Why and who needs Liver Transplantation
Liver is the largest internal organ of the human body and has a multitude of essential functions to sustain life that includes metabolism of carbohydrates, fat and protein, detoxification of various metabolites and production of bile necessary for digestion. Life without a healthy properly functioning liver is impossible. Unlike kidney diseases where dialysis can allow a person to lead an acceptable quality of life, people with end stage liver disease do not have the option of dialysis or artificial liver support system to compensate for loss of liver function. In advanced cases of cirrhosis/end stage liver disease, liver transplantation is the only treatment option. The most common cause of cirrhosis/end stage liver disease are alcoholic liver disease, Non alcoholic fatty liver disease, Chronic viral hepatitis, Auto-immune hepatitis, Primary Sclerosing cholangitis, Primary Biliary Cirrhosis etc. People usually need to consider this option when they develop symptoms from cirrhosis, such as jaundice, significant fluid retention (ascites), bleeding varices, hepatic encephalopathy, kidney dysfunction, or liver cancer. Liver transplant entails replacing diseased liver with a healthy liver from a deceased donor or part of a liver from a living donor.
Liver transplantation has significantly changed the management of advanced liver disease. Prior to the success of liver transplantation management of end stage liver disease/cirrhosis was directed against alleviating the symptoms arising from complications of cirrhosis; with liver transplantation not only do the symptoms disappear but quality of life improves remarkably and life expectancy increases.
Apart from cirrhosis/end stage liver disease another condition in which liver transplant is needed is acute liver failure (ALF). ALF is a rapidly progressive condition resulting from destruction of large number of liver cells over a short span of time (usually a few days to weeks) and therefore most of the life supportive liver functions are lost. The condition demands immediate care in a ICU setting and such patients should be ideally managed in a dedicated liver unit equipped to do emergency liver transplantation. ALF is commonly seen in the setting of acute viral hepatitis (Hepatitis A, B and E), drug intoxication/overdose ( Paracetamol, Anti-tubercular drugs and others) and Wilsons disease. In some cases the cause in not immediately known. The initial symptoms include fatigue, nausea, vomiting and rapidly increasing jaundice. Most patients become confused, disoriented and may lapse into coma (Hepatic encephalopathy) requiring ventilator support. The patient should be managed in a dedicated liver ICU and the treatment is mostly supportive. Patients who continue to deteriorate on supportive treatment should undergo an emergency liver transplantation. Both deceased donor and living donor liver transplantation can be offered. However due to low rates of deceased organ donation in our country living donor liver transplantation is the better feasible life saving approach.
Deceased donor liver transplantation
In deceased donor liver transplantation the family of a brain dead patient donates the organs before withdrawing critical life support system. Brain dead donors are individuals who have suffered brain death- which is the complete loss of brain function including the ability to control involuntary activity to sustain life like breathing, beating of heart etc. In such situations if the family members give consent to donate the organs then the whole liver can be transplanted in an adult or can be split into two for an adult and a child. The process by which organs are removed is known as organ retrieval. The liver after retrieval is preserved outside human body in special preservation solutions for transport and subsequent transplantation into a recipient. The liver can be preserved for approximately 12-15 hours in the special preservative solutions. The allocation of an organ to a recipient is based on the blood group, waiting period on transplant waiting list and urgency of requirement. The waiting period before a recipient gets an organ is variable varying from 1 to 12 months depending upon the position in the transplant waiting list.
Living Donor Liver Transplantation
In living donor liver transplantation a donor donates part of his/her liver. Donating a part of liver from a living human being is possible as liver has the capacity to regenerate and it is a highly resilient organ with huge reserves thereby allowing for safe removal of nearly 70% of the liver. However during living donor liver transplantation 40-60% of the liver is removed. The donor surgery is safe and the remaining liver starts to regenerate immediately at time of surgery. 90% of the liver regenerates within 10 to 12 weeks after surgery and the regeneration is complete by 1 year.
To be considered eligible for living liver donation, the donor should fulfill following criteria:
- The person must consent to donate of his/her own free will due to emotional bonding with the recipient.
- The person must be a close relative of the recipient.
- The donor and recipient blood group should be compatible.
- The person should be between 18-55 years of age.
- The person should not be obese.
- The donor liver structure / function, as well as the other systems must be normal for surgery
- Donor liver removed for the recipient must be enough in volume to sustain the life of the recipient.
When the above criteria’s are fulfilled then a person is considered eligible for donation. The donor undergoes a thorough evaluation before surgery to assess the quality, quantity and structural anatomy of liver along with evaluation of other organ systems to assess fitness for surgery as well as technical suitability for liver donation.
Liver Transplantation In Children
The treatment of liver disease in children is very challenging as the manifestations of liver disease are highly variable. Liver disease presentation can vary from overtly evident jaundice to subtle signs of growth failure and therefore early diagnosis is very important as any delay in diagnosis can have a detrimental impact on successful outcome and prognosis.
