Liver transplant
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What is a liver transplant?
Liver transplant is a major surgery where your damaged or poorly functioning liver is replaced by a healthy liver from another person called a liver donor.
The healthy liver can be obtained from a deceased person where it is called as deceased donor liver transplant (DDLT) or from a living person where only a part of the liver is removed, called a living donor liver transplant (LDLT).
Liver performs many essential tasks that are required for the normal functioning of the body. When the liver becomes severely damaged due to any disease or toxin, it can result in liver failure which can subsequently lead to death. The liver transplant helps by providing a healthy liver that can perform expected normal functioning.
A liver transplant removes your diseased or injured liver (right) and replaces it with a healthy liver (left).
How common are liver transplants?
The maximum number of liver transplants are done in the USA, about 7000 per year. It is followed by China and brazil. In India, about 800 to 1000 liver transplants are done every year. Most of them are LDLT accounting for about 85% transplants and remaining are DDLT consisting of 15% transplants.
Almost all transplants done in the north of India are LDLT constituting 97% transplants. While in southern and western parts of India DDLT is also done in significant numbers and has increased in recent years due to a higher number of deceased donors and changes done in transplant act.
It has been estimated that about 20,000 people in India require liver transplant every year which is also considered a gross underestimate.
Why the liver transplant is done? When do people need a liver transplant?
The liver transplantation is mostly done to treat liver failure. Usually, a person develops a chronic liver failure and less often an acute failure. Such a person needs a liver transplant to support his life.
Common causes of chronic liver failure/cirrhosis that needs a liver transplant (according to Indian scenario):
• Chronic hepatitis C (24%)- also the most common cause of liver transplant worldwide
• Alcoholic liver disease (22%)
• Nonalcoholic fatty liver disease (21%)
• Chronic hepatitis B (18%)
Less often acute liver failure occurs which may often need a liver transplant for the sustenance of life.
Common causes of acute liver failure are
• Drug-induced injury seen with anti-TB drugs in India and paracetamol in western countries.
• Fulminant viral hepatitis (mostly caused by hepatitis E in India and by hepatitis B especially in the combination of hepatitis D in other parts of the world)
• Less common causes include reaction to drugs, herbal medicines, toxins, blockage of blood vessels to the liver.
Liver transplant is also done in diseases with no cure or where another treatment has not been successful:
• Liver cancer (HCC) that has not invaded the blood vessels of the liver- also an important cause (10%).
• Biliary atresia– commonest reason in children for a liver transplant, accounting for 75% of cases. In this condition the drainage system of bile is abnormal.
• Enzyme deficiency causing other serious systemic problems- primary hyperoxaluria, maple syrup urine disease, etc.
• Metabolic diseases where the liver gets damaged such as tyrosinemia, Wilson’s disease.
• Others: Budd Chiari syndrome
What are the types of liver transplants?
There are mainly two types of liver transplant procedures done on the basis of the source of a healthy liver.
Living donor liver transplant (LDLT)
This is the commonest type of transplant done in India. Here the donor is a living person most often a family member who donates a part of his or her liver. Typically, the right lobe of the liver is removed from the donor’s liver which is then implanted in your body after removal of the damaged liver.
The donor’s remainder liver and the implanted liver in your body both grow back to normal size within several weeks after surgery. Thus, providing sufficient functioning to both donor and the recipient.
Deceased donor liver transplant (DDLT)
This type of transplant is most commonly done in western countries and to a substantial extent in the western and southern parts of India. In DDLT, typically the entire liver is obtained from a person who has died recently and is implanted in your body after removal of the damaged liver.
Sometimes, the donor liver is divided into two parts, where the larger part is put in an adult and smaller part is put in a child or a smaller adult. This type of transplant is called a split liver transplant.
The dead donors are typically the brain dead people who would not be able to sustain their lives due to their damaged brain. Donation from these people called donation after brain death (DBD). The liver once removed from the body has to be transplanted in a period of 12 hours.
The other type of dead donors are people who have undergone severe trauma which makes them unfit to sustain life even though their brain remains intact. This is called as donation after cardiac death (DCD).
What is the cost of liver transplant in India?
Most of the centers in India offer liver transplant packages in the range of 20–30 lakh rupees. Often the cost may turn out to be higher due to travel and stay expenses of the accompanying family members and due to the development of complications that may need longer stay and added treatment cost.
How many foreign nationals opt for liver transplant surgery in India?
