Liver Transplant

What is liver transplant

We all know that liver is a very essential organ in our body, which supports almost all other organs to function smoothly. Infact we develop symptoms only when 50% of the function is lost. ..Tranplantation is the process of removing the diseased organ and replacing it with a new liver obtained from a Brain dead patient or a Living Donor.

Do you know the fact that in our whole body liver is the only organ, which has capacity to recover by itself. Liver Failure can be Acute or Chronic. Acute Liver failure is maily due to drugs, poisons, or even due to certain viruses. Chronic Liver failure or cirrhosis is due to Alcohol, viral hepatitis, metabolic disease and so on. Some develop liver cancer for which transplant can be done

There are two ways of transplantations

1. Cadaveric Liver transplant where the liver is obtained from a Brain dead patient &


2. Living donor Liver transplant where a family member donates half of his liver to the patient

Our family members like siblings, parents, children, spouses or a donor can donate liver but there are conditions to donate liver for transplantation. They are as follows

• The person should be healthy/li>
• Donor should have the blood type that matches with the patient. But now days some centers perform blood group incompatible transplant with immune suppression protocols which is some technique where incompatible donor's liver also can be transplanted within patient's body without any harm.
• Donor's age should be between 18 to 50 years
• Before donating a liver doctors should go through intense testing of that person for any diseases. So that there is confirmation of donor is fit and safe to transplant his liver.

This liver transplantation process takes around 3-4 Weeks. The Pre-Transplant Investigations itself takes 4-5 days. Hospital stay will be around 2-3 weeks.

There is a gross mismatch between the availability of donor organs and recipients. That is why doctors these days recommend for Living donors.

Patient whose part of liver got donated can lead a normal life after the recovery of the injury while donating. There are only under 0.5% of a major risk for a donor.

INDICATIONS FOR LIVER TRANSPLANTATION

Liver transplantation is indicated for acute or chronic liver failure from any cause

CHRONIC NONCHOLESTATIC LIVER DISORDERS

• Chronic hepatitis C
• Chronic hepatitis B
• Autoimmune hepatitis
• Alcoholic liver disease

CHOLESTATIC LIVER DISORDERS

• Primary biliary cirrhosis
• Primary sclerosing cholangitis
• Biliary atresia
• Alagille syndrome
• Nonsyndromic paucity of the intrahepatic
• Bile ducts
• Cystic fibrosis
• Metabolic disorders causing cirrhosis
• Alpha-1 antitrypsin deficiency
• Wilson disease

SPECIFIC INDICATION FOR LIVER TRANSPLANTATION

Chronic Noncholestatic Liver Disorders

Cirrhosis secondary to chronic noncholestatic disordersis the most comman indication for liver transplantation in adults, accounting for more than 60% of all transplants performed annually. Included among this group are patients with end-stage liver disease secondary to chronic viral hepatitis, autoimmune hepatitis, and alcoholiccirrhosis.

CHRONIC HEPATITIS C

It is estimated that 15% to 20% of patients with chronic HCV infection develop cirrhosis within 20years of disease onset. 5-year survival is less than 50% after complications develop. Patients with cirrhosis secondary to chronic hepatitis C also have a 2% to 8% annual risk of developing HCC.

Patients with clinically decompensate cirrhosis from chronic hepatitis C infection should be referred for consideration of liver transplantation Antiviral therapy should be consideration in patients who have been accepted as candidates for liver transplantation.

CHRONIC HEPATITIS B

An estimated 350 million persons worldwide are infected with HBV. HBV carriers, particularly those who acquire the disease at birth or in early childhood, are at risk for the development of cirrhosis have an 84% 5-year survival rate and a 68% 10-year Survival rate: however, patients with decompensated cirrhosis have a 5-year survival rate of only 14%.

Patients with decompensate cirrhosis secondary to chronic hepatitis B should be considered for treatment with antiviral therapy in coordination with the transplant center.

AUTOIMMUNE HEPATITIS

Liver transplantation should be considered in decompensated patients with autoimmune hepatitis who are unable to undergo or be salvaged by medical Therapy. Patients with autoimmune hepatitis may require more immunosuppression.

ALCOHOLIC CIRRHOSIS

Alcoholic liver disease is the most common cause of cirrhosis and accounts for 40% of deaths from cirrhosis. The outcome after liver transplantation fro alcoholic liver disease is comparable to that of patients transplanted for most other conditions, with Rejection, graft failure, and the need for Re-transplantation all are less common in patients with alcoholic liver disease.

To be considered for transplantation, potential candidates with alcoholic liver disease should have careful assessment by a health care professional experienced in the management of patients with addictive behavior. It is prudent to delay transplantation for a minimum of 3 to 6 months of abstinence from alchol to avoid exposing patients who may not need transplantation to the risk of unnecessary surgery.

CHOLESTATIC LIVER DISORDERS

Liver transplantation is the only effective treatment for adults with end-stage liver disease secondary to PBC and PSC. Biliary atresia is the most common indication for liver transplantation in children, accounting for 60% to 70% of all procedures performed. Liver transplantation is the only effective treatment for liver failure secondary to primary biliary cirrhosis.

Primary Sclerosing Cholangitis

Liver transplantation is the only effective treatment decompensated cirrhosis secondary to primary sclerosing cholangitis. Because of the high incidence of colon cancer, regularly scheduled colonoscopies should be performed both before and after transplantation in all patients who have inflammatory bowel disease.

