Dr. Suresh Kumar Singhvi, Contact : +91-9560703966

Sir Ganga Ram Hospital, New Delhi 110060. OPD - F90 : .

Liver Transplant

1. What is Liver transplant

Liver transplant is the treatment for end stage liver disease in both adults and children. In this operation, the diseased liver is removed and replaced by a healthy one. The success rate for the operation is high and terminally ill patient can return to normal lives. This kind of transplant has been done for more than 40 years.

2. Who needs a liver transplant

The following diseases are common indications for liver transplant:
  • Cirrhosis due to chronic hepatitis B, hepatitis C or other causes.
  • Acute liver failure due to hepatitis A, hepatitis E, drug induced (anti TB drugs, paracetamol).
  • Metabolic disease, e.g. Wilson disease, hemochromatosis, Urea cycle enzyme deficiency.
  • Selected patients with early liver cancer and poor liver function due to cirrhosis.
  • Biliary atresia

3. When should a liver transplant be performed

When your liver is severely damaged and cannot function properly, the following complications may develop and liver transplant should be considered:
  • Hepatic coma.
  • Massive upper gastrointestinal bleeding.
  • Abdominal distension from fluid collection and ankle edema.
  • Infection of fluid in the abdomen.
  • Bleeding tendency.
  • Jaundice (yellowish discoloration of the white of the eye).
  • General weakness and malaise resulting in poor quality of life.
  • Liver cancer best treated by complete removal of the liver(cirrhotic liver).
  • Failure to grow in children with pre-existing liver disease.
  • In general, when you need a new liver, the earlier the operation, the higher the success rate.

4. Which patients are excluded from liver transplant procedure

Cancer in another part of the body.
  • Active alcohol or illegal drug abuse.
  • Active or severe infection in any part of the body.
  • Serious heart, lung or neurological conditions.
  • Inability to follow doctors instructions.

5. What will happen after a liver transplant

The overall success rate of liver transplant is high and the majority of liver transplant recipients can return to normal activities. Since your body may reject the new liver, it is essential for you to take immunosuppressive medications and continue follow up at our liver transplant clinic. You will need to continue these medications for life, at a reducing dosage

6. Where does the liver graft come from

Your new liver can come from either of the two sources: a living donor or a brain-dead deceased donor.

A) Living donor:

It is technically feasible to remove part of the liver from a living person and transplant it to a patient who needs a new liver. The operation has now been done since 1989. Depending on the size matching of the donor and recipient, either the left side (about 35%) or the right side (50-65%) of the liver will have to be removed. The liver remnant in the donor will grow to its original size in 6-8 weeks time.The donor complications-donor death 0.2 to 0.4%.

  • Benefits for the recipients:
    • Earlier transplant before the recipient s conditions deteriorates.
    • It is planned procedure.
    • Good quality liver graft from a living donor.
  • Risk for the donor:
    • Pain, discomfort and complications of the investigations and surgical procedures.
    • Average hospital stay of 7-10 days.
    • Average loss of work of 6-8 weeks.
    • Complication rate of about 10-15% ( wound infection, hernia, bleeding, bile leakage, bile duct problems, infection, pneumonia, liver failure which may require liver transplant, etc).

B) Brain-dead deceased donor:

You will be put on waiting list for a brain dead deceased donor liver and receive a liver graft according to the following criteria:

  • Your blood group matching.
  • The urgency of your operation.
  • Severity of your liver disease according to the Model for end-stage liver disease score(MELD) or Pediatric end stage liver disease (PELD).

Unfortunately, the availability of deceased donor liver is not very often. Depending on your blood group, you may have to wait for 12-36 months before you get a new liver. During this waiting period, you may develop complications like spontaneous bacterial peritonitis which, if repetitive may produce severe adhesions in your abdomen rendering liver transplant difficult if not impossible. Overall the complications of liver disease would adversely affect the success rate of the liver transplant.

When potential deceased donor liver graft is allocated to you, you will be admitted to the hospital by our liver transplant coordinator. A series of tests and investigations (blood tests, cultures, chest x-ray, ECG) and assessments by the anesthetist will be performed on you promptly after admission. You will be explained on the nature, purpose, and risk of the operation by our transplant surgeons in the ward. You are also required to sign a consent form referring to the success rate or diseases from the cadaveric organ. For a minor patient(age under 18yrs) the patient s parents, guardian or next of kin should sign the form. It is important for you and your family to understand that assessments and investigations on the potential deceased donor are on going and unexpected changes may happen to the donors medical condition. There are uncertain circumstances that may render the donor unsuitable for donation even when you have been admitted to the hospital.

  • Unstable hemodynamics of the donor.
  • Unhealthy, abnormal or doubtful appearance or pathology of the liver graft on examination by the harvesting surgeons during the donor operation.
  • Suspected malignant tumor(s) found during donor operation.

7. Who can be a suitable living donor

The most important criteria is that the donation of portion of the liver is done voluntarily. The potential donor should understand clearly.

  • The donor operation carries complication rate of 10-15%.
  • The recipient is successful in 90-95%.
  • The donation is out of his own wish and without any coercion.
  • There is no financial gains related to the act of donation.
  • The donor has the right to withdraw at any time without the need of giving any reasons to do so.

The liver transplant team will consider the donor who understands the above criteria and who has demonstrated true voluntarism as potential living donor. The donor has to be a first degree relative and should be able to prove the relationship to the patient. The potential donor will then undergo evaluation including blood tests, CT Scan, MRI scan, psychiatrist evaluation and assessment by various specialists including cardiologist, pulmonologists and anesthetists. Depending on the clinical situation, the investigations can take a day to a week. The Transplant committee needs to approve all living donor liver transplant. The legal paper work has to be completed and the papers have to be submitted to the Approval Committee (Independent committee appointed by the Government) for clearance. Only after this formality the liver transplant takes place.

