Everybody needs a healthy liver for proper functioning of the human system. Located on the right side of the abdomen below ribs, liver performs several vital functions. This powerhouse produces various substances like glucose, proteins, blood clotting substances which aid in healing & bile juice which aids in absorption of fats & vitamins from food we eat. This largest solid organ within us is also ideal for storing important substances like minerals & vitamins. Liver doubles up for acting as a filter by removing impurities from blood. It also helps in metabolizing & detoxifying substances ingested by the body. Liver disease is basically a result when any of these basic symptoms are disrupted. Whenever damage to liver severely impairs health & quality of life, liver transplant becomes imperative. Liver disease is a common & serious problem for people throughout the world. Therefore, it is least surprising that it is the second most commonly transplanted major organ after kidney.
Roughly a triangular organ extending across the entire abdominal cavity inferior to the diaphragm, most liver mass is located on the right side of the body. It is made of soft pinkish-brown tissue encapsulated & reinforced by peritoneum of abdominal cavity which protects & holds the liver in place within abdomen. Liver consists of 4 distinct lobes, namely the right, left, caudate & the quadrate lobes. The right & the left lobes are the largest & which are separated by falciform ligament. Small caudate lobe extends from posterior side of right lobe & wraps around inferior vena cava. Small quadrate lobe is inferior to caudate & extends from posterior side of right lobe wrapping around gallbladder. Other structures completing the liver anatomy include the bile ducts & the blood vessels. Internal structure of liver is made of about 100,000 small hexagonal functional units called lobules. Each lobule has a central vein surrounded by 6 hepatic arteries & 6 hepatic portal veins. These blood vessels are connected with several capillary like vessels called sinusoids that extend from arteries & portal veins to meet central vein like spokes in a wheel.
Liver functions are multi-dimensional in nature. These include aiding the process of digestion, detoxification of blood, storage of essential nutrients like minerals & vitamins, production of several vital protein components of blood plasma, performing important metabolic jobs that support the cells of the body & function as an organ of the immune system through kupffer cells lining sinusoids. Production of bile juice or bilirubin which help in the emulsification of fats in diet make it easier for the body to digest food.
Liver Disease Symptoms
People with liver disease share some of these following problems
- Jaundice – Yellowing of skin & eyes
- Tea-Colored dark urine
- Clay-Colored or gray bowels
- Blood in stools
- Ascites – Abnormal buildup of fluid in abdomen
- Tendency to bleed
- Vomiting of blood
- Mental confusion with forgetfulness
Signs & Symptoms of Decompensated Liver Disease
As liver fails to meet the basic needs of the body, patients exhibit minor signs of decompensated liver disease including fatigue, anorexia, diarrhea & nausea. Other more serious signs of liver failure include abnormal billirubin excretion, jaundice from accumulation of billirubin in tissues, upper right quadrant pain caused by inflammation, abnormal ammonium ion metabolism leading to hepatic encephalopathy, diminished protein synthesis, ascites which increase sinusoidal pressure from scarring or severe inflammation of liver & portal hypertension leading to rupture of esophageal varices with potentially massive fatal bleeding.
Symptoms of cirrhosis due to loss of hepatocyte function result in symptoms like
- Edema & Ascites
- Peripheral Neuropathy
- Portal Hypertension
- Kidney Failure
- Esophageal Varices
- Hepatic Encephalopathy
Who Needs Liver Transplant?
Some of the most common reasons for patients to seek Liver Transplants include –
- Chronic Viral Hepatitis B, C & D
- Autoimmune Hepatitis
- Laennec’s Cirrhosis
- Nonalcoholic Fatty Liver Disease (NAFLD)
- Cryptogenic Cirrhosis
- Biliary Cirrhosis
- Primary Sclerosing Cholangitis (PSC)
- Caroli’s Disease
- Choledochal Cyst
- Acute Liver Failure
- Toxic Exposures
- Hepatic Tumors
- Neuroendocrine Tumors
- Hepatocellular Carcinoma
- Slow Growing Metastatic Gastrointestinal Stromal Tumor (GIST)
- Metabolic & Genetic Disorders
- Alpha 1 Antitrypsin Deficiency
- Cystic Fibrosis
- Familial Hypercholesterolemia
- Wilson’s Disease
- Glycogen Storage Disease
- Budd-Chiari Syndrome (BCS)
- Adult Polycystic Disease
- Alagille’s Syndrome
- Hepatic Trauma
Causes of Chronic Liver Injury
The most common cause of chronic liver injury is abusing alcohol. Other causes of cirrhosis include hepatitis & other viruses, use of certain drugs, chemical exposure, bile duct obstruction, autoimmune diseases, obstruction of outflow of blood from liver, heart & blood vessel disturbances, alpha – antitrypsin deficiency, high blood glactose levels, high blood tyrosine levels at birth, cystic fibrosis, glycogen storage disease, diabetes, malnutrition & hereditary accumulation of too much copper or iron.
