Transplantation consists of 4 stages. First stage is evaluation. If you are deemed as the suitable candidate for liver transplantation, you will have 2 options: transplantation from cadaver or living donor. 2nd stage starts once you register in Ministry of Health Turkey Organ and Tissue Information System (TODS) for transplantation from cadaver and continues until compatible organ is found. 3rd stage is the liver transplantation surgery in the event that a compatible organ is found. 4rd stage is post-transplantation immunosuppressive (medication to suppress immunity) treatment and control process.

The process of your evaluation for liver transplantation starts as of you are accepted as a potential receiver for liver transplantation within Hacettepe University Liver Transplantation Program and continues until you are registered into the organ waiting list or you are deemed to be unsuitable for transplantation.

Evaluation process for liver transplantation involves several tests, interventions and meetings with the members of transplantation team. Furthermore, you may need to meet with other specialists outside the team. All of these consultations, tests and other procedures help us to decide if liver transplantation is the correct treatment for you and if you are sufficiently healthy for liver transplantation, which is a highly major and risky surgery. These tests also help us to decide if there are any other treatment options than liver transplantation suitable for you.

After your evaluation process ends, your file will be reviewed at Hacettepe University Council of Liver Transplantation Liver and it will be concluded if liver transplantation is the most appropriate treatment option for you. Council's decision will be communicated to you by your physician.

Liver transplantation team consists of; General Surgery Specialist and / or Pediatric Surgery Specialist (trained in liver transplantation), Adult Gastroenterology Specialist, Pediatric Gastroenterology Specialist, Psychiatrist, Anesthesiology and Reanimation Specialist and Organ Transplantation Coordinator.

Supervising Specialist of Liver Transplantation Program: Assist. Prof. Ahmet Bülent Doğrul, M.D. (link CV)
Assistant Supervising Specialist: Prof.Cahit Tanyel, M.D. (link CV)
Surgical team Member: Prof. Osman Abbasoğlu, M.D. (link CV)
Adult Gastroenterology Specialist: Prof.Yusuf Bayraktar, M.D. (link CV)
Pediatric Gastroenterology Specialist: Assoc. Prof. Hülya Demir (link CV)
Anesthesiology and Reanimation Specialist: Assoc. Prof. A. Gülsüm PAMUK(link CV)
Anesthesiology and Reanimation Specialist: Assoc. Prof. A. Heves KARAGÖZ(link CV)
Psychiatrist: Assist. Prof. Özlem Erden AKİ(link CV)

Organ Transplantation Coordinators
Specialist Nurse Seda Nihal Dikçınar YÜCESOY
Specialist Nurse Çiğdem TOPRAK
Nurse Aslı SEZER

If you have been deemed suitable for liver transplantation, you are included into the national information system consisting of active members waiting for transplantation from cadaver. Transplantation team should be able to contact you 24/7. You should arrive in hospital within a short period of time once compatible liver is found. Please make sure to give all of your contact numbers to organ transplantation coordinator. You should contact organ transplantation center in the event of address or teletelephone number changes.

Patients in the information system should periodically come to controls for evaluation.

In Turkey, the recipient of a liver harvested from a cadaver donor is decided based on MELD ( Model for End-stage Liver Disease) score of patients registered ad National Information System for liver transplantation. The score is calculated by using 3 variables (bilirubin, creatinine, INR). A patient with a higher score is more likely to be lost due to liver disease in this system that calculates the survival possibility of patient in need of liver transplantation.

Adaptations are applied in certain situations (for instance hepatocellular carcinoma patients)
Score is used for patients younger than 18.
MELD score should be recalculated and updated periodically based on MELD score.

Patients suffering from incurable liver disease with associated complications such as abdominal fluid accumulation, loss of consciousness, peritonitis, decreased life quality, etc.) are candidates for liver transplantation.

Diseases that could lead to incurable liver diseases
1: Acute liver failure (due to mushroom, drug, etc. poisoning)
2: Congenital absence of bile duct
3: Metabolical diseases:

• o Alpha-I antitrypsin deficiency

• o Crigler-Najjar disease, Type I

• o Byler disease

• o Glycogen storage diseases

• o Wilson disease

• o Hemochromatosis

• o Tyrosinemia

• o Familial amyloidotic polyneuropathy

• o Primary hyperoxaluria type 1

4: Liver cirrhosis (Reasons can be Hepatittis B,C, Alcohol, NASH, etc)
5: Hepatic vascular diseases
6: Liver tumors

Transplantation from cadaver
The procedure involves transplanting the entire or a part of the liver harvested from a cadaver instead of your diseased liver to be removed.

