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Liver Transplantation

What is liver transplantation?

Liver transplantation is also referred to as hepatic transplantation. It is a surgical procedure wherein a diseased liver is replaced by a healthy liver from a donor. The cause of liver disease could be attributed to several reasons. Liver transplantation is usually an option exercised if the diseased liver cannot recover. However, the availability of donors has made this procedure a limited option for many.

Liver transplantation is a highly technical and complex procedure. It is closely regulated by health ministries around the world and is performed only in specific centres who have highly trained medical staff. The surgery could take anywhere from four to 14 hours, depending on the medical condition of the patient and the donor.

The procedure is considered a viable option for patients with serious and irreparable liver disease and involves high risks. It is resource-intensive and must be followed by major life modifications after surgery in order to be successful.

Liver Disease

Liver disease can be caused by a range of conditions or illnesses. The liver, which is the second-largest organ in the body, is responsible for several important processes. These range from removing and filtering poisons and other harmful substances from the body, to the production of proteins to iron metabolism.

As such, when the liver does not function well, that can affect your whole body, apart from damaging the organ. This is why liver disease is a serious condition and must be addressed in a timely manner.

The liver can be affected negatively by several factors that range from infections to genetics to lifestyle conditions. However, once the degradation begins, the liver will be damaged in a predictable manner.

The first stage of liver damage is inflammation. This is caused by excessive fat in the liver, a condition also known as fatty liver. Though limited amounts of fat in the liver is normal, too much can lead to problems. Prolonged inflammation of the liver can lead to permanent damage. If the condition is detected in this stage, the liver can be treated, resulting in the inflammation subsiding.

There are two types of fatty liver disease — alcoholic fatty liver disease (AFLD) and non-alcoholic fatty liver disease (NAFLD). While NAFLD is one of the most common causes of liver diseases globally, AFLD is a condition that develops in those people who consume a lot of alcohol.

Irrespective of the reasons for inflammation, if it goes unchecked, it can lead to scarring. The build-up of scar tissue in the liver over time can lead to fibrosis. The scar tissue does not function like healthy liver cells and the rest of the liver has to work harder in order to make up for the loss of tissue. Liver damage can be effectively treated even at this stage if caught in a timely manner.

The accumulation of fat and build-up of hard scar tissue in the liver continuously can also cause cirrhosis. In fact, the scar tissue slowly replaces the healthy tissue, which can lead to a host of complications. Some of these include liver cancer, jaundice, an aneurysm in the liver, and type-2 diabetes. In this stage, the treatment will focus on slowing down the development of scar tissue and protecting the healthy tissue. Cirrhosis can lead to end-stage liver disease (ESLD) where the scarring cannot be controlled or stopped. Such types of patients are eligible for liver transplantation.

Liver failure can also occur suddenly without any pre-existing liver disease. This can happen due to acute malnutrition, infections, or an overdose of prescription drugs. This is a life-threatening condition and requires immediate emergency care. Patients with liver failure do not require liver transplantation and can be cured with medication and other procedures.

Types Of Liver Transplant

A liver transplant is also called a hepatic transplant. The first successful liver transplant took place in 1963. The operation was done by Dr Thomas E. Starzl, widely regarded as the ‘father of transplantation’. Before that, no patient had survived the operation. Though the patient died due to pneumonia a few weeks after the operation, it was still considered the first successful liver transplantation. Dr Starzl died in 2017 at age 90.

However, since 1963, medical technology and advances have come a long way to create more options for patients requiring liver transplants. Each patient and their liver diseases are unique, and only a qualified and well-trained medical team will be able to recommend the best course of action for said patient. The treatment involves surgically removing the diseased liver. This is then replaced with an entirely new, or part, of a healthy donor’s liver. This liver may come from a living person or a dead donor. A third procedure, known as split liver transplantation, is also employed. In this procedure, the liver of a deceased donor is divided into right and left portions, which are then implanted into two recipients simultaneously.

  1. Deceased donor liver transplantation

In this type of liver transplantation, which is also known as orthotopic transplantation, the healthy liver is derived from a person who recently died. The donor may be a victim of an accident or a head injury, whose heart is still beating, but the person has been declared brain dead. The family of the deceased person or the person themselves, when they were alive, can make the choice to donate viable organs. This is an important aspect of organ donation. The organ not only has to be viable but must also be a match for the patient who requires the liver transplant. This type of transplantation is more common in Western countries where the awareness surrounding organ donation is high.

