Over 200,000 patients in India die annually from end stage liver disease and its complications. Liver transplantation is the treatment of choice for those suffering from end-stage liver disease (ESLD). This procedure is now applied world wide as treatment for a large number of irreversible acute liver failure and chronic liver diseases for which there were previously no other treatment Options. The primary goals of liver transplantation are to prolong life and to improve the quality of life. It is essential to optimize patient selection and ideally time the transplant procedure so as to gain the maximum benefit. The number of liver transplants happening in India is only around 750 per year which is nothing in support of the need. The outcomes of liver transplantation are currently excellent and much improved as compared to 20 years ago due to advances in operative technique, a better understanding of the course and prognosis of several liver diseases, and more effective postoperative care including immunosuppression.
Liver donors could be deceased donors and live donors. Donors should be blood group matching to recipient’s. Deceased donors in India are presently the brain dead donors maintained on ventilator and other supports for blood pressure and kidney. Despite the fact that non governmental organizations like Chennai based MOHAN (Multi Organ Harvesting Aid Network), Cochin based SORT (Society for Organ Retrieval and Transplantation) and Calicut based HOPE (Human Organ Procurement and Education) have done commendable thrusts, deceased organ donation has not come to its true potential in India and Kerala. Due to this large volume centres in India practice living donor liver transplantation. Living donation is based on the fact of enormous regenerative capacity of liver. A healthy person with no liver disease and co morbidities could donate up to 60-70% of his liver. The functional status of remnant liver is minimally or unaltered by this donation and is fully recovered by time of discharge which is by 10 days.
The patients with ESLD are complicated by refractory ascites (fluid accumulation in abdomen), renal failure due to hepato renal Syndrome, hepatic encephalopathy (alteration in sensorium ranging from mild to comatose situation), recurrent variceal bleeding (presenting with vomiting of blood), pulmonary complications like Hepato pulmonary Syndrome and portopulmonary hypertension (presenting as respiratory difficulty) and liver malignancy like hepatocellular carcinoma. Transplantation should be considered in any patient with liver disease in whom the procedure would extend life expectancy beyond what the natural history of the underlying liver disease would predict or in whom transplantation is likely to improve quality of life. Timimg could not be delayed to the extent of patient having developed severe complications of ESLD like Portopulmonary hypertension, severe hepatopulmonary syndrome, severe hyponatremia as all these predicts mortality during procedure and are relative contraindications to procedure. On the other hand patients who are too well should not be transplanted. Since the goal of transplantation is to prolong survival, liver transplantation should be performed at the time point when the patient is expected to have greater survival with a liver transplant than without. A more scientific basis for this led to implementation of the MELD(Model for End Stage Liver disease ) scoring system, which is an objective, score depending on Prothrombin time, bilrubin and S. Creatinine of the patient. Organs are allocated in deceased organ sharing based on higher MELD score. In live donation scenario also same criteria for indication are used.
Usual stay of recipient in the hospital is 15-21 days and they need frequent monitoring by blood tests in first 2 weeks after discharge and after that the visits reduce to once in month to once in 3 month. Immunosuppression is with 3 drugs of which steroids are tapered and removed by 3 months and the dose of other two drugs could be reduced and kept at min levels. The complications that could occur include technical complications, primary nonfunction of liver, rejection and infectious complications. The overall one and 5 year survival after this procedure has improved from 80% and 50% to 90 % and 80% respectively in last two decades.
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Liver donors could be deceased donors and live donors. Donors should be blood group matching to recipient’s. Deceased donors in India are presently the brain dead donors maintained on ventilator and other supports for blood pressure and kidney. Despite the fact that non governmental organizations like Chennai based MOHAN (Multi Organ Harvesting Aid Network), Cochin based SORT (Society for Organ Retrieval and Transplantation) and Calicut based HOPE (Human Organ Procurement and Education) have done commendable thrusts, deceased organ donation has not come to its true potential in India and Kerala. Due to this large volume centres in India practice living donor liver transplantation. Living donation is based on the fact of enormous regenerative capacity of liver. A healthy person with no liver disease and co morbidities could donate up to 60-70% of his liver. The functional status of remnant liver is minimally or unaltered by this donation and is fully recovered by time of discharge which is by 10 days.
The patients with ESLD are complicated by refractory ascites (fluid accumulation in abdomen), renal failure due to hepato renal Syndrome, hepatic encephalopathy (alteration in sensorium ranging from mild to comatose situation), recurrent variceal bleeding (presenting with vomiting of blood), pulmonary complications like Hepato pulmonary Syndrome and portopulmonary hypertension (presenting as respiratory difficulty) and liver malignancy like hepatocellular carcinoma. Transplantation should be considered in any patient with liver disease in whom the procedure would extend life expectancy beyond what the natural history of the underlying liver disease would predict or in whom transplantation is likely to improve quality of life. Timimg could not be delayed to the extent of patient having developed severe complications of ESLD like Portopulmonary hypertension, severe hepatopulmonary syndrome, severe hyponatremia as all these predicts mortality during procedure and are relative contraindications to procedure. On the other hand patients who are too well should not be transplanted. Since the goal of transplantation is to prolong survival, liver transplantation should be performed at the time point when the patient is expected to have greater survival with a liver transplant than without. A more scientific basis for this led to implementation of the MELD(Model for End Stage Liver disease ) scoring system, which is an objective, score depending on Prothrombin time, bilrubin and S. Creatinine of the patient. Organs are allocated in deceased organ sharing based on higher MELD score. In live donation scenario also same criteria for indication are used.
Usual stay of recipient in the hospital is 15-21 days and they need frequent monitoring by blood tests in first 2 weeks after discharge and after that the visits reduce to once in month to once in 3 month. Immunosuppression is with 3 drugs of which steroids are tapered and removed by 3 months and the dose of other two drugs could be reduced and kept at min levels. The complications that could occur include technical complications, primary nonfunction of liver, rejection and infectious complications. The overall one and 5 year survival after this procedure has improved from 80% and 50% to 90 % and 80% respectively in last two decades.
By,
Dr.Sajeesh Sahadevan MS MCh
Senior
Consultant Surgical Gastroenterologist and Liver transplant Surgeon, MIMS
Calicut
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