Liver Transplant & Hepatic surgery

Liver Transplant - Columbia Asia India
The department of Liver Transplantation and Hepato-Pancreato Biliary Surgery at Columbia Asia Refferal Hospital, Yeshwanthpur offers a variety of options for those afflicted by liver diseases. Our team does living donor and deceased donor liver transplantations, both in adults and in children. The mission is to provide the state-of-the-art services, using evidence-based guidelines, at an affordable cost, and to facilitate training and research in the field of hepatobiliary sciences. This hospital is one of the few centers in the country where comprehensive treatment for hepatobiliary and pancreatic diseases are being offered to the patients under one roof.

Services offered:
Liver Transplant : The 2 types of transplant done are:
Deceased donor (brain dead, cadaveric) transplant:

This kind of transplant involves taking liver from a person who is brain dead.  The person’s family must first give consent if organs are to be used for transplantation. This type of transplant requires waiting on a list until a suitable liver is available.

Brain death is sudden death following a road traffic accident or a brain haemorrhage, with irreversible brain damage that is not compatible with life.  Brain dead patients may be artificially maintained on a ventilator and supportive medicines for a short duration, and may be able to donate their livers for transplantation, if their family so desires.

Living donor transplant:
This type of transplant occurs when a living person wishes to donate his liver to someone in need. Living donors are usually family members or spouses. All living donors must meet basic medical criteria and undergo a very thorough medical evaluation before being accepted as a suitable donor.

Human organ transplant act (HOTA) – link https://isot.co.in/hota_act

Who can donate?
All of us can be organ donors, irrespective of age, caste, religion, community, current or past medical condition.  However, active cancer, active HIV, active infection (for example, sepsis) or intravenous (IV) drug use are some of the contra-indications. A hepatitis C patient can donate to another with hepatitis C.  The same is true for hepatitis B.  A registry is an essential part of understanding who and where potential donors are.  A registry gives a planner enough information to devise strategies to get more public cooperation and commitment towards organ donation.

II. Other procedures:
The other procedures done are liver resections, laparoscopic radiofrequency ablation, liver trauma management, percutaneous procedures, shunting procedures, lap cholecystectomy, radical cholecystectomy, management of bile duct injuries, bile duct stricture management, hepaticojejunostomy, splenectomy, pancreaticojejunostomy, Whipple procedure, hepatectomy, pancreatectomy, cancer diagnostic procedures, ultrasound-guided biopsies, cancer surgeries, etc.
 
About Liver Diseases

What is end stage liver disease (ESLD) or cirrhosis?

Some diseases destroy healthy liver cells or replace them with scarred (fibrous) tissues causing loss of liver function. When a large part of the liver is scarred, it is called cirrhosis. Cirrhotic liver loses its capacity to regrow or regenerate causing loss of liver function; this is often progressive and irreversible. Cirrhosis cannot be treated or reversed with any medicines.

Liver has the capacity to regenerate. Even if 70% of the liver is damaged, the remaining liver can provide adequate organ function. However, damage beyond this causes loss of liver function or organ failure, called end stage liver disease (ESLD).

Although cirrhosis cannot be reversed, if diagnosed at an early stage, treating its cause such as viral or autoimmune hepatitis or abstinence from alcohol can halt its progression.

What are the signs and symptoms of liver disease?

Patients with cirrhosis feel normal until ESLD sets in, when following signs and symptoms may develop:

  • Yellowness of skin and white portions of the eyes or passing dark yellow urine (jaundice)
  • Swollen abdomen - fluid build-up in abdomen (ascites)
  • Excessive sleepiness, inability to sleep, becoming forgetful, drowsy or confused (encephalopathy), due to build-up of ammonia and other toxins
  • Throwing up blood (blood vomiting), passing tarry black stools or fresh red bleeding in stools due to bleeding in intestines
  • Passing light or clay coloured stools
  • Easy or excessive bruising or bleeding even from simple wounds
  • Constant and severe itching (pruritus) all over the body
  • Feeling tired or weak
  • Unintentional weight loss
  • Loss of appetite
  • Loss muscle mass
  • Swelling (edema) of hands and feet

Patients with mild liver damage might not experience any of the above symptoms and may only require medical or endoscopic therapy. Occurrence of above symptoms is called as decompensation and generally indicates poor or inadequate liver function or failure of medical therapy. Some symptoms are more serious than others; especially fever, blood vomiting and mental confusion demand immediate medical attention.

Unfortunately, by the time patients undergo tests and are diagnosed with liver problems, they already have decompensation (worsening) or advanced chronic liver disease with limited reserve and short life expectancy.

Some common findings on initial tests in cirrhotic patients are:

  • High bilirubin
  • Low albumin
  • High prothrombin time (INR)
  • Low platelet count

What is acute or fulminant liver failure?

Acute liver failure (ALF) is a devastating and life-threatening condition in which there is sudden and rapidly progressive damage to the liver developing over a few days or weeks in an otherwise normal individual. Its signs and symptoms typically start with jaundice and have a rapidly worsening course. Patients may become forgetful, drowsy or confused and may progress to coma over few hours to days.

Some diseases causing acute liver failure are:

  • Infection with hepatitis A or E virus
  • Side effects of medicines (anti-tubercular, paracetamol, ayurvedic drugs)
  • Fatty liver during pregnancy
Evaluation And Preparation For Liver Transplant

Recipient

What is the preparation required for transplant?

It is important to accept transplantation with a positive attitude because it is a big step and although its preparation is cumbersome, waiting period unpredictable (for DDLT), operation complex and recovery prolonged, most patients do well after transplant and lead an excellent quality of life.

The preparation starts with recipient’s evaluation. Once the patient is found suitable for transplantation, any potential donors in the family should have their blood group checked and one who is compatible should undergo donor evaluation. If the donor is suitable, authorisation committee clearance is obtained and transplant is scheduled. Patients planned for a living donor liver transplant can generally undergo the same in about 2–3 weeks.

If a suitable family donor is not available, after the recipient evaluation is found satisfactory, the patient is registered on the waiting list for a deceased donor liver transplant.

Patients should make adequate arrangements for blood products well in advance before surgery.

While preparing for a transplant, all doubts should be clarified and understood. Patients and the donors are encouraged to meet other patients and families who have undergone the operation and willing to share their experiences.

Pre transplant recipient (patient) evaluation

Once ESLD (end stage liver disease) is diagnosed and need for a transplant is perceived, patients undergo a formal evaluation, which involves blood tests, CT and other scans, tests for heart, lungs and other organ systems and assessment by various specialists. Evaluation is performed with the following goals:

  • To establish the diagnosis and find the cause of cirrhosis / ESLD
  • To determine the severity of liver disease and its effects on other organ systems such as kidneys, lungs, etc. and thus determine urgency of transplant
  • To actively look for liver tumour
  • To evaluate the condition of other organ systems such as heart, lungs, kidneys, etc. and determine patient’s ability to tolerate this major operation
  • To evaluate difficulty, technical feasibility and risk of surgery (previous abdominal infections, surgery, thrombosis of liver blood vessels)

Evaluation generally takes about 7–10 days and is done on outpatient basis. The evaluation period may be very hectic and stressful. Patients are advised to relax between tests and follow the instructions for each test carefully for accurate results. The transplant coordinator is the main contact person during evaluation and will fix appointments for any tests or procedures. At every stage of evaluation, the plan for further tests may change depending on your reports; therefore, it is important to visit the transplant clinic routinely for review by the transplant team. Patients who are sick may be advised to undergo evaluation in the hospital. If unexpected / incidental problems are discovered on evaluation such as cardiac disease, thyroid disease, infection, etc. These might have to be treated before transplant.