  1. Living donor liver transplantation

The human liver is a unique organ in that it is the only one that can regenerate itself. Because of this characteristic, a healthy person can donate a portion of their liver to a person with liver disease. In other words, living-donor transplantation involves removal of a portion of a person’s healthy liver, which would then be transplanted to a patient in need. The healthy liver in both the donor and the recipient will regenerate itself to form a whole, healthy liver. Either the right or left lobe of the liver will be selected for transplantation depending on the blood supply. Most living donors come from the recipient’s family as they have the highest chances of being a match. However, there have been successful living donor transplantations where the donor was not related to the recipient. The livers in both the donor and the recipient will regenerate within two to three months of the surgery.

  1. Split liver transplantation

This is a relatively newer form of liver transplantation. The whole liver of a deceased adult is split into its two separate lobes and is used in two recipients. Effectively, one healthy liver is transplanted into two patients with liver diseases, giving a new lease of life to both the patients. This procedure not only addresses the lack of available liver donors but is also found to be particularly effective for pediatric recipients. The left lobe is smaller and is recommended in split liver helps for size-matching in children with liver disease. The right lobe is used for an adult since it is larger.

Evaluation And Preparation For a Liver Transplant

Due to the complex nature and the excessive demand for liver transplantation, it is very tightly regulated globally. Only a select few are eligible for receiving a new liver. This eligibility is based on several factors. Each nation’s eligibility criteria vary, but it essentially boils down to the following two conditions:

  • ●        The patient’s quality of life would drastically improve with a transplant
  • The success rate for the surgery is high and the patient will have at least five years with an adequate quality of life

The evaluation process for liver transplantation is complex and involved. Apart from establishing the extent and range of liver disease, healthcare operatives will also evaluate the following criteria:

  • Other diseases or conditions: One of the most important criteria is if the patient has other serious medical conditions that can negatively affect the transplantation. This type of condition is usually a cardiac or pulmonary disease
  • Alcohol or substance abuse:  Alcohol dependency or any other type of substance abuse that the patient is unable to recover from
  • Lifestyle changes to support transplant: Healthcare personnel also need to evaluate if the patient can maintain the necessary post-surgery lifestyle. The regimen will be lifelong, and the patient has to have the psychological ability to follow it with minimal lapses
  • Adequate insurance or the lack of it: An unfortunate aspect that must be addressed is if the patient can afford not just the surgery but the post-surgery care, follow-up examinations, and lifestyle regimen change

In order to assess the above factors, the formal evaluation process will include the following type of tests:

  • A comprehensive medical history and physical examination, including risk-appropriate cardio-pulmonary evaluation
  • Laboratory tests to assess hepatic and renal function as well as viral serologies, including Hepatitis A, B, and C, in addition to cytomegalovirus, Epstein-Barr virus, and human immunodeficiency viruses (HIV) status
  • Detailed abdominal imaging to assess the patency of the portal vessels and to exclude the presence of liver cancer
  • Psycho-social evaluation

Once a patient is cleared for liver transplantation, they have to prepare themselves. In case they are unable to find a donor immediately from their family, they will have to wait until a viable liver is found from the common pool of donors. During this time, patients must ensure that they stay healthy. They can do this by keeping the following things in mind:

  • Cut out alcohol entirely: Alcohol negatively impacts the liver, and must not be introduced to the new liver under any cost
  • Quit smoking: While quitting smoking is important for any person, for those waiting for a liver transplant, it is all the more important to ensure that their health is not affected after the transplant
  • Exercise regularly, if possible: Even a stroll in the neighbourhood will have a positive effect on the overall health of the patient. A patient can also go for a swim. However, lifting heavy weights isn’t advisable
  • Watch the diet: Usually, the hospital’s staff will recommend a diet which must be strictly followed

Tests Before Liver Transplant

A liver transplant surgery is a complex procedure that requires a lot of pre work. In order to receive the best medical advice and treatment, the patient must clearly and honestly provide their medical history. This will not only include all the medical treatments and procedures they have undergone in their life, but also any major conditions of their parents. The patient will have to provide all their medical records, X-rays, liver biopsies, and list of medications. Apart from this information, the patient will also be required to have the following scans and procedures during their evaluation:

