Liver transplantation is a surgical procedure to replace a failing or damaged liver with a healthy well-functioning one. The most commonly used technique is Orthotropic liver transplantation, in which entire liver is removed and replaced by a donated liver.
Liver transplantation is universally the standard of care for treatment of end-stage chronic liver disease or cirrhosis and is a life-saving operation for patients with acute liver failure. Donated liver can be from a living donor or a deceased (brain dead, cadaveric) donor.
Signs and symptoms of liver disease and results of some blood tests are commonly used to determine severity of liver disease, which in turn determines the treatment required.
Some patients might have an irreversible liver disease but not enough to warrant a transplant, whereas others might be too sick to benefit from a transplant. This assessment can best be made by doctors who specialise in liver diseases i.e. liver transplant surgeons and hepatologists. Transplantation will be offered only if the benefits of a liver transplant outweigh its risks.
Liver transplant is not offered to patients with current alcohol abuse problems, those with uncontrolled active infections, widespread cancer or severe, untreatable diseases of the brain, heart or lung.
There are two types of liver transplant depending on the source of liver:Deceased donor transplant
Brain death is sudden death after an accident, brain haemorrhage or stroke with irreversible brain damage, not compatible with life. Donation by a single deceased donor can allow as many as nine lifesaving organ transplants and numerous life-enhancing tissue replacements.Living donor liver transplant
This is technically more complex than deceased donor liver transplantation, but can be safely performed with an experienced team and well-established setup. A few advantages of living donor transplants are:
The preparation starts with recipient's evaluation. Once the patient is found suitable for transplantation, any potential donors in the family should have their blood group checked and one who is compatible should undergo donor evaluation. If the donor is suitable, authorisation committee clearance is obtained and transplant scheduled. Patients planned for a living donor liver transplant can generally undergo the same in about 2-3 weeks.
Once ESLD is diagnosed and need for a transplant is perceived, patients undergo a formal evaluation, which involves blood tests, CT and other scans, tests for heart, lungs and other organ systems and assessment by various specialists. Evaluation is performed with the following goals:
To establish the diagnosis and find the cause of cirrhosis / ESLD
To determine the severity of liver disease and its effects on other organ systems such as kidneys, lungs, etc. and thus determine urgency of transplant
To actively look for liver tumour
To evaluate the condition of other organ systems such as heart, lungs, kidneys, etc. and determine patients' ability to tolerate this major operation
To evaluate difficulty, technical feasibility and risk of surgery (previous abdominal infections, surgery, thrombosis of liver blood vessels)
Evaluation generally takes about 7-10 days and is done on outpatient basis.
A living donor should meet the following criteria:
Compatible blood group with the recipient
A family member (wife, husband, mother, father, brother, sister, son, daughter, grandfather, grandmother, grandson, granddaughter) or close relative of the patient
We do not accept family friends, well-wishers, staff or neighbours as donors
Age group 18-55 years
Should not be overweight, because people who are overweight may have fatty liver
The donor liver should be large enough to provide adequate volume for the recipient (patient) as well as for the donor
Donor should be in good overall physical and mental health and undergo a thorough medical and psychological evaluation and volunteer for donation after fully understanding the risks of surgery
The decision to donate can be changed at any stage of the evaluation, before or after the tests are done or any time before the surgery.
Donor evaluation takes about 7-10 days and are done on an outpatient basis, commonly along with the recipient evaluation. Donors usually undergo liver function tests, liver volumes, tests to evaluate other organ in first phase. Few donors might need a biopsy to study liver quality in more details, where a tiny piece of liver is examined under a microscope.
When potential donors are rejected, it can be stressful for the family, but this is done for the safety of the donor and success of transplant, an alternative donor should then be identified. Both the patients and donors emotional health and willingness for transplant is important for the operation and they would be counselled by a psychologist during Evaluation.
All patients planned for living donor transplant need clearance by the government appointed authorization committee. Our administrative staff will help patients and their families understand and prepare various legal forms, affidavits and supporting documents. The transplant team is independent of the authorisation committee and cannot influence its decision. All cases who have completed both patient and donor evaluations are reviewed by the multi-disciplinary transplant team, where their suitability for transplant is discussed and tentative date for transplant decided. The transplant is scheduled only after clearance by the authorisation committee.
Once the medical decision for transplant is made, patient's family is advised to donate about 18 units of blood (any blood group, unless the patient has a rare blood group), well before the date of surgery and prepare 3 platelet donors (same group as the patient). Platelets have a short shelf-life and therefore should be donated only one day prior to surgery. If the surgery is expected or found to be difficult, additional blood donations may be required before surgery or may have to be replaced after surgery, as and when notified by the transplant team.
Liver transplant is offered as a package at our institute. It includes pre-transplant workup fee, operation charges and life-long consultation charges for both patient and the donor. The pre-transplant coordinators will explain expected expenses at various phases, mode of payment, inclusions and exclusions of the package. Patients with additional risk factors such as kidney or cardio-respiratory problems, those expected to undergo a complex operation, need prolonged ICU care or hospitalisation might be offered the high-risk package. Patients undergoing combined liver-kidney transplant, dual lobe transplant, ABO incompatible transplant or have hepatitis B or other diseases require use of additional expensive medicines, they should discuss the package applicable to them with the pre-transplant coordinator.
Patients whose expenses for transplant and post-operative medical care will be borne by insurance company, employer or embassy should discuss the same with the patient financial liaison or TPA helpdesk, who will guide patients with required paperwork. Some insurance companies only pay part of the package and the remaining amount has to be arranged by the patients' family.
When one of patient's family members is suitable and willing for donation, but is not a good match for the patient, a paired donation or swap transplant may be considered. In this type of transplant, two families with suitable living donors exchange their donors because they are not a good match for their own patient, but are appropriate for each other's patients. Both transplants are performed simultaneously and therefore can only be done by a large experienced transplant team after careful planning.
Dual lobe liver transplant
When a potential living donor's liver volume is found inadequate for the recipient on pre-operative CT scan, they may be rejected and another donor evaluated. It is common that in one family two or more people might have been rejected for donation each because of low liver volumes, who were otherwise suitable. If partial livers from both donors are combined; it is often adequate for the patient. In such a transplant, three operations (one recipient and two donors) are performed simultaneously.
ABO incompatible (ABM) transplant
Generally, liver transplant is performed with blood group compatible donor livers, because ABO (blood group) incompatible transplantation triggers production of antibodies against the transplanted liver causing organ rejection. However, if some special immunosuppressive medicines and measures are used, antibody levels can be reduced before transplant and organ rejection prevented.
Deceased donor transplant
Once recipient evaluation is completed and patient is found medically fit for transplant, the prescribed forms have to be completed and submitted through the hospital to the state-wide appropriate authority for registering their names on the waiting list for a deceased donor transplant.
When a potential deceased donor liver is available, patients are alerted immediately and called to the hospital. While one team prepares the patient for transplant, another team retrieves the donor liver. The liver is carefully checked for its suitability for transplantation. Livers from donors may be considered high risk if they had previous hepatitis B or hepatitis C infection, had risk factors for HIV infection, had active infection or cancer. Patients should discuss the quality of liver and associated risks with the transplant team before accepting or rejecting it. If the transplant team finds the liver unsuitable, the donor family withdraws their consent to donate or for any other reason the transplant is cancelled; patients will have to return home and continue waiting for the next offer. While such "false alarms" could be stressful, these decisions are always taken in the interest of patient safety and to optimize chances of a successful transplant.
FICS, FALS (HPB), FIAGES, MSc (Organ Transplant), MBA