Assessment for Liver Transplantation
Liver transplantation is a major surgical undertaking. A patient should be considered for transplantation only if the procedure improves his/her chance of survival or quality of life. At the same time, the patient should be well enough to survive the operation. All patients undergo a formal assessment before a decision is made regarding liver transplantation. The aim of liver transplantation assessment is two fold.
1. To confirm that the patient needs a transplant.
2. To confirm that the patient is fit enough to survive the operation
The assessment process involves a detailed evaluation of the severity of liver disease, evaluation of the function of other organ systems such as the heart, lungs, kidneys. The patient will be seen by consultants of all specialties to identify any problems that can increase the risk of surgery and treat the problems so that he/she is in an optimal condition to undergo the operation. The entire clinical information and reports are discussed in the pre-transplant assessment meeting before the patient is listed for liver transplantation.
Deceased Donor vs Living Donor Liver Transplantation Liver transplantation can be undertaken in two ways depending on the origin of the new liver. When a person donates the liver after his/her death it is called deceased donor liver transplantation. If on the other hand, a close family member donates a part of their liver then it is called living donor liver transplantation.
Deceased donor Liver Transplantation
Deceased donor liver transplantation (also known as cadaver liver transplantation) involves transplanting a healthy liver from an individual who has died in the ICU because of irreversible brain injury. The cause of death is usually head injury sustained in a road traffic accident or a fall from height. Brain stroke can also lead to irreversible brain damage. These patients can also donate their organs. The treating team will do a series of internationally standardized tests to confirm that the brain damage is irreversible and there is no chance of the patient recovering. Then the family of the patient is approached and counseled regarding organ donation. If the family is agreeable, then our surgical team will carefully remove the organs in the operation theater and place them in a special cold preservative solution while they are transported back to Global Hospital by road or air.
Wait-listing for deceased donor Liver Transplantation
For patients with serious liver disease who do not have a suitable family donor, waiting for a suitable cadaver liver is the only option. Once the patient is considered suitable for transplantation, he/she is registered on the official state-wise waiting list. Offer of a donor liver is based on the blood group and the time for which the patient is on the waiting list. Considerations such as relative size of the patient and the donor, quality of the donor liver and condition of the patient are also taken into consideration when deciding on the best match.
Life on the waiting list
Being on the waiting list can be difficult and frustrating period. The key is to maintain the patient’s health in the best possible condition so that when ultimately a liver becomes available, transplantation can proceed. The patient should continue on the prescribed liver medications and be under regular follow up with the treating liver physician, so that any problems or complications can be treated early.
Your health while on the waiting list
In some patients, the transplant team may do regular investigations of the heart and lungs to identify any new problems that can impact the safety of liver transplantation. Patients may have intermittent infections and deterioration of liver function on the waiting list needing hospital or even intensive care admissions. The aim of treatment is always to treat the complication and stabilize his/her condition so that transplant can proceed when the organ becomes available. If the patient gets admitted in a local hospital for any medical problem, this should be informed to our transplant team. This will help us in communicating with your local doctor regarding the best treatment for the illness.
What happens when you get the call?
When a suitable donor liver becomes available, the surgical team will check to see if the liver is compatible for the patient. If so, the patient will be contacted immediately and advised to come to the hospital immediately. The call may come at any time during the day or night and the patient usually has about 6 hours to come to the hospital. Hence it is advisable for them to look at their transport options beforehand (contact numbers of taxis, flight timings etc). We advise patients from outside the city to stay in Chennai when they reach the top of the waiting list to avoid losing an opportunity due to travel related issues. The patient should always be contactable while on the waiting list. It is important that the transplant team is informed if the patient changes their contact telephone, email ID or address.
How long does it take to get a donor liver?
Donor livers are allocated based on the time spent on the waiting list. The average waiting time is around 6 – 12 months. The waiting time is variable and depends on multiple factors including the patient’s blood group. For example, patients with blood group AB may have to wait less than those with blood group O. The problem with the transplant waiting list is that unfortunately, not every one will get a liver transplant. Some of the patients will deteriorate while waiting for a new liver and will become too sick to have a transplant. In Western countries, the risk of patients dying before they get a suitable liver is around 10%. In India, because cadaver donors are much less in number, the risk of dying on the waiting list can be as high as 50%. This again underlines the importance of looking after your health carefully during the waiting period. We advise our patients to continue to explore the possibility of a family donor during this period, as that will ensure a timely transplant.