Patients with other co-existing disease such as uncontrolled blood pressure, diabetes or untreated cardiac problems, might have to wait until they are corrected. Liver transplant can even be performed after successful cardiac angioplasty or with heart bypass surgery.

Donor

Who can be a living liver donor?

A living donor should meet the following criteria:

  • Compatible blood group with the recipient (refer table 1 below).
  • A family member (wife, husband, mother, father, brother, sister, son, daughter, grandfather, grandmother, grandson, granddaughter) or close relative of the patient as defined by the Act
  • We do not accept family friends, well-wishers, staff or neighbours as donors.
  • Age group 18-55 years
  • Not overweight, because people who are overweight may have fatty liver
  • The donor liver should be large enough to provide adequate volume for the recipient (patient) as well as for the donor.
  • Donor should be in good overall physical and mental health and undergo a thorough medical and psychological evaluation and volunteer for donation after fully understanding the risks of surgery.

Table 1: Compatible blood group

If you are blood group You can donate to
O O, A, B or AB
A A or AB
B B or AB
AB AB

* Rh factor (+ve or -ve) is not important.

The decision to donate can be changed at any stage of the evaluation, before or after the tests are done or any time before the surgery.

Pre transplant donor evaluation

Donor evaluation is performed in four phases, with more expensive and invasive tests reserved for later phases. The test take about 7–10 days and are done on an outpatient basis, commonly along with the recipient evaluation.

Phase I Phase II Phase III Phase IV
Liver function tests Liver volumes Tests to evaluate other organ systems Evaluation by specialists
Liver fat estimation Anatomy of liver blood vessels

Fatty liver (steatosis) is quantified by liver attenuation index (LAI) and liver volumes is calculated by the second (tri-phasic) CT scan. The tri-phasic CT also gives surgeons a detailed view of the liver, its blood supply and anatomy. Few donors might need a biopsy to study liver quality in more details, where a tiny piece of liver is examined under a microscope. Most donors with a non-fatty liver and adequate volumes i.e. donors who have cleared phases I & II, have a high chance of being accepted for donation. When potential donors are rejected, it can be stressful for the family, but this is done for the safety of the donor and success of transplant, an alternative donor should then be identified.

Both the patients and donor’s emotional health and willingness for transplant is important for the operation and they would be counselled by a psychologist during evaluation.

HLA testing and matching is performed before the authorisation committee meeting.

Authorisation committee clearance

All patients planned for living donor transplant need clearance by the government appointed authorisation committee. Our administrative staff will help patients and their families understand and prepare various legal forms, affidavits (statements under oath) and supporting documents. Proof of identity, residence and donor-recipient relationship have to be submitted with the application to authorisation committee. Donors who are not near relatives and foreign nationals have to obtain a no-objection certificate (NOC) from the state of domicile (residence) or embassy. The transplant team is independent of the authorisation committee and cannot influence its decision. Falsification of documents or other efforts to provide false information / mislead the authorisation committee constitutes violation of the law and carries heavy penalty.

All cases who have completed both patient and donor evaluations are reviewed by the multi-disciplinary transplant team, where their suitability for transplant is discussed and tentative date for transplant decided. The transplant is scheduled only after clearance by the authorisation committee.

Arrangement of blood and blood products

Once the medical decision for transplant is made, patient’s family is advised to donate about 18 units of blood (any blood group, unless the patient has a rare blood group), well before the date of surgery and prepare 3 platelet donors (same group as the patient). Platelets have a short shelf life and therefore should be donated only one day prior to surgery. If the surgery is expected or found to be difficult, additional blood donations may be required before surgery or may have to be replaced after surgery, as and when notified by the transplant team.

Financial arrangement

Liver transplant is offered as a package at Columbia Asia Hospital. It includes pre transplant workup fee, operation charges and life long consultation charges for both patient and the donor. The transplant coordinator will explain expected expenses at various phases, mode of payment, inclusions and exclusions of the package.

Patients with additional risk factors such as kidney or cardio-respiratory problems, those expected to undergo a complex operation, need prolonged ICU care or hospitalisation might be offered the high-risk package. Patients undergoing combined liver-kidney transplant, dual lobe transplant, ABO incompatible transplant or having hepatitis B or other diseases requiring use of additional expensive medicines should discuss the package applicable to them with the transplant coordinator.

Patients whose expenses for transplant and post operative medical care will be borne by insurance company, employer or embassy should discuss the same with the patient financial liaison or TPA helpdesk, who will guide patients with required paperwork. Some insurance companies only pay part of the package and the remaining amount has to be arranged by the patient's family.

What if a patient does not have a suitable living donor?

Patients who do not have a suitable living donor or are unlikely to get a deceased donor transplant in time for their disease severity might benefit from one of the following innovative procedures.

Alternative in living liver transplant

Swap transplant

When one of patient’s family members is suitable and willing for donation, but is not a good match for the patient, a paired donation or swap transplant may be considered. In this type of transplant, two families with suitable living donors exchange their donors because they are not a good match for their own patient, but are appropriate for each other’s patients.

Swap transplant is commonly done for blood group mismatch, e.g. if donors and patients of one family have blood groups A and B and that of the second family B and A, respectively, these donors are not suitable for their own recipient. However, if donors are exchanged, both patients can undergo transplantation. Both transplants are performed simultaneously and therefore can only be done by a large experienced transplant team after careful planning.

Dual lobe liver transplant

When a potential living donor’s liver volume is found inadequate for the recipient on pre operative CT scan, they may be rejected and another donor evaluated. It is common that in one family, two or more people might have been rejected for donation, each because of low liver volumes, who were otherwise suitable. If partial livers from both donors are combined; it is often adequate for the patient. In such a transplant, three operations (one recipient and two donors) are performed simultaneously. Dual lobe transplants are technically complex and offered by few centres only.

ABO incompatible (ABOi) transplant

Generally, liver transplant is performed with blood group compatible donor livers, because ABO (blood group) incompatible transplantation triggers production of antibodies against the transplanted liver causing organ rejection. However, if some special immunosuppressive medicines and measures are used, antibody levels can be reduced before transplant and organ rejection prevented. In small children, the antibody levels are very low and ABOi transplant can be performed with less preparation and better success. Since very few centres have experience with ABOi liver transplants, it is offered only at experienced centres.

Deceased donor transplant

Once recipient evaluation is completed and the patient is found medically fit for transplant, the prescribed forms have to be completed and submitted through the hospital to the state-wide appropriate authority for registering their names on the waiting list for a deceased donor transplant. Patients may register at more than one hospital, even in different states (Maharashtra, Gujarat and Karnataka). After listing, patients should undergo periodic testing and review with the transplant team and also inform them of any significant changes in patient’s medical condition.

When a potential deceased donor liver is available, patients are alerted immediately and called to the hospital. The contact information of the patient should be updated with the coordinators so that the transplant team can contact the patient and the family when a liver is available any time of day or night. The coordinators should be informed if the patient is going out of the country.

Patients not living in the same city should pre plan for the emergency trip well in advance. They should also have flight options and important phone numbers handy and plan on getting to the hospital quickly. They should alert their employer about sudden leave in advance. They should designate someone who will take care of their family and home in their absence and maybe make a power of attorney for their business. The waiting period is highly variable, ranging from weeks to months.

While one team prepares the patient for transplant, another team retrieves the donor liver. The liver is carefully checked for its suitability for transplantation. Livers from donors may be considered high-risk if they had previous hepatitis B or hepatitis C infection, had risk factors for HIV infection, had active infection or cancer. Patients should discuss the quality of liver and associated risks with the transplant team before accepting or rejecting it. If the transplant team finds the liver unsuitable, the donor family withdraws their consent to donate or if the transplant is cancelled for any other reason; patients will have to return home and continue waiting for the next offer. While such “false alarms” could be stressful, these decisions are always taken in the interest of patient safety and to optimise chances of a successful transplant.

