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Liver Transplant in India

Liver                                                                                                             Human Liver


Liver is the largest internal organ, which weighs about approximately 3 pounds in adults. It is situated on the right side of the belly, and protected by the rib cage. Structurally liver is divided into two large lobes, which are called as the right and the left lobes. Just below the liver gallbladder is located, along with parts of pancreas and intestines. Liver along with these organs work together to digest, absorb, and process food.


Functions of liver

Main function of liver is to filter the blood coming from the digestive tract, before it passes to the rest of the body. The liver also detoxifies chemicals and metabolizes drugs.

                                    Functions of a Liver

  • Liver regulates most of the chemical levels in the blood and excretes a product called "bile," which helps carry away waste products from the liver

  • It detoxifies the blood ,that is to get rid it of harmful substances such as alcohol and drugs

  • Stores some vitamins and iron

  • Stores the sugar glucose

  • Converts stored sugar to functional sugar when the body’s sugar (glucose) levels fall below normal

  • Breaks down haemoglobin as well as insulin and other hormones

  • Converts ammonia to urea, which is vital in metabolism

  • Destroys old red blood cells (called RBC’s)

 

Liver transplant


Liver transplant is a surgical method of replacing a diseased or injured liver with a donated, healthy liver. It is generally recommended when the liver has been damaged to the point that it is unable to function normally. This stage is known as liver failure or end-stage liver disease.

The liver can come from a deceased donor or from a living donor.

Complete liver (from a deceased donor) or just a section, can be transplanted. As liver is the only organ in the body which is able to regenerate, a transplanted portion of a liver can grow to normal capacity within weeks.

 

Who needs a transplant

There are number of diseases which can impair or destroy the functioning of a liver to such a level that liver transplant is the only treatment option left. These conditions include:

  • Cirrhosis (scarring of the liver) is the most common reason for liver transplants

  • Chronic viral hepatitis B ,C

  • Autoimmune hepatitis

  • Bile duct diseases

  • Metabolic & Genetic disorders

  • Autoimmune liver diseases

  • Primary liver cancer

  • Alcoholic liver disease

  • Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH)

  • Primary biliary cirrhosis(PBC) primary sclerosing cholangitis (PSC)

 

Liver Transplant Details

 

Signs & symptoms of Liver Failure

  • Itching
  • Jaundice
  • Nausea
  • Fatigue
  • Loss of Appetite
  • Vomiting
  • Weight Loss
  • Muscle Loss
  • Confusion or Forgetfulness

 

Candidate for liver transplant

There will be an assessment done to decide if a patient is a suitable candidate for liver transplant or not. There are many people with cirrhosis and decompensated liver disease but all of them are not suitable candidates for liver transplantation.

After going for the transplant, patient must be able to survive the operation and the potential post-operative complications, constantly take the medications that prevent rejection and opportunistic infections, ensure timely doctor visits and laboratory tests, and not to get engage in activity that would injure the liver, such as drinking alcohol.

 

Candidate for transplant

  • A liver transplant is done only to people who have irreversible, chronic liver failure.

  • Generally, other medical or surgical treatments options have been tried before a transplant is considered.

  • Age is not necessarily a factor in deciding a candidate for liver transplant.

 

Who is not a candidate for transplant

  • History of non-compliance, or inability to adhere to a strict medical regimen

  •  An active, severe infection that cannot be completely treated or cured, such as tuberculosis

  • Active substance abuse (drugs and/or alcohol)

  • Cancer that has spread outside of the liver

  • Severe, irreversible medical illness that limits short-term life expectancy

  • Severe pulmonary hypertension (mean pulmonary artery pressure greater than 50mmHg)

  • Unacceptable risk for substance abuse (drugs and/or alcohol)

  • Severe, uncontrolled psychiatric disease

 

Types of transplant


Three different types of liver transplant are used:

Orthotropic transplant

This is the most common type of transplant. In this entire liver is taken from a recently deceased donor. This is mostly from a donor who had pledged his or her organs for donation prior to death.