  • CT scan of the liver which highlights any lesions, the blood supply, shape and size
  • Doppler ultrasound to determine the health of the blood vessels to and in the liver
  • Echocardiogram and stress test to evaluate the health of the patient’s heart
  • Pulmonary function test to evaluate the health of the patient’s lungs and its ability to exchange oxygen and carbon dioxide
  • Blood type and antibody screen
  • A viral hepatitis profile
  • Autoimmune markers as well as iron and copper studies
  • Cancer markers
  • Complete blood count (CBC), complete metabolic panel (CMP) to include magnesium and phosphate
  • Coagulation studies
  • Cytomegalovirus status

If any further testing needs to be done, the healthcare professional will make sure that the patient is up to date and their medical team is intimated of the same. Female patients will also be ordered a mammogram and pap smear test.

Liver Transplant Surgery

Liver transplant surgery involves several complex steps that only an experienced surgeon and their medical team can perform. The steps are:

  • Surgical resection or hepatectomy of a donor’s liver or portion of the liver for transplant
  • Hepatectomy of the recipient’s diseased liver
  • Placing the donated liver or portion of the donated liver into the body of the recipient
  • Connecting the recipient’s blood vessels and bile ducts to the transplanted liver

The liver has several connections like the bile ducts and arteries that must be established by the surgeon. The major arteries that must be reconnected are the portal vein, the hepatic artery, and the inferior vena cava. The connections will depend on the healthy liver, the recipient’s condition, and the anatomy of the tissues.

The sequence of events in the operating room will be as follows:

  • An incision in the abdominal region
  • Evaluation of the abdomen for abnormalities that might stop the liver transplantation like an undiagnosed infection or malignancy
  • Dissection of the liver attachments to the abdominal cavity
  • Isolation of important structures including the inferior vena cava above, behind, and below the liver, the portal vein, the common bile duct, and the hepatic artery
  • Removal of the diseased liver
  • Sewing in the new liver
  • The venous blood flow is re-established by connecting the donor’s and the recipient’s inferior vena cava and portal veins
  • Arterial flow is re-established by sewing the donor’s and recipient’s hepatic arteries
  • Bile drainage is achieved by sewing the donor’s and recipient’s common bile ducts
  • Ensuring adequate control of bleeding
  • Closure of the incision

The liver transplantation procedure is complicated and like any other surgery has complications. In about 1-5% of cases, the donor liver can be rejected or not function. In such a situation, the second transplantation will be necessary. Some other complications that might arise due to the surgery are as follows:

  • Clotting in the hepatic artery, or hepatic artery thrombosis, can occur in 2-10% of all cases. The risk of a clot is higher in living donor transplants. The hepatic artery is responsible for the nourishing of the bile ducts. A clot in the artery can cause loss of nutrition to the ducts which could in turn cause scarring of the ducts or an infection. In such a case, a second transplant might be necessary
  • Clotting in the portal vein or portal vein thrombosis can affect the actual cells of the liver. However, this is not a serious complication and can be treated without requiring a second transplantation

Biliary complications can occur in about 15 to 40% of all cases. The risk is higher in living donor transplantations. There are two types of biliary complications:

  • The biliary leak is when there is a leak in the bile duct resulting in the pooling of bile in the abdominal cavity. Most leaks repair themselves over time and the only cause for concern is if the bile continues to accumulate in the abdomen. The leak occurs if the bile ducts are not sewn together properly or at the site where the liver is cut in the case of live or split transplants. The leak is repaired using a stent which allows the leak to heal and repair itself
  • Biliary stricture is a condition where the bile ducts narrow to the point where they are blocked. This could lead to an infection which could prove to be dangerous. Usually, in the case of liver transplants, a biliary stricture will occur at a single site. In such a case, the blockage is eased by a stent to re-establish the flow of bile. If this approach of treatment is unsuccessful, then a new connection might be created surgically. In rare case, biliary stricture might occur in multiple points. This is usually indicative of a defect in the donor’s liver or improper handling of the liver

In about 10% of cases, the patient might face complications with bleeding. In any surgery, bleeding is a very real complication. However, the risk of bleeding in liver transplants is higher due to the complex nature of the procedure and the clotting functionalities of the liver

Liver transplant patients are also susceptible to infections particularly if bile is leaking into the abdomen. The patients are put on a course of immunosuppressants, which makes them more vulnerable to infections.