Preparing for an emergency liver transplant

Patients with acute liver failure very critical in the ICU, often on a ventilator, may have a rapidly progressive worsening disease and might need an emergency transplant. Although the preparation required is similar, all tests and arrangements have to be done in a very short duration. Recipient and donor evaluations are done emergently within few hours to days. Recipient evaluation is similar, although neurological evaluation, including a CT scan of the head may sometimes be required. Donors also simultaneously undergo a rapid evaluation; all tests being done in less than 12–24 hours. An emergency legal authorisation committee clearance is also required. If a suitable living donor is not available, patients are enrolled on the waiting list, where they are given priority on the cadaver list.

Precautions to be taken while waiting for the transplant

While waiting for the transplant, it is important that patients undergo regular tests, adhere to all appointments and medical advice, and comply with treatment and dietary restrictions. In order to remain healthy, prevent any infections, prevent any complications, enable early identification of any problems or significant change in condition and allow prompt treatment before transplant, some simple precautions can be taken.

  • Hand washing and scrubbing for at least one minute using soap and water including between fingers, under the fingernail and around the nail beds before eating, after using the bathroom or when they are dirty
  • Using antiseptic hand-rubs frequently
  • Malnourished patients may be advised few weeks of medical nutrition therapy.
  • Perform light exercises, walk and remain active (as much as possible)
  • Getting enough rest
  • Taking only the prescribed medicines. Do not take any new medicines, including vitamins, herbs or supplements without discussion with the transplant team.
  • Children are advised to undergo all vaccinations appropriate for age, because they cannot receive live vaccines after transplant.
  • Eating low salt diet, as prescribed and adhering to liquid intake restriction. This will help in controlling ascites (fluid in the belly).
  • Eating smaller meals, a low-fat, high protein adequate calorie diet, keeping the muscles strong
  • Patients can consider taking nutritional supplements if they are unable to get enough calories or proteins in their diet, as advised by the dietician.
  • The transplant team should be informed about any significant change in the health or any hospitalisations.
  • No alcohol intake, if the transplant team has any doubt about lifetime commitment to sobriety or abstinence from alcohol or illicit drugs, they can perform random screenings, blood or urine tests for the same and if found positive, make the patient inactive on the waiting list.
  • Patients should quit smoking before the transplant, because it can cause lung infections after surgery and prolong recovery from ventilator after surgery.
  • The transplant team should be notified of any the unexpected change in health such as blood vomiting or black stools, changes in mental condition, excessive sleepiness (drowsiness), confusion, nose bleeding, weight gain, swelling in abdomen or arms and feet, severe or sudden abdominal pain, fever, fainting spell, severe vomiting or loose motions.
  • Patients may be able to continue to work and even travel while on the waiting list after discussing the same with the transplant team. It may not be safe for patients with very low platelet counts, high INR, history of GI bleed or encephalopathy to travel. While travelling, the co-coordinators should be updated with the contact numbers. Patients should also identify a doctor locally who can take care of any urgent problems while travelling.
  • Patients should keep the phone numbers of their family members and the transplant team handy to deal with any urgent situations.
Tests And Appointments

Being regular with follow-up tests and visits to the transplant team are most important to make transplant a success.

  • Donors need follow-up every 5-7 days for the first 1 month, after which they will have to get tests and review at 3 months and 1 year.
  • Recipients need lifelong follow-ups, very frequently initially and less often later, as per the schedule given at discharge. Once the reports become stable and medicines well adjusted, patients can travel, e-mail their reports to us and visit the clinic once in every 3-6 months.
  • Transplant clinics are held in selected cities of the country every month so that it is convenient for patients / their families to attend. Please contact the post transplant coordinator to know the schedule for your city.
  • In case of problems, please call the transplant team. Please identify a local physician and gastroenterologist for an urgent situation.
  • Routine monitoring of blood pressure, blood sugar, diet intake, exercise, insulin administration and other parameters as advised at discharge. Post transplant coordinators will teach the patient and the donors the same and this should preferably be done by one of the family members. Maintain a file and keep charts of all the lab reports in chronological order and the dose of immunosuppressants taken and bring this file during clinic visits.
  • In case patients need dressing changes, physiotherapy or administration of injections at home, family should make arrangements for a nurse or physiotherapist. Our coordinators will help in identifying qualified people familiar with the needs of transplant patients.
  • It is important that one follows our team’s instructions about any problems before they become serious. This enables the treatment to start early and courses to be shorter and milder.

Medications

At the time of discharge, patients are generally prescribed 10–15 medicines, some of these may be injections. As they make progress, the numbers of drugs are reduced and at about 1 year, most patients are on 1-2 anti-rejection medicines and those for pre existing illnesses. Patients and their families should familiarise themselves with the medicines prescribed.

  • Anti-rejection (immunosuppressant) drugs lower the immune response, thus prevent rejection of the liver and have to be taken lifelong, because the liver always retains its original identity. Failure to take these medicines may lead to rejection even many years after transplant.
  • Drugs to prevent complications and side effects: antacids, antibiotics, anti-fungal and blood thinning medicines
  • Supplements: vitamins, calcium, magnesium
  • Drugs for pre existing illnesses (e.g. anti-asthmatic, anti-diabetic, anti-hypertensive)
  • Medications should be taken at fixed times and their doses, frequency or duration changes should never be changed unless advised by the transplant team. Also, whether the medicine should be taken before or after meals or before going to sleep at night is mentioned in the discharge summary.
  • Drug levels of anti-rejection medicines (tacrolimus, cyclosporine, sirolimus) should be drawn before taking the medicine in the morning, this is to ensure desired results and avoid any side effects. Missed medication doses should not be double dosed; it should be resumed at the normal dose.
  • Failure to take prescribed medicines is dangerous and is the most common reason for rejection and even failure of transplanted liver.
  • Patients should not self-medicate, even with over-the-counter medicines, for small problems such as cough, cold, loose motions or fever because they might not be aware of the interactions of these medicines with their transplant medicines. They should consult a specialist doctor and speak to the transplant team before starting treatment, including the ones prescribed by other doctors.
  • Patients should always check with their transplant doctors before having any immunisation or vaccines.
  • Patients should try to discuss and learn side effects of various medicines and inform the transplant team if they are experiencing any problems after taking them.
  • Detailed updated medication record should be maintained including doses given.
  • Most importantly, one of the family members or the patient himself should take charge and responsibility for medication administration.

Guide for medication frequency

  • OD : Once a day (at 24 hrs. gap)
  • BD : Twice a day (at 12 hrs. gap)
  • TDS : Thrice a day (at 8 hrs. gap)
  • QID : Four time a day (at 6 hrs. gap)
  • BBF : Before breakfast
  • HS : At night before going to sleep
  • A/D : Every alternate day
  • SOS : Whenever needed

Blood sugars / insulin

  1. Please check blood sugars as instructed by the transplant coordinator, generally it should be checked 4 times daily.
    • Before breakfast : 7 am
    • Before lunch : 12 noon
    • Before dinner : 7 pm
    • 2 hours after dinner : 9 pm
  2. Insulin should be taken only after checking blood sugar and before a meal.
  3. If blood sugar is less than 100, please skip the dose, However, regular meal can be taken.
  4. If blood sugar is less than 80, eat some glucose rich food such as sugar, chocolate, etc. skip insulin dose, have a regular meal and recheck blood sugar.
  5. If blood sugar is more than 400, please take prescribed insulin, have meal and speak to the endocrinologist / transplant team.
  6. Follow the doctor’s advise.

