Dr Shailendra Lalwani
Liver Transplant Surgeon at Manipal Dwarka
Who needs a liver transplant?
Most common reason for needing a liver transplant is cirrhosis. In cirrhosis healthy liver cells are destroyed and replaced with scar tissue. The severity of liver disease is graded from A to C based on Child’s scoring or calculated according to a newly devised formula known as the MELD score. Usually all grade C and most grade B (with complications of cirrhosis) patients are candidates for transplant.
Some causes of cirrhosis are
- hepatitis B or C virus
- drinking too much alcohol over time
- autoimmune liver diseases
- excess fat or uncontrolled diabetes
- hereditary liver diseases.
Other reasons for needing a liver transplant include
- acute liver failure, most often caused by viruses (hepatitis A or E) or taking too much acetaminophen
- liver cancers that have not spread outside the liver.
In children, the most common reason for needing a liver transplant is biliary atresia.
Symptoms of liver failure due to cirrhosis
- blood vomiting or black stools
- water in the abdomen (ascites) or infection in the fluid
- drowsiness and mental confusion
- excessive bleeding from minor wounds
- jaundice
- decreased urine output
Evaluation for the patient for liver transplant
If someone have liver disease and are, being considered for liver transplantation he would have to undergo extensive investigation. Because end stage liver disease has harmful effects on many other organ systems of the body, a multidisciplinary team works together to care for you. This team includes Transplant surgeons, Anaesthesiologists, Cardiologists, Chest physicians, Dental surgeons, Psychiatrists and Gynaecologist (if patient is female).
The evaluation is done in the following steps.
- To find out the cause of the chronic liver disease
- Examination to assess fitness for the transplantation procedure
- Authorization Committee clearance
Evaluation of the liver donor
Liver donor needs to be from family or relatives.
The donor’s blood group should be compatible with patient.
The table below is a guide for this.
| Blood group | Can donate liver to | Can receive a liver from |
| O | O, A, B, AB | O |
| A | A, AB | A, O |
| B | B, AB | B, O |
| AB | AB | A, B, AB, O |
In a person who has a normally functioning liver, 60%–70% of it can be safely removed. In an adult patient the right lobe is generally taken as the graft as it constitutes 60% of the liver volume, while the left lobe is 40% of whole liver volume and is generally used as a graft in small adults or in children. For children, only part of the left lobe the left lateral segment is removed for the graft. The liver has a capacity to regenerate very quickly and the liver that is left behind in the donor grows back to its normal size in 6weeks to 3 months.
Average hospital stay for the donor is 7 days. Liver functions return to normal by 5–6 days following surgery.
The donor should avoid strenuous activity and lifting heavy weights for 3 months following surgery. However he/she can resume daily activities and jobs which do not require physical exertion.
The Living donor liver transplant operation
In its essentials, the operation involves removal of the diseased liver of the patient and its replacement with a portion of the donor’s liver. Normally the donor operation begins first and the recipient operation is begun after looking at the donor liver to make sure there are no unexpected problems.
RECIPIENT SURGERY
Your diseased liver must be removed before the donor liver can be placed in your abdomen. This is often the most difficult part of the operation. The liver has to be removed in such a way that the blood vessels which carry blood into the liver, the bile duct and the blood vessels which carry blood out of the liver are long enough and otherwise suitable to be joined to those of the donor liver.
After removal of the patient’s liver the part of the liver, which is removed from the donor, is implanted in the patient. Implantation is the process of putting the new liver in place of the old one and joining the blood vessels and bile ducts of the new liver to those of the recipient. This typically takes about 2-4 hours.
RECOVERY
After surgery patient is shifted to the ICU on the ventilator. Next day if recovery is satisfactory ventilator is taken off. The ICU stay is typically 3–5 days after which patient is shifted to a room. The typical duration of stay in the hospital is about 14 days.
Complications after liver transplant
As with any other surgery, complications may occur after a liver transplant operation. It is important to be aware of these complications and risks but this does not necessarily mean that you will experience all or any of them. Some of the major postoperative complications related to liver transplant are given below:
- Haemorrhage
It is expected that your new liver will start working very quickly to help prevent any untoward bleeding,but you may have to be re-operated if the bleeding is excessive.
- Thrombosis
A blood clot in the vessels (hepatic artery, portal vein and hepatic veins) leading to or from your liver may injure your new liver. This is a serious complication which may require a second transplant.
- Rejection
Your body’s immune system protects you from invading organisms. Unfortunately, it also see your new liver as foreign and will try to destroy it to protect you. This is known as rejection. To prevent this, immunosuppressive medications are given which will continue for the rest of your life.
- Infection
You may have to take medication to help prevent infections but you will have to be careful and avoid contact with infected people, especially during the first six months after a transplant.
Follow up after discharge
The liver transplant operation generally has good results but it is important that you keep in close touch with your doctor and follow his or her advice. Failure to take your immunosuppression medication is dangerous and is the foremost cause of rejection, which may lead to organ failure. Close follow up with your transplant team can help ensure a good outcome.
Care after liver transplant
MEDICATION
- Do not change or discontinue on your own the medications prescribed by the liver transplant team.
- Please keep the investigation chart and medication record updated regularly.
DIET AND NUTRITION
- Small and frequent meals are advisable.
- Buy fresh fruits and vegetables
- Food must be washed and cooked in clean water.
- Wash utensils before use.
- Drink boiled water only.
- Do not take food that has been left overnight.
- Peel off the skin of fruits and salad vegetables before consuming them.
- Avoid alcohol as it damages the liver.
- Avoid food containing raw eggs or mayonnaise.
- Take foods rich in calcium such as skimmed milk, cheese, soya, eggs, chicken, fish and green, leafy vegetables.
EXERCISE
- Do deep breathing exercises as these help your lungs to expand and enables you to cough up sputum.
- Take adequate rest and sleep.
- You should progressively increase the level of exercises to strengthen your leg muscles
- After 3 months you can do almost all exercises such as sit-ups, abdominal exercises and swimming to tighten the
abdominal muscles and flatten your tummy.
DENTAL CARE
- Maintain your oral hygiene.
OTHER DOs AND DON’Ts
Avoid smoking: smoking damages the lungs, putting you at greater risk for lung infections, including bronchitis, emphysema and pneumonia.
Driving: You should speak with your doctor before driving for the first time after your transplant. You will not be able to drive for approximately 2-3 months after your transplant.
Sexual activity: It is common for transplant recipients to resume a more normal lifestyle, including sexual activity, as they recover.
Family and pregnancy: Some people want to start a family once they have had a transplant and have recovered. However, we recommend waiting for a period of 2 years following liver transplant.