Patient Care After Surgery

After the surgery, the patient will be taken to the intensive care unit (ICU). They will be closely watched in the ICU for several days, where their vitals and other pertinent factors are monitored. They will need to stay in the hospital for 1 to 2 weeks or longer depending on their recovery and if they face any complications. The patient will most likely be connected to a ventilator to aid them with their breathing. This is done until they can breathe on their own. The ventilator can be used for a few hours or a few days, depending on the patient’s situation.

The patient may have a thin plastic tube inserted through the nose to the stomach to remove any swallowed air. The tube will be taken out when the bowels start working normally again. The patient will not be given anything to eat or drink until the tube is removed. Once the breathing and stomach tubes have been removed, the patient may start to drink liquids and can slowly begin to eat solid foods as directed.

The patient will also have regular blood tests to check the new liver. The medical team will also closely monitor the functioning of the kidneys, lungs, and circulatory system to make sure that they are all working properly.

IV drips might be used to help manage the blood pressure and the heart. It is also used to control any problems with bleeding. The IV fluids will be removed as the patient’s condition stabilizes with time. The IV can also be used to administer antibiotics.

Once the patient has been cleared by the medical team, they will be moved from the ICU to a room in the hospital where they can work on their mobility.

After being discharged from the hospital following the successful liver transplant, once the patient gets back home, which is usually about two weeks after the transplant, he/she must keep the surgical area clean and dry. Also, the patient must maintain strict hygiene, such as washing hands often, using a separate towel, drinking safe and filtered water, and follow specific bathing instructions. If any stitches or surgical staples were not removed before leaving the hospital, they will be removed at a follow-up visit.

When it comes to food, the diet should be protein-rich. Raw food, salads, sweets and any food that can raise blood sugar levels must be avoided

Regular exercise is also recommended. However, like the pre-surgery, heavyweights shouldn’t be lifted. These apart, the patient and their family must keep an eye out for the following:

  • Fever, as it may be a sign of rejection or infection
  • Redness, swelling, or bleeding or other drainages from the incision site
  • More pain around the incision site, which again is an indication or sign of infection or rejection
  • Vomiting or diarrhoea
  • Bleeding
  • Jaundice (yellowing of the skin and eyes)

In case any of these symptoms are observed, the patient must immediately contact their medical service provider and follow their instructions. As mentioned above, complications of liver transplantation can be serious and any delay in treatment could have negative consequences.

If these symptoms are not observed, a patient can get back to normal life within four to six weeks after the surgery. Though the time taken to recover varies, about four to six weeks is what most patients take. However, the patient will need to get regular medical checkups to make sure that the liver is functioning properly and that there are no other underlying health conditions.

Immunosuppressants

The immune system of the human body is designed to attack and defend the body against any foreign body. The donor’s liver is considered to be a foreign body by the human body. In order to ensure that the natural defences of the recipient’s body do not attack or reject the donated liver, their immune system will have to be suppressed. This is done through a range of immunosuppressants, which might have to be taken for life. Having a compromised immune system means that the patient must take extra care of their health and avoid any scenario where they can be subjected to infection.

Checkup And Tests After Surgery

A patient who has had a liver transplant will need to get the relevant blood tests for life. Initially, the frequency of these tests will be high, almost 2-3 times a week. With time, the frequency of these tests will reduce. These tests check the health of the liver and if it is functioning the way it is supposed to.

The first checkup will be scheduled a week after the patient is discharged. At this checkup, the medical team, including the surgeon, will check on the incision and drain. The team will address any changes required in the medication and will also help with pain management if necessary. The patient will be required to bring in all their medications while also giving the team a detailed account of their diet and movements.

The patient will be asked to follow a strict schedule of checkups. Usually, this follows a pattern of one week, three weeks, three months, six months, nine months, and 12 months from the date of the transplantation. After the first year, the patient will have to have a checkup once every year. This is subject to the patient having no further complications.

Life After Liver Transplant

Many liver transplant patients will go one to lead a full life if they take the proper precautions with the right lifestyle changes and are regular with their tests and checkups. One of the biggest threats to liver transplant recipients is common infections due to the use of immunosuppressants. These medications are administered in order to keep the body from rejecting the new liver. Recipients must exercise caution and keep themselves safe in situations where they could catch an infection. They can do so by following the general actions:

  • Maintain a healthy lifestyle with a good diet and adequate exercise
  • Make sure they get good rest and deal with stress effectively
  • Avoid people and places with infectious diseases especially viral diseases like the flu, chickenpox, and measles
  • Take preventive antibiotics when getting a dental procedure
  • Follow proper hygiene practices and wash their hands with soap for 20 seconds several times a day
  • Wear protective shoes when outside to prevent infections through cuts on the feet
  • Avoid touching their face
  • They cannot receive live vaccinations
  • Practice safe sex
  • They should not share razors, scissors, and utensils with others
  • Drink only safely filtered water

Avoid alcohol completely: Medical practitioners also recommend that liver transplant recipients avoid drinking too much alcohol. They should avoid it entirely if their liver disease was caused by the abuse of alcohol. They must also abstain from the use of any recreational drugs as it puts too much pressure on the liver.