Danger and warning signs

At home, some of the warning signs to watch are:

  • Fever greater than 100˚
  • Shortness of breath
  • Cough with yellow / green sputum
  • Nausea / vomiting / loose motions
  • Drainage / redness / swelling at incision site
  • Persistent or worsening abdominal pain
  • Burning sensation while passing urine

If he tdonor / patient experiences any of these symptoms, please contact the transplant helpline. One of the doctors from the transplant team is always available in the hospital to take care of urgent problems. If the problem appears serious, patient should go to the emergency department and will be seen by a doctor from the transplant team who would be able to conduct tests, give IV medicines or even readmit, if required.

Types Of Liver Transplant

What are the types of transplant?

There are two types of liver transplant depending on the source of liver:

Deceased donor (brain-dead, cadaveric) transplant

Brain death is sudden death after an accident, brain haemorrhage or stroke with irreversible brain damage, not compatible with life. Brain-dead patients may be artificially maintained on a ventilator and supportive medicines for a short duration and may be able to donate their organs for transplantation, if their family desires. Donation by a single deceased donor can enable as many as nine life-saving organ transplants and numerous life-enhancing tissue replacements.

Livers from deceased donors are matched with recipient’s blood group and size, offered to the first patient on the waiting list, and if suitable, transplanted. The whole liver is usually transplanted, although sometimes it may be divided into two portions and offered to two patients, generally a child and an adult. Unfortunately, the number of patients in need of a transplant far outnumber the availability of such organs; therefore, not all patients are able to undergo a deceased donor liver transplant.

Living donor transplant

Living donors can donate one of a paired organ such as a kidney or one lobe of the liver. Living donors are family members or close relatives of the patient. The diseased liver is replaced with a segment of liver from a healthy human donor (usually an immediate relative of the patient for example father, mother, sibling, spouse, children, grandfather, grandmother or grandchildren) Living donor liver transplant is based on two remarkable qualities of the liver:

Reserve

Even 25% of the liver can provide sufficient function for a person; therefore, one can easily tolerate removal of a large portion of the liver.

Regeneration

Liver has the capacity to regenerate / regrow back to its normal size. The process starts soon after division / transplantation of the liver in both the donor and the patient. About 90–100% of regeneration happens within 2-3 months.

Because of these properties, 50–70% of normal liver can be safely removed and the remaining liver provides adequate function until complete regeneration. A margin of safety is always kept for the donor when planning the transplant. Generally, patients need a liver which is 0.8-1% of their body weight to recover well from the operation, which commonly corresponds to a right lobe for an adult patient, left lobe for an adolescent and left lateral segment for a small child.

Living donor liver transplant is technically more complex than deceased donor liver transplantation, but can be safely performed at experienced and established institutes.

A few advantages of living donor transplants are:

  • Living donors are healthy people with a perfectly healthy liver and go through a rigorous process of evaluation, therefore the chances of liver not working after transplantation is very minimal.
  • Better genetic match between living donors and candidates may decrease the risk of organ rejection.
  • It is an elective, planned operation allowing doctors to schedule the transplant at an optimum time, this is especially important for patients who are very sick and need stabilisation before surgery.
  • It also allows doctors to perform an emergency transplant for patients with acute liver failure as a life-saving measure.
  • Patients with liver tumours carry the risk of the tumour spreading while waiting for a deceased donor liver transplant and might benefit from an early living donor liver transplant.
  • Donation is a positive experience and most donors experience a sense of heroism in being able to save (in case of liver transplantation) or dramatically change (in case of kidney transplantation) the recipient’s life.
Getting Admitted To The Hospital For Transplant

Living donor transplants are planned in advance, patients and donors are admitted to the hospital a day prior to surgery. Both donors and recipients must not eat or drink anything after midnight before the operation. Deceased donor transplants are performed on emergency basis when a cadaveric liver is available. Patients are called to the hospital urgently; they undergo a rapid review and tests before surgery to ensure that they are healthy and ready for surgery. Patients should not eat or drink anything once they receive intimation for the transplant. After the patients are admitted, the transplant team has a discussion about the quality of organ and transplantation process and ask the patient to sign the consent form after complete understanding of the process. Patients should inform the transplant team about pre existing health problems, current medicines and known drug allergies, to prevent any accidental use and interaction with transplant medicines. If patients develop new unexpected problems such as fever, if review tests show significant change compared to previous reports or if any new concerns or active problems are discovered, they might need treatment first and the transplant might have to be postponed.

The operation

The timings of donor and recipient surgeries are synchronised to ensure minimal ischemia (storage damage) to the liver. In deceased donor transplant, patients’ surgery is started only after donor liver has been examined and found satisfactory. The operation does not start immediately after the patient is taken to the operation theatre as it takes about 2 hours to prepare for the operation. Both donors and recipients undergo the operation under general anaesthesia, where they are put to sleep, with no consciousness, pain, awareness or recollection of the operation. While under anaesthesia, they are put on a ventilator and various lines / catheters (arterial line, central line, endotracheal tube, urinary catheter, naso-gastric tube, etc.) are used to accurately monitor various parameters and allow rapid administration of blood products, IV fluids and drugs. During the surgery, various blood and other tests are continuously performed for monitoring.

Donor operation

The living donor operation involves removal of a portion of the liver and may be done using different types of incisions or even with laparoscopy (keyhole) or robotic surgery. The choice of incision depends on donor’s body habitus and findings during surgery. This decision is best made during surgery. The transplant surgeons always keep in mind the cosmetic results and safety while choosing an incision. The liver is split in two parts as planned pre operatively. One of these parts is removed along with the blood vessels and bile ducts going in and out of the lobe, leaving the other half in the donor with its blood vessels and bile ducts intact. The surgery lasts about 6-8 hours. In addition to the planned portion of the liver, the gall bladder is always removed because it is stuck to the under surface of the liver. A drain tube is kept in the abdomen to monitor any bleeding and the incision line is closed using very fine absorbable sutures or staples.

Recipient operation

The first step is to remove the entire cirrhotic liver (including gall bladder) to make space for the new liver. The cirrhotic liver is shrunken, stiff, with multiple thin-walled blood vessels around it under high pressure and may be stuck to surrounding organs because of previous infection or surgery. This part of the operation is done slowly to minimise chances of bleeding. This is followed by transplantation of the new liver by joining (anastomoses) all blood vessels and allowing blood circulation through the liver. The liver starts working immediately. Bile ducts of the new liver may be joined with the patient’s own bile duct or directly with the intestine. A drain tube is kept in the abdomen to monitor for any bleeding and the incision line is closed using staples. The recipient surgery generally takes 8-12 hours and about 5-10 units of blood and blood products are used, however, in difficult cases, it may be much longer with significantly more blood product requirement. At the end of surgery, the donor is taken off the ventilator and shifted to the ICU for overnight observation; the recipient is generally shifted to the ICU on a ventilator. While the operation is going on, family members should stay in the waiting lounge. The transplant team will talk to them at the end of the surgery.

Post-Operative Care And Recovery After Transplant

Recovery from liver transplantation depends on many factors including the patient’s age, overall health, severity of liver disease, infections, secondary organ dysfunction or complications before or after the operation. Good understanding of the process, moral support and encouragement from family, a positive attitude and strong willpower are important in the patient’s recovery.

