Liver transplantation involves removing the damaged liver in a patient with liver disease and replacing it with a healthy liver from a deceased donor (cadaveric liver transplant) or a part of a healthy liver from a normal living donor (living donor liver transplant).
Who Requires a Liver Transplant?
Liver transplant is the only treatment that can cure liver failure either due to chronic liver disease or acute liver failure.
Cirrhosis is the common cause of chronic end-stage liver disease. Common causes of cirrhosis are
- Alcohol Consumption
- Non – Alcoholic Steatohepatitis (fatty liver disease )
- Hepatitis B
- Hepatitis C
- Hepatocellular carcinoma
- Auto immune liver diseases
- Biliary atresia
- Metabolic liver disorders
Acute liver failure, when not improving with medical treatment, may need emergency liver transplantation. Causes of acute liver failure are
- Drug over dose
- Poisons such as consumption of Rat killer (Ratol)
- Hepatitis A,B or E infection
- Genetic diseases like Wilson’s disease
Timing of Liver Transplantation
Patients with acute liver failure who are unlikely to recover with medical treatment alone will require an emergency liver transplantation as a life-saving measure. These patients are usually admitted to the hospital or the ICU and are managed with supportive treatment and close monitoring. Worsening bleeding tendency or deterioration of sensorium (coma or encephalopathy) indicates that medical treatment alone will not salvage the patient. In such patients, emergency liver transplantation is the best treatment option.
The timing of liver transplant for a patient with cirrhosis is more complex. It depends upon the relative balance between the benefit of liver transplantation and the small but definite risk associated with major surgery.
Several factors are considered to decide when a patient with cirrhosis is better off with a liver transplant rather than continued medical treatment. In general, the patient should be of such physical and mental health to survive the complex transplant surgery and withstand the potential postoperative complications, be reliably able to take the medications on time and come for regular blood checks and follow up to the clinics.
Factors affecting the timing of liver transplantation in cirrhosis
- Degree of severity of liver failure, MELD score
- Presence of liver cancer within transplantation criteria
- Other comorbid conditions like diabetes, heart disease
- Presence or absence of chronic or active infections
- Overall physical and psychological condition of the patient
- Level of social support from the family.
- Abstinence from substance abuse like chronic alcoholism
What is Liver Transplant assessment?
Liver transplantation is a major operation and has associated risks of complications. The liver transplant team will evaluate the fitness of a patient who needs liver transplantation to decide whether this can be performed safely. A multi-disciplinary team including cardiologist, chest physician, anesthesiologist, general physician and psychologist evaluates the fitness. Additional specialists are also involved in this process if necessary. The patient will undergo blood investigations and scans as part of this process. The whole process will take 2-3 days. Once all the required tests are completed, these are all discussed in a multi-disciplinary meeting and clearance is given once the team is satisfied that the patient needs liver transplantation and the benefit of the surgery far outweigh the risk of the surgical procedure.
Types of liver transplantation
Living Donor Liver Transplantation (LDLT)
The liver has the unique ability to regrow when a part of it is removed by surgery.
In Living Donor Liver Transplantation, a healthy donor, who is a near -relative of the patient is carefully evaluated to see if he/she can safely donate a part of their liver for performing transplantation to their loved one. If the donor is found to be suitable, then after necessary legal clearances, the liver transplantation is performed.
A portion of the donor’s liver is carefully removed during surgery and is transplanted into the sick patient. Both donor and recipient surgeries are performed nearly simultaneously. The donor makes a full recovery in 5-6 days, and the remaining liver grows back to its usual size in 4 to 6 weeks. The recipient’s liver grows slowly to its usual size in 3 months as the patient makes a full recovery.
Deceased donor liver transplantation (DDLT)
Here the liver is recovered from a patient who had a severe irreversible brain injury and after the patient has been certified by an independent medical committee to be ‘brain dead’. If the donor’s relatives agree to donate his/her organs for transplantation, these are carefully removed by surgery for transplantation. Usually, the full donor liver is used for transplantation. However, in selected cases, a donor liver may be surgically divided into two parts and used for transplanting two patients needing liver transplantation- usually an adult and a child.
