Ans : Liver transplantation is a surgical where the damaged liver is removed and replaced with a healthy liver from another individual.
Ans : It is needed when the liver is damaged or failed to an extent where there is a significant danger to life. It is also needed for tumors in the liver.
Ans : There are various diseases for which liver transplantation needs to be performed and in each case disease-specific criteria vary. Severity of chronic liver disease is assessed by three systems. The Child-Turcotte-Pough (CTP) system relies on bilirubin, albumin, prothrombin time prolongation, degree of ascites and degree of hepatic encephalopathy, the Mayo End-stage Liver Disease (MELD) system relies on creatinine, bilirubin and international normalized ratio (INR) while the Pediatric End-stage Liver Disease system for children relies on bilirubin, INR, albumin and degree of growth retardation. (As a general rule once the CTP score is more than 10 or the MELD score is more than 14, liver transplantation should be considered.) In acute liver failure, cancer and metabolic diseases, these criteria do not apply.
Ans : When there is evidence to suggest major liver damage making recovery very unlikely. The King's College and Clichy criteria are commonly followed.
For chronic liver disease, Child Pough Score and the MELD (in adults) and PELD (children) is followed. These are not absolute and have limitations. Other clinical parameters need to be judged. The criteria for liver transplant is different for Acute and Chronic conditions.
Ans :Although you may need a liver transplant, you may not be suitable for it since liver transplantation requires major surgery and high compliance.
Absolute contraindications are: 1. Psychiatric conditions including substance abuse
2. Recent malignancy outside the liver 3. Active infections
4. Multi-organ failureRelative contraindications are:
1. Age > 75 years2. Poor general condition and nutrition
3. Portal vein and mesenteric vein thrombosis4. HIV positive status with CD4<500
Ans : You should contact a transplant centre either directly or through your physician.
Ans : At the centre you will be assessed by the medical and surgical team to evaluate your suitability for liver transplant.
Ans : During this process a detailed evaluation of your liver and general health is made for any contraindications for liver transplantations. This includes physical examination by doctors, blood tests, CT scan/ultrasound/MRI to get images of the liver to check if there are tumors in the liver or blockages to blood vessels.
Chest X ray/EKG/ Echocardiogram to rule out heart or lung problems during surgery. Psychologist or social worker review to discuss your understanding of liver transplantation, your social and family surroundings and ability to adjust to life after transplantation. Additional tests may be required to clarify any issues that become apparent during evaluation.
Ans : You will be placed on the cadaver transplant waiting list with the appropriate authority by the centre. You will be listed based on your blood group, severity of liver disease and date of registration. When a suitable deceased donor liver becomes available for you will be contacted to come for liver transplant procedure. However in India, there are very few cadaver donations and the waiting list is very long during which many patients die. In case you have a related donor willing to donate part of his liver, he/she would be evaluated for suitability and if acceptable after processing by ethics committee, transplantation can proceed.
Ans : Waiting period for a deceased liver transplant is extremely variable and may go on for months to years. While waiting for a transplant you should strictly follow the medical instructions provided and remain in regular contact with the transplant coordinator and your primary physician. Your physician or you should inform the transplant centre about any illness you may have and if you are likely to be away or moving to a different location and inform the coordinator how you can be contacted at all times. You will have to get tests done periodically and keep your transplant physician informed of the results. The transplant centre will update your listing status as and when it gets revised.
Ans : You will be asked to come to the transplant centre by the fastest means possible and remain nil by mouth. Since you will have to deposit the entire amount for the surgery or a credit note at admission (it is a good idea to have these made ready when you are high on waiting list). You will need to provide replacement blood and blood product donors who should be contacted to arrive at the hospital blood bank as soon as possible.
On arrival at the transplant centre you will be evaluated by the team and fresh laboratory work done. If it is found that you are not fit for any reason, you will not be transplanted. If found fit you will be admitted and prepared for surgery. Your operation will commence when the deceased donor organ has been retrieved and found to be of acceptable quality for transplantation.