CHILDHOOD CHOLESTATIC DISEASES

Liver transplantation is indicated in appropriately selected children with biliary atresia if portoenterostomy is unsuccessful, or if intractable portal hypertension or liver failure develops despite successful portoenterostomy.

Liver transplantation should be considered for its ability to significantly prolong survival and improve quality of life by reducing pruritus in syndromic and nonsyndromic forms of intrahepatic cholestasis in children.

ANTITRYPSIN DISEASE

Liver transplantation is the only effective treatment for decompensated cirrhosis secondary to antitrypsin deficiency. Careful assessment for lung disease should be performed before transplantation in patients with cirrhosis secondary to antitrypsin deficiency, although coexistent disease in uncommon.

WILSON DISEASE

Urgent liver transplantation is the only effective option for patients with fulminant hepatic failure resulting from Wilson disease. Liver transplantation also is indicated for patients with decompensated chronic disease who fail to respond to medical therapy.

Nonalcoholic Steatohepatitis and Cryptogenic Cirrhosis Liver transplantation should be considered for selected patients with decompensated cirrhosis secondary to nonalcoholic steatohepatitis (NASH). The posttranplantation care of these patients should include metabolic monitoring.

Liver transplantation should be considered for selected patients with decompensated cryptogenic cirrhosis. These patients should be screened for metabolic dysregulation because of the possibility of underlying nonalcoholic steatohepatitis.

HEPATOCELLULAR CARCINOMA (HCC)

Liver transplantation should be viewed as the treatment of choice for selected patients with hepatocellular carcinoma who are not candidates for surgical resection and in whom malignancy is confined to the liver.

Optimal results following transplantation are achieved in patients with a single lesion 2 cm or larger and less than 5 cm, or no more than three lesions, the largest of which is less than 3 cm, and no radiographic evidence of extrahepatic disease.

For ideal outcomes, patients who meet these criteria should receive a donor organ within 6 months of listing for transplantation.

FIBROLAMELLAR HEPATOCELLULAR CARCINOMA AND HEMANGIOENDOTHELIOMA

When the tumor is not resectable, liver transplantation should be considered for patients with fibrolamellar HCC, if there is no evidence of extrahepatic disease. Transplantation should be considered for patients with epithelioid hemangioendothelioma.

METASTATIC NEUROENDOCRINE TUMORS

Liver transplantation for metastatic neuroendocrine tumors should be confined to highly selected patients who are not candidates for surgical resection in whom symptoms have persisted despite optimal medical therapy.

METASTATIC NEUROENDOCRINE TUMORS

• Hereditary hemochromatosis
• Tyrosinemia
• Glycogen storage disease type IV
• Neonatal hemochromatosis
• Metabolic disorders causing severe extra-hepatic morbidity
• Amyloidosis
• Hyperoxaluria
• Urea cycle defects
• Disorders of branch chain amino acids

PRIMARY MALIGNANCIES OF THE LIVER

• Hepatocellular carcinoma
• Hepatoblastoma
• Fibrolamellar hepatocellular carcinoma
• Hemangioendothelioma

FULMINANT HEPATIC FAILURE

• Miscellaneous conditions
• Budd-Chiari syndrome
• Metastatic neuroendocrine tumors
• Polycystic disease

Symptoms of liver failure due to cirrhosis

• Black stool
• Blood vomiting
• Water in the abdomen (ascites)
• Drowsiness and mental confusion
• Excessive bleeding from minor wounds
• Jaundice
• Kidney dysfunction
• Excessive tiredness
• Low hemoglobin and other blood counts

Liver Hepatitis

There are two types of Hepatitis

Acute hepatitis - meaning the new onset of Hepatitis

Chronic hepatitis - meaning the Hepatitis has been present for more than 6 months

Acute Hepatitis Causes

Common causes of acute hepatitis may include :

• Infection with a virus (viral hepatitis A, B, C, D, or E)
• Overdose of drugs (such as acetaminophen, paracetamol)
• Chemical exposure (such as dry cleaning chemicals, and some wild mushrooms)

Chronic Hepatitis Causes

Certain viruses and drugs may cause chronic hepatitis in some people, but not in others.

Common causes include :

• Viral hepatitis
• Heavy alcohol consumption
• Autoimmune disorder (when the body attacks its own tissues)
• Reaction to certain medications especially those given for TB.
• Metabolic disorders (such as Hemochromatosis or Wilson's Disease).

RECIPIENT EVALUATION AT THE TRANSPLANT CENTER

The typical evaluation of potential transplant recipients performed at our transplant centers includes

• A careful history and physical examination
• Cardiopulmonary assessment, including cardiac echocardiography, pulmonary function tests, dobutaminestress testing, and cardiac catheterization in selected patients.
• Laboratory studies to confirm the etiology and severity of liver disease:
• Creatinine clearance
• Laboratory studies to determine the status of current or previous hepatitis B virus (HBV), hepatitis C virus (HCV), Epsteinbarr virus, cytomegalovirus, and human immunodeficiency virus (HIV) infection:
• Abdominal imaging to determine hepatic arteryand portal vein anatomy and the presence of hepatocellular carcinoma (HCC).