8. What happens in the hospital

When a liver is available, you will be prepared for the liver transplant. If your new liver is from a living donor, both you and the donor operation will be done at the same time in two different operating theaters. If your new liver is from a person who has recently lost life, your liver transplant starts when the new liver arrives at the hospital.

9. What happens during a liver transplant procedure

  • The liver transplant can take from 4 to 14 hours. While the doctor removes your diseased liver, other doctors prepare the new liver. In case of living donor Liver transplant- the donor operation is going on at the same time to remove the partial liver graft.
  • The doctor will disconnect your diseased liver from your bile ducts and blood vessels before removing it. The blood that flows into your liver will be blocked. The doctor will put the healthy liver in place and reconnect it to your bile ducts and blood vessels. Your blood will then flow into your new liver

10. What happens during the donor operation

Depending on the size and requirement of the recipient, the donor may donate the left lateral segment (about 20%) , left liver (35%) , or right lobe(about 50-65%) of the liver. The operation is done under general anesthesia. The incision is done and the abdomen is opened. After deciding the liver is normal and suitable for donation, the surgeon will remove the gallbladder and cannulate the cystic duct for operative cholangiography (to see the bile ducts). The absence of the gallbladder in the donor will not affect the quality of life afterwards. Next, the relevant inflow and outflow blood vessels and bile duct are freed. The liver is then transected at the plane depending on the type of liver donation. Finally the donated part of the liver is removed after the relevant inflow and outflow blood vessels are divided and ligated. The wound is then sutured. The duration of the operation is approximately 6 hours, but it may be a bit longer. There are possibilities that the donor operation is stopped because of the following reasons:

  • The donor liver is found to be abnormal and not suitable for donation.
  • The recipient is found for various reasons not suitable for liver transplant after the abdomen is opened.

In this situation, the donor may have an abdominal wound, although he/she has not gone through the donor hepatectomy.

11. What happens after liver transplant

After the operation, the recipient and the donor (Living donor) will be treated in the Intensive care Unit. The duration of stay in the ICU depends on the rapidity of recovery of the donor and the recipient. Usually, the recipient stays for 5 days in ICU and the donor stays for 2-3 days in ICU.

You will stay in the hospital for an average of 1 to 3 weeks to be sure your new liver is working. You will take medications to prevent rejection of your new liver and to prevent infections. Your doctor will check for bleeding, infection and rejection. During this period you will start to learn how to take care of yourself and use your medicines to protect your new liver after you go home. In the hospital, you will slowly start eating again. You will start with clear liquids, then switch to solid food as your new liver starts to work

12. What is rejection

Rejection occurs when your body s natural defenses, called the immune system, damage the new liver. Your immune system keeps you healthy by fighting against things that don’t belong in your body, such as bacteria and viruses. It is common for your immune system to fight against the liver and try to destroy it.
To keep your body from rejecting the new liver, you will take medicines. These drugs, such as steroids, cyclosporines, tacrolimus, sirolimus, everolimus and Mycophenalat Mofetil (MMF) , are called immunosuppresants. Along with these medications you may need to take antibiotics, antivirals and antifungals too.

13. What are the other problems that cause problems with liver graft functioning

  • Return of the original problem that necessitated the liver transplant in the first place, e.g. hepatitis C, recidivism (return to alcoholism) , non compliance of medications.
  • Thrombosis of the hepatic artery, hepatic vein, portal vein (blockage of the blood vessels going into or out of the liver).
  • Primary graft non-function.
  • Delayed graft function
  • Bile duct complications.
  • Graft failure due to hepatitis, recurrent disease or rejection
  • Sepsis
  • Recurrence of liver cancer.
  • Renal failure.
  • Intra abdominal bleeding.
  • Minor complications like wound infection, lung infections, diabetis mellitus, hypertension.

14. How do I take care of my liver after I leave the hospital

Liver transplant patients will see the doctor regularly to be sure that the new liver is working well. You will have regular blood tests to check that your new liver is not being damaged by rejection, infection or problems with blood vessels or bile ducts. You will need to avoid sick people and report any illnesses to your doctor. You will need to eat a healthy diet, exercise and not drink alcohol, especially if alcohol was the cause of damage to your own liver. You should use medicines prescribed to you by your doctor and not to take medicines over the counter. A information leaflet will be given to all patients to follow at home.

15. Can I go back to my daily activities

Yes. After a successful liver transplant, most people can go back to their normal daily activities. Getting your strength back will take some time, though depending on how sick you were before the transplant. You will need to check with your doctor on how long your recovery period should be. After recovery, most people are able to go back to work.
Diet, most people can go back to eating as they did before. Some medicines may cause you to gain weight and other may cause diabetes or a rise in your cholesterol. Meal planning and a balanced low fat diet can help you remain healthy.

16. About Your Liver

The liver is the largest internal organ in one’s body. It is a complex organ that works non-stop, 24 hours a day, detoxifying just about everything that enters the body. It plays a vital role in regulating life processes – virtually all the blood returning from the intestinal tract to the heart passes through the liver. Anything that we consume is absorbed into the bloodstream, which passes through the liver. Therefore, the liver is essential to our life.
The liver’s sheer complexity makes it susceptible to many different diseases – including liver diseases like chronic hepatitis which leads to liver cirrhosis, unknown cause of liver failure or biliary diseases in adults, as well as biliary atresia in children and adolescents.

When the liver fails, a liver transplant provides hope for you and your family. Liver transplant offers as the last option for patients with end-stage liver disease