All You Need to Know about Liver Transplantation

Liver transplantation is a life-saving medical procedure that involves replacing a diseased or damaged liver with a healthy liver from a donor. This surgical intervention has revolutionised the treatment of end-stage liver diseases, providing hope and renewed life for thousands of patients worldwide. In this comprehensive guide, we will explore the various aspects of liver transplant, including the reasons for the procedure, eligibility criteria, the transplant process, recovery, and post-transplant care.

What is Liver Transplantation?

A liver transplant is a surgical procedure in which a diseased liver is replaced with a healthy one. A healthy liver for transplantation is typically taken from a deceased or living donor. Deceased donor is one who is brain dead or who has recently passed away. Living donor is one of the family member who is willing to donate a part of his liver to the patient. One remarkable feature of the liver sets it apart from other organs: it can regenerate lost or damaged tissue. This regenerative capacity is pivotal in the donor and recipient's recovery.

When is Liver Transplantation Required?

Liver transplantation is typically considered when a person's liver is severely damaged, dysfunctional, or at the end stage due to a liver disease or condition. Following are the common conditions in which Liver transplant is required.

Chronic Hepatitis with Cirrhosis: Chronic hepatitis, particularly caused by hepatitis B or C viruses, can lead to cirrhosis if left untreated. Cirrhosis is characterised by the formation of scar tissue in the liver, impairing its function over time. Liver transplantation is considered when cirrhosis caused by chronic hepatitis progresses to end-stage liver disease, resulting in complications like portal hypertension and liver failure.

Primary Biliary Cirrhosis (Primary Biliary Cholangitis): Primary biliary cirrhosis is an autoimmune disease that primarily affects the small bile ducts within the liver. Over time, it can lead to cirrhosis and liver failure. Transplantation may be necessary when primary biliary cirrhosis reaches an advanced stage with severe liver damage and complications, or if medical management fails to control the disease.

Biliary Atresia: Biliary atresia is a rare congenital condition where the bile ducts inside and outside the liver are abnormally narrow, blocked, or absent. It is the most common reason for liver transplantation in children. Liver transplantation is often the only effective treatment for biliary atresia when surgical interventions ( Kasai procedure) fails to correct the bile duct abnormalities and prevent liver damage.

Chronic Alcoholism: Chronic and excessive alcohol consumption can cause alcoholic liver disease, which may progress to cirrhosis and end-stage liver disease. Liver transplantation is considered when liver damage due to alcoholism reaches a point where other treatments are ineffective, and abstinence from alcohol is maintained.

Wilson's Disease: Wilson's disease is a rare genetic disorder that leads to the accumulation of copper in the liver and other organs. Without treatment, it can result in liver failure. Transplantation is required when Wilson's disease leads to severe liver damage and complications, especially if the patient does not respond to copper-chelating medications.

Hemochromatosis: Hemochromatosis is an inherited disorder that causes excessive iron absorption by the body, leading to iron overload in various organs, including the liver. Liver transplantation may be considered if hemochromatosis leads to severe liver fibrosis, cirrhosis, or other complications, and medical treatment or therapeutic phlebotomy is insufficient.

Metabolic Disorders: Certain metabolic disorders, such as glycogen storage diseases and organic acidemias, can affect the liver's function and lead to liver damage or failure. Liver transplantation is considered when metabolic disorders result in severe liver dysfunction, recurrent metabolic crises, or other complications that are unmanageable with medical treatment or dietary restrictions.

Other Chronic Liver diseases: Diseases like non-alcoholic fatty liver disease (NAFLD) and autoimmune liver diseases can lead to advanced cirrhosis and further liver decompensation. These complications present as jaundice, fatigue, and fluid retention.

Acute Liver Failure: Acute liver failure is a sudden and rapid loss of liver function, which can result from various causes, including viral hepatitis, drug-induced liver injury, and certain toxins. Patients with acute liver failure may experience severe symptoms, such as confusion, bleeding, and hepatic encephalopathy, and often require immediate transplantation to survive.

Liver tumours: Liver tumours particularly hepatoblastoma and hepatocellular carcinoma (HCC), may necessitate a liver transplant in some cases. Transplantation is considered when the tumour is confined to the liver, meets specific size and number criteria, and does not involve major blood vessels. In these cases, a transplant offers a chance to remove both the tumour and the diseased liver.

Indications for Liver Transplant

While there are several liver diseases and conditions that may necessitate transplantation, medical professionals evaluate each patient's unique situation to determine the appropriateness of the procedure. Some common indications for liver transplantation include:

End-Stage Liver Disease: Liver transplantation is often considered when a patient's liver reaches end-stage disease, meaning it is severely damaged, scarred, and can no longer perform its essential functions adequately. End-stage liver disease is associated with significant symptoms, a high risk of complications, and a poor prognosis without transplantation.

