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The liver is one of the largest human organs and performs some very vital bodily functions. It is the body’s second largest organ; second only to the skin which is larger and heavier. Many essential functions related to digestion, metabolism, immunity, and the storage of nutrients within the body are performed by the liver. These functions are crucial for survival and without a well-functioning liver, the tissues of the body would quickly die from lack of energy and nutrients. Fortunately, the liver has an incredible capacity for regeneration of dead or damaged tissues. In fact, it is the only organ in our body which has the capacity to regenerate. Even if 70% of the liver is damaged, the remaining liver can function adequately for survival.
Some diseases, however, are capable of destroying healthy liver cells or replacing them with scarred tissue that cause a loss of liver function. They can so severely damage the liver, that a transplant is the only option. Unfortunately, in the past decade in India, the number of patients with liver diseases has doubled, and an approximate 50000 livers are needed for transplantation every year. There are also thousands of liver transplants done in India every year with a reasonably good success rate of around 95%. These however are mostly ‘live’ transplants, where the liver is donated from a living donor. Deceased donations are very few because of lack of donors. (More about that below).
It is important to accept transplantation with a positive attitude. It is a big step and although preparation is cumbersome, waiting period unpredictable (for decease donations), operation complex and recovery prolonged, most patients do well after transplant and lead an excellent quality of life.
Unfortunately in Delhi/NCR and much of north India, it is unadvisable to wait for a deceased donor. Those is dire need should think about registering themselves in hospitals in Tamil Nadu, Maharashtra or Karnataka where the governments have established a deceased organ donor programme, created awareness on a massive scale and established a registry to ensure that organs go to the recipients on their lists.
What should I know about liver transplantation?
Liver transplantation is a surgical procedure that replaces a failing or damaged liver with a healthy and well-functioning one. Liver transplantation is the universal treatment for end-stage chronic liver disease (ESLD) or cirrhosis, and is a life-saving operation for patients with acute liver failure. The most commonly used technique is Orthotopic liver transplantation, in which the entire liver is removed and replaced with the donated liver.
What are the types of transplant?
The donated liver can be from a living donor or a deceased (brain dead) donor.
Living Donor Transplant
Living donors can donate one of a paired organ such as kidney or one lobe of the liver. Living donors are mainly family members or close relatives of the patient. A 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: Since liver has the unique capacity to regenerate/re-grow back to its normal size, this 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.
Deceased donor transplant
Recipients may receive a liver from a deceased donor, who has been declared brain dead. 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 generally transplanted, though 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 has far outnumbered the availability of such organs, therefore not all patients are able to undergo a deceased donor liver transplant.
Which diseases may necessitate a liver transplant?
Several diseases destroy healthy liver cells or replace them with scarred tissues. When a large part of the liver is scarred, it is called cirrhosis. A cirrhotic liver not only loses its capacity to regenerate, but also causes loss of liver function. Scar tissue cannot do what healthy liver tissue does: make protein, help fight infections, clean the blood, help digest food, and store energy for the body. Scar tissue also blocks the normal flow of blood through the liver. Most of the time cirrhosis is progressive and irreversible. However if caught in time, its progression can be halted. The liver can function even at 30% of its original capacity. But if the loss of liver function is more than that, then it causes what is known as End Stage Liver Disease (ESLD)
Symptoms, a physical examination, and certain tests can help a doctor diagnose cirrhosis. A liver biopsy will confirm the diagnosis. Unfortunately, cirrhosis cannot be treated or reversed with any medicines, making transplant the only option.
ESLD or End Stage Liver Disease or Cirrhosis
These are the most common diseases that lead to a need for transplants among adults, and are caused by:
- Long-term infection due to Hepatitis C or Hepatitis B virus
- Excess consumption of alcohol over a period of time
- Fatty liver, obesity or high cholesterol levels
- Biliary diseases (damage or blockage to bile ducts inside the liver) like primary Biliary Cirrhosis and Primary Sclerosing Cholangitis
- Autoimmune liver diseases (immune system attack against the liver)
- Hereditary diseases, such as Wilson’s disease, wherein copper deposition causes liver failure, and hemochromatosis, wherein iron accumulation leads to liver failure
- Liver cancer
Acute Liver Failure (ALF)
Acute liver failure is a devastating and life-threatening condition, in which there is sudden and rapidly progressive damage to the liver developing over few days or weeks in otherwise normal individuals. 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.
Reasons for acute liver failure include:
- Infection with Hepatitis A or E virus
- Side effects of medicines (Anti-tubercular, paracetamol, ayurvedic drugs)
- Fatty liver during pregnancy
Children’s Liver Diseases
- Biliary, in which the bile ducts are missing, damaged or blocked by birth, which causes bile accumulation in the liver, and hence cirrhosis
- Metabolic diseases wherein some enzymes made by the liver are deficient at birth
Diagnosis and Pre-transplant
Recipient Evaluation and Preparation
Donor Evaluation and Preparation
Approaching the Transplant
References: www.medanta.org http://www.bhf.org.uk/ www.unos.org