Living donor transplant

Living donor transplant means the donor is a person who is ready to donate the kidney. Piece of liver is removed from the living donor, as liver has the capability to regenerate itself, both the transplanted section and the remaining section of the donor's liver are able to regrow into a normal-sized liver.

Split type of transplant

Liver is removed from a person who had died recently and it is then split into two pieces. Each piece is transplanted into a different person, where they will grow back to a normal size.

 

Test required before the transplant

Patient is advised to get all their previous medical records, X-rays, liver biopsy slides, operative reports and a record of medications to the pre-evaluation. To match and to update the previous tests, some or all of the following diagnostic test are normally performed during the evaluation. If specific problems are identified, additional tests may be ordered.

  • CT scan: Computed tomography uses X-rays and a computer to generate pictures of the liver, showing its size and shape.

  • Doppler ultrasound: to determine if the blood vessels to and from the liver are open.

  • Echocardiogram and stress testing to help evaluate your heart.

  • Pulmonary function studies to determine the lungs ability to exchange oxygen and carbon dioxide.

  • Blood tests to determine blood type, clotting ability, and biochemical status of blood, and to gauge liver function. Serology screening is also included.

 

Waiting list

The waiting time for a transplant is different for each person. Waiting time will depend on patients’ blood type, body size, stage of liver disease, overall health, and the most important availability of a matching live. The wait list for liver transplant is long as the number of people requiring the transplant is more in comparison to the donated livers. Because of which priority is mostly given to patients who are critically ill.

Both Indian & international patients have an equal chance of obtaining a cadaveric organ, but as the list is very long, wait can take several months or even a year long. This much long waiting is logistically impossible for most of the International patients travelling to India for transplant .Hence, they all are advised to bring along with them a suitable living donors.

 

What to do while you are in the wait list.

When a patient is kept on the wait list, it is advised to remain as healthy as possible and be prepared for the transplant centre to contact them any moment, day or night. It is important for the patient to inform the transplant centre about any changes, like changes in health, address or contact details.

 

Procedure

Patient is contacted when a liver is available. If the liver is,

  • From a living donor: both the patient and the donor will be in surgery at the same time.

  • Orthotropic: then the surgery starts as soon as the new liver arrives the hospital.

Transplant process takes approximate 4 to 14 hours. It is performed under general anaesthesia. Liver has several main connections that are essential to re-establish for the new organ to in order to receive blood flow and to drain bile from the liver. The structures that are to be reconnected are the inferior vena cava, the portal vein, the hepatic artery, and the bile duct. The exact method of connecting these structures depends on specific donor and anatomy or recipient anatomic issues and, in most cases, the recipient disease.

The sequence of events that take place during transplantation are as follows:

  1. Incision is made in the upper part of the abdomen.

  2. Evaluation of the abdomen for the abnormalities that can cause a hindrance in liver transplantation (for example: undiagnosed infection or malignancy).

  3. Mobilization of the natural liver.

  4. Segregation of important structures (the inferior vena cava above, behind, and below the liver, the portal vein, the common bile duct, the hepatic artery)

  5. Removal of the natural, diseased liver.

  6.  Placement of the new & healthy liver, which is then reconnected to the bile ducts and blood vessels. Blood will now flow into this new liver.

  7. Adequate control of bleeding is established.

  8. Finally closure of the incision

 

Liver Transplant Procedure
 

 

After the operation

After the transplant is complete patient is moved to an intensive care unit (ICU).A machine called a ventilator will assist the patients breathing, and a tube will be inserted through the nose and into the stomach to provide the p.atient with fluid and nutrients. Usually these are after a few days. Pain killers will be provided to provide relief from pain. Hospital stay after the surgery will be of minimum ten days. This will depend on the severity of the patient’s condition & how complicated the surgery was.

