The liver is one of the most vital organs in our body which processes nutrients and gets rid of toxins. It plays a vital role in maintain the body’s metabolic balance. Sadly, liver-related diseases are on the rise and more and more people need liver transplants. Dr. Vijay Kumaran, Head of the Liver Transplantation and Hepatobiliary and Pancreatic Surgery at the Kokilaben Dhirubhai Ambani Hospital, Mumbai tells us all about liver transplants.
Who needs a liver transplant? Why?
A liver transplant is most commonly required by patients whose liver is failing due to cirrhosis or due to acute liver failure. Some patients with liver cancer are also candidates for liver transplant. Cancer often develops in those who have cirrhosis already and extensive surgery to remove the tumour is not possible in such cases. There are rarer indications like some genetic diseases as well.
Are there many cases where a transplant cannot be done even if a patient needs one?
A transplant cannot be done unless there is a donor. In most cases there is a living donor from the family who volunteers to undergo and operation to remove part of the liver which is transplanted into the patient. Occasionally, the family of a brain dead patient agrees to donate the organs but this is quite rare.
Who can donate? How does one ‘find’ a suitable donor?
For living donor liver transplant, the donor is a family member whose blood group is compatible with the patient. The donor must be 18 to 60 years of age. Other tests are required to determine that the liver is not fatty and that the anatomy and size of the liver are suitable for donation and that the donor is fit to undergo the operation.
Can liver be taken from cadavers too like the eyes? How can one pledge their liver?
Yes, in a very specific situation. The cadaver should be a person who has died of brain damage (head injury, stroke, etc) and is on a ventilator at the time of death. The heart continues to beat for some time after brain death and we can continue to ventilate the lungs and give medicines to maintain blood pressure and nutrition. As long as adequate blood flow and oxygen delivery can be maintained to the other organs of the cadaver, they can be removed and transplanted with the permission of the next of kin. We can apply online for a donor card which states that we want our organs and tissues to be used after death. However, the donor card is little more than a gesture. What we really need to do is make sure our family knows that we want our organs donated in case we are left in a situation in which we are brain dead. The eyes and some tissues can even be used in the usual form of death when the heart stops first.
How is the liver ‘transplanted’?
The donor and recipient operations go on together. The patient’s own liver is removed. Meanwhile the donor liver (part of it in case of living donor transplants) is removed. The donor liver is flushed with a preservative solution and the blood vessels and bile duct are prepared for joining to the patient’s blood vessels and bile duct. This often involves extending the blood vessel with a vein graft. The donor liver is then implanted in place of the recipient’s liver by joining the corresponding blood vessels and bile ducts.
What about the donor after he/she has donated? Can he/she lead a normal life?
The risk to the donor from the operation is 0.1 to 0.5% depending on how much of the liver needs to be removed. The hospitalization is typically 1 week. It takes about a month before the donor feels recovered enough to return to work. For 3 months the donor has to avoid lifting heavy weights as with any abdominal surgery. Long term problems are rare but hernias can occur and some donors have had intestinal obstruction due to the intestine getting stuck to the scar of surgery. These can occur after any abdominal surgery. Life is otherwise normal. There are no medicines in the long term and no dietary restrictions. Beyond 3 months there are no restrictions on activity either.
Pre-op care: The patient is often very sick before a liver transplant and his condition needs to be medically improved to the point where a transplant can safely be done. This comprises chiefly of identifying and treating any infection and making sure that the other organs (particularly the kidneys which tend to be affected by the liver disease or the medicines used to treat it) are working well.
Post-op care: After transplant the patient needs immune-suppressants (medicines to prevent the body from rejecting the new liver). These medicines make the patient susceptible to infection and the patient is also given prophylactic antibiotics and anti-fungals and sometimes anti-virals as well. Over a period of time the requirement of these medicines comes down and they are gradually withdrawn. At least one immunosuppressant medicine continues lifelong. The ICU stay of the recipient is typically 4-5 days and the hospital stay 2-3 weeks.
We have only one liver, so if one donates his/her liver will they not die, without a liver?
The liver has two qualities which make it possible for a donor to donate part of the liver. The first is ‘reserve’. The liver has enough functional reserve that up to 75% of the liver can be removed if required (in liver donors we restrict it to 70% in order to have a margin of safety). The remaining 25% is enough to perform the functions required of the liver. The other quality is the ability to ‘regenerate’. After removal of part of the liver, the remaining liver rapidly grows back to its full size in a few weeks.
When is a liver transplant ‘successful’? What is the rate of success of a liver transplant?
A liver transplant can be said to be successful when the patient returns to a normal productive life. The success rate is about 85-90% at one year after transplant and about 75% 5 years after transplant. Some patients will have a recurrence of their disease, side effects of the medicines, complications of the transplant etc. hence the difference.
What are the side/after effects of getting a liver transplant? What is the rate of rejection?
The patient has to be on medicines to prevent rejection for the rest of their life. This increases somewhat their risk of getting infections and such infections have to be recognized and treated. There is also a higher than usual risk of cancer over their lifetimes, predominantly skin cancers (this seems to be much less of a problem in Indian patients because of our darker skin). The medicines have side effects including a risk of kidney problems, diabetes and blood pressure over the years at a higher rate than the normal populations. In general, the life of a liver transplant patient is similar to that of a patient with a chronic but controllable medical condition like high blood pressure in that periodic (once in 3 months long term) checkups and adjustment of medication is required. Episodes of rejection occur in 10 to 30% of patients who have undergone a liver transplant. These are usually easy to recognize (from periodic blood tests) and easy to treat (by increasing the dose or adding immunosuppressive medicines). Rejection that does not respond to treatment and leads to loss of the liver is very rare.