Transplantation from living donor
The procedure involves transplantation of a part of the liver of a healthy individual.

After the organ transplantation, you should take medication to suppress your immune system everyday so that your body does not reject the transplanted organ.
Several patients are nervous while departing from this environment, but the suggestions given below will help to create and maintain a safe environment at home.

Your medication
Your physicians and nurses will inform you on how to use your medication. You should take your medication regularly. If you have trouble in maintaining regular medication intake, you should receive support from family members in this regard.

Controls
You should pay control visits 3 times a week nice you are discharged from hospital. You should come to control examination without taking your medication before as your medication levels will be observed.
The frequency of your control examinations in the long term will be stated to you by your physician.

Home Environment
Living flowers and plants should not be put into patient room as these can be source of infection.
Pets should be avoided after transplantation. You can talk to your cat or dog with a distance in between. But you should by no means allow your pet to contact and lick you or sleep together with you.

Personal Contact
Close contact (hugging, kissing, hand shaking) should be avoided in order to reduce the probability to exposure to bacteria and other agents that could cause infections.
Persons who are not suffering from any infectious disease or upper respiratory tract infection can visit you after they wash their hands. The best protection is to avoid crowded places in the initial days.
You should avoid contact with persons suffering from upper respiratory tract infection (such as flu). Live vaccine should be avoided.

Daily Cleaning
Taking showers or bathing frequently are good for you. You can use a mild soap particularly in the event of a rash. You should avoid using soap with strong scent.
You should check your skin. Immediately inform your physician or nurse in case of a redness, puffiness or itchiness on your skin.
Always use your own towel and clothes. Do not use such belongings used by others and do not allow anyone else use what has been used by you.

Sea and Swimming Pool
Do not swim in lakes or public swimming pools as your immune system will have been suppressed. Do not engage in activities such as swimming without consulting to your physician.

Daily Exercise
Regular exercising is an important part of recovery process. Restoring your muscular strength and motion with exercise will make you feel good not only in physical but also in emotional terms.

You will feel that your resistance to activity or exercise has dropped down after you are discharged. Daily routine exercises can be very difficult at the outset as your energy level can be low or you might not feel good. Planning both resting and exercising periods together can help.

Sexual Life
Sexual activity subsequent to transplantation depends on how you feel yourself. Both male and female patients should inform a physician or nurse in the event of a discharge, skin lesion, chap or rash in the genital area. Sexual intercourse should be avoided until full recovery in the event of an active infection in your partner.

Nonetheless, birth control is of major importance. Transplantation team will inform you on the birth control options available.

Fever
If your fever reaches up to 38 degrees celsius and does not go down to normal level in 2 hours, you should call your nurse or physician.
Circumstances in which you should inform your transplantation team:
• Fever above 38 degrees celsius
• any bleeding from the palate, nose, rectum or bladder
• Cough, nasal congestion or shortness of breath,
• Nausea, vomiting or diarrhea,
• Skin rash or redness (check on a daily basis while in the bathroom),
• Any problem, pain, swelling, redness or discharge in the surgery site
• Mouth sores or rectal pain
• Genital scars, vaginal bleeding, discharge or odor.
• Frequent urination, pain or burning during urination,
• Yellow color on your skin or the white parts of your eyes
• Itchy skin

Smoking/Alcohol/Medication
We suggest you not to smoke after transplantation. Additionally, you should not allow anyone smoke near you and avoid from environments where tobacco is smoked.

Alcohol intake after transplantation should be avoided as well. It is not recommended as alcohol intake while taking medication on a regular basis should be avoided.

If you need to use any medication for a reason, consult with your physician or nurse. The medication given to you might not be compliant to the medication that suppresses your immune system, so you can change the expected effect.

Nutrition
As your immune system is suppressed, a great risk is posed in respect to the infections spreading with food.

The majority of food includes certain types of bacteria which are usually harmless for anyone who has a full-functioning immune system. This being said, food which includes high level of bacteria can be harmful to certain people and these food types can be a source of infection.

This section sets out information on considerations about selecting, buying, preparing and storing food in the post-transplant period.

Considerations about preparing and storing food are as follows:

• • Start with cleaning your fridge and make sure the temperature is set below 5 °C.

• • You should buy new food for your first arrival at home from the hospital. Discard or move away open cans or packages for a while.

• • Remember to wash your hands frequently.

• • Keep all the areas you prepare food in a clean and dry condition.

• • Wash plates with hot water and soap, and set them aside as soon as they dry up.

