Liver transplantation is the process by which a diseased or poorly functioning liver is removed and replaced with a healthy liver from a donor. Today, liver transplantation provides a 90% chance of 1 year survival and a 80% chance of long-term survival for patients who would otherwise survive only 12 to 18 months. The difficulty for the patient is that the decision to undergo a transplantation has to be made while they are still in reasonably good condition because unlike a kidney transplant there is no liver substitute (like dialysis for kidney failure) that will keep them alive when their liver has failed completely. Liver transplantation therefore has to be planned in anticipation of liver failure Ė so information is vital.
Liver disease places a huge burden on our population:
Approximately 5% people suffer from chronic hepatitis B
Approximately 2% people suffer from hepatitis C
Aapproximately 6 million are alcoholics
The epidemics of obesity, diabetes and metabolic syndrome add to this burden. By conservative estimates 20,000 people suffer from end-stage liver failure in India every year and are in need of liver transplantion.
Chronic Liver Disease: This is the most common indication for transplantation. Hepatitis viruses, alcohol and a variety of other metabolic disorders result in progressive liver damage, which results in cirrhosis of the liver. The scarred and damaged liver makes valiant efforts to regenerate and become nodular in appearance (see figure) as compared to a healthy liver (see figure). The process of deterioration is generally slow and may take an average of about 10 to 14 years to reach a point at which it begins to impact the patientís daily activities. If the disease is diagnosed early and the cause treated effectively, the rate of progression of the disease may be halted or slowed significantly. Ultimately, the patient may develop symptoms like fatigue, jaundice, itching, swelling of the legs and abdomen from accumulation of fluid, vomiting of blood, confusion, loss of consciousness or repeated infections. The patientís physician may estimate the degree of liver dysfunction and the prognosis using scoring systems like the Childís Score or the MELD (Model for End-stage Liver Disease) score to determine the need for transplantation.
Acute Liver Failure: This catastrophic disease has a high mortality without transplantation. It is most commonly caused by hepatitis viruses or by drugs and poisons. Once again there are scoring systems available to predict the likelihood of spontaneous recovery. Transplantation is the only hope of survival for the remaining patients. Generally those with drowsiness or confusion, and those with worsening bleeding parameters are candidates for transplantation.
Congenital and developmental disorders: These are usually diagnosed in the childhood stage. The most common disorder is biliary atresia where the child is born without any bile ducts to drain bile into the intestine, from the liver. An operation called Kasaiís operation may postpone the need for transplantation if performed appropriately, but liver transplantation remains the definitive procedure to save these patients. A variety of other metabolic disorders can also be cured by transplantation.
Liver Cancer: Approximately 2-5% of cirrhotics develop primary hepatocellular carcinoma every year. These tumours are often silent and produce symptoms only when very large. Therefore these patients should be screened regularly with ultrasound or MRI to detect cancers early. Primary liver cancer that remains confined to the liver and does not involve the major blood vessels of the liver may be effectively treated and even cured with liver transplantation. Other cancers like neuroendocrine cancer or cholangiocarcinoma may also be suitable for transplantation.
TYPES OF LIVER TRANSPLANTATION
Cadaveric Transplantation: The most ideal source of a new liver is a brain dead cadaver. An individual who dies from severe brain injury may still have functioning organs for a period of a few days. When the family of such an individual permits harvesting of the organs for transplantation, it benefits a large number of patients with end stage liver.
Donor Liver Transplant: We need only about 25-30% of our liver function to be able to lead a normal life. It is therefore feasible for us to remove about two-thirds of an individualís liver to transplant into a patient without harming the donor. The liver is also able to regenerate itself completely so that over a period of a few weeks the donor regains a nearly normal liver volume. This process of removing a part of the liver from a donor to replace the diseased liver in the recipient is called living donor liver transplant and remains the most common form of transplantation performed in India today due to the shortage of cadaveric organs. The legal requirements of a donor are that they should be a close family member of the patient, aged between 18 and 50 years, and blood group compatible with the recipient. All foreign nationals and any Indian national in whom the donor is not a first degree relative (spouse, sibling, parent or child) must be presented before a state government committee for approval prior to transplantation. This is to safeguard the rights of the donor and ensure the donation is voluntary and not coerced. The safety of the donor is paramount in LDLT and a detailed evaluation of the mental and physical health of the donor is needed prior to selection. Despite this, there is a small but significant risk to the life of the donor of approximately 0.1 to 0.5%.
HCG TRANSPLANT TEAM
Liver transplantation needs the involvement of a wide variety of health professionals working together as a team. The process of accreditation for transplantation ensures that HCG has all the requirements to put together such a program. We have been working to put together a specialized HPB (Hepato- Pancreato- Biliary) service for the past 18 months, and liver transplantation completes the wide range of services we have available for the treatment of liver cancers as well as other liver diseases. The core members of the team are our surgeons, anaesthetists and intensivists, ably supported by