Liver Transplant

The term End-Stage Liver Disease (ESLD) is used to describe advanced liver disease, liver failure, and decompensated cirrhosis (the final stage of cirrhosis).
Life expectancy depends on the stage of liver disease and associated complications of liver disease.
The only effective treatment for people with end-stage liver disease is a Liver Transplant.

• Liver inflammation
• Liver fibrosis
• Liver Cirrhosis
• Liver failure

When the damage to the liver is acute and severe, as in some infections like Hepatitis A or poisoning etc., the liver can progress to acute liver failure rapidly without fibrosis or cirrhosis.

When there is slow damage to the liver, the normal liver cells get killed and are replaced by scar tissue (fibrosis). As fibrosis progresses, the whole liver gets scarred, hardened and shrinks. This damage cannot be reversed with medical treatment.
Cirrhosis can occur due to

• Alcohol abuse
• Infections: Hepatitis B, Hepatitis C
• Fatty liver disease (NASH, NALFD) when there is a build up of fat in the liver of people who are overweight or have diabetes etc.
• Autoimmune Hepatitis: When a person’s own immune (defense) system attacks the liver and causes injury.

Liver Cirrhosis is an irreversible stage of liver disease. At first there may not be any symptoms or signs of liver disease (compensated liver cirrhosis). A person can liver many years with cirrhosis not knowing that their liver is cirrhotic. If the cause of liver illness continues like alcohol, excess fat, autoimmune illness then the reserve cells get exhausted and pressures in the liver veins (portal veins increase) and the patient gets sicker
Patients usually present with

• Poor appetite, loss of muscle mass
• Jaundice – yellowish discoloration of the eyes, skin.
• Buildup of fluid in the body in the form of swelling of ankles, feet or fluid in the belly – Ascites
• Excess sleepiness during the day, lethargy, low energy and sometimes confusion due to build up of toxic products in the blood.
• Vomiting blood or passing dark colored stools due to rupture of a tense distended blood vessel at the food pipe or stomach. If this happens – patient should be taken to the emergency immediately as it can life threatening.

When there is decompensated Cirrhosis and patient requires frequent hospitalization due to infections, confusions, coma episodes, bleeding or complications of other organs like kidney and lung it is End Stage Liver Disease.

Liver Transplant.
When the complications of liver cirrhosis cannot be controlled with medications and patient progresses to End Stage Liver Disease.
Life expectancy is greatly reduced in End Stage Liver Disease- Liver Transplant is the only treatment which can improve life survival.

Liver Transplant is a major surgery where the sick (diseased liver) is removed and a healthy liver is connected in its place. The surgery takes about 8-10 hours. The patient may spend a day or two in a Liver Transplant ICU and a few days later in Transplant ward depending on their condition. Usual hospital stay for an uncomplicated transplant is for 1 week to 10 days.

Deceased donor Liver transplant: When a whole new healthy liver is transplanted from a Brain-dead Donor
Living Donor Liver Transplant: When a half liver is removed from a healthy living door and is transplanted into the recipient. The half liver regenerates into its original size in a few months (3-6) and starts functioning optimally similar to a whole liver transplant.

Transplant physicians and Transplant Surgeons use the MELD score to assess the prognosis of the liver disease and understand the urgency for liver transplant for the patient.
It is calculated from the following blood parameters:

• Total Bilirubin
• Serum creatinine
• Prothrombin time
• Serum Sodium

A higher MELD score predicts the patient’s chances of surviving their disease during the next three months. The MELD score changes depending on the severity of the patient’s illness. The higher the MELD score the sicker the patient and may need to come to the hospital more frequently to be monitored or tested.

Liver transplant process comprises of following stages

• Assessment / Pre-operative work up / Registration for Liver Transplant at the ZTCC (Zonal Transplant Coordination Center).
• Multi-disciplinary team Evaluation
• Optimization of Health, Frequent monitoring of health.

The Team comprises specialists and nurses and support staff from various fields who participate in the patient management for transplant. They Include

• Transplant Anesthesiologist
• Transplant physician (Hepatologist)
• Transplant Anesthesiologist
• Intensivists
• Cardiology & Pulmonary team
• Transplant Infectious Disease consultant
• Nutritionist
• Physiotherapy
• Psychology Counsellor/ Psychiatrist
• Transplant Coordinator
• Transplant Social Worker
• Transplant Financial Advisor

Most patients can return to a regular lifestyle 6 months after liver transplant.
A healthy diet, regular exercise, healthy lifestyle, regular medical lab tests, compliance in taking recommended medications is important.

About 90 % of recipients have an uncomplicated course in the first-year after liver transplant. Nearly 75- 80% of liver transplant recipients are alive 5 years after liver transplant

The waiting period for a Deceased Donor Liver Transplant is unpredictable. It depends on the blood group, how severe is the recipients MELD score, presence/ absence of infection and availability of a donor liver.
While in a Living donor Liver Transplant – the process can be planned as soon as an eligible donor is found in the family or relations.

Sometimes unhealthy cells in the liver undergo uncontrolled multiplications and become cancerous. Liver Cirrhosis patients are at risk for such liver cancers (Hepatocellular Carcinoma). Liver Transplant offers a good chance at improving survival and control of such cancer.

Liver transplant has excellent outcomes. Recipients are known to be alive 30 years post liver transplant. Rejection, infection, recurrence of the disease, other associated health problems can impact how long a liver transplant can survive.

All normal activities like playing sports and getting healthy exercise, socializing, and traveling for business and pleasure are all possible. Keeping a healthy lifestyle allows the patient to explore and enjoy all the gifts of a normal life post Liver transplant.

Good healthy life style and dietary habits help maintain a Healthy liver.
Here are some recommendations:

• Exercise Regularly
• Eat Healthy Foods: Avoid excessive fats and fried food (monitor your lipid levels and annually check your liver ultrasound especially if you are more than 50 years of age)
• Maintain a healthy weight & Body mass Index (BMI)
• Avoid illegal drugs/ excess alcohol/ over the counter herbal preparations/self-medications
• Vaccination: Ensure you are vaccinated against Hepatitis A & B
• Practice Safe Sex: Use protection to avoid sexually transmitted diseases like Hepatitis C

Liver function tests help to evaluate your liver function and extent of liver damage.
If you have liver disease, you will be asked to get these tests done to monitor your liver function.
Some of them are:

• SGPT or ALT: measures the Alanine transaminase enzyme
• SGOT or AST: measures the Aspartate transaminase enzyme
• Alkaline Phosphatase (ALP)
• Gamma-glutamyl transpeptidase (GGT)
• Total Protein levels (Serum Albumin, Serum Globulin)
• Total Bilirubin levels (Direct + Indirect)
• Prothrombin time (PT, INR)

Liver Cirrhosis is irreversible and can get complicated despite medical management.

• There aren’t enough liver donors available to fulfil the needs for the number of patients on the waitlist for liver transplant. The waiting time for liver transplant can be unpredictable and sometimes the wait for a new healthy liver can be long.
• The liver transplant is a major complex surgery and one needs to go through the detailed evaluation process and investigations before one becomes eligible for transplant.
• Sometimes funds need to be raised to ensure adequate financial support for the recipient.
• To ensure that the patient is well prepared for liver transplant when the time comes also ensures a good outcome and better survival for transplant – it is important to plan ahead.