Irreversible Liver Damage: In many cases, liver diseases progress to a point where the damage to the liver is irreversible. This damage may result in complications like portal hypertension, ascites (abdominal fluid retention), and hepatic encephalopathy, significantly impacting a patient's quality of life and survival.

Failure of Medical Management: When conventional medical treatments and interventions no longer effectively manage liver disease or its complications, transplantation may be the last viable option to extend a patient's life and improve their overall health.

Types of Liver Transplant

Liver transplantation can be performed in different ways, depending on the specific circumstances of the patient and the availability of suitable donor organs. There are three primary types of liver transplantation:

Deceased Donor Liver Transplant (DDLT): This type of transplant involves obtaining a healthy liver from a deceased individual who had previously consented to organ donation. Deceased donor livers are primarily used for whole liver transplants.

Living Donor Liver Transplant (LDLT): In this procedure, a living person donates a portion of their liver to the recipient. The liver possesses a special ability to regenerate, ensuring that both the donor and recipient have fully functional livers after surgery. LDLT is often utilised when a suitable deceased donor is unavailable, and can be further categorised into two subtypes:

• Related Living Donor: Involves a family member, such as a parent, sibling, or close relative, donating a portion of their liver.

• Non-Related Living Donor: This occurs when an unrelated individual, often a friend or acquaintance with a compatible blood type, volunteers to donate a portion of their liver.

In India, only living related liver transplants are done.

Split Liver Transplant: This specialised procedure entails dividing a deceased donor's liver into two portions. One part is transplanted into an adult recipient, while the other part is transplanted into a paediatric recipient. Split liver transplants are crucial for maximising the number of patients benefiting from a single donated organ.

Tests Before a Liver Transplant

Before undergoing a transplant procedure, it's essential to undergo a series of tests when you consult a liver specialist. These tests provide crucial information about your health and compatibility with the donated organ. Here is a comprehensive list of recommended pre-transplant tests:

Blood Group Matching: Matching the blood type of the donor and recipient is fundamental to prevent compatibility issues and potential complications during and after the transplant.

Virology Workup: This assessment screens for viral infections, such as hepatitis B and C and HIV. These are mandatory to screen most of surgeries including liver transplants.

Computed Tomography (CT) Scan: A CT scan provides detailed images of the organ to be transplanted, helping surgeons assess its condition and plan the procedure accurately.

Doppler Ultrasound: This non-invasive test evaluates blood flow in the blood vessels around the transplant site, ensuring adequate circulation for the new organ.

Echocardiogram: An echocardiogram assesses the health and function of your heart, as heart health is critical for the success of many transplant surgeries.

Lung Function Tests: For lung transplant candidates, pulmonary function tests are essential to evaluate lung capacity and suitability for transplantation.

Blood Tests: Comprehensive blood tests check various parameters, including liver and kidney function, to assess overall health and detect any underlying issues.

Cancer Workup (in case of liver cancers): For individuals with liver cancers, additional tests are necessary to determine the extent of the tumour and assess its impact on transplant eligibility.

Kidney Function Tests: If you're undergoing a kidney transplant, specific tests are conducted to evaluate your current kidney function and identify any underlying kidney diseases.

Eligibility and Evaluation

Before a liver transplant can be performed, a comprehensive evaluation process is undertaken to determine the patient's eligibility and assess their overall health. This section outlines the crucial steps involved in pre-transplant evaluation and the factors that influence a patient's suitability for a liver transplant.

Pre-Transplant Evaluation: The pre-transplant evaluation is a thorough assessment conducted by a transplant team to evaluate the patient's medical history, current health status, and the severity of their liver disease. The evaluation includes several key components:

Medical History: The patient's medical history is carefully reviewed to assess factors such as the underlying liver disease, previous treatments, and any comorbid conditions (e.g. diabetes, heart disease) that could impact the transplant procedure or outcomes.

Physical Examination: A comprehensive physical examination is conducted to assess the patient's overall health and identify any signs of advanced liver disease, such as jaundice, ascites, or hepatic encephalopathy.

Laboratory Tests: Blood tests are performed to assess liver function, blood clotting factors, and to determine the patient's suitability for surgery. These tests may include liver function tests, complete blood count, blood chemistries, and coagulation studies.

Imaging Studies: Radiological imaging, such as ultrasound, CT scans, and MRI, is utilised to evaluate the liver's size, structure, and the presence of tumours or complications like portal hypertension.

