Things to Know About Liver Transplant

A liver transplant is a surgical procedure that replaces the permanently damaged end-stage liver with a healthy liver from a deceased donor or a portion of a healthy liver from a living donor. Liver transplants are done when the liver has been damaged by disease, such as alcohol abuse, fatty liver, viral infections such as hepatitis C/ hepatitis B, genetic disorders and so on. Liver transplantation is also indicated in children born with biliary tract obstruction, such as biliary atresia.

The liver is your largest internal organ and a chemical factory powerhouse, performing several critical functions, including:

• Processing nutrients, drug metabolism
• Producing bile, which helps the body absorb fats, cholesterol and fat-soluble vitamins
• Making proteins that help the blood clot
• Removing bacteria and toxins from the blood
• An important source of innate immunity

A liver transplant can be performed using part of a donor's healthy liver if the donor's blood type is compatible with the recipient's and if the donor is healthy enough to donate part of their liver. A living donor can also be someone related to the patient, age > 18 years and < 55 years, healthy, non-fatty and preferably non-diabetic, with a compatible blood type. The liver transplant surgery to remove a portion of the donor's liver is called "donor partial hepatectomy".

When is Liver Transplant Performed?

Liver Transplant is the recommended long term definitive curative option when there is end-stage liver cirrhosis with progressive functional failure leading to numerous complications, many of which can be potentially life-threatening. It is also done as an emergency life-saving procedure for acute liver failure. A liver transplant is a curative option for primary liver cancer without vascular invasion. The waiting time for a cadaveric liver ranges from days to months, depending on the geographical location. In our state of Telangana, the average waiting time for a cadaveric liver is about 3 – 4 months. However, in a living donor liver transplant, the liver transplant surgery is performed as a planned procedure in the best ideal time for the patient who is medically optimised. Secondly, the donor is a healthy and fit person. So logically, in our country with a long waiting list, always living donor liver transplant is a better option if there is a suitable donor in the family.

Most liver transplants are successful when performed in the best possible time for the patient after medical optimisation and detailed pre-transplant assessment to ascertain medical fitness for liver transplant surgery. In our centre, the success rate is more than 95%.

Common indications for Liver Transplant

1. Progressive end-stage liver cirrhosis with MELD score ³ 15
2. Complications of liver cirrhosis such as hepatic encephalopathy (altered behaviour, forgetfulness, coma), spontaneous bacterial peritonitis (spontaneous infection of water in the abdomen), hepatocellular carcinoma (liver cancer), hepatopulmonary syndrome (progressive breathing difficulty because of liver disease)
3. Acute liver failure: A clinical syndrome entity wherein a patient with no pre-existing liver disease develops jaundice followed by encephalopathy (liver coma) within four weeks
4. Liver diseases in children such as extra-hepatic biliary atresia, metabolic liver disease, hepatoblastoma
5. Hereditary diseases such as Wilsons disease, hereditary hemochromatosis, hereditary hyperoxaluria

STEPWISE INITIAL ASSESSMENT

Step 1: Assessment by Hepatologist

Patients with liver disease will be assessed clinically by a hepatologist to decide the need for liver transplantation.

Once it is decided that the patient will benefit by proceeding with liver transplantation as a long-term curative option, then the incurred risks and costs involved will be briefly explained by the hepatologist.

The patient and family will be explained the two modalities of liver transplantation, namely living donor and cadaveric donor liver transplantation.

The ABO-incompatible living donor liver transplant option will also be explained in detail in selected patients. SWAP living donor liver transplant will also be explored if an opportunity arises

Step 2: Initial Assessment by liver transplant surgeon

The patient will be seen by a liver transplant surgeon to assess the feasibility of the operation based on the patient's clinical status and radiological imaging.

If there is a living donor option available, the surgeon will also briefly assess the donor's health and fitness.

Patient and family will be counselled regarding the operation procedure, postoperative care, expected hospital stay, commonly seen complications in recipient and donor and any queries of patient and family.

Step 3: Meeting liver transplant coordinator

The family will meet the transplant coordinators team for further guidance and counselling so that they can get further information about pre-transplant assessment procedure, previous patient testimonials, video presentation of the operation, post-transplant follow up and importantly, funding options, namely insurance, government support, cost differences between living donor and cadaver donor options, legal formalities involved in living donor liver transplant and any further queries by the patient and family.

Step 4: Psycho-social assessment

The initial assessment by a clinical psychologist is essential to ascertain the understanding of the liver transplant procedure post-transplant care by the patient and immediate family members. It will also help assess the expected patient compliance to life-long immunosuppression, which is of paramount importance for the long-term success of liver transplantation.

