Adult liver transplantation for the advanced clinical practitioner: an overview
Liver transplantation (LT) is a major surgical undertaking but, in a carefully selected population, it provides excellent outcomes in terms of prolongation of life and improvements in quality of life. This article outlines the processes of referral, assessment, operative course and post-transplant complications of LT, in the UK context. Specific consideration is also given to immunosuppressive medications and considerations around their prescription. The role of the advanced clinical practitioner (ACP) in primary or secondary care may focus on identifying potential candidates for transplantation and ensuring timely discussion and referral. Thus, a familiarity with eligibility criteria, and where to access this information, is important for all ACPs. Additionally, the increasing numbers of transplants performed in the UK mean that there is a large population of post-transplant patients in the wider community. These patients may present to healthcare services with a variety of issues relating to their LT, where early recognition and treatment has the potential to have major impacts on patient, or graft, function and longevity. Due to this, early discussions with specialist transplant centres is advised.
Since the first successful liver transplant (LT), performed by Thomas Starzl in 1967 (Fricker, 2017), LT has become an accepted and effective treatment for a select cohort of patients with end-stage chronic liver disease, or other potential indications. Although never a routine procedure, more than 900 LTs are performed annually in the UK (NHS Blood and Transplant (NHSBT), 2022a), with approximately 36 000 worldwide per year (Global Observatory on Donation and Transplantation, 2022). Despite this level of activity, a mismatch between supply and demand persists, with 400 to 500 patients awaiting LT at any one time in the UK (NHSBT, 2022a).
Organisation of transplants in the UK is regional, with post-transplant patients normally followed up in local centres. If unwell, they will likely present to primary or secondary care services prior to referral on to tertiary transplant units if indicated. Excellent, and continuously improving, survival rates post-transplant mean that there is a large population of LT recipients within the general community. It is therefore important that advanced clinical practitioners (ACPs) are aware of some of the key issues associated with the transplant assessment process, the appropriate clinical management of transplant patients and develop an understanding of some of the specific complexities discussed in this article.
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