Not all liver failure cases are eligible for transplants

15/01/2021

Liver failure occurs when most of the liver is damaged and the liver cells or the hepatocytes, are no longer able to carry out normal functions. Acute Liver failure can happen rapidly over a period of days to couple of weeks as a reaction to some infection or drug toxicity and so on. Chronic Liver failure occurs as a result of progressive worsening of liver functions in a patient of end stage liver cirrhosis, which happens over few years depending on cause of liver cirrhosis and other contributory factors.

Acute liver failure is a medical emergency as it is a life-threatening condition that can result in permanent brain damage and death. In Chronic liver failure, patient suffers from complications of end stage liver cirrhosis namely vomiting of blood or infection in ascites (abdomen fluid collection) or coma or kidney failure, few of these can be life threatening.

Liver transplant is a surgical procedure wherein the damaged liver is replaced with new liver. The first successful liver transplant was done in 1963 by Prof Thomas Starzl in US. Since then, many advances have been achieved in this field and now it has become standard of care for patients in liver failure. Most of the Western countries have deceased donor liver transplant program wherein the failed liver in the patient is replaced by liver which has been harvested from a brain-dead donor whose family has agreed to donate their loved one’s organs to save others’ life.

In our country, due to lack of awareness of organ donation, waiting lists are expectedly long for getting deceased donor liver and most of the patients succumb on waiting list due to progressive liver failure. Hence, majority of transplants in our country are living donor related. Living donor liver transplant means the completely damaged liver in the patient is replaced by a portion of liver taken from a healthy individual, who needs to be related to the patient and having similar compatible blood group. Healthy liver has the inherent capacity to regenerate and hence the healthy liver portion grows to normal volume in couple of weeks in both donor and patient. At present, the only long-term curative option for progressive liver failure is liver transplantation.

However, it must be noted that not all cases of liver failure are eligible for a liver transplant. The transplant team follows a strict protocol for pre-transplant assessment to assess fitness for surgery as it is a long surgery and patient should be relatively stable to recuperate from the surgery and immediate post-transplant period. The team must be convinced that there will be a successful outcome, that is, the possibility of a good quality of life for at least 5 years, once the liver transplant is carried out. Many times, it has been seen that patient has been counselled for need for liver transplant but due to lack of awareness and improper decision making, they delay the procedure and precious time is lost. After a certain stage, most of them become too sick to consider transplant. Hence, timing of the transplant is as important as transplant surgery itself.

Certain persons with liver failure are not considered to be the right candidates for the liver transplant surgery. Therefore, the following patients are not considered for a liver transplant:

  • Those who cannot reliably take their medications that prevent rejection of the transplanted liver
  • Those who cannot come for frequent follow-up visits and do laboratory tests as and when required
  • Those who are expected to engage in continued activity that would injure the transplanted liver, such as drinking alcohol, or to take recreational drugs; most transplant centers will only consider a person for a transplant if they haven't had alcohol or used recreational drugs for at least a few months

The conditions that are generally considered to be absolute contra-indications to liver transplantation include:

  • Persons with severe malnourishment and muscle wasting who may not survive the surgery itself
  • Critical medical condition with uncertain outcome
  • Significant pulmonary artery hypertension (mean pulmonary artery pressure greater than 50mmHg)
  • Advanced liver cancer that has spread outside of the liver
  • Systemic or uncontrollable infection
  • Active substance abuse (recreational drugs and/or alcohol)
  • Severe, uncontrolled psychiatric disease
Dr Chandan Kumar KN
Senior Consultant - Hepatology & Lead Transplant Physician
Gleneagles Global Hospital Lakdikapul

Disclaimer:The views and opinions expressed in this article belong solely to the author. They do not reflect the opinions or views of the organization.

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