In India, the number of deceased donations is very low. The chance of a patient receiving a suitable donor liver is unfortunately low. Living donor liver transplantation is hence the best option for patients who need a timely transplant. However, if a patient has no suitable donors in the family, the patient is then listed on the Tamil Nadu Waiting list for liver transplantation. The waiting time may take three months to one year, depending on the blood group and several other factors.
Split Liver Transplantation
This is a type of deceased donor liver transplantation, where a liver from a deceased donor is divided during surgery into two parts and each part is transplanted into two patients needing liver transplantation. Commonly it involves splitting a liver to transplant one adult patient and a child. This helps in better utilization of donor livers and benefits more patients awaiting liver transplantation. There are strict criteria for doing this procedure, and the surgical team will decide the feasibility of doing such a procedure.
Auxiliary liver transplantation
This is a modified type of liver transplantation performed occasionally in selected patients with acute liver failure where the patient’s own damaged liver is likely to recover slowly after a few months. In such cases, a part of the donor liver (either as split liver transplantation or living donor liver transplantation) is transplanted while a part of the patient’s own liver is left behind. The newly transplanted liver ensures that the patient recovers from acute liver failure. Then over a period of 12-18 months, the doctors gradually modify the anti-rejection medications to stimulate the growth of the patient’s own liver. Ultimately, the aim is to stop anti-rejection medications completely. This procedure is particularly ideal for small children who need liver transplantation for acute liver failure.
Liver transplantation surgery
A liver transplant involves the removing of and preparing the donor liver, removing the diseased liver, and implantation of the new organ. Duration of the surgery will take anywhere between 6 to 12 hours and the procedure is performed by a team of surgeons. The liver has several key connections that must be re-established for the new organ to receive blood flow and to drain bile from the liver. The structures that must be reconnected are the portal vein and the hepatic artery to take blood into the new liver and the hepatic veins to take blood out of the liver and into the heart, and the bile duct to transport the bile produced by the new liver to the intestine. The exact method of connecting these structures varies depending on specific donor and anatomy or recipient anatomic issues and, in some cases, the recipient disease.
Post-operative recovery after liver transplantation
After liver transplantation, the patient is shifted to the ICU under sedation and on respiratory support. The following day, multiple blood tests, including liver function tests are performed. Hepatic Doppler ultrasonography of the liver is done to ensure proper blood flow in the newly reconstructed blood vessels that supply the liver. After reviewing the patient’s clinical condition and the investigations, the sedation is stopped and the patient is made to wake up gradually and then removed from the ventilator. After this, the patient can communicate with others.
Usually the patient needs to be in the ICU for 3 to 5 days and then shifted to the ward for another 10-14 days. Oral liquid diet is gradually started from the day after surgery. By day 2 or 3, the patients are allowed to take soft, solid diet.
Immunosuppression (Anti-rejection medications)
Human body immune machinery has evolved over millions of years, and it works such that it destroys anything foreign to the body – whether it is a bacteria, virus or a transplanted organ. To dampen the immunological attack on the transplanted liver and allow the body to accept the new liver, all transplant recipients are given anti-rejection medications. Some of the commonly used immunosuppressive drugs post transplant are steroids, calcineurin inhibitors (tacrolimus , cyclosporine) , mTOR inhibitors (sirolimus, everolimus) and mycophenolate mofetil. Your doctor will decide the best medication and the best dose for you.
Initially, the dosage and strength of these immune suppressants will be high and gradually over a few weeks the dosage will be reduced appropriately to maintain a sufficient level that will allow the transplanted liver to work normally. Over some time, the dosage and the number of drugs will be decreased, but they can never be stopped completely. The transplant recipient has to take these drugs life-long regularly with regular follow up.
Complications after Liver Transplantation
Bleeding and risk of infection are the two common complications that one can expect after any major abdominal surgery. Complications that are specific to liver transplant include blockage of blood vessels, bile leaks and graft rejection. In the long-term, patients can develop complications related to the use of immunosuppressive medications such as diabetes, kidney problems or few types of tumors.
Outcomes after Liver Transplant
Outcomes following liver transplantation are excellent due to improving technical expertise and experience. Gleneagles Global Health City hospital is one of the high volume centers for liver transplant in South India. Our success rate for both adult patients and children is more than 95%.