Assessment of alcohol recidivism by using SALT score or CAGE questionnaire or AUDIT questionnaire

Step 5: Hepatologist review

To medically optimize the ongoing medications

Address any concerns regarding liver transplantation procedure and post-transplant expected morbidity and mortality, both recipient and donor, if any

Review the psycho-social assessment and identify patients with risk of alcohol recidivism. Guide them regarding the need and possibilities of alcohol de-addiction programs

Periodic close medical follow-up of patients who have been explained the need for liver transplantation but need some time to decide regarding the same

It is important to remember that if your liver condition mandates consideration for a liver transplant as a definitive long-term option, you will have the right to decide that you will NOT prefer to undergo a transplant. The team will respect your decision. The only objective of the transplant team is to explain the present medical condition and provide the right advice at the right time before it is too late.

Step 6: To start a detailed pre-transplant evaluation as per the institutional protocol.

The evaluation is usually done in three working days on an outpatient basis or an in-patient.

This is important to rule out occult infections, assess for cardio-pulmonary abnormalities, have numerous specialities seen in detail, and give their opinion and clearance for surgery. The main intention of such a detailed evaluation is mainly to ensure no new surprises in the immediate post-transplant period and aim for a smooth recovery.

Types of Liver Transplantation

Types of liver transplant procedures are as follows

1. Living donor liver transplantation

In living donor liver transplantation (LDLT), the live donor voluntarily gives a portion of the liver transplant to the patient (recipient). Usually, about 65-70% of the liver will be taken from the donor (for a right lobe liver donation, which is the commonest type in adults). For an adult donating to a small child, about 20% of the liver will usually be taken from the donor. The liver is the only organ in the body that has the capacity to regenerate, therefore providing a unique opportunity for a relative to donate part of his or her healthy liver to the recipient. The liver regenerates to its original functional mass in about 3-4 weeks. There are usually no long-term adverse effects to the donor due to the donation, and they can lead a normal life once they recover from the operation. This is an elective planned operation, and there is no waiting period. The primary benefit of LDLT is an expedited and well-timed transplant that can be performed before the candidate deteriorates to the point that the outcome of the liver transplant surgery is jeopardized. Consequently, patients do much better, as it is a planned operation, ideally done when the patient is in the best clinical condition and for sure, he is going to get a healthy liver from a healthy person. Hence, one should expect a shorter hospital stay with a quicker recovery and, finally, better cost-effectivity. The donor generally stays in the hospital for 1-2 weeks after the operation.

The donor should be a healthy person, blood group compatible with the patient, of age > 18 years and preferably less than 50 years, non-diabetic, non-fatty, stopped on alcohol or smoking for at least three months and have no obvious medical conditions. Equally important to know that the donor should be a relative to the patient (even up to third-degree relation is acceptable as per Govt of India norms), but the relationship should be proven to the transplant authorization committee. The most important part of LDLT is donor safety, and minimal morbidity should be ensured with a detailed pre-transplant evaluation both technically and medically. Hence, the donor will also undergo a detailed pre-transplant evaluation with a depth assessment of liver volumes and anatomy to assess the technical suitability for the recipient.

2. Deceased donor liver transplantation

It is important to understand that the process of organ donation is completely voluntary and confidential. When a person donates their organs, eight lives can be saved at one time. When a patient receives liver from an unknown brain-dead person after voluntary consent from his next of kin in the family, only out of kindness and joy of giving life to others, such a transplant is called deceased donor liver transplantation (DDLT).

The usual procedure in DDLT is that patient undergoes a detailed pre-transplant evaluation, as mentioned previously, to ascertain medical fitness for liver transplant surgery. Once deemed medically fit, then he/she gets registered on our hospital's waitlist for a cadaveric donor, which in turn will be sent to the Cadaver Transplant Program- Jeevandan. Suppose a related live Liver Donor is available, then they will work up to assess the suitability of donation. The waiting list is categorized as per the blood groups (A, B, O and AB), and the donor's liver is matched to the recipient according to blood group, weight and height. It is difficult to predict how long you will have to wait for a liver to become available. For some people, it may be a matter of days; for others, it may take several months. We understand that the waiting period can be difficult for you and your family, so please feel free to speak to the liver transplant coordinators.

There is a priority on the waiting list as organ donation is not that common, and usually, there is a long waiting list. Allocation is based on disease severity as measured by the MELD score. The patient with the highest MELD score in that blood group will be prioritised. However, the exception is acute liver failure, wherein that particular patient can be registered in the super-urgent category and will be given top priority for organ allocation in the entire state as it is an emergency.

If a patient on a cadaveric waiting list gets a living donor option in the family, then the team will proceed with the surgery once donor evaluation is satisfactory. Once the patient is deemed medically fit and registered on the cadaveric waiting list, there is no necessity to repeat the tests again before proceeding for living donor liver transplant surgery.

All patients on the cadaveric waiting list will be reviewed regularly by the hepatologist to identify any medical issues which need to be addressed immediately. As the cadaveric organ can become available at any time, the patients on top of the list should be medically and financially prepared for the same. Deceased donor liver transplantation always happens as an emergency, it is useful to have two contact numbers whilst you are waiting. A home number and a mobile number are satisfactory.