In the hospital

Donors

Donors wake up immediately after surgery, although they might feel drowsy for a few hours. They are able to get out of bed in 1-2 days and made to walk in 2-3 days. Various lines, catheters and drains are removed as they recover. Generally, they can have a liquid diet followed by a normal diet in 2-5 days, shifted to the ward in 1-2 days and discharged in 5-7 days. Pain medicines are given depending on their pain threshold. Some patients prefer to take pain medicines before walking or any exercise that may trigger pain or just before going to sleep for a comfortable night. On discharge, they are generally given painkillers and vitamins. Most donors will have an uneventful recovery although some might have mild problems such as fever, loss of appetite, nausea or even vomiting because of slow bowel movement after surgery, which can be treated easily and resolves over time.

Recipients

Patients (recipients) are kept on a ventilator overnight and it is removed when they are fully awake. Patients are closely monitored for any bleeding, infection or other complications. First 24-48 hours are critical and their condition and liver function are monitored by doing frequent blood tests. Various lines, catheters and drains are removed as they make progress / recover over 3-4 days. Patients are given a liquid diet followed by a normal diet in 2-5 days. In patients where the bile duct has been joined directly with the intestine, the naso-gastric tube may be kept longer and diet may be delayed. Patients are helped out of bed in 1-2 days; they participate in the physiotherapy programme, walk in 4-5 days and gradually become more active.

Patients should actively do incentive spirometry to prevent collapse of lungs, prevent lung infections and recover faster. Patients should learn to support their incision with a pillow when coughing. Patients generally do not have a lot of abdominal pain after surgery although they may experience back and shoulder pain because of lying down on the operating table for a prolonged time. Patients are given pain medicines as per their need. Some patients may be confused, agitated or have mood changes because of the effect of sedatives or disturbance in sleep pattern after surgery, it generally gets resolved in a few days. Patients are shifted to the ward in 3-5 days and remain the in hospital for about 10-15 days. At discharge, patients receive anti-rejection medicines, antibiotics and some other medicines.

In both donors and recipients, blood tests, ultrasound and chest x-ray are done regularly to monitor liver function and recovery as per standard protocol. Patient's families are generally updated about their progress by the transplant team once a day or more often, if appropriate. While it is natural for patients and families to be anxious, questions for the transplant team should be asked during the counselling sessions or during ward rounds. Visiting hours and the number of visitors is restricted to prevent infections.

Discharge from the hospital

While the patient recovers from the operation, the family should take the opportunity to learn about precautions to be taken after discharge, understand the schedule for testing and follow-up appointments, become familiar with medicines, learn about the warning signs of potential problems and understand the mechanism to contact the liver transplant team round-the-clock in case of urgent problems. We have daily group counselling sessions for both the patients and the donors and the relatives where they are counselled by our post op coordinators, physiotherapists and the nutritionists. Attending these sessions will help in discharge planning.

At the time of discharge, patients will get a discharge summary with detailed instructions about testing and medication schedule, which should be discussed with the transplant coordinator. Patients also get a copy of the investigation chart, blood sugar and blood pressure monitoring chart, which they should be familiar with and learn how to fill.

After discharge, patients are required to undergo tests and visit the post transplant clinic every 5-7 days. They should therefore stay in the vicinity of the hospital for 4-6 weeks after discharge. The house where the patient would be staying after discharge should be prepared.

Prevention of infections

  • The house should be thoroughly cleaned with disinfectants.
  • The accommodation should be close to the hospital with available transportation 24 hours a day, there should not be too many stairs and the locality should be neat and clean.
  • Patients are encouraged to walk and avoid using a wheelchair.
  • The number of visitors should be restricted for a few weeks.
  • Patients should avoid meeting people who are ill and report any illnesses- fever / flu / cold / persistent cough / pain in abdomen / loose motions or transmissible infections or infectious diseases such as influenza, pneumonia, chicken pox, hepatitis etc.
  • Patients should avoid contact with animals and birds to prevent infection.
  • For the first 2 to 3 months, patients are advised to wear a mask and avoid crowded public places like malls, cinemas, restaurants, department stores, etc. After this, patients can attend social events and live a normal life.

Personal hygiene and wound care

  • Frequent hand washing with soap, especially before eating, should be practiced by all family members and hand washing with antiseptic solution after using the bathroom.
  • Oral hygiene should be maintained by brushing teeth daily and rinsing the mouth after eating.
  • Finger nails should be trimmed.
  • After discharge, dressing might need change 2-3 times a week.
  • Few donors / patients may be discharged with a drain tube in the abdomen, which is removed few days after discharge.
  • While one has wound dressings and drain bags, the body should be cleaned with a wet towel only, fresh washed clothes should be worn daily.
  • Once the wound heals and bags are removed, patients / donors can use waterproof dressings and take normal bath before every dressing change.
  • Donor stitches / staples are generally removed within 2-3 weeks and recipients' within 3-4 weeks, unless absorbable stitches are used which do not need removal.
  • Once the staples are removed, incision should be kept clean and dry. Patients / donors can take a daily shower or normal bath.
  • If the incision oozes some fluid or if the dressing nurse says that there is some infection in the wound, please insist that the nurse speaks to the transplant team immediately.
  • The dressing nurses are trained and will evaluate the condition of wound, decide the frequency of dressing changes and timing of staples / stitches removal, in consultation with the doctor.

Diet and nutrition

Patients’ may have loss of appetite after surgery. The appetite slowly improves with time. However, it is important to take a high protein diet to help with wound healing and liver regeneration. If necessary, the dietician advises supplements in the diet. If patients have preference for a certain type of meal or cuisine, they should check with the dietician.

Foods - how to prepare / consume

  • Food should be cooked hygienically.
  • Wash utensils well before cooking.
  • Wash and cook in clean water.
  • Use boiled / filtered water.
  • Eat small frequent meals.
  • Drink plenty of liquids; intake is not restricted, as before transplant.
  • Salt restriction is not necessary unless one has high blood pressure.
  • Eat plenty of fresh fruits and green leafy vegetables after washing well and peeling off their skin.
  • Consume a balanced, low-fat high-protein diet.
  • Take foods rich in calcium, such as skimmed milk, cheese, soya, eggs, chicken and fish.
  • In a few weeks, patients can resume eating as they did before the transplant.

Foods to avoid

  • Avoid deep fried or greasy foods.
  • Do not eat food left overnight.
  • Avoid raw eggs or mayonnaise.
  • Avoid partially cooked foods.
  • Avoid cold meat.
  • Avoid red meat.
  • Avoid overripe fruits.
  • Do not consume expired packaged foods.
  • If potassium is high, avoid foods such as banana, coconut water, fruit juices / pulp.
  • If blood sugar is high, avoid sweets and fruits such as mangoes.

Activity and exercise

  • At the time of discharge, patients are generally allowed active walking and routine activities like bending or climbing stairs. Regular exercise increases energy level, strengthens muscles and makes one feel more active.
  • It is common to experience weakness and mild abdominal discomfort at the site of the operation, especially with movements for the first few weeks to months after the transplant. Do not postpone exercising because of this reason, in case one has severe discomfort with movements, talk to the transplant team.
  • Perform deep breathing exercise to expand lungs and help cough out sputum.
  • The physiotherapist will teach limb exercises, so that limb muscles are strengthened, blood circulation is increased and the risk of complications such as venous thrombosis is reduced.
  • Speak to transplant physiotherapists to progressively increase the level of exercise and optimise the exercise schedule.
  • Take adequate rest and sleep
  • Avoid lifting heavy weights (>5 kg), including babies or performing abdominal exercises for first 3 months to allow the scar to mature and prevent hernia in the long term.
  • After 3 months, one can resume normal physical activities; perform any exercises, including abdominal exercises, weight training and swimming. These will help strengthen abdominal muscles and flatten the tummy.
Life After Transplant

Resuming your life after transplant

Quality of life

Most patients are able to lead a comfortable and healthy life. After transplant they return to work and enjoy an excellent quality of life.

