personal communication, January 31, 2007).


Carpenito-Moyet, Lynda Juall (2006). Nursing Diagnosis: Application to

Clinical Practices. (11th ed.) Philadelphia, J.B. Lippincott Company.

Gulanick. M. & Meyers, J. (2003). Nursing Care Plans: Nursing Diagnosis

and Interventions. (5th ed.) St. Louis, Mosby, Inc.

Huether, S.E. & McCance, K.L. (2004). Understanding Pathophysiology.

(3rd ed.) St. Louis Mosby, Inc.

Miller-Keane (Ed.). (2003). Encyclopedia and Dictionary of Medicine,

Nursing, and Allied Health. (7th ed., Vols.1). Philadelphia: W.B. Saunders


The New England Journal of Medicine 2003. Dominican University of

California, Web Cat, February 12, 2007.

Ruthledge, DN. (2003). Caring for Families of patients in Acute or Chronic Care

Settings: Part I-Principals, Online Journal Clinical Innovate3 (3):1, 2000a

Dominican University of California, Web Cat, December 1, 2006.

Frequently Asked Questions About Hepatitis C. (n.d.) Retrieved February 9, 2007 from

Liver Transplantation, Journal Vol. 8, No 10, Suppl.1. October, 2002: pp S19-S.

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