Stay away from paints, pesticides: People who have had a liver transplant are also susceptible to common household chemicals like paint, paint removers, pesticides, gasoline, drain cleaners, and insecticides. They must avoid using these items and even the fumes from these can prove to be harmful.

Be careful around pets: Recipients who have pets must make sure that they take care when interacting with them. Animal faeces, urine, or vomit can be harmful. They must wash their hands after touching pets and have their sick pets looked after by someone else. The pets should be cleaned up by someone else particularly cat litter or cages for small animals like rabbits.

Wait for a couple of years before getting pregnant: Women who have had a transplant must wait a year or two before trying to become pregnant. They are also advised to look for intensive prenatal care. The risk of premature deliveries is high and so they must have adequate care and medical attention during their pregnancy.

Travel freely, but not recklessly: Once the patient has recovered sufficiently, they can travel freely as long as they take the right precautions. They must make sure that their travel is not scheduled when they have a scheduled checkup. They should follow standard health protocols and consume only well-cooked food and water that is adequately filtered. They can also check ahead for the destination’s public health updates.

Conclusion

Liver transplantation is a complex procedure that requires several factors to be considered. It is imperative that the patient has a good support system in place in order to increase their chances of successful transplantation and long life of good quality after the fact.

FAQs

1.      Who will decide if a patient can have a liver transplant?

The referring consultant will decide if a transplant will be of benefit to the patient. Priority is always given to those patients on the ‘super urgent’ list. This list is for very sick patients who are expected to die within days without a liver transplant.

2.      Are some livers better than others?

Livers from brain dead donors have less damage than one from a donor with a circulatory death. A liver from a young and previously fit donor with an isolated head injury is a better liver than one retrieved from an elderly donor who smokes and who has diabetes.

3.      How long will the liver transplant last?

Majority of liver transplant patients have an excellent prognosis. Some recipients have been known to live a normal life over 30 years after the operation.

The average one-year graft survival is at 83%. Patient survival is 87% for deceased donor livers and 92% for living donors. However, it must be said that transplant recipients contribute to the success of their transplant. The immunosuppression medical regimen is critical and failure to do so is the primary reason for organ failure. Careful attention to medication schedules, lifestyle changes, infection-avoidance techniques is all important ways to prolong one’s life after transplantation.

4.      Will the liver disease come back after a transplant?

Certain liver diseases like hepatitis C can reappear in the new liver. If the risk of recurrence is high, the medical team will monitor the patient closely to help prevent a recurrence.

5.      What are the side effects of the prescribed medications after transplant?

The side effects typical with post-transplant medications include elevated blood pressure, changes in mood, hair loss or hair growth, elevated blood sugar, bone and muscle weakness, kidney dysfunction, nausea, vomiting, diarrhoea, and headache. However, these side effects will subside as the dosage of the medications are reduced.

6.      How should a transplantation centre be selected?

The most important factors in choosing a liver transplant centre are the team’s experience and expertise. The program must perform a high volume of transplants each year, with experience in complex liver transplant surgeries. The range of specialists includes hepatologists, transplant surgeons, nutritionists, transplant pharmacists, nurse care managers, interventional radiologists, and pathologists.

7.      How many years after transplant are the tests and checkups necessary?

The patient will need to be checked for possible side effects of transplant for the rest of their life. Most of the tests are not difficult or time-consuming. Some only require a physical examination or a simple blood test. Most of the tests are for problems that may occur after transplant and a patient might never experience any of these problems.

8.      What are anti-rejection medications?

Immunosuppressants are drugs that slow or suppress the immune system to prevent it from rejecting the new liver. There are three types of immunosuppressants and most people will be prescribed at least two. Once the patient regains adequate liver function and is free from rejection for six months, the immunosuppression will be relegated to a single drug.

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