Work / sports

Most people can return to their normal daily activities, 2-3 months after surgery. Children can resume schooling after 3 months. Playing sports and getting healthy exercise is possible after 3 months although it is advisable to avoid contact sports such as boxing, karate, rock climbing etc. for 6 months. It may take longer for patients who were very sick before the transplant. Initial family support is very crucial to leading an active and productive life in the long term.

Driving / travelling

Most patients resume driving in about 2 months after a transplant. It is recommended that patients should not drive themselves after taking pain medications as they may contain narcotics. If the seat belt rubs against the wound and bothers, one can place a towel between the abdomen and the seat belt. Most patients can undertake occasional train / plane travel in 2 – 3 months. If one is travelling to another city or country, discuss the trip with the transplant team to make sure that the patient carries enough supply of medications and is put in touch with a doctor locally who can take care of urgent problems.

Sexual activity / pregnancy / breastfeeding

There are no restrictions on sexual activity and these may be resumed when one feels comfortable. Donors can resume sexual activity in a month, and recipients in 2-3 months. Women should not conceive for up to 6 months after donation and 12 months after transplantation. For recipients, use of oral contraceptives and hormones should be done in consultation with the hepatologist and gynaecologist. Recipients who are planning to conceive should discuss the same with the transplant team as some medicines may have damaging effects on the child or may be passed into breast milk causing problems in nursing babies. Some medicines might have to be stopped or changed before pregnancy.

Dental care

The patient should see the dentist every 6 months and the dentist should be told about the transplant, as you might have to take antibiotics before any dental procedure.

Follow-up: e-mail and visits

Once discharged, the donor / patient, should perform regular tests as per given schedule and e-mail their reports in the format given by the transplant coordinator. Patients have to visit the hospital for follow-ups as per schedule given and these should be accompanied with detailed tests.

Possible complications after liver transplant

Doctors and coordinators from the transplant team discuss various possible complications and risks of transplant before surgery, although it is important to remember that very few patients experience any of them. Most of these problems can be diagnosed easily and treated in time. Complications after liver transplant may occur early (within 1 month) or late. Some early complications patients may experience are

  • Bleeding: Patients may have bleeding after the operation, which can be controlled with medicines and blood products, but may rarely require re-opening of the abdomen to stop the bleeding.
  • Primary non-function: Rarely the transplanted liver may not work well called as primary non-function. It is more common in deceased donor transplantation and may require an emergency re-transplantation.
  • Thrombosis: A blood clot in an important blood vessel of the liver (hepatic artery, portal vein or hepatic veins) is a serious problem and may require an urgent CT scan, angiography, liver angioplasty, or re-operation to remove the clot or even re-transplantation.
  • Bile leak: Bile may leak from the anastamosis (joint) of the bile duct or cut edge requiring further tests. It may either resolve spontaneously in a few weeks, or may require putting a stent in the bile duct by endoscopy or by a radiologist. Another operation to fix the leak is uncommonly required.
  • Post operative infections: These can usually be identified and treated effectively with antibiotics, anti-fungal and antiviral drugs depending on the type of infection. Immunosuppressant drugs reduce patient’s resistance to infection and make infections harder to treat, especially if the infecting organism is resistant to antibiotics or if patients are weak. CMV (cytomegalovirus) infection is common in transplant patients. The risk of infection becomes less as the requirement for anti-rejection medicines reduce over time. If there is a white coating on the tongue, the transplant team should be informed as it may be a fungal infection known as oral thrush. Women are more prone to vaginal yeast infection.
  • Rejection: it is the patient’s immune system’s attempt to mount a response against the newly transplanted liver as the donor liver always retains its original immunological identity, which is different from that of the patient. It is prevented by taking anti-rejection immunosuppressive medicines. If these are not taken, even many years after the transplant, rejection may happen; therefore, they have to be taken lifelong. Rejection does not always make one feel ill or have any symptoms and is commonly diagnosed through blood tests or a liver biopsy. Mild rejection is common, especially in the first few months, however it does not mean that one is losing the liver, like it is commonly perceived, it is not a serious problem because it can be treated and reversed with higher doses of anti-rejection medicines and steroids and does not cause loss of liver function in the long term. Some patients may experience complications few months after surgery.
  • Biliary Stricture: In few patients, a stricture (blockage) may form in the bile duct, which can be diagnosed using a type of MRI called MRCP and may require opening up the blockage and putting a stent in the bile duct either with endoscopic or by a radiologist. Very uncommonly another operation may be required where the bile duct is joined directly to the intestine.
  • High blood sugar (diabetes): Patient may temporarily become diabetic following transplantation because of new medications. However, in most cases it recovers over few weeks to months, hence monitoring and regulating sugar intake is important.
  • High blood pressure (hypertension) is more common and generally requires medical treatment.
  • High cholesterol and weight gain: Some medicines prescribed after the transplant may cause one to gain weight, or raise cholesterol levels. Diet control and regular exercise can help counter these effects, although cholesterol lowering medications may be required in some patients.
  • Brittle bones (osteoporosis): The use of steroids in the long term can cause thinning of bones, especially in women and patients with primary biliary cirrhosis (PBC). Calcium supplementation and regular exercise are important to contain damage to the bones.
  • Cancer: Anti-rejection medicines weaken immune system and make patients more susceptible to certain kinds of cancers. Higher likelihood of skin cancer in those patients with significant sun exposure. Use of sun-blocks prevents skin cancer. Avoid smoking or tobacco use because the risk of throat or lung cancer from these habits increases manifold after transplant. Yearly cancer screening for cancer prevention helps too.
  • Disease recurrence: Certain liver diseases can recur in the transplanted liver, especially viral hepatitis (HBV and HCV). Howe ver, most of these cases can be effectively treated with anti-viral drugs. Liver cancer may recur after transplant, the risk of recurrence depends on the size and number of tumours and involvement of small blood vessels on biopsy.

Disease specific out come after transplant

Depending on the cause of liver disease, the experience may differ for patients.

Hepatitis C (HCV)

Although liver transplant cures cirrhosis of the liver, HCV infection remains in the blood and other organs in the body and can infect the new liver as well. With the newer oral medications available, HCV infection is generally treated a few months after transplant with good success rate. Only 30 % of them may need treatment for HCV after transplant.

Hepatitis B (HBV)

Current medical treatment for HBV allows us to control HBV infection in almost all patients before transplant, thus the chances of re-infection in the new liver is low.

Alcoholic liver disease

Patients with alcoholic liver disease are offered transplantation only if they are committed to abstinence from alcohol for the rest of their lives, for which at least 3 months of abstinence period before transplant is required, unless they have a life-threatening problem and cannot wait. This is because even small amounts of alcohol use after transplant can not only damage the graft but negate all efforts that go into the transplant.

Hepato-pulmonary syndrome (HPS)

Patients who undergo liver transplant because of HPS generally are unable to maintain oxygen levels in their body because of microscopic shunts in the lungs. These shunts close down after transplant in a few weeks to months. HPS patients may require more duration in the ICU or hospital and may continue to need oxygen therapy for a few months after transplant.

What is the role of stem cell therapy or hepatocyte transplant in liver failure?

Stem cell therapy or hepatotocyte transplantation holds promise for future as an alternative to liver transplant. However, they are currently at an experimental stage and may be offered only as a part of clinical trial. From the research done so far, it is clear that these therapies may be more suitable for certain group of patients such as children with metabolic diseases and patients with acute liver failure. The protocols for such therapies have not been standardised and they are not approved for clinical use by the FDA (Food and Drug Authority).

Will my gall bladder be removed at the time of liver donation / transplant?