Psychological Evaluation: A psychological assessment may be conducted to evaluate the patient's mental and emotional readiness for the transplant procedure and the challenges of post-transplant life.

Cardiac Evaluation: Cardiac health is assessed through tests like electrocardiograms (ECGs) and echocardiograms to ensure that the patient's heart can withstand the stress of surgery.

Cancer Screening: Patients are screened for the presence of cancer, particularly hepatocellular carcinoma (HCC), through imaging studies and tumour marker tests.

MELD Score

The Model for End-Stage Liver Disease (MELD) score is a crucial factor in determining a patient's priority for liver transplantation. The MELD score is calculated based on laboratory values, including serum bilirubin, serum creatinine, and the international normalised ratio (INR) of blood clotting. It provides a numerical representation of the patient's severity of liver disease and is used to prioritise patients on the transplant waiting list. The higher the MELD score, the higher the priority for transplantation.

The MELD score is a dynamic tool, constantly updated based on a patient's laboratory results, to ensure that the most critically ill patients receive timely access to donor organs.

Finding a Donor

Liver transplantation relies on the availability of a suitable donor organ, whether from a deceased donor or a living donor. Finding a compatible and healthy donor is a critical step in the transplantation process. This section explores the two primary sources of donor organs and the considerations involved.

Living Donors

Living donors can provide a portion of their liver for transplantation. This process is possible because the liver has the remarkable ability to regenerate. Here are the key aspects of living donor liver transplantation:

Eligibility Criteria: Not everyone can be a living donor. Donors must be in good physical and mental health, have a compatible blood type with the recipient, and undergo a comprehensive evaluation to ensure their suitability for donation.

Donor Evaluation: The living donor undergoes a rigorous evaluation that includes medical, psychological, and social assessments to ensure their safety and willingness to donate.

Partial Liver Donation: In living donor liver transplantation, typically the left or right lobe of the donor's liver is removed. The liver is divided into two lobes, and the smaller lobe is transplanted into the recipient. Over time, both the donor and recipient's livers regenerate to near-normal size.

Transplant Surgery: The living donor and recipient undergo simultaneous surgeries in two separate operating rooms. Once the recipient's diseased liver is removed, the donor's lobe is transplanted into the recipient.

Donor Recovery: Living donors usually experience a shorter recovery period compared to recipients. Their remaining liver lobe regenerates, and they can typically return to normal activities within a few month.

In the western countries deceased donors provide the majority of liver transplant organs. These donors are individuals who have experienced brain death or circulatory death, and their organs are made available for transplantation. In India the deceased donors are not that common.

Matching: Once the suitability of the liver is confirmed, it is matched with a recipient from the transplant waiting list based on factors such as blood type, body size, and the urgency of the transplant (as determined by the MELD score). The goal is to find the best possible match to ensure a successful tran

Transplant Surgery: When a suitable match is found, the transplant surgery is scheduled. The recipient undergoes a thorough medical evaluation to ensure they are in the best possible condition for the surgery. A part of the living donor liver is then surgically removed for transplantation.

Transplantation: The transplant surgery involves the removal of the recipient's diseased liver and the implantation of the donor liver. The new liver is carefully connected to the recipient's blood vessels and bile ducts to ensure proper function.

The Transplant Procedure

The liver transplant procedure itself is a complex surgical intervention that involves the removal of the recipient's diseased liver and the implantation of the donor liver. It is a meticulous and intricate surgical process that requires a highly skilled surgical team and specialised equipment. Here, we delve into the various stages of the liver transplant procedure.

Anaesthesia: The liver transplant surgery begins with the administration of anaesthesia to both the recipient and the living donor. General anaesthesia is used to ensure that the patient remains unconscious and pain-free throughout the procedure.

Incision: Once anaesthesia is induced, the surgical team makes an incision in the recipient's abdomen. The location and size of the incision may vary depending on the recipient's anatomy, previous surgeries, and the type of transplant (whole liver or partial liver).

Preparation of Recipient's Liver: The recipient's liver is then carefully assessed and disconnected from its blood vessels (hepatic artery, portal vein, and hepatic vein) and bile ducts. The surgeon ensures that the recipient's liver is fully mobilised and can be safely removed.

Implantation of the Donor Liver: With the recipient's liver prepared, the donor liver is brought into the operating room. The new liver is carefully inspected and prepared for transplantation.

Orthotopic Transplant: In most cases, the new liver is implanted in the same location as the recipient's liver, which is referred to as an orthotopic transplant. The donor liver is positioned and secured in place.