Jaundice in the new born can be physiological immediately after birth and at the same time can be the sign of a life threatening condition. Any evidence of jaundice after 2 weeks of age should raise suspicion of serious liver disease and prompt a thorough evaluation.
Children with severe liver dysfunction (end stage liver disease) not responding to conservative treatment need liver transplantation and the most common indication is biliary atresia – others include Wilsons disease, metabolic liver disease, haemochromatosis, acute liver failure.
Both deceased and living donor liver transplantation can be offered to children. In deceased donor liver transplant the child may receive a whole liver (from a pediatric brain dead donor) or in case of an adult brain dead donor the liver can be split into two for an adult and a child. In living donor transplantation a living donor donates a part of his liver. There is no difference in survival and recovery between those receiving a partial or a whole liver.
The management of children after liver transplant is very challenging and the child stays in ICU for a week and is gradually weaned off from ventilator, started on immunosuppressive medication and oral feeds. After stabilization in ICU the child is shifted to a private ward, during the course of stay in the ward (approximately 2-3 weeks) the parents take an active part in the care of the child with the help of nursing staff, nutritionist and the transplant coordinator. This prepares the parents to take care of the specialized needs of child once he/she is discharged from hospital. Before the child goes home the parents are provided with all the necessary instructions for proper care of the child and the schedule for follow-up clinics which becomes fewer and further apart with time.
Most children return to normal life 6 months after the transplant with the onus of avoiding infections during this phase. The child has to be on a balanced diet and religiously adhere to the immunosuppressive medications. The child can attend school, participate in sports and other co-curricular activities as their peers and over long term can lead a normal married life with no reproductive issues.
Liver Transplantation In Adults
The treatment for end stage liver disease is liver transplantation which can either be deceased donor or living donor transplantation. The recipient undergoes extensive evaluation to ascertain fitness for liver transplantation before the surgery.
The duration of liver transplantation surgery is between 10-12 hours in which the recipient diseased liver is removed and a healthy new liver (whole/partial) is implanted in the liver bed. After the surgery the patient is shifted to ICU on a ventilator, on which he stays for generally 24 hours and is gradually weaned off from the ventilator. As the new organ is a foreign body, the recipient is given immunosuppressive medications so that the transplanted liver is not rejected by the body. The immunosuppressive medications have to be taken life-long by the recipient.
The recipient spends 4 to 5 days in ICU following which he/she is shifted to a private room to protect the recipient from infections as the recipient will be on immunosuppressive drugs after the transplant. Gradually the patient undergoes physical, nutritional and psychological rehabilitation in the ward and the patient is discharged after 2 weeks.
After discharge the recipient stays in and around the hospital for 2 months during which time he follows up with the transplant team weekly with relevant investigations to titrate the maintenance dose of immunosuppressive medications. During the recovery phase avoiding exposure to infection is very important. Gradually over a period of three months the patient recovers fully and is able to go home lead a good quality of life, participate in sports and other age-appropriate activities with a normal married life without any fertility problems under the supervision of the transplant team with lifelong follow up.
Living Liver Donor
A liver donor is a perfectly healthy person between the ages of 18-55 years closely related to the patient, who is donating out of his/her free will due to emotional bonding with the recipient. The donor and recipient blood group must match or the donor should be of O blood group (Universal donor).
Prior to the donor surgery the donor is educated about the risks of the surgery, post operative hospital course and recovery. The duration of surgery varies between 5-8 hours in which typically the right lobe (for an adult) of the liver (depending upon the weight of the recipient) along with gall bladder is removed. For a child either a left lobe or left lateral segment of liver along with gall bladder is removed. Generally 40-60% of the donor liver is removed. The remaining liver begins to regenerate almost immediately. Most of the regeneration occurs in the first two to three weeks after the surgery and by 10-12 weeks 90% of original liver volume is restored, followed by a slower phase of growth over the next year. Results of liver donation are very good and it is 99.8% safe.
The donor stays in hospital for a week after surgery. The donor is seen for a follow-up visit by the surgeon after discharge, then again at 3, 6, 12 and 24 months. After discharge from the hospital he/she requires another 3-4 weeks for recovery at home. After that, the donor can resume normal activity (except strenuous physical exercise) and return to work 4 to 6 weeks after surgery. Sexual activity can be resumed as soon as the donor feels well enough. Heavy physical activity, sports including lifting weights should be avoided in the first three to six months after surgery. If the donor has a desk job, he/she may be able to return to work sooner than patients with a more physically demanding job.
Following liver donation there is no dietary or any other health related restrictions in normal life. The donor leads a normal life with normal liver function without any long term consequences or a decrease in longevity of life.