Overall around 10–15% of patients who undergo live donor liver transplants in India are from foreign countries which are as high as 25% in some of the centers.
What are the survival rates after a liver transplant?
The chances of a successful liver transplant and having a good chance of survival depends upon the number of factors including the complexity of surgery and post-op treatment care.
However, in general, it is estimated that in the USA out of 100 people undergoing liver transplant 75 people survive even after 5 years of transplant surgery. In India, the 5-year survival rate in recent years at major centers has been estimated to be around 80% to 90% ie from 100 people undergoing transplant about 80 to 90 people survive after 5 years.
The long term survival rate depends upon post-transplant care, regular follow up with your doctor, and how well you take medicines for the rest of your life. This is discussed in detail later.
What to do if you think you need a liver transplant?
The first thing to do while considering liver transplant as an option for your disease is to talk to your doctor. The doctor would consider liver transplant as an option if all other treatment options have failed or when the disease is incurable and you can’t manage anymore without a new liver. He would assess you by means of clinical observations and calculate a score by means of laboratory findings to indicate how urgently you would need a liver transplant.
The score is called as MELD (model end-stage liver disease) for adults and PELD (pediatric end-stage liver disease) for children. The score is calculated by means of simple blood tests such as creatinine, bilirubin, and INR. The higher the score more urgently you would be needing a transplant. The score ranges from 6 to 40 where 6 represents the least sick person and 40 represents the sickest person. The doctor would also order some imaging tests to evaluate your liver disease and the presence of any other disease
Contraindications:
However, in some circumstances, a doctor may also tell you that your other medical conditions (such as diseased/weakened heart or lung) doesn’t support a major surgery such as transplant or reduces your chances of survival.
Sometimes a disease such as liver cancer may extend into blood vessels or to other parts of the body which may also restrict you to undergo a liver transplant or may delay it till the time other treatment helps it restrict it to the liver only.
A severe infection or alcohol or drug abuse problem may also restrict you to undergo a liver transplant.
What are the tests done to consider you fit for the transplant?
To get yourself tested for being fit for liver transplant you should get all of your medical records, reports of previous lab tests, imaging studies and liver biopsy report which has been done during the course of your disease.
The doctors would ask you to undergo following tests to deem you fit just before transplant:
Imaging studies:
Generally done for the donor and recipient liver
• Multiphase CT abdomen: A special type of CT called dynamic or triple-phase CT is done where a dye is injected in your body and images are taken at different times to allow good visualization of liver and its blood vessels. This test is done in both the recipient and the donor. A special test called CT Volumetry calculates the volume of donor liver in living donor liver transplant.
• Ultrasound of abdomen and pelvis
• Doppler ultrasound is done to determine the patency and flow inside the blood vessels of the liver. Done in liver recipients.
• MRCP: this is a special type of MRI that shows the anatomy of the bile ducts which allows better planning of surgery to avoid bile duct complications.
Blood tests:
To check blood type, clotting function, LFT, and biochemical status of blood. Serology screening and cancer screening such as PSA in males and CA 125 in females may also be included.
If the above tests suggest any suspicion, other additional tests may also be performed accordingly.
The person also undergoes an extensive evaluation of various systems of the body involving examination of heart and blood vessels, lungs, psychological or psychiatric problems, screening for malignancies and infections, and the need for vaccination. Following tests are done before
Heart and blood vessels evaluation:
• 2D Echo
• Stress echo
• Carotid doppler
Lung evaluation:
• Arterial blood gas on 100% FiO₂
• Pulmonary function test (PFT): to determine the functional capacity of your lungs.
• Chest X-ray: to evaluate any lung abnormality like infection or mass.
Malignancy screenings:
• Colonoscopy: to rule out colon cancer
• Paps smear: to rule out cervical cancer
• Mammography: to rule out breast cancer
• Prostate-specific antigen (PSA): to rule out prostate cancer
Infection screening
• Dental examination to exclude infection
• Screening for tuberculosis
Vaccine screening
Administration of the following vaccines if indicated:
• Hepatitis A virus
• Hepatitis B virus
• Pneumococcus
• Influenza
• DTaP
• HPV
Psychiatric examination
How the liver transplant surgery is done?
The liver transplant is a major surgical procedure that can take up to 12 hours or more to complete.
Depending upon whether the donor liver is obtained from a living person or a diseased one, the transplant procedure varies.
In general, the person to be operated is prepared for the surgery by:
• Putting in an IV line to give medicines and fluids
• By connecting with machines that monitor vitals like heart rate, respiratory rate, blood pressure etc.