Blood Vessel and Bile Duct Connection: The critical step in the transplantation process is the meticulous reconnection of the donor liver's blood vessels and bile ducts to the recipient's circulatory and digestive systems. This includes suturing or grafting the hepatic artery, portal vein, and hepatic vein to the recipient's vessels. The bile ducts are also carefully reconnected to ensure proper bile flow.

Blood Flow Restoration: Once the vascular connections are secured, blood flow is gradually restored to the new liver. This is a crucial moment in the surgery as it allows the transplanted liver to begin functioning.

Closure: After ensuring that the new liver is functioning correctly and that there are no leaks or bleeding, the surgical team proceeds to close the incision. Surgical drains may be placed to monitor fluid accumulation post-surgery.

Postoperative Care & Recovery

After the transplant, the recipient is then moved to the intensive care unit (ICU) for close monitoring during the initial recovery period. Transplant recipients typically remain in the ICU for a few days to ensure that the new liver is functioning well and that there are no immediate complications.

Over the following weeks and months, the recipient's condition is closely monitored, and adjustments are made to medications and treatments as needed to prevent rejection and manage

any complications. Regular follow-up appointments are scheduled to assess the long-term success of the transplant.

Cost of Liver Transplantation

Liver transplantation is a complex and costly medical procedure. The expenses associated with liver transplantation can be substantial and may include the following components:

Surgery and Hospital Fees: The primary cost of liver transplantation includes the surgical procedure itself and the hospital stay. This encompasses expenses such as the surgeon's fees, operating room charges, anaesthesia, and the intensive care unit (ICU) stay immediately following the surgery. Hospitalisation costs can vary depending on the duration of the stay and the complexity of the surgery.

Post-Transplant Medications: After the transplant, patients must take immunosuppressive medications for the rest of their lives to prevent rejection of the new liver. These medications can be expensive and may include drugs like tacrolimus, mycophenolate, and corticosteroids. The cost of these medications adds up over time and is a significant ongoing expense.

Laboratory Tests and Imaging: Regular monitoring through blood tests, imaging studies (such as CT scans and ultrasounds), and other diagnostic procedures is essential for transplant recipients. These tests help ensure the health of the transplanted liver and the overall well-being of the patient.

Follow-Up Care: Transplant recipients require ongoing follow-up care and consultations with hepatologists and transplant specialists. These appointments are necessary to monitor for complications, adjust medications, and address any emerging health concerns.

Complications and Additional Surgeries: In some cases, complications may arise post-transplant that necessitate additional surgeries or medical interventions. The cost of these procedures can vary widely depending on the nature and complexity of the complication.

Possible Complications after a Liver Transplant

Rejection: Rejection stands as one of the foremost concerns after a liver transplant. The recipient's immune system may perceive the new liver as foreign and initiate an attack. To thwart rejection, physicians prescribe immunosuppressive medications, but regular monitoring is imperative.

Infection: Immunosuppressive drugs, while necessary to prevent rejection, can weaken the recipient's immune system, rendering them more vulnerable to infections. These infections can range from mild to severe and affect various parts of the body.

Bile Duct Complications: Complications involving the bile ducts can emerge, leading to issues such as bile leaks, strictures, or blockages. These issues may manifest as abdominal pain or jaundice and could necessitate additional procedures or surgeries.

Vascular Complications: Blood flow to and from the new liver might be compromised, resulting in issues like blood clots or narrowing of blood vessels. Such complications may require medical intervention.

Primary Non-function: In exceedingly rare cases, the transplanted liver may exhibit improper function immediately after surgery. This constitutes a medical emergency and may mandate re-transplantation.

Side-Effects of Immunosuppressive Drugs: Immunosuppressive medications can have side effects, including kidney problems, high blood pressure, diabetes, and an increased susceptibility to certain infections.

Metabolic Issues: Some patients may encounter metabolic concerns post-transplant, such as high cholesterol, weight gain, or decreased bone density.

Psychological and Emotional Challenges: The emotional toll of a transplant, including adjusting to a new life and coping with ongoing medical care, can be substantial. Many individuals benefit from support provided by mental health professionals and participation in support groups.

Chronic Rejection: Over time, certain transplant patients may grapple with chronic rejection, resulting in a gradual decline in liver function. Additional treatment or, in some instances, re-transplantation may become necessary.

Final Words

Liver transplantation has been a breakthrough medical advancement that offers a second chance at life to individuals with severe liver diseases. While the process can be challenging and costly, the potential benefits, including extended life and improved quality of life, are substantial. With ongoing research and improvements in medical technology, the field of liver transplantation continues to evolve, providing hope for even better outcomes and increased accessibility to this life-saving procedure in the future.

For more information on the best liver transplant in India, you can visit a Max hospital near you.