Pls, note: Listing does not guarantee a transplant. Sometimes, while waiting for a liver transplant, people become too unwell or die before a liver is available. We cannot predict how long you will have to wait for a liver transplant.

If you are being transplanted because you have a liver tumour, you may be taken off the list if your tumor grows beyond the criteria for transplantation. Every effort will be made to try to keep the tumor within criteria while waiting on the cadaveric waiting list. This is most often done by trans-arterial chemo-embolization (TACE) and sometimes heat treatment of the tumor (RFA). Three monthly once imaging will be done whilst on the waiting list.

The Call

Our Transplant coordinator will contact you when there is a suitable liver offer for you. This can be at any time of the day or night. We will try your emergency contact person/number. Once you are on the waitlist, you must be reached 24×7 in order for us to intimate you in the case of a liver offer from a deceased donor.

They will discuss with you what time you need to come in and explain which ward to come to. Usually, we ask for you to be at the hospital within 2-3 hours of the call. You will be asked to have nothing more to eat or drink from the time of the call. If you have any ongoing fever, cough or any other medical issues, let the caller know of it. It is important to us to assess if you have an infection prior to the transplantation.

In case of any change in the address for correspondence or the contact number, please ensure that you inform the transplant coordinators. Also, if you are planning to be away from home or out of the city for a break, please inform the coordinators so that they have an additional number of where you will be staying and know if your travelling time to the hospital is likely to be increased.

Whilst we have a lot of details pertaining to the donor, it isn't until our surgeons retrieve the liver that we will know if the transplant will go ahead. If the surgeons are not happy with the condition of the liver, then the transplant can also get cancelled. This is only done in the interest of the patient.

Immediately before the liver transplant

You will be asked to arrive at the Gleneagles Global Hospital, Lakdi-ka-pul, Hyderabad, within 2-3 hours of receiving the call. Once you have been admitted, you will undergo basic blood tests, a chest X-Ray, an electrocardiogram (ECG) and a 2D Echo to assess the current clinical condition. Your spouse/partner/member of the family may stay with you if you wish.

The average liver transplant operation takes between 6 – 10 hours.

Usual postoperative course

Donor: The living donor is moved from ICU to ward by the third day and then discharged in a week's time from the hospital. He/she should take some rest at home for the next two to three weeks till the operative wound heals before resuming normal duties. There are no follow-ups required for the donor after one month of liver transplant surgery, no lifelong medicines etc. The risk of donor death has been reported to range from 1 in 200 to 1 in 1000 worldwide. However, with the stringent evaluation and protocol-based approach, such untoward events are a rarity in the present scenario.

Patient: The patient is moved from ICU to ward within one week depending on clinical progress and then usually is discharged from the ward in the next two weeks' time. Post-discharge, the patient will be advised to come for twice a week follow up with lab tests for the first one month and then weekly once for the next one month. Subsequently, it will be reduced gradually to monthly once for the next six months and then thrice monthly once and so on.

It is very important to understand that the patient will be on lifelong immunosuppressive medicines. However, since most of the immunity in the body is from the liver, unlike other solid organ transplants, the number of medicines are gradually reduced, and by the end of one year, the patient will be taking only one tablet to protect the new liver graft from body's immunity which needs to be taken lifelong without fail.

FINALLY

As mentioned before, the time on the waiting list is quite stressful for you and your family. You may be anxious every time the phone rings and find it difficult to plan anything in advance.

This is all very draining for you emotionally, and if you are waiting for a long time, you may feel worse physically. It is all completely outside of your control can also be quite frustrating, and you may begin to feel that we have forgotten all about you as time goes by!

If you decide at any point that you would like to explore liver donor transplantation, please contact any member of the Liver team to discuss.

Finally, we strongly discourage you from approaching any agents/touts for cadaveric organs. Also, please do not encourage anyone who approached you to promise an organ for a fee. Organ trafficking is a punishable offence as per Govt of India norms. Patient directed cadaveric donations can never happen.

If you have any questions or concerns, be sure to talk to your transplant team.

Why Gleneagles Global Hospital, Lakdi-ka-pul, Hyderabad?

At Gleneagles Global Hospital, you will experience the best care and treatment. Our patients have faith and trust in us, and that is why they choose us for their treatment, which makes us one of the best hospitals for a liver transplant in Hyderabad. Our doctors and specialists have become the best liver transplant doctors in Hyderabad through extensive research and clinical trials. For the betterment of our patients, we have updated our technology, which gives excellent treatment to our patients. The training we give to our doctors and the patience that we have makes our liver transplantation department a class-apart. That is why we are known as one of the best hospitals for liver transplant surgery in Hyderabad. We will guide you through all the alternatives and assist you in making healthy and fully informed decisions.

Our department's advantage is that we provide care and treatment and promote preventive care by educating them about periodic comprehensive health check-ups. We have the best liver transplant surgeon in Hyderabad for liver failures.