Unsuitable Candidates for Liver Transplant
Patients who are unsuitable candidates for liver transplant include –
- Active Alcohol or Substance Abusers
- Cancer Patients with Cancers in other Locations
- Patients with Advanced Heart & Lung Disease
- Patients with Severe Infections as threat to Successful Procedure
- Massive Liver Failure accompanied by associated Brain Injury
- HIV Infected Persons
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Types of Organ Donors
There are two basic types of liver organ donors for liver transplantation procedures.
Living Donors & Deceased Donors –
Living Donors are also an option for some patients who are suffering from end-stage liver disease. Living donors involve removing a segment of healthy liver & implanting into a recipient. Both recipient & donor livers will eventually grow to normal size in few weeks. Living donors may be blood relatives, friend or spouse will have to undergo extensive medical & psychological evaluations. Body size, blood type & various other critical factors will determine appropriate donors.
Deceased Donors may be victims of accident or head injury. Brain-dead donors who are usually in intensive care units of hospitals are also considered legally dead, hence can donate liver for transplantation purposes. However, the circumstances of death & identity of deceased donors is kept confidential.
Search for a Liver Donor
Search for a suitable donor begins when diagnosis is complete & the patient is accepted for transplantation. Various countries have various laws concerning organ donation. Waiting time may often be long with shortage of donor organs & need to match donor & patient blood & body type. It is important for patients to stay in good health during wait with a nutritious diet & light exercise. Quite often donors are victims of trauma & declared brain dead. Apart from matching the right blood type & similar body weight, chances of rejection by the patient’s body to the new liver is a possibility as well.
Liver Transplantation Team
The liver transplantation team usually consists of transplant coordinator, social worker or medical service facilitator, liver specialist, & transplant surgeon. It may also be essential to see a heart specialist & lung specialist depending upon the age & health of the patient. Since, liver transplantation procedure is quite emotional, a psychiatrist may also be consulted. A positive support group is equally important for a successful outcome.
Liver Transplant Surgery
Liver transplant surgery procedures may vary depending upon patient’s condition & surgeons practices. Generally, you will be asked to remove clothing & given a gown to wear. An IV line will be started along with catheters which will be inserted in neck & wrist so as to monitor status of heart & blood pressure. Alternate sites for additional catheters may include under collarbone area & groin. Laid back on the operating table, excessive hair may be clipped off & urine drained from bladder. Anesthesiologist will insert tube into lungs after sedation to put you on ventilator. He will continue monitoring your breathing, heart rate, blood pressure & blood oxygen level during surgery. After cleaning the skin over surgical site the surgeon will make a slanting incision under ribs on both sides of abdomen which will extend straight up for short distance over breast bone. After carefully separating the diseased liver from surrounding organs & structures, the surgeon will clamp the attached arteries to stop blood flow into liver. Different surgical techniques will now be employed depending upon the type of transplant which can be a complete donor liver or just a portion. Diseased liver will be removed & cut-off from blood vessels & donor liver will be attached to blood vessels. Blood flow to the new liver will be established & checked for bleeding along suture lines. The new liver will be now connected to bile ducts before incision is closed with stitches or surgical staples. While a sterile bandage or dressing is applied, a drain may be placed in incision so as to reduce swelling.
Surgical complications of liver transplantation generally include rejection, graft failure, risk of infection, biliary conditions & risk of developing cancer in future. While rejection of the new liver is almost one in every three cases, immune system attacks & prevents the new liver function properly. This generally occurs within weeks or months after transplant. However, rejection can be successfully managed by altering dosage of immunosuppressant medications. More than one in ten patients experience problems in biliary tract as leaks or obstruction caused by scar tissue in bile ducts after liver transplants. Drainage tubes & endoscopy procedures can effectively fix these issues. Kidney failure is quite often a side effect of immunosuppressant medication in one of the three people undergoing liver transplant. Patients may at times need to undergo dialysis or kidney transplant as medical solutions. There is an increased risk of developing some type of cancers like non-melanoma skin cancer, melanoma skin cancer & cervical cancer with liver transplant. Posing a one in 50 chance, these types of cancers known as post-transplant lymphoproliferative disorder (PTLD) usually affect white blood cells in people undergoing liver transplants.
