The only cure for advanced liver failure is liver replacement. Liver transplant extends life expectancy and infuses unprecedented quality of life. Patients with acute or chronic liver failure lead to shrinkage of the liver and can be benefited from liver replacement. Liver transplant is recommended when the chance of patient survival drops below 48 months. The patients with this stage of liver failure will have 95% chance of dying without a transplant within 2 years. The best indicator to determine the prognosis is the MELD SCORE (Modified end stage liver disease score). A MELD score > 12 indicates the need to evaluate and recommend liver transplantation. Clinical incidents like, GI bleed, peritonitis, recurrent fluid collection in the belly or attacks of liver coma are indications for early liver transplantation. Once patients are prognosticated based on the MELD score, it is advisable to transplant them early. Longer wait will deteriorate the health of the patient and adversely influence the outcome of transplant in more advanced stages.

In a liver transplant procedure the diseased liver is removed completely by surgery and replaced with either a new part liver or whole liver. Blood vessels and bile duct are connected with the patient’s structures and blood is allowed to flow through the new organ. This takes approximately 8 to12 hours (longer for living donor transplants). Patient is managed in the ICU for 2-3 days and 2-3 weeks in a dedicated special ward.

An appointment to meet the liver transplant team is followed by a detailed medical evaluation. Based on the clinical and lab results you will be advised about the treatment choices. Identification of a related part liver donor is the quickest way to get a liver transplant and it involves donor evaluation and ethical/legal committee clearances. Those with no related donors are kept on a waitlist for cadaver liver transplant, where the wait could be long.

Liver being the only solid organ that can regenerate completely after part removal, it can be donated with reasonable safety (95.5%), by any healthy relative with blood group and weight match. Donor fitness is assessed by evaluation. In living donor surgery 50% of the liver is removed surgically and implanted into the patient. Donors are discharged within 10 days and 90% of the part removed regenerates within 3 months, though the liver function returns to normal range within 2 weeks.

Close follow up is done for 2-3 months by regular blood tests and scan tests. Immunosuppressant medicines are given regularly for life. The survival after liver transplant is 90% at 1 year and 75-80% for lifetime. All forms of physical, sports, scholastic and sexual activities are usually restored within 3 months of transplant.

Who needs Liver Transplant

Absolute indications for liver transplant
Ascites (fluid in the belly) Recurrent collection, not responding to diuretic medicines or repeated removal by needle
GI bleed Vomiting blood or passing blood in stool, more than once
SBP Spontaneous infection in the fluid in the belly (Polymorph cell count >250/cc)
Coma Repeated admission to hospital for loss of orientation and conscious state
Serum Albumin Measurement consistently below 3.5 Gm/dl
Prothrombin time Measurement in patient sample 5 seconds above the control lab value (or INR>1.5)
Total bilurubin Serum total bilurubin >6 mg/dl, especially in patients with bile outflow problems like- PSC & PBC

Majority of patients with sudden (acute) liver failure who meet the internationally accepted criterion will die without liver transplant at the appropriate time. Some of the criterion include- Prothrombin time > 100 seconds, worsening level of conciousness, rapidity of onset of coma, onset of kidney failure and moderate jaundice accompanying coma. Liver failure caused by viral hepatitis-A invariably recovers spontaneously except in 2% of patients. Liver failure caused by liver poisons (chemicals and drugs) are invariably fatal without a transplant. Patients with severe acute liver failure should be admitted to center with facility for emergency liver transplantation, whenever possible. The outcome of acute liver failure patients without transplant depends on the cause, reporting time, early correct medical therapy and provision of good intensive care. Invariably all patients with cirrhosis will need liver transplant at some point in time. The only absolute contraindications being HIV infection and wide spread cancer (primary or secondary). Tranplant is not advisable in patients with heart and lung failure as well as in those with systemic infections(TB), severe malnutrition and cancer without liver cirrhosis.

