Dr A.S Soin
According to international guidelines, any patient suffering from liver cirrhosis who is assessed to have a life expectancy of less than a year should be considered for a transplant.
Severity of liver disease is graded from A to C. Usually all Grade C and most grade B patients are candidates for transplant. Any patient with any of the liver failure symptoms listed below should seek specialist opinion so that liver experts can assess whether a transplant or drug treatment is more suitable for them. In any case, the better the condition of the patient at the time of transplant, the better are the results of surgery. In patients who are critically ill in ICU, malnourished, have active infection, or other organ damage such as kidney impairment at the time of the operation, the results of transplantation are dismal. Therefore, timely transplant is of essence in obtaining good results. A timely transplant done on a patient who is in a reasonable condition, with a good donor liver has around 80% chance of success.
In most instances, the above causes initially result in Hepatitis which can usually be treated. However, if the offending factor is not removed or treated on time, cirrhosis develops and then it is usually too late to change the course of the disease.
Symptoms of liver failure due to cirrhosis
Water in the abdomen (ascites)
Drowsiness and mental confusion
Excessive bleeding from minor wounds
Low hemoglobin and other blood counts
Pre-transplant evaluation (Liver Transplant Assessment)
The liver specialist usually suggests this evaluation once he has diagnosed end-stage liver disease. Recipient evaluation is done in three phases and normally takes 5-7 days in hospital.
To establish definite diagnosis, determine the severity of liver disease and the urgency of the transplant.
To determine the fitness of the patient for a transplant. The other systems such as heart, lungs, kidneys, blood counts are tested and the presence of any infection is ruled out. The liver specialist then decides how successful the surgery is likely to be depending on the status of the patient and the cause and severity of liver disease.
The final phase entails the psychological and mental preparation of the patient. The patient and the family are counseled about the procedure, hospital stay, the likely course after surgery, follow up and aftercare.
After evaluation, the patient is either placed on the waiting list for cadaveric donation, or , if there is a willing and blood group matched family donor available, he/she is evaluated for donation and a transplant is scheduled.
While on the cadaver waiting list, the patient follows up with the Transplant Team until a suitable liver becomes available. If the patient’s condition shows signs of deteriorating, we normally suggest the family to consider living liver donation.
Cadaveric donor (deceased donor) liver transplant
The waiting time can be very variable from 1 to 12 months depending on your blood group and your waiting list number. While waiting, if you are not available at your usual numbers, you must inform the Transplant Team of your whereabouts at all times so that they can contact you as soon as an organ becomes available.
It is good idea to have a suitcase already packed with essential toiletry and underwear at home so that no time is wasted before you go to the hospital.
Live Donor Liver Transplant
Due to a lack of cadaveric donors in India, majority of the transplants are live donor liver transplants whereby a portion of the patient’s relative’s liver is removed and is used to replace the diseased liver of the patient.
After the operation
After the operation you will be taken to the intensive care unit and connected to a respirator (breathing machine). If all goes well, the respirator can gradually be phased out over 24-48 hours, although it is not unusual to require the respirator for longer periods of time.
After three to ten days in intensive care, you will probably spend another two to four weeks convalescing in the transplant unit before being allowed to go home. It is important that you try to get up and about as soon possible so that blood circulatory problems can be avoided.
Since the donor liver is foreign to the body, the body mounts an immune response to reject it. This is prevented by certain medicines referred to as immunosuppressive drugs.
After another one month at home, you will start feeling normal again and gradually be able to get back to normal activities. Once the donor liver takes in the body (if the person remains well for about 3 months after operation), the person has an excellent chance of leading a normal life and with longevity comparable to any other person of their age and fitness.
During the first 3 months after discharge from the hospital, it is important that you return to the Transplant Unit once or twice a week for follow-up visits. The purpose of follow-up visit is to monitor your progress and detect any potential complications. On each visit, your liver function will be carefully assessed and you will undergo an examination so that any infections can be identified. Once you are stable, the frequency of visits will decline.
(The author is Chief Hepatobiliary and Liver Transplant Surgeon, Medanta Institute of Liver Science)
Dr A.S Soin