Yes, gall bladder is closely attached to the undersurface of the liver and it is a standard step to remove the gall bladder during any liver surgery and it will be removed during both the donor and recipient surgeries along with the liver. The gall bladder is a storage organ for bile, which temporarily stores bile, which is formed by the liver. After removal of gall bladder, bile formed by the liver directly goes into the intestine for digestion. Removal of gall bladder does not harm in any way nor influence digestion as is commonly perceived. This fact is very well studied from thousands of gall bladder removal surgeries done every day to treat gall bladder stones.

What kind of matching is required between the patient and donor for liver transplant? Is same blood group donor better than compatible blood group donor?

Fortunately, liver is a very sturdy organ and is relatively privileged because the immune system does not mount a strong reaction against it. If the donor has compatible blood group, they can be accepted for transplant. Rejection if it happens, is generally mild. HLA testing and tissue cross match is not required (as is done for kidney and some other transplants), however, HLA testing maybe required for legally establishing relationship between blood relatives.

What is the success rate of liver transplant?

All donors are expected to recover well after the surgery. However, it is a complex major surgery with a very small risk. Recipient success hugely depends on their pre operative sickness. Patients who are stable and active and have less severe liver disease are expected to have better outcomes compared to very sick patients who are in the ICU on ventilator requiring support. Overall, 90 - 95% success can be expected depending on severity of liver disease.

After transplant / liver donation, when can I occasionally take alcohol?

No, patients cannot have alcohol in any form in any quantity at any time after transplant because even a small amount of alcohol can cause significant damage to the transplanted liver. Donors may be able to drink alcohol socially 1-2 years after transplant.

Is it more difficult to do a transplant in a child?

Yes, it is because the minute blood vessels in them are difficult to join, their post operative care can be done only by doctors trained and experienced in paediatric critical care and transplantation and there are few of them available.

How many years will my transplanted liver last?

The new liver will last you a life-time if you take good care of it. Regular tests and follow-up with the transplant team and medicines as prescribed are the most important things to enjoy good health and normal lifestyle after transplant.

What is the law about transplant in India? What is the procedure for cadaver donation? Can the hospital arrange a living donor if I pay money?

The Transplantation of Human Organs Act, 1994 lays down the definition of ‘brain-stem death’ (commonly called as ‘cadaver’). Once brain-stem death is diagnosed by authorised doctors using specified criteria, the family may donate the organs for transplantation to save lives of many. Law has laid down the procedure to be followed for living related transplantation and imposed very stringent penalties for any violation of the act or organ trading. Every case of living donor transplantation has to be reviewed and approved by the government appointed authorisation committee before transplantation. For any living donor transplantation, the donor has to be a family member of the patient and cannot be allowed to donate by paying money. The law has been an effective step by the government in curbing illegal unrelated transplantation.

Where can I get more information about liver transplant?

You can call on duty and coordinators, The best source of information are transplant coordinators and patients who have undergone a transplant in the past. One can search the web for information available. Most websites hosted by governments are reliable such as UNOS (United Network for Organ Sharing), Europeon Liver Transplant Registry (ELTR)etc. Liver disease scoring systems such as MELD and CTP are available as online calculators. Information on some other websites, chat groups or blogs may be misleading and don’t always give true information. Patients are advised to check the information collected with the transplant team and ask questions whenever in doubt.

Paediatric liver transplantation

Frequently asked questions

Most of the information provided in this booklet on liver transplantation is common, however, there are few issues which need special emphasis and have been covered in the subsequent pages.

What are the indications of liver transplantation in children and adolescents? Indications for liver transplantation are:

  • Cholestasis: biliary atresia, progressive fulminant intrahepatic cholestasis, Alagille’s, neonatal hepatitis
  • Metabolic: Wilson’s disease, galactosemia, hereditary fructose intolerance, tryrosinaemia, 1 anti trypsin, bile acid disorders, storage disorders – glycogen storage disorders
  • Chronic hepatitis: hepatitis B and C, autoimmune disease, nonalcoholic fatty liver disease (NAFLD)
  • Non-alcoholic fatty liver disease (NAFLD)

Acute liver failure

  • Fulminant hepatitis: viral hepatitis (A,E,B,C others), autoimmune hepatitis, drugs and poisoning (including paracetamol poisoning)
  •  
  • Metabolic liver disease: tyrosinemia, Wilson’s disease, fatty acid oxidation defects, neonatal haemochromatosis, galactosemia

Inborn errors of metabolism

  • Criggler-Najjar syndrome type-1
  • Organic acidemias
  • Urea cycle defects like maple syrup urine disease (MSUD)
  • Primary oxalosis

Hepatic tumours

  • Benign tumours that have replaced the whole liver
  • Malignant, without extrahepatic metastasis
  • Certain rare conditions such as factor VII deficiency, protein C and protein S deficiency
  • Common indications in children are cholestatic liver disease, mostly biliary atresia, metabolic liver disease and acute liver failure.

Who needs a liver transplant?

The primary indication for OLT are the symptoms of end-stage liver disease and the prognosis is assessed by Child Pugh score, MELD Score (>12 yrs), PELD Score (<12yrs). Consider OLT early in patients who do not achieve clearing of jaundice by 3 months, following Kasai in patients with extrahepatic biliary atresia. OLT as the primary treatment for biliary atresia may be indicated only for patients>120 days of age with an enlarged hard liver and decompensated cirrhosis. Also if the quality of life, the number of days spent in hospitalisation, limitation of day to day activities and well-being is affected because of liver disease, that in itself is an indication for liver transplant. Growth retardation due to underlying liver disease is another indication of liver transplant.

What does pre transplant evaluation include?

Besides the patient evaluation for liver transplantation as mentioned in the previous section, the pre-transplant evaluation in a paediatric liver transplant includes the following issues:

Immunisations pre-transplantation

Most units including ours, consider live vaccines to be contraindicated after liver transplant because of the risk of dissemination secondary to immunosuppression. It is therefore better to complete normal immunisations before transplant. These include – BCG, DPT + Hib, hepatitis B, measles, MMR. It’s suggested to give even optional vaccine such as hepatitis A, typhoid, chickenpox, influenza rotavirus and pneumococcal vaccines. The vaccination schedule may be expedited and may differ from the normal recommendations. Our target is to especially complete the live vaccination prior to transplant. Following live vaccination, liver transplant surgery is deferred by 2-3 weeks. In acute liver failure scenario, the doctor does not have time to look into this issue as the need for liver transplant is on an urgent basis. However, killed vaccines like tetanus, hepatitis B vaccines are especially given if need be.

Management of hepatic complications

It is important to ensure that specific hepatic complications are appropriately managed while the patient waits for transplant. These include portal hypertension, oesophageal varices, ascites, hypoproteinemia etc.

Nutritional support

It has been demonstrated in several studies that nutritional status at liver transplant is an important prognostic factor in survival i.e. better outcome is seen in patients with good nutritional status. The patient needs to be on a high calorie diet (150- 200% calories good protein intake) with two times the RDA of multi vitamins and in patients with cholestasis supplementation with fat soluble vitamins like vitamin A,D,E,K is done. In patients with cholestasis MCT oil, as in coconut oil, is used for cooking. If a child is not able to feed well orally then tube feed supplementation is done, which could be for overnight feeds or during the day as per the need. Efforts are made especially in small babies to improve their nutrition and weight, however, occasionally despite good calorie intake one is not able to achieve improvement in weight, in that scenario the doctor may decide to proceed for liver transplant even at a low weight. Thus, the decision of timing of liver transplantation will need to be individualised to patient.

How many bloods are to be arranged for liver transplant surgery?

Number of units of blood and blood products to be arranged for a child are less than what we need for adults. On an average 4-6 units each of packed cells, FFP and 1-2 units of platelet apheresis are arranged.

