Liver Transplant International
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 B and C are offered transplants. CPT- A patients with hepatocellular cancer are also considered for transplantation.
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 need sometime for optimization before surgery so that the results of liver transplantation can be brought at par with those who are relatively stable at time of transplantation. Therefore, timing of the 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 excellent outcomes.
Common causes of chronic liver disease and cirrhosis include
- Viral illnesses such as Hepatitis B and Hepatitis C
- Alcohol induced damage to liver
- Fatty liver disease
- Tendency for blockage of blood vessels of liver (Budd Chiari syndrome)
- Developmental malformations of liver as in biliary atresia in children
- Enzyme deficiencies in children leading to chronic liver damage (Wilsons disease etc.)
- Sometimes from still unknown factors
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.
Another reason for liver damage is Acute Liver Failure. In this following a viral infection (Hepatitis A, Hepatitis E), or due to consumption of large amount of acetaminophen, or certain drugs, which are toxic to liver, patient can develop rapid onset of liver failure. This is manifested by onset of jaundice and within a few days development of confusional state or even coma with worsening of liver synthetic functions. This is usually an emergency situation wherein if the patient doesn’t receive or respond to proper treatment, then he or she may end up requiring an urgent liver transplant.
A patient with acute liver failure should be transferred to a center where liver transplant facilities are available as early as possible, so that appropriate intervention can be done timely. Almost 50% of patients with acute liver failure can be salvaged without the need of undergoing an urgent liver transplant at specialized centers that have liver transplant facilities available.
Liver Transplant is needed when a person develops either acute (sudden) or chronic liver failure. Liver transplant is a life saving procedure in this setting.
Acute liver failure (ALF) happens suddenly. It may be caused by various reasons. In India, acute viral infection from Hepatitis A and E are the commonest cause, though it may also occur from drug induced liver damage (DILI), with acetaminophen being the leading cause
Chronic liver failure, also called end-stage liver disease, is a slower process, which progresses over months, years, or decades. Most often, chronic liver failure is the result of cirrhosis, a condition in which the liver cells progressively get destroyed and are replaced with scar tissue through out the liver.
In India the common reasons for end stage liver disease include chronic hepatitis B and C infection and long-standing alcohol abuse.
Many other liver diseases also cause cirrhosis, including autoimmune hepatitis, diseases that affect the bile ducts, which are the tubes that carry bile from the liver to the gallbladder and small intestine and include biliary atresia, Alagille syndrome, primary biliary cirrhosis, and primary sclerosing cholangitis.
Other causes include:
Hemochromatosis, a genetic condition in which iron builds up in the liver, Wilson’s disease, a genetic condition in which copper builds up in the liver, nonalcoholic steatohepatitis, or NASH, a disease caused by fat and inflammation in the liver
In children, biliary atresia is the most common cause of liver failure and the need for a liver transplant. Biliary atresia is a disease in newborns in which the bile ducts are absent, damaged, or blocked. As a result, toxic bile builds up in the liver, resulting in cirrhosis.
Other reasons for liver transplantation include cancers originating in the liver such as hepatocellular carcinoma, hepatoblastoma, and cholangiocarcinomas.
How do I assess just how bad is my disease?
End stage liver disease is a progressive disease and has different stages. There are different scoring systems through which one can evaluate the stage of disease and Liver Transplant needed. The common scoring systems used are the Child- Pugh-Turcotte scoring system and the MELD scoring system. Different parameters such as bilirubin, prothrombin time, serum albumin level etc. are required to assess the disease severity
Procedure of liver transplant in a Recipient In the recipient, the surgical procedure involves removing the entire diseased liver. The new liver (either from a deceased donor or living donor) is kept perfused with a preservative solution and is then attached in the cavity left behind on removing the old liver. The blood vessels and the bile duct of the new liver are then connected with the recipient vessels and ducts.
Recovery period after liver transplantation in the intensive care unit and nursing unit in the hospital?
In the initial 1 week following transplant, the patient requires care in intensive care unit. The patients have round the clock nursing and doctor supervision. Regular blood tests and Doppler ultrasound (sonography) evaluation of the liver is carried out on a daily basis. On the first night of surgery, they are usually on the ventilator (support for respiration), and usually are extubated (removal of the ventilator) on the next morning, if all the parameters are favorable. The patients are on bed rest for the first 2 days and are allowed to be ambulated (walk) from the third day onwards. Those patients who are having an uneventful recovery are usually shifted to step down HDU (High Dependency Unit) by the fourth or the fifth day). If any complications are suspected then the ICU stay may get prolonged. For the first few days the family members are not allowed to come into the ICU to meet the patients as this may increase the chance of infections. The family members can however talk to the patient on phone and can view him or her on a screen through a camera attached in the patient’s room.
Potential complications during and after a transplant
Complications following liver transplant can be divided into early and late. Early complications can include kidney dysfunction, heart problems, infections, organ rejection and technical complications such as blockage of blood vessels or bile leaks. The incidence of these complications is quite low but nevertheless one needs to be prepared for these complications and their remedies. There are set protocols to deal with every complication, though the main emphasis remains on preventing these complications from occurring in the first place.Late complications include bile duct strictures, viral infections such as CMV, organ rejection, and recurrence of old disease or recidivism (going back to alcohol consumption). Patient needs to be on a regular follow up with monthly blood tests which are analyzed through emails, and a 6 monthly out patient visit for the first year and an yearly visit there after. This allows timely detection of any alteration of the normal postoperative course and it helps in taking appropriate corrective measures in time.
Recover Time from Liver Transplantation
Recovery after liver transplantation depends in part on how ill the patient was prior to surgery. Most patients need to count on spending a few days in the hospital in the intensive care unit and another few days on the ward; on an average the patent stays in the hospital for approximately 2-3 weeks in an uncomplicated post operative course and is in a dis-chargeable condition.
Process of post-operative care for the donor
Postoperatively a live donor is managed in the intensive care unit for the first 3 – 4 days. The donor may experience a little more pain on the first post-operative day. The donor is given a ‘patient controlled analgesia’ device through which the patient can self-medicate himself or herself with pain suppressant medication and stay comfortable. The donor is on bed rest for two post-operative days and is ambulated (allowed to be out of bed) from the third post-operative day. From the third day the donor is also allowed oral intake and is shifted to the ward from the ICU. By the 7th postoperative day the abdominal drain is usually removed and the donor is usually discharged on the 8th post-operative day if the recovery has been uneventful.
Liver Regenerate after donation:
The liver regenerates after the donor surgery. The liver will increase in weight to about 75-85% of the original weight in both the donor and the recipient by around the end of 3-4 weeks and it grows to 90-97% of the original weight by around the end of first year after surgery.
Donor resume to work after surgery
The donor can usually go back to work about 3 weeks after surgery and can resume all daily activities by that time, if the post-operative course has been uneventful.
Precautions a donor has to take in the postoperative period
The donor is advised to refrain from lifting weights more than 7 – 8 kg for a period of 3 months post surgery to decrease the chance of hernia formation at the wound site. The donor should be on healthy diet and ideally avoid junk food for a period of about a month post operative.