Liver Transplantation

What is Liver Transplantation? 

Liver transplantation is a surgical procedure to remove a diseased or injured liver and replace it with a whole or a portion of a healthy liver from another person, known as the donor. The liver is the largest internal organ in the body, performing many critical functions, including detoxifying harmful substances, purifying the blood, making vital nutrients, and fighting infections.

Who is Suitable for Liver Transplantation?

Candidates for liver transplantation typically have chronic liver diseases that have led to irreversible damage and scarring (cirrhosis) or those with liver failure or certain types of liver cancer. Common conditions that may lead to the need for a transplant include:

• Chronic Hepatitis (B, C)
• Alcoholic liver disease
• Non-alcoholic fatty liver disease (NAFLD)
• Autoimmune liver diseases
• Metabolic diseases such as hemochromatosis and Wilson's disease
• Biliary cirrhosis
• Liver cancer

Patients with active infections, advanced heart or lung disease, active substance abuse issues, or those who cannot comply with the medical regimen are usually considered unsuitable for liver transplantation. This is a complex decision-making process, with each case considered individually.

Benefits of Liver Transplantation

• Prolongation of Life: A liver transplant can significantly prolong life for individuals with end-stage liver disease or acute liver failure.
• Improved Quality of Life: After recovery from the surgery, many liver transplant recipients can lead normal, productive lives. The constant fatigue and discomfort associated with severe liver disease are often resolved.
• Resolution of Liver Disease Symptoms: A liver transplant can help resolve many symptoms of liver disease, such as jaundice, severe itching, ascites (fluid accumulation in the abdomen), and hepatic encephalopathy (mental confusion due to liver disease).

Types of Liver Transplantation

• Deceased Donor Transplant: This is the most common type of liver transplant. The liver is taken from a deceased donor who has expressed wishes to donate or whose family has consented after their death.
• Living Donor Transplant: A portion of the liver is taken from a living donor. The liver can regenerate, allowing the donor and recipient to have functional livers.
• Split Donation: This involves dividing a deceased donor's liver between two recipients, an adult and a child. This type of transplant helps to make the best use of available organs.
• Auxiliary Transplantation: A portion of the recipient's diseased liver is replaced with a portion of a healthy liver from a donor. This technique can be used for patients with certain types of metabolic disorders or acute liver failure, where there is a chance that the remaining native liver may recover.

Alternative Options to Liver Transplantation

• Medication: Medication might help control the condition and slow the progression of certain types of liver diseases.
• Diet and Lifestyle Changes: In diseases like non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease, lifestyle changes such as cessation of alcohol, a healthy diet, and regular exercise can help manage the condition.
• Tumour Ablation Procedures: For certain types of liver cancer, local ablation procedures (like radiofrequency ablation) can be considered if a transplant is not an option.
• Liver Dialysis: In some cases, liver dialysis can be used temporarily for patients with acute liver failure or as a bridge to transplantation. It involves removing the blood from the body, cleaning it outside the body, and then returning it to the body.
• Liver Regeneration Therapies: Although still in experimental stages, there are ongoing studies to develop methods to regenerate a person's liver using stem cells.

While these alternatives may help manage liver disease symptoms, they are typically not cures, particularly for end-stage liver disease. For many patients with advanced liver disease, a liver transplant is the best option for long-term survival and quality of life.

What to do Before a Liver Transplantation?

Before liver transplantation, you will be thoroughly evaluated by a team of doctors and specialists. This is often called the pre-transplant evaluation. Steps typically include:

• Physical Examination: Checking overall health status and identifying any other health issues.
• Laboratory Tests: Blood tests, imaging studies, and possibly a liver biopsy to determine the extent of the liver disease and overall health.
• Psychosocial Evaluation: Assessing your mental and emotional health, your support system, and whether you can follow a strict post-transplant care plan.
• Financial Counseling: A financial counsellor will help you understand the transplantation cost, including post-transplant care and medications.
• Meet with the Transplant Team: You'll meet with the transplant surgeon, transplant hepatologist, transplant coordinator, and other healthcare professionals who will be part of your care.

If you're deemed a good candidate for transplant, you'll be placed on a national organ transplant waiting list. It's crucial to stay as healthy as possible during this period, including diet changes, medication, regular medical appointments, and possibly hospitalisations.