How to increase the donor pool for liver transplant in children?

The donor pool can be increased for paediatric liver transplant cases by using split livers i.e. a single deceased (cadaveric) donor liver is divided into right and left portions that are implanted into two recipients simultaneously, usually the right lobe in adults and left / left lateral lobe is given to children. ABO incompatible donors may occasionally be used in children as the antibodies are not formed in young age. So the chances of rejection are less. In ABO incompatible liver transplants, usually few sessions of plasmapheresis are carried out in the patient a week prior to the transplant and the cost of transplant would accordingly increase. Another option of increasing the donor pool is swap donor, which means when the same blood group donors are not available, the donors of 2 different patients with similar problem donate to each other. In a paired donor exchange, also known as a liver swap, two liver recipients essentially “swap” willing donors. While medically eligible to donate, each donor has an incompatible blood type or antigens to his or her intended recipient. By agreeing to exchange recipients—giving the liver to an unknown, but compatible individual-the donors can provide two patients with healthy livers where previously no transplant would have been possible.

Is liver transplant surgery in children technically more difficult?

Yes, liver transplant in children is technically more difficult and requires much more expertise, as the blood vessels and bile duct in a child and especially whose weight is < 10 kg are very small. Also majority of paediatric patients being post Kasai (post biliary atresia surgery), chances of adhesions are much more inside which make it all the more difficult to operate for surgeons.

Is the anaesthetic care during surgery in children different from adults?

Yes, the anaesthetic care in children is also different as the lung volumes are less and chances of intraop bleeds due to adhesions inside, are much more which need to managed and at the same time volume overload has to be avoided. There is relatively a narrow margin as compared to adults. Anaesthetists experienced in paediatric care are ideal.

How does post transplant care different in children?

Post transplant care of paediatric patients has to be done by specialised paediatric intensivists and nurses trained in paediatric intensive care. Post transplant paediatric patients, in addition to the care needed for adults, may sometimes require prolonged ventilation, and ICU stay. Also as a lot of patients have Roux en Y surgery for bile ducts, so feeds are delayed till around 3rd day post-op. Their need for analgesia is also a bit higher. They also require regular chest physiotherapy; else lungs would develop collapse consolidation. Physiotherapy in small babies and children requires experts.

What about medicines post liver transplant?

To make the baby comfortable we like to use music, TV with child friendly programmes and toys which can be washed cleaned by sterilium. Stuffed toys are to be avoided.

Immunosuppression

Following liver transplant the patient requires immunosuppression usually for life long (according to the present consensus). There are 3 drugs, tacrolimus, mycophenolatemofetil and steroids. Steroids are discontinued first followed by mycophenolatemofetil. Thereafter patient is on 1 immunosuppressive drug, usually tacrolimus, which needs to be taken twice a day daily. The caretaker must ensure that regular blood tests are done to monitor the liver functions, kidney functions and immunosuppressive drug levels as advised by the doctor. After the initial couple of years, the frequency of testing may be reduced to once in a quarter of a year.

What’s life after liver transplantation in a child or adolescent?

Children who survive liver transplant will usually achieve a normal lifestyle despite the necessity for continuous monitoring of immunosuppressive drug levels. They attend normal school sports, activities etc. Most children are able to resume daily life after 3 months of transplant and sports after 3-6 months of transplant. Most studies from large paediatric liver transplant centres show a patient survival of 90% at 1 year and >85% at or beyond 10 years. Usually there are no significant issues related to mortality after this. Patients usually lead a normal life. There are patients who have been operated as children / adolescents and have also produced children. Patients take part in sports, normal activities and there are examples of children who’ve climbed mountain peaks. However, regular follow-up with doctor is a must to monitor the organ functions and side effects of immunosuppression. Occasionally adolescents may defer from their normal routine of medication and in such a scenario, it is very important to have the adolescent counselled from the doctor.

Liver transplant follow-up plan

Brief test panel Routine test panel Detailed test panel
  • Complete blood count (CBC)
  • SGOT
  • Creatinine
  • Complete blood count (CBC)
  • Liver function tests (LFT)
  • Sodium (Na)
  • Potassium (K)
  • Creatinine
  • Tacrolimus (tac) or cyclosporine (C0, C2) or sirolimus level
  • Complete blood count (CBC
  • Liver function tests (LFT)
  • Sodium (Na), Potassium (K)
  • Creatinine
  • Uric acid
  • Hb A1C
  • Lipid profile
  • Chest x-Ray
  • Urine routine / microscopy
  • Urine culture / sensitivity
  • Ultrasound abdomen + liver doppler
  • Tacrolimus (tac) or cyclosporine (C0, C2) or sirolimus level
  • serum mg
Please alternate between brief and routine panel of tests

Every 1 week for 3 months, then

every 2 weeks for next 3 months, then

every 1 month for next 2 years, then

every 2 months life-long

Every 3 months for 1 year, then

every 6 months life-long

Hepatitis B (HBV) panel

Anti HBs (titres) Every 1 month before every dose of HBIg
HbsAg Every 6 months life-long
HBV DNA

Hepatitis C (HCV) panel

HCV RNA Every 6 months
Liver biopsy Every 1 year

Hepatocellular carcinoma (HCC) panel

AFP and USG abdomen Every 3 months for 2 years, then
Every 6 months life-long
CECT scan abdomen Every 6 months for 2 years, then
Every 1 year for next 3 years

Contact transplant team

Please e-mail all reports to Liver.colasia@gmail.com. Follow-up visits at Columbia Asia Hospital Yeshwanthpur (with reports of detailed test panel).

Indian patients : every 3 months for 1 year, then every 6 months life-long.

International patients: Every 6 months for 2 years, then every 1 year life-long.

Law Related To Liver Transplant
  • A coordination committee is constituted by the state government to oversee all transplant related issues.
  • Only licensed hospitals can conduct liver transplants.
  • All liver transplants require prior approval from the competent authority/ hospital based authorization committee / state authorisation committee.
  • Live donation from “near relative” - spouse, son, daughter, father, mother, brother, sister, grandfather, grandmother, grandson or granddaughter is encouraged.
  • Cadaver transplant is encouraged from brain-dead persons.
  • Where any human organ, tissue or both are to be removed from the body of the person in the event of his brain stem death, such removal requires the approval of the board of medical experts in the manner prescribed by the Act and the Rules thereunder.
  • In the event of the donor and recipient being 'near relatives' and either of them is a foreign national, the approval of the state authorisation committee or hospital based authorization committee, (constituted as per the Act and Rules) is mandatory.
  • Unrelated donors who donate for altruistic reasons should be cleared by the authorisation committee duly appointed by the Government.
  • There shall be no money transactions between donor and recipient. The Act prescribes punishment for persons who are commercially dealing in human organs and also for removal of human organs without authority.
Our Multi-Disciplinary Transplant Team

Management of ESLD and its multisystem effects is complex and requires the expertise of a group of healthcare professionals including several doctors and trained staff, who have special training and experience in transplantation.

  • Liver transplant surgeons
  • Transplant hepatologists (liver physicians)
  • Anaesthesiologists
  • Critical care specialists (ICU doctors)
  • Radiologists (diagnostic and interventional specialists)
  • Transplant coordinators
  • Operation theatre staff and nurses
  • ICU and ward staff and nurses
  • Blood bank personnel
  • Cardiologist
  • Pulmonologist (lung specialist)
  • Psychiatrist
  • Nutritionist and dietician
  • Physiotherapists / play therapists (for children)
  • Haematologist, biochemist, pathologist and microbiologist

The transplant team will discuss between them all treatment options for each patient, help them choose the right treatment and follow the best available practices and standards in healthcare.