• • Be careful while handling kitchenware and hold them from their grips or edges.

• • Keep your fingers off food.

• • Put on gloves while preparing food with any injury or open wound in your hands.

• • Make sure not to cough or sneeze near food or plates.

• • Check the expiration date of all products.

• • Cook all types of meat and eggs well.

• • Keep meat and prepared food in the fridge only once. Keep all the food in the fridge in containers with closed lids.

• • Leftover food should be served after it is re-cooked.

• • Leftover food should be eaten within 24 hours or packaged and frozen.

IMMUNOSUPPRESSIVE DRUGS
Immune system is the body’s defense system. It serves to the purpose of defending the body against factors causing diseases and ensures body’s resistance against these factors. If the immune system is strong, body overcomes these factors so that there won’t be a disease. After the heart transplantation immunosuppressive drugs are used to prevent the rejection of the transplanted organ by the recipient’s immune system. Therefore, while you are on immunosuppressive drugs, you have to protect yourself from diseases and related factors, better than you did before. Period of use and dosage of these drugs are determined/arranged by your physician and these are modified depending on your condition.

Immunosuppressive drugs repress your immune system and weaken it. In other words, they suppress your body’s defense mechanisms (which it normally has) that attack and reject foreign tissues. It helps your body to accept the new organ. While these drugs prevent organ rejection, on the other hand, these decrease your body’s defense against infections. While you are on immunosuppressive drugs, your body is open to infections; besides, while you are on this treatment, you should not be vaccinated with live viruses. You should consult to your doctor and transplantation team in every case of medication use and vaccination.

General Side Effects of Drugs
Opportunistic infections; cytomegalovirus, fungus, herpes simplex (blain, cold sore) are observed commonly
An increase in malignant diseases may occur. Therefore, you have your medical controls regularly.
Do not change or skip doses without consulting your doctor. Use medication according to recommended dose and directions. Even before using a simple drug -even if it is recommended by another physician- you should consult to your own doctor. Please remember to take your medication with you while travelling. Do not switch drugs with others. Even if they have the same content, before switching your drugs, please do consult with your physician.

Prednisolone (Deltacortril)
It has an immunosuppressive effect.
The dose of Prednisolone decreases to the maintenance dose. You will keep using prednisolone unless otherwise stated by your physician. If you receive the medication in a single dose, you should take it after breakfast with a full stomach.

Side Effects
It can cause water and salt retention, increase in gastric and perspiration acidity.
The risk of fungal infection in mouth increases. Increased hairiness and acnes on skin might be observed. It may cause muscle and bone weaknesses in the long term.

It may cause cataract and increased blood glucose. Psychological problems are observed more commonly.

Prograf (Tacrolimus): By blocking T cells, it prevents T cells to damage the transplanted organ. Mechanism of action is similar to cyclosporine and cannot be used together with it.

The given circumstances for cyclosporine also applies to tacrolimus.

High blood levels disrupts the kidney functions. For this reason, blood values should be followed up closely. Please have your blood values tested whenever your physician instructs you. To obtain accurate and correct results, please use your medication on time and regularly. The dosage arranged according to tacrolimus level in blood. It has similar side effects with cyclosporine. Cosmetic side effects (pubescence, swollen gingiva etc.) are observed less, while drug related diabetes and neurological symptoms are observed more commonly.

Do not take the medication with grapefruit juice. Grapefruit juice affects blood levels. Do not drink grapefruit juice 2 hours before or after receiving medication. Certain drugs (such as ketoconazole, erythromycin) may have greater effect the level of tacrolimus. Therefore, as it was mentioned before, please do not take any medication without consulting your physician, even if it is recommended by another physician.

Take the drug only with water.

Cellcept(Mikofenolate Mofetile – MMF) and Myfortic (Mikofenolate Sodium)
Cellept, an inosine monophosphate dehydrogenase inhibitor, prevents the rejection of transplanted organ by body. Usually, it is taken with cyclosporine, tacrolimus and/or sirolimus. It should not be taken together with the anti-acids containing magnesium and aluminum hydroxide since it will decrease the absorption.

Most common symptoms are diarrhea, decrease in leukocyte count, nausea, vomiting. It causes an increased tendency to certain infections.

Cyclosporine (Neoral-sandmimmun)
It is an immunosuppressive drug. It shows its effect by blocking T cells. It has two forms: oily liquid and pills, both of which are taken orally. Capsule form is swallowed with a liquid like other medications. If you are using the fluid form, your physician or nurse will show you how to adjust the dosage. You should take the proper dosage of medication immediately after mixing it with milk (room temperature heat), chocolate milk or orange juice. Do not forget that you should never take cyclosporine with grapefruit juice! If you have taken the medication, please do not eat grapefruit for at least two hours.