Ans : Liver transplantation is a major surgery and carries a significant risk of complications including death. While most patients recover fully after the operation there is a risk of serious complications during the surgery as well as after it.
Risks are related to anesthesia, the surgery, as well as medications administered in the preoperative period. There may be a reaction to anesthetic drugs or you may develop chest problems like infection. You can develop problems from the tube inserted into your wind-pipe during the operation. Clots can develop in your legs and some can travel to circulation in the lungs. There may also be fluctuations in blood pressure or heart rate and rhythm.The overall risk of developing surgical complications is 20-30%. Most of these are however minor.
Massive intra-operative bleeding (due to deranged liver function and clotting) may be difficult to control and require placement of packs in the abdomen which may have to be removed surgically through one or more surgeries.Despite all precautions taken during retrieval of the transplanted liver, it may not function (a condition called primary non-function). In such cases, death may occur unless re-transplantation with a new liver is performed in time.
In the postoperative period, there may be bleeding, problems with blood flow to the transplanted liver or other complications like leakage of bile or intestinal contents that may need one or more operations to control.Thrombosis (blockage by clot) of any of the blood vessels hepatic artery, portal vein, hepatic veins etc.) can occur at any time after the transplant. Which may be managed successfully but sometimes this is not possible leading to death.
There can be leakage from the bile duct connection and in majority of patients this can be managed successfully but occasionally it can lead to severe infection which can be fatal. .Narrowing or blockage of the bile duct can occur at any stage after the transplant and may require intervention including operation.Due to the complex nature of surgery, chances of massive bleeding and drug toxicity, pre-existing kidney disease (such as diabetes, hypertension, dysfunction, etc) there is a chance of developing kidney dysfunction during or after liver transplant. This dysfunction is usually temporary and may require dialysis for short periods of time but occasionally can be permanent.
The patient's compromised general condition coupled with administration of drugs necessary to prevent rejection of the transplanted liver (immunosuppressant drugs) can make them prone to develop infections. Some of these infections can result in septicemia and be fatal in spite of measures.Some problems may appear later. There may be inadequate healing or infection in the wound or scar which may need surgical correction.
This is by no means a complete list of potential risks. You should get all the information from the team.In spite of anti-rejection medication acute rejection can develop at sometime after transplant. While most of these cases respond to changing medication or altering the doses, a small proportion may not and progress to graft failure and death unless a re-transplant can be done in time. Very rarely chronic rejection occurs which leads to graft loss and even death if re-transplantation cannot be performed.
Any and all medicines that are administered during and after the transplant can lead to side-effects such as hypertension, diabetes, kidney toxicity, infections, lowering of blood cell counts and susceptibility to cancer.Many diseases such as viral hepatitis (of all types) , liver cancer, some autoimmune conditions have the potential to recur in the transplanted liver. Medication or measures can help to reduce chances of recurrence for some diseases (eg: hepatitis B or cancer) but not all can be prevented. While cancer tends to progress rapidly after recurrence other diseases can be slowly progressive.
Ans : This is extremely variable and dependent upon your overall health status at the time transplantation is performed. If no complications occur, most patients can expect to be out of intensive care unit within 3-7 days and remain in hospital for an additional 10-14 days. You will be sent home only when liver function is normal, there is no infection, you are able to take a full diet, fully ambulatory and your care-givers and you have been familiarized with instructions medications and post-transplant follow-up schedule.
Ans : You will need to contact the hospital anytime you feel unwell or have any symptoms and report to hospital as advised. For the first month you will have to be seen by a member of the transplant team twice weekly, weekly for the next month and every month thereafter for a year. After that you will need to communicate your laboratory tests to the transplant centre and follow-up twice a year lifelong but you will need to be seen periodically by your primary physician.
