A liver transplant is a surgical procedure that removes a liver that no longer functions properly (liver failure) and replaces it with a healthy liver from a deceased donor or a portion of a healthy liver from a living donor.
Your liver is your largest internal organ and performs several critical functions, including:
- Processing nutrients, medications and hormones.
- Producing bile, which helps the body absorb fats, cholesterol and fatsoluble vitamins.
- Making proteins that help the blood clot.
- Removing bacteria and toxins from the blood.
- Preventing infection and regulating immune responses.
Unless liver damage is fairly severe or advanced, diseases of the liver are often “silent” and patients may be unaware of any problem. The signs and symptoms of liver disease can be explained by considering the various liver functions.
The impairment of processing of nutrients results in wasting of tissues, particularly muscle. Impairment of the liver’s ability to excrete bile causes accumulation of its constituents including bilirubin pigment, responsible for the yellow discoloration of skin and urine (jaundice), and bile acids, which may be responsible for the chronic itch, suffered by some patients. The decreased absorption of vitamin K and inadequate production of blood clotting factors causes easy bruising and bleeding, initially from the gums. Massive bleeding from the gut is due, in part, to blood from the gut being diverted away from its usual course through the liver, to other channels in the esophagus, which may rupture under pressure. The decreased production of blood proteins involved in body fluid balance and the scarring of the liver contribute to the accumulation of fluid in the abdomen and legs. The failure of the liver to deal adequately with toxins produced in the gut can cause drowsiness, forgetfulness, and lack of concentration, confusion and coma. A damaged liver is also much slower at dealing with alcohol and drugs causing increasing sensitivity to their use. Inadequate removal of microorganisms or “germs” from the blood coming from the gut partly explains the increased incidence of serious infections in patients with liver disease.
Common causes for Liver Disease
- Alcohol-Related Liver Disease: Most common cause of liver disease in India with most patients whose liver disease is not advanced can be managed with abstinence from alcohol intake and medical management. However in case of advanced liver disease when abstinence and medical management fails toimprove patient condition liver transplant is offered.
- Hepatitis B and C: Hepatitis B & C are viral disease, which if left untreated can cause the liver to progress towards end stage liver disease over several years and also predispose the liver towards cancer formation. This viral infection is transmitted through vertical transmission from the mother or later in life through infected blood transfusion, sharing of infected needles or blades, sexual transmission etc. India comes under moderate risk zone for both these vaccines. For Hepatitis B there is effective vaccine which has been included under universal immunisation programme and thereby decreasing prevalencee of disease. For Hepatitis C there is no effective vaccine available however newer drugs (DAA’s) are highly effective in holding progression of disease if started at appropriate time.
- Non Alcoholic Fatty liver disease (NAFLD): NAFLD is caused by progressive accumulation of fat in liver and is partly due to unhealthy life style and partly comorbid illness such as Diabetes, Hypertension, metabolic syndrome etc. Different stages of fatty liver disease have been described depending upon the amount of fat accumulated and whether this is leading to damage to liver cells which is evident by rising liver enzymes on LFT. Proper evaluation to know the cause of the diseases, dietary counselling, regular exercise regimen, and avoidance of liver toxic medications can help control and sometimes revert this disease and halt the progression of liver damage. If however this goes untreated, then it can progress to cirrhosis and infact is now becoming a leading cause in the world for development of cirrhosis.
- Hepatocellular Carcinoma (Liver Cancer): HCC is 5th most common cancer worldwide and is mostly on background of liver cirrhosis. HCC can be single or multifocal and treatment is based on state of liver disease and extent of liver cancer. In patient of advanced liver disease and HCC , Transplant offers the best treatment as chances of cure are maximum with least disease recurrence. In patient with localised liver cancer resection can also be done depending upon status of liver disease.
Cirrhosis is a stage where liver due to progressive destruction of liver cells and replacement with scarred tissue becomes shrunken in size and nodular in appearance. Patients with cirrhosis present with prolonged jaundice, loss of weight and appetite, itching, abdominal distension and accumulation of fluid in abdomen (Ascites), pedal edema and comatose state(Encephalopathy). In patient with compensated liver disease (non advanced liver disease) , initially medical management is done to stabilise. However in progressing liver disease or patient with decompensated liver disease liver transplant offers best treatment and cure.
Any patient suffering from liver disease in form of cirrhosis and has a life expectancy of less than one year should be considered for liver transplant. There are various scores to assess for status of liver disease most common of which are Child Turcott Pugh (CTP) score and MELD score. Mostly all patients of CTP score equal or more than 10 are offered liver transplant. For patient with cirrhosis and HCC liver transplant is most optimal treatment.
Another reason for emergency liver transplant is Acute Liver Failure (ALF). ALF is an emergency situation where due to acute damage to liver there is failure of liver function.In India, acute viral infection from Hepatitis A and E are the commonest cause, though it may also occur from drug induced liver damage (DILI), with acetaminophen being the leading cause. Patient with ALF should be urgently shifted to centre with liver transplant facility as timely done liver transplant results in upto 80% success in comparison to less than 20% survival without transplant.
Liver transplant is only cure from advanced liver disease and after transplant patient can have normal and productive life. Liver transplant can be done by donation from a brain dead person or by taking a partial liver from a close living relative with matching blood group. Blood group incompatible liver transplant can also be done in appropriately selected patient. Timely done liver transplant in current era has success rate of more than 90%. Patient after transplant has to remain under closed follow up and coordination with medical team.
Liver donation in current era is a safe procedure with minimal associated risks. Any family member between age 18-55 years can be evaluated for donation. All potential liver donors undergo evaluation as per protocol and are considered for donation once found fit. Donors are kept in ICU for 1-2 days and are shifted to ward thereafter. They are normally discharged on POD 7 and can resume there normal routine 3 weeks post transplant. The liver regenerates after the donor surgery. The liver will increase in weight to about 75-85% of the original weight in both the donor and the recipient by around the end of 3-4 weeks and it grows to 90-97% of the original weight by around the end of first year after surgery.