Liver Transplantation

Liver Transplantation

About the Liver

• The liver is the single largest organ in the human body
• Its located below the right rib cage in the upper aspect of the abdomen
• The liver is richly supplied by a dual set of blood vessels – the hepatic artery and the portal vein ( which takes blood from the intestines to the liver )
• The liver performs a wide variety of function and is chemical laboratory synthesising a lrge number of proteins and also makes enzymes which help in digestion
• The liver is connected to the digestive tract via the bile ducts which take bile from the liver to the intestines and help in digestion

What is liver transplantation ?

Liver transplantation is the only treatment for end stage liver disease . Irreversible damage to the liver due to any reason , makes life untenable and liver transplant is the only way to salvage this clinical condition. Liver transplantation involves , removal of the diseased liver and replacing it with a new healthy liver which may either a full liver ( from a deceased liver – Brain dead donor ) or a partial graft – ( usually 50-60% of the liver from a healthy living donor ).

What are the indications for liver transplant ? who needs a liver transplant ?

liver transplantation is required for all patients who have end stage and irreversible liver disease , for which there is no medical or any other treatment. Liver transplantation is the only treatment without which they would unfortunately succumb to their disease . End stage liver disease is referred to as Cirrhosis .

• Alcohol damage to liver
• Hepatitis B
• Hepatitis C
• NAFLD / NASH Cirrhosis : damage from fatty liver and fatty liver disease leading to cirrhosis and end stage liver disease
• Primary Scelorosing Cholangitis ( PSC )
• Primary Biliary Cholangitis / Cirrhosis ( PBC )
• Wilson disease
• Auto Immune Hepatitis ( AIH )

Liver transplantation is also done for selected cases of Liver Cancer – Hepato Cellular Carcinoma.

How do you investigate a patient ( recipient ) who needs a liver transplant

atients with end stage liver disease need a transplant . end stage liver disease – cirrhosis results and causes multiple complications within patients these include

• Bleeding – gastro intestinal bleeding- vommiting of blood or passage of blood in stools
• Jaundice – yellowing of the skin
• Hepato renal syndrome – progressive cirrhosis and jaundice results in kidney damage and at times can be irreversible
• Ascitis- formation and development of water / fluid inside the abdomen
• Increased susceptibility to infections
• General deterioration in overall state of health

Patients with cirrhosis usually have multiple admissions into hospitals , due to direct or indirect complications related to cirrhosis and liver disease.

how is the severity of my liver disease assessed ?

this will be done based on

• clinical symptoms and investigations
• based on the blood tests severity scores are calculated – MELD / MELD- NA/ Child Pugh Scores – these determine the severity of liver disease and need for transplant . generally higher the score, more severe the liver disease . this predicts the development of complications from liver disease and predict mortality from liver disease
• ultrasound , CT scan and MRI will be required to determine the condition of the liver

What are the methods of liver transplant ?

A blood group match is mandatory for a recipient to receive a liver transplant from a bloodgroup matching donor.

Deceased Donor Liver Transplantation : DDLT

• The liver is harvested along with other organs ( heart / lungs / kidney / pancreas ) from a brain dead donor
• The donor is identified in an ICU and once found fit his organs can be harvested
• Depending on the blood group match and size they can be implanted into an appropriate recipient
• Patients receive the entire ( full liver ) from the donor

Living Donor Liver Transplantation : LDLT

Part of the liver ( either the right or the left side -about 50-60% ) is surgically removed from a related living donor and implanted into the recipient.

The donor is carefully chosen from within the family / extended family of the recipient and after going through a series of checks , selected as being able to donate.

The operative procedure involves

• Removal of the part of the organ from the donor- usually for adults the right part of the liver with its blood vessels is removed
• The remaining liver within the donor functions perfectly well
• The liver has an unparalleled and an unique regenerative capacity which quickly allows for the growth of the remainder in the donor
• The implanted liver within the recipient also grows enabling healthy liver function .

DOING THE TRANSPLANT – DDLT and LDLT

For Deceased donor liver transplant – the recipient if put on a waiting list – this is regulated and monitored by the Zonal Transplant Coordination Committee ( ZTCC ) .

When the matching donor liver is available from the brain dead donor – the recipient is intimated.

Living Donor liver transplant : LDLT

Part of the donor liver is removed surgically and transplanted into the recipient.

Detailed and intensive investigations are carried out on the donor – CT scan , MRI of the liver , blood tests and other investigations to confirm fitness and suitability to go through the door operation.

The donor operation takes about 6 hours and usually it takes a week for the donor to be discharged from hospital . he can resume his normal life slowly over the next few weeks . Donor hepatectomy is a safe operation.

About the living donor operation – the liver as an organ has a unique and unparalleled ability to regenerate and grow , which enables this operation to be conducted with safety and success.

• Detailed investigations are carried out on the donor to assess his/ her suitability to donate part of their liver
• This includes a CT scan and MRI to view the internal anatomy ( arrangement of the liver and the blood vessels , bile ducts ) , which helps plan the operation
• The CT scan and MRI also helps calculate the volume of the liver which will be removed and the volume of the liver which will be left behind. Generally speaking in healthy individuals , upto 70% of the normal healthy liver may be safely removed with no short term or long term complications or side effects .
• Upon removal – the remaining liver in the donor and the implanted liver in the recipient both grow and increase in size to return back to the normal sizes .
• Donors are kept in ICU for 1-2 days and are generally discharged in a weeks time – they return to normal life in a few weeks time
• Liver donation has no short term or long term adverse consequences , complications or side effects on the donor. Donors can lead an absolutely normal life.

About the liver transplant operation

• The operation can last upto about 8 hours on an average
• The entire diseased liver is removed and the new liver is implanted by connecting the blood vessels and the bile ducts .
• The recipient is shifted to a dedicated liver transplant ICU and is looked after by a multidisciplinary team of doctors including intensivists and medical doctors apart from the transplant surgeons.
• The recipient is usually shifted out of ICU to the wards in about 4 days and requires approximately another week on the ward to recover, before discharge .
• Generally most recipients can be discharged in about 2 weeks time
• Liver transplant surgery can have complications and the chance of major complications generally is about upto 5% .

• A close follow up with the liver transplant team is required
• Patients are kept on a set of medications , which include antibtioics, vitamins and most importantly immunosuppressant medications .
• The immunosuppressants are to be taken for life and keep the immunity surpressed to enable the body to accept the foreign liver . initially the doses of the immunosuppressants are high and these are slowly reduced over time and minimal at 6 months following transplant .
• Recipients will also require regular blood tests and ultrasound tests among others as part of their follow up .