Please take your medication regularly and at the same hour everyday, as it will help you to keep the medication in your blood at the same level at all times. If you forget to take the medication and you remember in 1-2 hours, take the missing dosage immediately, keep your regular schedule. If you don’t remember to take it until the time of the next dosage, do not take two dosages at once, and consult with your doctor. If you have diarrhea and/or vomit, inform your doctor immediately. Diarrhea causes disposal of drug before it affects your system. So that, it may cause rejection of transplanted organ. In this case, the drug will be given to you through an intravascular line. At this period you should avoid using laxatives.

Keep your medication in dry place, and in room temperature. Direct exposure to sun, storage in the fridge, extreme hot or cold weather will cause the drug lose it efficiency. Also, if you are using the fluid form of the drug, do not use it once it has been 60 days after opening it. You will be required to check cyclosporine level in your blood regularly. On the test days you have to take and bring your medicine as you were told to do. Please have your blood values tested whenever your physician instructs you. To obtain accurate and correct results, please use your medication on time and regularly.

Do not take the medication with grapefruit juice. It affects blood level. Do not drink grapefruit juice two hours before and after the time of medication. Certain drugs (such as ketoconazole, erythromycin) can have greater effect on the level of cyclosporine. Therefore, as it was mentioned before, please do not take any medication without consulting to your physician, even if it is recommended by another physician. You may take the medication with orange juice or milk.

Side Effects
Cyclosporine may have severe side effects. Commonly, it may cause hypertension. After you start taking the medication, your blood pressure should be monitored regularly. If it is necessary, your physician may recommend you to take your pills for blood pressure. Blood cholesterol and triglyceride levels might increase. Kidney and liver functions might increase. For this reason, you should do your laboratory checks regularly. Your hands may start shaking as well as headache, cramps in legs, swollen gingiva, nausea and vomiting. Also, your hair may get thick and wayward and shape and its form and dispersion may change to some extent.

You should be careful about the oral hygiene since long-term use of the drug may cause swelling in gingiva. You should brush your teeth after each meal and have your teeth checked once in every 4 to 6 months. Your dentist should also know about this medication.

You have to tell every side effect you are experiencing to your doctor. There might by grow of hair, kidney function disorder, nausea and vomiting and headache may occur. Please do not forget that the problems related to this drug will decrease in time with the decrease in dosage.

Rapamune (Sirolimus)
Rapamune (Sirolimus) prevents rejection of transplanted kidney by suppressing your immune system. In certain circumstances, it is used to treat acute rejection. It is used with cyclosporine and prednisone.

Rapamune (Sirolimus) in 1-5 mg dosage. It has liquid and tablet forms. Liquid form can only be mixed with orange juice or only water. It should be mixed in a glass and consumed before it precipitates. If Rapamune (Sirolimus) is used with cyclosporine (neural), it should be taken once in a day after four hours of the morning dosage of Neodal. Liquid form should be maintained inside fridge and the tablet form should be maintained somewhere dry and cool.

Side Effects
Rapamune may decrease white blood cell count, therefore it increases the risk of infection. Also, it may cause risk of bleeding by lowering the thrombocyte count. By adjusting dosage these two side effects may be decreased.

Rapamune may cause indigestion, diarrhea, nose bleeding, headache, joint pain, and increased level of cholesterol and lipid.

Certican (Everolimus)
It is an immunosuppressive drug which suppresses T cell activation and reproduction. It is only for oral use and should be taken two times a day. Tablets are taken with water without crushing and should be swallowed in one piece. It should be taken at the same time everyday. It should only be taken with water. When it is taken with fatty foods or grapefruit or grapefruit juice, its absorption decreases.

Side Effects:
General: pain (in general), muscle weakness, swollen hands, feet, arms and legs, wheezing, dyspnea, sudden urge to urinate, influenza symptoms, fever, chill, sore throat, joint pain, swollen glands, new moles and swellings, sudden bleedings and bruises, fatigue, headache, dysphagia caused by swollen face, lips, mouth, tongue, shortness of breath, increase in blood lipids may occur.

Dermatological: Acne, heat rash and sensitivity in certain parts of the body.
Hematological: Decrease in blood levels caused by repression of bone marrow.
Gastrointestinal: Stomachache, diarrhea, nausea and vomiting.