• Giving general anesthesia to make the person lose conciseness
Living donor liver transplant (LDLT)
• LDLT surgeries are elective surgeries where the date and timing of the surgery are planned several days earlier.
• The surgery is done on the same day for donor and the recipient.
• The surgeon starts operating first on the donor removing a part of the liver usually the right lobe of the liver, in case of an adult recipient. If the recipient is a child, typically the left lobe of donor liver is removed.
• The removed part is then immediately placed inside the abdomen of the recipient after removal of the damaged liver.
• The surgeon then connects the blood vessels and the bile duct of the recipient with that of the transplanted liver.
• The transplanted part of the liver in the recipient and the residual part of the liver in the donor both regenerate rapidly to attain the normal size in a matter of several weeks.
Deceased donor liver transplant (DDLT)
• DDLT is usually not done in a pre-planned manner unlike LDLT. The surgery can only be performed once the donor liver arrives at the hospital.
• When the donor liver is available at the hospital the recipient is asked to immediately come to the hospital.
• The person is immediately admitted and made to undergo several tests to confirm the fitness for the surgery.
• The surgeon after preparing the patient for the surgery makes a long incision across the abdomen and carefully removes the diseased liver from the recipient.
• After the removal, the donor liver is placed inside the abdomen and the blood vessels and bile duct of the donor liver are carefully connected to that of the recipient.
• At last the surgeon closes the abdomen by putting the staples and stitches.
What happens after the procedure and during the hospital stay?
• ICU (intensive care unit): After the transplant, the person is taken to the ICU where he is kept under continuous rigorous monitoring for a few days while he recovers from the surgery.
• Ventilator support: in the ICU, the person is often kept on a ventilator for the first 1–2 days which helps him to breathe with support.
• Antibiotic: the person is also kept under antibiotic cover to prevent the development of Infection. Antibiotics such as trimethoprim/sulfamethoxazole, fluconazole, and ganciclovir are given.
• Multiple tubes and catheters are put inside the body in various parts to aid the person to carry out certain functions while he recovers. These are as follows
– Endotracheal tube: a tube is placed through the mouth into the windpipe (trachea) which is attached to a ventilator that helps the person to breathe without putting his own effort.
– Nasogastric tube: a thin long tube that is inserted through the nose into the stomach to drain secretions from the stomach. The tube is kept for a few days until the bowel function becomes normal.
– Drainage tubes: few tubes are also placed in the abdomen through the skin to drain blood and fluid that collects around the liver. These are kept in place for about a week’s time.
– Foleys catheter: A tube is also placed inside the bladder through the urinary outlet which helps to continuously drain out urine.
• During the stay a number of lab tests and doppler studies of the liver are regularly done to rule out any possibility of developing a complication and to supervise the recovery of the person.
• After the person becomes stable he or she is taken to a transplant recovery area for further recovery.
• The entire hospital stay may take around 10 to 14 days if no significant complications develop post-surgery.
• Just before the discharge, a doctor from the team would explain the person and his family how to take care of the liver and the body after transplant, how to take medicines, and how to follow the scheduled blood tests.
• It is important for the person to understand the importance of taking medicines as prescribed, to regularly get himself tested as scheduled, and to follow the dos and don’t’s as advised. This is considered to play an important role in increasing the chances of survival after the surgery.
What are the possible problems or complications of liver transplant surgery?
There are a number of complications that can occur after a short period post-surgery or after a long period of post-transplant.
These complications are as follows:
Immediate complications:
They typically occur within a short period after surgery generally within 3 months. They generally consists of complications related to graft rejection or surgical complications:
• Liver graft (new liver) dysfunction/ rejection
• Bleeding after surgery
• Complications related blood vessels of liver- hepatic artery clot, portal vein clot or hepatic vein obstruction
• Complications related to bile duct- bile leak, bile coming out of an opening in the skin (fistula), bile duct narrowing (stricture)
• Infection
Long term complications:
The complications occurring after a long time usually related to long term use of immuno-suppressive medicines which are given to prevent the body from rejecting the liver from another person.
• Chronic graft (transplant liver) rejection
• Renal failure
• Hypertension (increased BP)
• Diabetes Mellitus
• Dyslipidemia (abnormal blood lipid levels)
• Decreased bone density or non-traumatic fracture
• Obesity
• Nervous system related issues- Tremor, headache, paraesthesia or insomnia
• Liver cancer
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