Living Donor Liver Transplantation
This is the most common form of liver transplantation in India and the Eastern world. A close relative who is fit and healthy and is voluntarily willing to donate can donate a part of his/her liver for the patient. The transplanted liver works immediately and then grows to the necessary size in the patient over a few months. The donor liver regrows much more rapidly and would have reached the normal size in 4-6 weeks.
The main advantage of living donor liver transplantation, is that it avoids prolonged and uncertain wait for a cadaveric liver graft. This means that the patient can be transplanted at the earliest time before he/she becomes too sick. Also the date of the operation can be planned when it is convenient for the patient, donor and the operating team. Recovery of patients can be quicker as the patient is better prepared. The quality of the liver graft is also better than a cadaveric liver graft which is recovered from a dying patient.
The living liver donor
Who is a suitable living liver donor?
Any healthy person can be considered as a living liver donor. We will usually consider adults over 18 years but less than 50 years for assessment, when fit and healthy, Even the over-50s have successfully donated to save their loved ones. The potential donor should be blood group compatible. We only consider close family relatives as potential donors. Documentation as prescribed by governmental authorities to prove the existence of a blood relation is necessary to proceed with donation.
How is liver donor assessed?
The potential donor undergoes a battery of tests, scans and specialist consultations to assess the fitness. The entire donor process may take 3-4 days, though occasionally it can be longer. If during any of these tests a problem in the donor is identified which can increase the risk of surgery then further testing will not be continued and the donor will be informed (in private if requested by the donor) about it. On an average, 50% of all tested donors can proceed with liver donation. The aim of these tests is to
1. Confirm that the donor and patient are blood group compatible.
2. Confirm that the donor has a healthy liver and excellent liver function.
3. Assess the size of the liver and make sure that when divided into two parts during the donor operation, the removed liver will be sufficient for the patient to recover while the donor will be left with enough amount of liver to help make a quick recovery from the operation.
4. To assess the overall health of the donor in terms of his heart function, lungs, kidneys. Various specialists including an independent assessor (a physician outside the transplant team) and a senior anesthetic consultant will also see the donor. This is important as donors with health problems such as diabetes, heart disease or lung problems will not be considered suitable for donation.
5. The donor will also have private discussions with the transplant team members and the psychologist to evaluate whether the donor want to undergo the donor operation voluntarily.
What are the risks of living liver donation?
Surgery for liver donation is a technically complex procedure and only units with good experience should carry out these procedures. The extensive workup done for the donor is mainly to identify any risk factors in the donor which may affect the outcome.
Risks of the procedure are low though not zero. The risk of serious donor complications causing death is rare and the internationally quoted risk is 1 in 300. Other complications such as bleeding, infection, bile leaks or clots in the leg veins occur in about 10% of donors and most can be treated effectively with medications or minor procedures. Less than 2 in 100 donors will need a second operation to treat a complication.
What documents are necessary for LDLT(Living Donor Liver Transplantation)
The Government required a list of documents from the patient and donor to give approval for living donor liver transplantation. The documentation is primarily to verify the quoted relationship between the donor and recipient and also to confirm that both have full information regarding the nature of surgery and possible complications.
Finalizing the date for surgery?
It is natural that patients and donors would like to have the operation done with at the earliest possible date. However, the surgery can only be scheduled once the assessment is complete, the governmental approval process is complete and the plan has been formally discussed in the team meeting. In addition, in patients who are very sick, it may be appropriate to delay the operation until he/she is optimized to the best possible extent. This will improve the chance of an excellent outcome after transplantation.
What happens in donor surgery?
The donor operation usually takes 6-8 hours. It is carried out under general anesthesia. The liver is divided into two according to the pre-decided plan while taking care to preserve its blood vessels. At the end of the surgery, the removed part of liver is flushed with preservation fluid and stored in ice. The wound is carefully closed after leaving a plastic tube in the abdomen, which will stay for about 4-5 days but occasionally longer.