ALSO READ: Liver Cancer Treatment
Advanced operative techniques & immunosuppressive therapy have eventually allowed liver transplantation become extremely successful treatment procedure for end-stage liver disease patients around the world. Immunosuppressive regimens have evolved since 1970s with present statistics confirming a one-year graft survival rate above 80 percent. Most of these medications target different sites in T cell activation cascade by inhibiting or depletion. Used as induction therapy in immediate & post-operative periods & long-term maintenance medication to preserve graft function, & salvage therapy for acute rejection in liver transplanted patients, existing immunosuppressive agents are destined to improve with newer medications on the horizon.
Rejection to any foreign object is a normal body reaction. So, whenever new liver is transplanted the body recognizes this as a threat & develops an attack. The immune system starts producing antibodies so as to destroy the new organ without realizing that the transplanted liver is here to benefit. Physicians thereby give medications to trick the immune system to accept transplant & allow the new organ to be accepted by the body. These medications need to be given to the patient for the rest of his life. Some of these medications include cyclosporine, takrolimus, sirolimus, prednisone, azathioprine & mycophenolate mofetil. Depending upon the patient’s response dosage of medications may be changed from time to time. Since anti-rejection medicines affect immune system, a balance needs to be maintained so as to minimize risk of infections. Blood tests are also required to periodically measure whether too much or too little medication is being delivered. White blood cells are also important indicators of the amount of medication required. Symptoms & signs of rejection generally include dark urine, jaundice – yellowing of skin & eyes, fevers greater than 100 degrees Fahrenheit, nausea, headaches, irritability, fatigue, abdominal swelling or tenderness & itching. It is advisable you consult the transplant team when you are facing any of the above concerns.
Post Liver Transplant Care
Care after surgery within the hospital after liver transplant surgery would be your stay in the intensive care unit (ICU) for several days where patients are closely monitored. Stay at the hospital is usually between 7 – 14 days or more while blood pressure, EKG tracing, oxygen level & breathing rate will be monitored along with other pressure readings. Patients are given special IV drips to help blood pressure & heart & to control any problems with bleeding. Once breathing & stomach tubes are removed & patient’s condition is stabilized, he will be allowed to begin with liquids in diet & subsequently advance to solid foods as tolerated. Anti-rejection medications will be closely monitored so as to make sure patients get the optimum dose. Patients will be shifted to a regular nursing room or transplant unit from ICU before being sent back home. Members of the transplant team teach patients how to take care of themselves before discharging them from hospital. At home it would now be on the patient to keep surgical area clean & dry & follow specific bathing instructions. Follow other activity instructions given by the transplant team & do not drive until the doctor’s advice. Notify the doctor if you observe any signs of rejection. They may give additional or alternate instructions depending upon the situation.
Liver Transplant Guidelines in India
Patients must essentially carry a letter or prescription from his physician/hepatologist / or gastroenterologist suggesting liver transplant as treatment for his hepatic problem. The liver transplant hospital in India will re-diagnose & confirm your need after you arrive. In case you seek an opinion through mail, please make it a point to send the following reports.
- Urine Routine Microscopy & Urine Protein Creatinine
- Liver Function Tests (LFT), Anti HCV, P time / INR, HIV I & II, HbsAg, Sodium, Potassium, AFP, Urea, Creatinine, CBC / Hemogram
- Triple Phase CT Angiography of Liver (Safe for patients with no contrast allergy, urea & normal Creatinine)
- Medical summary by doctor carrying information on symptoms & past medical history
- Recent Report of Upper GI Endoscopy
All of the above reports are required to confirm cost & requirement of a Liver Transplant.
Other tests which will be conducted on liver transplant candidates on arrival include PFT, PA pressure measurements, ABG, & Stress Echo for checking fitness prior to undergoing liver transplant surgery.
Evaluation of Donor
Donor should be related to the patient & be happy to donate liver on selfless basis. S/he should preferably be between 18 45 years of age, fit & strong with a matching or compatible blood group. It is mandatory that donor should be psychologically sound adult & well aware of taking this decision. Liver transplant done by unrelated donors for financial reasons is illegal & punishable under Indian law. In order to save time Level I & Level II tests of donors can be done in their own countries & reports mailed prior to arrival. Subsequent Level III & Level IV can be done on arrival within 48 hours at the Indian hospital. If all reports are fine, liver transplant can be quickly performed once permission is sought from the Government of India Transplant Authorization Committee. This entire legal procedure might take about a week’s time.
Low Cost Liver Transplant in India
Travcure healthcare consultants are associated with top liver transplant hospitals in India. Donor livers function well when transplanted within 8 hours. A normal liver transplantation procedure lasts between 6 – 8 hours & therefore requires excellent team coordination for success. Travcure medical tourism consultants are experts with constant interaction with the best liver transplant surgeons in the country. Many of them are world renowned & have gained experience in the United States. The infrastructure they embrace is an ideal platform which can deliver one of the best affordable organ transplant experience for patients from all around the world.
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