One cannot survive for more than 24 hours in the absence of the liver. The functioning of the liver can be deranged by acute illness such as alcoholism, viral hepatitis or sepsis. Most of these illness recover spontaneously , but few take a downhill path resulting in fulminant failure. Since no tested artificial liver support system are yet available ,many people die without liver transplantation . Birth defects, viral infection and alcohol abuse also cause a gradual crippling of liver function resulting in a state called cirrhosis. In this state much many of the liver tissue get replaced with scar tissue , causing strangulation of blood supply in the liver .As a result there is damming of blood in the portal veins .As nature seeks alternative routes to empty the blood . Multiple channels are created to shunt the blood away from the constricted liver into the veins draining into the heart .When the pressure in these channels exceeds in the limit they may break down causing massive bleeding .In some patients it may be terminal event . The blood that bypass the toxin removal process in the liver ,eventually reaches the brain causing several neuropsychiatric disturbances

When to time transplant

All patients who have moderate synthetic dysfunction due to liver cirrhosis should be evaluated and listed for cadaveric liver transplant early. The average international waiting time for cadaveric liver is about 8 to 12 months. This is likely to be even longer in India. Hence there is a lot of sense in early enrollment. Close follow up by the transplant team is essential during the waiting period to attend to the intercurrent medical problems that may contraindicate transplant. The following are the indications for evaluation and early listing for transplant- Prothrombin time raised 5 seconds above control value, Serum Albumin < 3.5 G/dl, Ascites(fluid in the belly) not responsive to medications, one episode of infection in ascites(SBP), episodes of gastrointestinal bleeding and presence of gastric-fundal varices (on endoscopy). The advantages of early transplant include cost saving on recurrent therapy for medical illness which is common in chronic liver disease and better post transplant outcome.

Source of Cadaver Livers

Due to active organ donation campaign by organization such as ORBO and HOPE at New Delhi. The organ donation rate has increased remarkable since January 2003. As a result cadaver liver transplant have been carried out at the author's centre since Dec 2002. From the year 2006, there has been a significant increase in the rate of Cadaver donations from the Southeren part of India & the author has been successful in arranging such donations for a number of his patients.

The national rate of liver procurement in India is around 5 livers per year. Though 10-15 muliorgan donors are available per year nationally, not all of them are procured due to logistic reasons and lack of co-ordinated effort. At times due to logistic reasons chartered flights have to be arranged to procure livers outside Delhi. Though the potential for cadaver organ donation is quite large in India, due to lack of awareness about organ donation after death, poor ICU infrastructure, poor co-ordinate infrastructure and appropriate legislations to remove legal hassles in organ transportation around the country, the organ donation rates are set to remain poor for sometime to come.

Liver Donation

Partial liver donation by relatives of the patient is becoming more and more common all over the world. More than 1000 live donations have been carried out globally. Though the liver is a single organ, the anatomical disposition of the organ allows it to be split into two useful portions safely. Moreover the liver has in excess of 300% reserver capacity and can theoretically survive with only 30% of the total liver volume. The liver is also very unique in its ability to regenerate. It is documented that the liver regenerates to 90% of the original liver volume within 3 months of removing > 50% of the liver for donation. Liver donation is a major surgery and will leave a large scar. At the author's center over 50 live donor operations have been performed with few minor complications. 60% of the patients did not require blood transfusion during surgery. The only notable complication was a bile leak from the raw area of the liver that settled spontaneously within 3 weeks. Most donors were discharged within 10 days of surgery and they can return to non-manual work 4-6 weeks after surgery and full active life within 3 months. The only long term morbidity seems to be wound pain which may persist beyond 3 months in about 30% of the donors. Occassional death has been reported after live donation which underlines the fact that the procedure should be carried out only by experts in this field in transplant centers with good track record, who can guarantee donor safety and low complication rate.

Factors in Donation Process

When an organ is donated from a person who has died, it is made available to an eligible patient on the waiting list. Before the transplant can take place, however, several things happen. Although a patient meets all the criteria and appears to be a good match for the organ, the organ still has to be accepted by the transplant center. The transplant team has a very short time to consider several factors before accepting that organ for the particular patient. If, in the physician's judgment, the organ offered presents undue risks to the patient, it may be refused. There are a number of reasons for refusing an organ, such as: There are some differences among transplant centers overall in terms of how often organs are accepted or refused. But recent studies have found that how often a center accepts or refuses transplant organs does not seem to affect such important factors as how long patients wait for transplant or how well those patients do either before or after transplant.*

* From the United Network for Organ Sharing (UNOS') Summary of Key Findings 1113197. The UNOS 1997 Report on Center-Specific Organ Acceptance Rates.

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