What happens after donor surgery?
After donor operation, the donor is transferred to the Liver ICU where he/she will be carefully monitored for 2-3 days. An epidural catheter will be placed in the back prior to surgery in the operating room and continuous pain killer medication will be administered in the ICU through this to keep the donor comfortable and pain free. The donor will have regular blood tests and scans to ensure that the liver is recovering well. He/she will be made to get out of bed and walk a few steps in the ICU itself and will be started on diet. The donor will have regular blood tests and scans to ensure that the liver is recovering well. Once stable, he/she will be transferred to the Ward where he/she will stay for another 4-5 days. The average duration of stay in hospital is 7 days. The donor is well, on normal diet and walking comfortably by the time of discharge.
Are there any long-term side effects of liver donation?
There are no long-term side effects of liver donation. The liver regenerates within 4-6 weeks to its normal size. The operation should not impact the donor’s studies, career options, diet, exercise, pregnancy and family.
The Liver Transplant operation
The transplant operation usually takes 8-10 hours. First, the diseased liver is removed by dividing the blood supply. The new liver graft is then placed in the same place as the old liver and new connections are made between the blood vessels of the patient and the new liver graft. The bile duct of the liver is also joined to the patient’s bile duct. The wound is then closed after placement of one or two drains, to drain excess fluid that usually forms after surgery.
Special types of Liver Transplantation
Split Liver Transplantation
Here a cadaveric liver is divided into two parts and can be then used for transplanting two patients in need of a liver transplant. Usually the left part of the liver is transplanted into a child and the right part can be used for an adult. Split liver transplantation is a challenging procedure and few in India have the technical skills to complete the procedure safely. Our team at Global Hospital, Chennai has the largest experience of split liver transplantations in the country
Auxiliary Liver Transplantation
This is a special type of liver transplantation where, only a part of the patient’s liver is removed and a partial liver graft is implanted. This operation is especially useful in some patients with acute liver failure where the liver is expected to recover over a period of time. The liver transplant is necessary to tide over this period and give chance for the patients’ own liver to recover and grow. The main advantage of this procedure is that once the patient’s own liver grows back, anti- rejection medication can be slowly stopped for the patient and the transplanted liver gradually degenerates. This gives an opportunity for these patients (especially children) to avoid lifelong anti-rejection medications. This is also indicated in some special metabolic disorders in children. This is again a technically challenging operation and we are the only unit in India with the expertise to do the procedure.
The post-operative period
Liver transplantation is a major operation in a patient who has been unwell for a while. However, most patients tolerate the procedure surprising well and feel a sense of well-being within 2-3 days after the operation. The recipient usually is managed in the ICU for the first 3-4 days. During this period, he/she will have regular blood tests and ultrasound scans to ensure that the liver is recovering well. Once stable, the patient will be transferred to the ward. We encourage the patient to sit up, do deep breathing exercises and slowly start walking in the first few days after transplantation. It is important that the patient cooperates with the medical and nursing team while they put him through the standard course of recovery. The average duration of stay in the hospital after transplantation is about 2-3 weeks. By the time the patient is discharged, he/she is able to eat normally, walk comfortably and will need minimal analgesic medications. During the hospital stay, the patient will also be taught the medications that need to be continued after discharge.
Medications to be continued after Transplantation
The post-transplant patient will be on quite a few medications following the transplant. The most important of these are the “Immune-suppressant” medications which are usually three in number. These medications are of utmost importance to keep the liver functioning well and to prevent the body from rejecting the new liver. The dose of these medications will be changed on a regular basis based on the level of the drug in the body. The number and dose will gradually be reduced over a period of moths and eventually the patient will be on a single drug only. It is important to keep in mind that these are live saving drugs to be taken life long after transplantation. The recipient will be familiarized with these medications before discharge. In addition to medications, additional medications to prevent viral and fungal infections, multivitamins and medications to prevent acidity are also given at the time of discharge.
Going home after a Liver Transplant
Patients are discharged from the ward once they are comfortable, pain-free, walking independently, eating normal diet and able to take medications on their own.