Liver Transplantation Procedure

During liver transplantation, you will be placed under general anaesthesia, meaning you will be asleep and not feel any pain. The procedure typically proceeds as follows:

• Incision: The surgeon makes a large incision across the upper part of the abdomen to access the liver. The shape and size of the incision may vary based on the surgeon's approach and your anatomy.
• Removal of the Diseased Liver: The surgeon disconnects the diseased liver from the bile ducts and blood vessels that deliver blood to the liver. Techniques to minimise blood loss are utilised, and blood transfusion is available.
• Placement of the Donor Liver: Once the diseased liver has been removed, the donor liver will be placed in your body.
• Reattachment: The surgeon then reconnects the bile ducts and blood vessels to the new liver to ensure proper blood flow and bile drainage. The positioning has to be precise to ensure the liver functions correctly.
• Closure: Once the new liver is successfully connected and the surgeon confirms that the liver is receiving good blood flow and producing bile, the incision will be closed with sutures or surgical staples. A drain may be placed to help reduce fluid accumulation in the area.
• Monitoring: After the surgery, you will be taken to an intensive care unit (ICU) to closely monitor your condition and the function of the new liver.

The entire procedure typically takes between 6 and 12 hours, depending on the complexity of the operation. It requires a team of surgeons, anesthesiologists, and nurses specially trained in liver transplantation.

Liver Transplantation Recovery Plan

After a liver transplant:

• Monitoring: Your transplant team will monitor you closely for signs of complications. They'll adjust your medications and care as needed.
• Medication: You'll take medications for the rest of your life to suppress your immune system and prevent it from attacking your new liver, a condition known as rejection. These are called immunosuppressive medications.
• Follow-up Appointments: Frequent follow-up visits are necessary. They'll be more frequent initially, and the frequency usually decreases over time.
• Lifestyle Changes: You'll need to make lifestyle changes to keep your liver healthy, such as avoiding alcohol, adopting a healthy diet, not smoking, and exercising regularly.
• Rehabilitation: Physical and occupational therapy might be necessary to regain strength and independence with activities of daily living.
• Support: Psychological and social support is important to cope with feelings and challenges that might arise post-transplant.

Liver Transplantation Prognosis

The prognosis after liver transplantation can vary widely, depending on a variety of factors, such as the recipient's overall health, the donor's liver, and other medical conditions. However, generally, the prognosis is quite good.

According to data from the Organ Procurement and Transplantation Network in the U.S., as of 2021:

• One-year survival rates are approximately 85-90%.
• Five-year survival rates are around 70-75%.

These rates continue to improve with ongoing improvements in surgical techniques, immunosuppressive drugs, and overall patient care.

Liver Transplantation Risks

Like any major surgery, liver transplantation carries risks, including:

• Rejection: The recipient's immune system may treat the new liver as a foreign object and attempt to destroy it.
• Infection: Immunosuppressant drugs that prevent rejection can make patients more susceptible to infections.
• Bleeding: As with any surgical procedure, there's a risk of bleeding during or after the operation.
• Bile Duct Complications: These could include leaks or strictures (narrowing) of the bile ducts.
• Blood Clots could form in the large vessels leading to and from the liver.
• Side Effects of Immunosuppressants: These can include high blood pressure, high cholesterol, kidney damage, diabetes, bone thinning, and increased risk of certain types of cancer.

What If Liver Transplantation Is Delayed?

Delay in liver transplantation can have severe consequences, given that patients who are candidates for transplantation typically have end-stage liver disease or acute liver failure. Possible implications include:

• Worsening of Liver Function: As the disease progresses, the liver's function will continue to deteriorate, which can lead to life-threatening complications.
• Development of Additional Health Issues: These can include kidney dysfunction, ascites (fluid in the abdomen), hepatic encephalopathy (confusion due to liver failure), and increased risk of infections.
• Increased Risk of Death: Many end-stage liver disease patients have a poor prognosis without a transplant. The risk of death increases the longer a transplant is delayed.

While waiting for a transplant, patients are closely managed by their healthcare team to slow the progression of liver disease and manage any complications that arise. The patient's position on the waiting list is based on their Model for End-Stage Liver Disease (MELD) score, which considers how urgently they need a liver transplant.