1. What is liver Transplant?

  • Liver transplant is the treatment for end stage liver disease in both adults and children.
  • In this operation, the diseased liver is removed and replaced by a healthy liver.
  • The success rate for the operation is high and terminally ill patient can return to normal lives.
  • This kind of transplant has been done for more than 35-40 years.

2. Common Indications for Liver Transplant?

The following diseases are common indications for liver transplant:

  • Cirrhosis due to chronic hepatitis B, hepatitis C, NAFLD, Autoimmune Hepatitis other causes.
  • Acute liver failure due to hepatitis A, hepatitis E, drug induced (anti TB drugs, Paracetamol) etc.
  • Metabolic disease, e.g. Wilson disease, hemochromatosis, Urea cycle enzyme deficiency.
  • Selected patients with early liver cancer (HCC) and poor liver function due to cirrhosis.
  • Biliary atresia.

3. When to perform liver transplant?

When your liver is severely damaged and cannot function properly (Decompensated), the following complications may develop and liver transplant should be considered:

  • Hepatic coma (Hepatic Encephalopathy).
  • Massive upper gastrointestinal bleeding.
  • Abdominal distension from fluid collection (Refractory Ascites)
  • Infection of fluid in the abdomen (Spontaneous Bacterial Peritonitis)
  • Bleeding tendency.
  • Jaundice (yellowish discoloration of the white of the eye).
  • Renal dysfunction with cirrhosis (Hepato-renal syndrome)
  • General weakness and malaise resulting in poor quality of life.
  • Early Liver cancer with Cirrhosis
  • Failure to grow in children with pre-existing liver disease.

4. Contraindications for liver Transplant?

The following conditions/ diseases render liver transplant process unsuitable for the patient

  • Cancer in another part of the body.
  • Advance Hepatocellular carcinoma
  • Active alcohol or illegal drug abuse.
  • Active or severe infection in any part of the body.
  • Severe/ uncontrolled metabolic, heart, lung, Renal or neurological conditions etc.
  • Poor compliance i.e., Inability to follow doctors instructions

5. Where does the liver graft come from?

Your new liver can come from either of the two sources: a living donor or a brain-dead deceased donor.

  1. Living donor:
    • It is technically feasible to remove part of the liver from a living person and transplant it to a patient who needs a new liver.
    • Depending on the size matching of the donor and recipient, either the left side (25-30%) or the right side (65-70%) of the liver will have to be removed.
    • The liver remnant in the donor will grow to its original size in 6-8 weeks.
    • The donor complications-donor death 0.2 to 0.4% with left lobe & 0.5-1% with right lobe graft.
    • Complication rate of about 10-15% (wound infection, hernia, bleeding, bile leakage, bile duct problems, infection, pneumonia, vascular problems, liver failure which may require liver transplant, etc.).
    • Average loss of work of 6-8 weeks.
    • Average hospital stay of 7-10 days.
  2. Brain-dead deceased donor:
    • You will be put on waiting list for a brain dead deceased donor liver and receive a liver graft according to the following criteria:
      • Your blood group matching.
      • The urgency of your operation.
      • Severity of your liver disease according to the Model for end-stage liver disease score(MELD) or Pediatric end stage liver disease (PELD).
    • Unfortunately, the availability of deceased donor liver is not very often& is not culturally & religiously practiced in Pakistan.

6. Who can be a suitable living donor?

The most important criteria are that the donation of portion of the liver is done voluntarily& should be a close blood relative of the recipient.

  • The potential donor should understand clearly that,
    • The donor operation carries complication rate of 10-15%.
    • The donor complications-donor death rate is 0.2 to 0.4% with left lobe & 0.5-1% with right lobe graft.
    • There are possibilities that the donor operation is stopped if the donor liver is found to be abnormal and not suitable for donation or recipient is found for various reasons not suitable for liver transplant after the abdomen is opened.
    • The recipient operation is successful in 70-80% of cases.
    • The donation is on his own wish and without any coercion.
    • There are no financial gains related to the act of donation.
    • The donor has the right to withdraw at any time without the need of giving any reasons to do so.
  • The liver transplant team will consider the donor who understands the above criteria and who has demonstrated true voluntarism as potential living donor.
  • The potential donor will then undergo evaluation including blood tests, CT Scan, MRI scan, liver biopsy, psychiatrist evaluation and assessment by various specialists including cardiologist, pulmonologists, nephrologist and anesthetists. Depending on the clinical situation, the investigations can take a day to a week.
  • The case will be than evaluated by Transplant Evaluation Committeefor approval.
  • The family registration certificate (FRC) will be required for the confirmation of close blood relation between liver donor and the recipient fromNADRA.
  • The papers have to be submitted to the Human Organ Transplant Authority(HOTA)for clearance.
  • Only after this formality the liver transplant takes place.

7. What happens during a liver transplant procedure?

  • The liver transplant operationlast from 8 to 10 hours.
  • First the diseased liveris removed from the patient (Explantation).
  • The donor operation is going on at the same time to remove the partial liver graft (Donor Hepatectomy).
  • The donor liver graft will be than attached to the recipient. (Implantation)
  • During implantation, Firstly hepatic veins were anastomosed (outflow), then portal vein & the hepatic artery (Inflow) and finally the bile duct anastomosis will be done.

8. What are immediate Post Transplant Complications?

  • Thrombosis of the hepatic artery, hepatic vein, portal vein (blockage of the blood vessels going into or out of the liver).
  • Primary graft non-function.
  • Delayed graft function
  • Bile duct complications.
  • Graft failure due to hepatitis, recurrent disease or rejection
  • Sepsis
  • Renal failure.
  • Intra-abdominal bleeding/ Biliary leakage
  • Other complications like wound infection, lung infections, diabetes mellitus, hypertension, neurological problems etc.

9. What happens after liver transplant?

  • After the operation, the recipient and the donor (Living donor) will be treated in the Intensive care Unit.
  • The duration of stay in the ICU depends on the rapidity of recovery of the donor and the recipient.
  • The recipient (patient) stays for 5-7 days in ICU and 2-4 weeks in the hospital.
  • In the hospital, the recipient will slowly start eating again. You will start with clear liquids, and then switch to solid food as the new liver starts to work.
  • During this period you will start to learn how to take care of yourself and use your medicines to protect your new liver after you go home.
  • The donor stays for 2-3 days in ICU and 7-10 days in the ward.

10. Can I go back to my daily activities?

  • Transplant recipients return to work or school at various times after recovery from transplant, depending on the extent of their illness before transplant, recovery time, complications, and the type of work that is done.
  • Most patients are ready to return to work or school within three months after transplant.
  • When possible, it can be helpful to return to work or school on a part-time basis.
  • You can gradually increase your hours as your energy and endurance improves.
  • Discuss returning to work or school with your doctor and transplant coordinator. They can help you decide on the time that is best for you based on your workplace and responsibilities.