Ans : You will be operated under general anesthesia. During the operation a cut (inverted T shaped) will be made in your upper abdomen and your liver will be removed. The donor liver will then be stitched in its place creating connections between the donor liver blood vessels with your blood vessels so that blood can flow in and out of the new liver and bile can flow into the intestine through a connection between your bile duct and that of the donor or between the donors bile duct and your intestine. After closing your abdomen you will be shifted into the intensive care unit where you will gradually recover from effect of anesthesia and surgery.
Ans : Most patients within 12 weeks are able to resume normal non-strenuous activities. For 6 months after discharge frequent follow-up visits will be required to assess recovery. Strenuous activities may be resumed after 3 months but female donors should avoid pregnancy for two years after surgery. Time for returning to work would depend on the nature of work and personal choice but usually takes 12-24 weeks.
Ans : Rejection is an attack on the donor liver by your immune system which leads to inflammation and injury to the liver. Up to 10-15% liver transplant patients will experience an episode of acute rejection that may present as pain in abdomen, fever and abnormalities in liver tests. In rare cases there is chronic rejection and destruction of the liver graft. The best way to minimize rejection is to strictly follow your immunosuppressant schedule and monitor your liver function tests and report any abnormalities early. Nearly all episodes of acute rejection are managed with increasing doses of immunosuppression or giving steroids. During this period chances of infection are higher and hence you may need to be admitted and given antibiotics. Most if not all acute rejection episodes respond to this treatment without residual damage to liver function.
Ans : You will need to take immunosuppressant medications to prevent rejection of the liver lifelong. Other than that ; dietary supplements, micronutrients and minerals will have to be taken to prevent complications and side-effects of medications for extended periods. Other medications will be as per your health status. You will have to be careful to eat only clean, fresh, well-cooked and balanced diet to prevent deficiencies and infection. Although there are no uniform dietary restrictions a low fat diet is advised for most people after transplant. Diabetics will have to have sugar free diet to keep blood sugar under control.
Ans : Even if your transplanted liver is functioning normally, smoking and alcohol consumption cannot be recommended to anyone.
LIVING DONOR LIVER TRANSPLANTATION
Ans : Living donor liver transplantation is a procedure in which a part of the healthy liver of a living person is transplanted into a patient.
Ans : The main advantage of LDLT over DDLT is that there is almost no waiting period. That means the transplant can be planned and performed in time before the patient becomes too sick or dies while waiting for a deceased donor organ to be available. Other advantages are that the donor graft in LDLT comes from a donor who has been thoroughly evaluated , ischaemic time and cold preservation injury is abbreviated as compared to DDLT and the condition of LDLT recipient can usually be optimized before operation.
Ans : The obvious disadvantage of LDLT is that a healthy living person has to undergo a major surgery that essentially does not benefit him/ her. Apart from this the other disadvantages are that the graft volume is smaller providing smaller functional liver mass to the LDLT recipient than the whole liver in DDLT. Also since LDLT is more technically challenging, the incidence of biliary and vascular problems were initially higher however with more experience this is no longer more than in DDLT.
Ans : 1. Be an adult ( ≥ 18 years) below the age of 55 years
2. Have the same or compatible ABO blood group as the intended recipient3. Not be suffering from major medical or mental illness
4. Understand and comply with instructions during evaluation5. Not be actively smoking or abusing alcohol or illegal drugs
6. Free from transmissible disease or infections
Ans : Under Indian law, only close relatives of the intended recipient (spouse, sibling, parent or offspring and soon grandparent or grandchild) or those who have obtained permission from appropriate authorities after due procedure can be living donors. The donor should voluntarily present before the transplant physicians or coordinator who will ascertain basic suitability and offer information regarding donation.
Ans : The evaluation is done to answer to two questions
1. Are you having any condition that could increase your risks for problems during or after your operation for donation?2. Is the part of your liver being removed for transplantation and the remnant left with you likely to be normal and adequate for both you and the intended recipient?
