Liver transplantation [LT] is now an established therapy for acute and chronic liver failure. The refinement in surgical techniques, improvements in anaesthesia and preoperative care and access to newer immunosuppressant drugs has resulted in a one year survival rate of 90 per cent and 5 – 10 year survival rate of 75 – 80 per cent.
Patients with severe liver disease and those who do not respond to the standard medical and surgical therapy are considered for liver transplantation. People recommended for LT include those suffering from:
- Cholestatic diseases [diseases due to suppressed flow of bile from liver to the duodenum]
- Hepatitis B- and C-associated end stage liver disease
- Alcoholic cirrhosis [a type of liver disease caused by chronic, excessive drinking]
- Liver cancer
- Hepatic failure [when the liver loses the ability to regenerate or repair]
- Metabolic diseases such as hemochromatosis [abnormal accumulation of iron in the body] or Wilson’s disease [abnormal accumulation of copper in the body] to name a few.
There is limited availability of liver donors. Hence, transplantation is not recommended for patients who are unlikely to survive the procedure or obtain long-term benefit. Such patients include those suffering from:
- HIV infection
- Uncontrolled alcohol or drug abuse
- Complicated systemic infections
- Life-limiting medical conditions
- Uncontrolled psychiatric disorder
All patients suffering from chronic liver disease are referred for liver transplant assessment and listing at a liver transplant centre. Thorough assessment and counselling of the patient is an important aspect of the pre-transplant process. It helps accurately identify the cause of liver failure to rule out any contraindications for the transplant and to determine the fitness of the patient for the procedure.
- Assessment of liver disease through:
- Liver function tests
- Doppler ultrasonography/CT scan/MRI
- Liver biopsy [in some patients]
- Infection/cancer markers
- Infection screening.
- Assessment of nutritional and electrolyte status
- Assessment of cardiac, respiratory and renal functions
- Assessment of surgical and anaesthetic risks
- Assessment of social, psychological and economic issues
- Patient and family counselling.
Selection of patients for transplant requires consideration of not only medical criteria, but also the socioeconomic and educational background of the family. This is of paramount importance because in addition to the initial expenditure, receiving a transplant also involves a lifelong commitment on the family’s part to spend an average of Rs 12,000 per month on immunosuppression [suppression of the body’s immune response with the help of drugs or radiation to prevent the rejection of the transplants] and to adhere strictly to the postoperative care protocol including anti-infection precautions and long-term medications.
The patient is taken for transplantation as soon as a healthy liver is available. If the new liver is to be taken from a living person, then both the donor and patient are taken in together for the surgery. If the liver is from a dead person, surgery starts as soon as the new liver arrives at the hospital. The surgery usually takes about 4 – 14 hours depending upon the complexity of the patient’s condition.
Depending on how well and how fast the patient shows signs of recovery, s/he remains hospitalised for an average of three weeks. During this time, the patient is continuously monitored for bleeding, infections, and organ rejection. Medicines are administered to prevent the occurrence of such instances.
The patient is guided on taking care of herself/himself after s/he returns home. The diet is gradually shifted from clear liquids to solid foods as the new liver begins to work efficiently.
After being discharged from the hospital, the patient needs to undergo regular blood tests to check for rejection, infections, or problems with blood vessels/bile ducts. Usually recovery is fast if patients follow the instructions diligently.
Most people can resume their normal activities including work within three months of the transplant.
Apart from the fact that they need lifelong immunosuppressive medication [as is the case with any organ transplant] to prevent rejection of their new liver, they can expect a life, which is normal in all respects including longevity, reproductive function and physical activity. Most women have normal pregnancy even after liver transplant.
However, not all patients are that lucky. Some show early complications like initial non-functioning of liver, vascular thrombosis [blood clot in the vein], sepsis [inflammation], and biliary leak [leakage of bile].
Late complications include biliary stricture [abnormal narrowing of the bile duct], chronic rejection, infections and occasionally malignancy [cancer].
Recurrence of the primary disease may be a problem in patients with hepatic tumours and hepatitis C infection. Hepatitis B recurrence is rare after transplantation as it can be reduced by 10 – 15 per cent with pre and post operative use of anti-hepatitis B immunoglobulins and antiviral agents.
The world over, liver transplantation remains a high risk procedure with a mortality of 15 – 20 per cent with high preoperative morbidity. Most patients who cross one year survival live up to their normal life expectancy. They lead an excellent life with no functional disability whatsoever.
Source of organ
Liver for transplantation can be obtained from:
- Brain dead cadavers [those who donate their liver after death]. The benefit here is that the whole liver can be used for transplant.
- Live donors: a living person donating a portion of his/her liver.
The living donor should be a relative with compatible blood group and similar body weight. S/he should be medically fit and in the age group of 18 – 55 years. The donor is thoroughly evaluated for fitness—the most important test is the volume of the two lobes of the liver as estimated by CT volumetry.
There is no need for tissue typing [a procedure in which the tissues of a prospective donor and recipient are tested for compatibility] in liver transplant, only the donor and recipient should have same or compatible blood group.
Shortage of donor organs continues to remain a significant problem. Innovative surgical techniques of segmental transplantation, split liver transplantation and living-related transplantation have been developed to address this problem.
So far so good
Four years ago, Santosh Bhushan had jaundice. She was diagnosed with autoimmune liver cirrhosis, an end stage liver disease, and was put on conservative treatment. However, she wasn’t responding well to it and in fact her health was worsening due to the accumulation of fluid in tummy. She was listed for cadaver liver transplant [transplant from a dead person].
She got an opportunity once; however the liver was unsuitable for transplantation. On March 24, 2010, cadaver liver was available and Ms Bhushan was first on the waiting list. She underwent a liver transplant on March 25.
Post operation, she was off ventilator on the first day and on full oral diet by third day.
She was shifted out of ICU after seven days. She had an uneventful ward stay and was discharged after three weeks.
Now after five months post transplant, she is now doing all her normal activities and is on minimal medications called immunosurpresect drugs to keep liver acceptable to the body.