 

Recovery

Recovering from a liver transplant is a long & a slow process. Most of the people will be able to return their normal activities within a few months and will have a good quality of life.

Long term management
 

  • After getting discharge from the hospital, patient has to come for regular follow-up visits. Throughout life the medical team will monitor the patients’ health progress.

  • Regular blood tests are recommended, so as to keep a track of the new liver. That is, it is not being damaged by rejection, infections, or problems with blood vessels or bile ducts.

  • Initial six months after the transplant is critical as most of the problems are likely to occur at this time. With time, both the frequency of lab tests and the doses of medicine are reduced.

  • Patient is advised to have a healthy diet, exercise, and not drink alcohol, especially if alcohol had already been a cause of liver damage.

 

Returning to normal activities
 

  • After a successful liver transplant, a patient can get back to their normal day to day activities. Regaining the complete strength back can take some time, as this will depend on how sick the patient was before the transplant.

  • Patient should avoid driving for up to two months, because the transplant procedure and immunosuppressant medication can have an effect on the patient’s vision, reaction times and ability to perform emergency stops.

  • After being able to return to daily work, patient should engage in normal exercise, and can return to a normal sex life.

  • Women are advised to avoid getting pregnant during the first year after a transplant. It’s best to consult with the doctors about sex and pregnancy.

 

Immunosuppressants

After liver transplant, patient is advised to take immunosuppressants for the rest of your life .This is because there is a risk that body can identify the new liver as foreign and the immune system can attack it. This is known as rejection


Rejection:

After the first three months of transplant, the risk of rejection is highest. Hence, the patient is given a relatively high dose at first. Eventually the dosage is reduced to a level, thought high enough to prevent rejection, but low enough to minimise unpleasant side effects. After a transplant, two main types of immunosuppressants are used to treat people. These are mainly:

  • Calcineurin inhibitors – such as cyclosporine and tacrolimus

  • Corticosteroids – such as prednisolone

 

Side effects

The long-term outlook for a liver transplant is generally good. Liver transplant being a major operation carries risk of some potentially serious complications. These complications can occur during, soon after, or several years after the procedure. Some of the side effects that might occur are:

  • Headache ,nausea and vomiting

  • High blood pressure

  • Diarrhoea

  • Anemia

  • Increased appetite & Weight gain

  • Trouble sleeping

  • Swelling and tingling of the hands and feet

  • Acne and other skin problems

  • High cholesterol

  • Hair loss or unwanted hair growth

  • Puffy face

  • Weakened bones, arthritis

  • Mood swings ,tremors

  • Body rejecting the new liver

  • Bleeding (haemorrhage)

  • New liver unable to within the first few hours (primary non-function), which will require a new transplant to be carried out as soon as possible.

  • Weakened immunity

  • Loss of kidney function

  • Problems with blood flow to and from the liver

  • Increased risk of certain types of cancer – particularly skin cancer

 

Success rate

Liver transplant can extend a patients lifespan. Results of liver transplantation are mostly very good, but they significantly vary depending on the indication for liver transplant and also on the factors associated with the donor. Presently, the overall estimated patient survival rate is:

  • One year after liver transplant: 88%.

  • Five years after liver transplant: 73%.

 

Cost of Liver Transplant in India

The cost of liver transplant in India is approximately USD 38,000.

Know more: Cost of treatment in India

Why India?

The question succeeding where to go for liver transplant issue is the one that is very important to ensure safe recovery. Most major countries offer great liver transplants, though the issues that patients in the developed countries usually face are the huge bills and long waiting periods.

Whereas India has grown to become one of the leading countries for cardiac surgeries and other such organ replacement medical care. Indian surgeons are well known all over the world for their skill and experience. Hospitals in India are well equipped with the latest and most sophisticated technology for a successful transplant. A huge number of skilled professionals provide various treatments to over 65000 medical tourists every year. Many patients favour liver transplant and they look upon India as the preferred destinations, as it allows for more than 52% savings and provides par excellence medical care.