Ans : The evaluation process includes Blood tests for blood group compatibility, liver function, kidney function, counts of red blood cells etc. As well as to rule out hepatitis B ,C and HIV infection. Tests will also be done to rule out common liver diseases.
Physical Examination by physicians and surgeon if the results of blood tests are favourable CT scan/Ultrasound/MRI to get images of the liver with its bile ducts, arteries and veins to ensure they are of favourable size and configuration to suit the intended recipient. Chest X ray/EKG/ Echocardiogramto rule out heart or lung problems before surgery Consults with psychologist or social worker to discuss your reasons for donation, your understanding of the process and its potential impact on your life in the short and long term. Additional tests and consults may be done to further clarify any issues that become apparent during evaluation
Ans : Transplant centres are very stringent in choosing donors. This is to keep donation as safe as possible. The chance of being unsuitable to donate despite being apparently healthy and having the same or compatible blood group as the intended recipient varies between 25-50%. This is for your own safety.
Ans : Surgery for liver donation is a major surgery. While most donors recover fully after the operation and return to normal life and activity within a couple of months, there is a risk of serious complications during the surgery as well as after it .
Risks are related to anaesthesia and the surgery. There may be a reaction to anaesthetic drugs or you may develop chest problems like collapse or infection. You can develop problems from the tube inserted into your wind-pipe during the operation. Clots can develop in your legs and some can travel to circulation in the lungs. There may also be fluctuations in blood pressure or heart rate and rhythm. You may accumulate fluid around your lungs.The overall risk of developing surgical complications is 20-30%. Most of these are minor. Commonest complication is bile leak and intra-abdominal collection of fluid that may require intervention. There may be bleeding during cutting of the liver for which blood or clotting factors may have to be transfused. Rarely the part of liver left with the donor may get damaged or not function adequately and the donor may need a liver transplant. The risk of death after donation is estimated to be 1 in 500 to 1 in 1000.
Some problems may appear later. There may be inadequate healing or infection in the wound or scar which may need surgical correction. This is by no means a complete list of potential risks. You should get all the information from the transplant physicians, surgeons as well as from other living donors.
Ans : Evaluation and actual donation are separate processes. Your fitness will not be revealed to the intended recipient without your consent. If you are unwilling to donate after being found fit to donate you will be allowed a cool-off period depending upon the condition of the intended recipient at that time. If you do not wish to donate even after that period, you will be offered a medical opt-out ie you will be declared medically unsuitable.
Ans : If no problems occur, you may be discharged 5 to 7 days after the operation. The stay may be prolonged if complications arise. You will be in ICU usually for 24 hours and then in the ward cared for by trained nursing staff. You will be encouraged to sit, feed yourself and walk as soon as you are able to reduce stay in the hospital.
Ans : During the operation a cut will be made in your abdomen and your liver is reassessed and if found suitable split into two parts. Depending upon the size and status of the intended recipient, one part is removed for transplantation and the other left inside. The cut is then closed by the surgeon with stitches or staples which may be need to be removed during follow-up visit. The part of liver left inside you heals and grows new tissue (a unique property of the liver) and attains nearly the pre-donation size between 4-8 weeks after surgery.
Ans : Most donors within 4 weeks are able to resume normal non-strenuous activities. For a month after discharge frequent follow-up visits will be required to assess recovery. Strenuous activities may be resumed after 3 months but female donors should avoid pregnancy for a year after donation. Time for returning to work would depend on the nature of work and personal choice but is usually takes 6-12 weeks.
Ans : Usually no medications are required apart from pain killers or dietary supplements after discharge. If complications develop medications may be needed. There is no dietary restriction after discharge or in the long term but a healthy, balanced diet is beneficial for everyone even if you are not a donor.
Ans : Essentially you will be fully normal between 4-8 weeks once your liver has fully grown. However in the interests of overall health, smoking and alcohol consumption cannot be recommended to anyone even for those with normal liver and lung function.