 

Legal requirements in India

All organ transplants in India is governed by rules laid out by the Government of India.  The rules for liver transplant in India are quite strict and any deviation from the law attracts heavy punishment.  The important highlights of kidney transplant in India are as follows:

  • Close relatives can donate kidney to the patient.  Siblings, parents, children and spouse come under the category of 'close relatives'.

  • In cases where the donor is not a close relative, government permission is required and is given only if it is established that there is no commercial angle whatsoever to the donation.

If the proposed donor or the recipient or both are foreigners and are seeking liver transplant operation in India, a senior Embassy official of the country of origin or the government of the country concerned (authenticated by the Embassy concerned in India) has to certify the relationship between the donor and the recipient. Any commercial transaction between the donor and the patient is considered illegal and attracts heavy punishment.

 

FAQ’s

> Who is a perfect candidate for live liver donor?

Living donors are mostly relatives, friends or close acquaintances of the recipient. The criteria for donating their liver is :

They must have a compatible blood type and body size, as determined by the recipient's height and weight.

Donors must be between the age of 18 and 60.

They must also test negative for liver diseases and should have no serious medical conditions such as diabetes, cancer or heart disease.


> Patients who have undergone liver transplant do they have to take medicines to treat or prevent rejection for the rest of their lives?

Yes, mostly every patient who has undergone liver transplantation has to be on long tern medication. Slowly, a dose reduction will be done as the body gets adjusted to the transplanted liver and the medication needed to control or prevent rejection is reduced.


> Patients who have undergone liver transplant, are they more susceptible to other infections?

Patients who have undergone liver transplant must try to avoid exposure to any kind of infections as their immune system is very weak. They should immediately report to their doctor any illness they have, especially fevers. They must take over-the-counter medications or prescription medications only under their doctor’s direct supervision. 

 

> Can a patient's original liver disease that caused the need for transplantation reoccur in the new, transplanted liver?

There are certain liver diseases which can reoccur in the new liver. If the patient’s previous liver disease had been caused by autoimmune hepatitis, hepatitis B or C viruses, then recurrence is quite possible. For other types of liver disease, recurrence is less likely, but still there is a possibility, except for genetic disease that had been cured by the liver transplantation.

 

> Will the patient experience pain after the surgery?

Patient does experiences pain after liver transplant surgery, but the severity of pain is less as compared to other abdominal surgeries. This is because nerves are severed during the initial abdominal incision which causes a numbness of the skin present around the abdomen. In the next six months these nerves then regenerate and their sensation returns back. The most common post-transplant discomfort which a patient will have is back pain. This is because of the span of time on the operating table.

 

> How large is the scar?

The usual incision used for liver transplant is called a "chevron incision." It begins from the right side of the midsection just below the ribs and extends to the left edge of the abdomen. There is also a short incision starting under the sternum (breastbone) which extends to meet the horizontal incision.

 

> Can a patient consume alcoholic beverages after the transplant?

Alcohol is a big no for the patients who have undergone liver transplant. As alcohol is toxic to the liver and it can also interfere with the metabolization of certain medications.

 

> Will a patient be able to have children after the transplant?

Most of the couples are able to have children after liver transplantation with minimal risk to the mother and baby. But women are advised to wait at least for one year following transplantation before trying to conceive.

 

Summary

  • Liver transplant is a surgical method of replacing a diseased or injured liver with a donated, healthy liver. It is generally recommended when the liver has been damaged to the point that it is unable to function normally. This stage is known as liver failure or end-stage liver disease.

  • Cirrhosis or scarring of the liver is the most common reason for liver transplants.

  • Three different types of liver transplant are used:

  • Orthotropic transplant

  • Living donor transplant

  • Split type of transplant

  • Recovering from a liver transplant is a long & a slow process. Most of the people will be able to return their normal activities within a few months and will have a good quality of life.

  • Results of liver transplantation are mostly very good, but they significantl

 

References

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