Demystifying Liver Transplantation

Dr Abhideep ChaudharyConsultant Surgeon

Surgical Gastroenterology and Liver Transplantation

Sir Ganga Ram HospitalNew Delhi

Myths

Facts

Human liverLargest & Most massive internal

organ

Position :• Upper right part of abdomen behind

ribs Weighs : 1.2 to 1.5 kg

Performs > 500 different functions in body

Natural regeneration capacity due to hepatocyte function • Long term repeated exposure

however causes liver damage & may finally cause liver failure

http://hypertextbook.com/facts/2004/MaryPennisi.shtml * http://www.liver.ca/Liver_Health/

I am a non-complainer I can't and won't tell you I'm in trouble

untilI'm almost at the end of my rope... and

yours.

Your….. Liver

If…..the functioning of liver is inadequate to meet the requirement of body

© 2007 Thomson - Wadsworth

What Happens When Liver Fails

Causes of Liver Cirrhosis Acute Liver Failure Alcoholic cirrhosis

◦ Represents the most common cause of cirrhosis5

◦ Accounts for 40% of US deaths from cirrhosis5

HCV◦ HCV is the most frequent diagnosis in patients

undergoing liver transplantation1

◦ Viral recurrence is nearly universal, with up to 30% of patients progressing to cirrhosis1,2

HBV HCC

◦ Accounts for 90% of all liver cancers3

◦ Causes 50% to 70% of liver-related mortality among patients with cirrhosis4

◦ Incidence and mortality is rising4

Viral hepatitis (40%)

Alcoholic hepatitis (32%)

Primary biliary cirrhosis (10%)

Unknown (7%)

Viral + alcoholic hepatitis (5%)

Autoimmune hepatitis (4%) Other causes

(2%)

Causes of cirrhosis

Source: CDC. Slide 45. ftp://ftp.cdc.gov/pub/infectious_diseases/hepatitis/slides/technote.

txt.

HCV = hepatitis C virus; HCC = hepatocellular carcinoma; HBV = hepatitis B virus1. Berenguer M, et al. Hepatology. 2002;36:202–10; 2. Berenguer M, et al. J Hepatol. 2001;35:666–78; 3. Jelic S, Sotiropoulos GC. Ann Oncol. 2010;21 (Suppl 5):v59–64; 4. Varela M, et al. Liver Transpl. 2006;12:1028–36; 5. Murray KF, Carithers RL. Hepatology. 2005;41:1407–32 7

Treatment of liver failure

Liver Transplant

1967 : 1st successful Liver Transplant

1989 : 1st successful LDLT ( Adult to child )

1998 : 1st successful LDLT ( Adult to Adult )

In last 40 years, Liver Transplantation has evolved from an experimental procedure to a definite treatment option for patients with acute liver failure and end-stage liver disease

Is liver transplant Successful?

Liver transplant success

Long-term survival of liver transplant recipients has become the rule rather than the

exception

Chronic Liver Disease - One of top ten cause of death in India

About 2,00,000 Indians die of liver failure every year.

25,000 liver transplants need to be done every year in India.

Only 1,100 transplants performed in India every year

Indian Scenario

Need / rate of Liver Transplantation: India vs West

Region Rate of LTs

Developed West 12-32 per millionIndia - future 20/million (25000/yr)

realistic – 5000/yrIndia- current 0.06 per million (2010)

(320, 500, 750 transplants in 2008, 2009, 2010)

Liver Transplants in India: annual trends

No.

of

liver

tr

ansp

lants

Should all liver disease patients have a LT ?

NO

Success rate

Disease progression

Donor availability

Cost

Disease recurrence

Compliance with post operative restrictions

Why No ?

Determine the need for transplant

Confirm all effective treatments have been

exhausted

Assess whether patient is an appropriate candidate

When to Consider Transplantation?

Timing of the transplant -- from the initial referral to the actual surgery-- can have a profound impact on outcome.

When patients undergo a transplant before multisystem complications of ESLD have a chance to develop, their prognosis is excellent.

However, in severely debilitated patients, survival decreases by 20% to 30%.

When to do transplant?

Patients with cirrhosis should be referred for a transplant when they develop evidence of synthetic dysfunction, experience their first major complication or develop malnutrition

Waiting to refer patients until they have intractable ascites or hepatorenal syndrome frequently results in death before a transplant can even occur

Patients with HCC and cirrhosis should be referred as soon as the tumor is discovered

Patients with FHF can deteriorate rapidly, so should be referred as soon as the diagnosis is suspected

Referral to transplant surgeon- timing!

When medical therapy is effective in stopping the progression of liver disease, transplantation may be avoided or delayed

Can it be avoided/postponed?

Expensive surgery (18-20 lac rupees)

Cost cutting measures

Avoid technical complications

Decrease transfusion requirements

Use medications of proven efficiency

Cost

Liver transplant surgery carries a risk of significant complications, including:

Bile duct complications, including bile duct leaks or shrinking of the bile ducts

Bleeding Blood clots Failure of donated liver Infection Memory and thinking problems Rejection of donated liver

What risks are involved?

For those in whom prolonged abstinence and medical treatment fails to restore health, transplantation may be considered. 

Patients who continue to drink alcohol despite medical advice are not considered for transplantation

Can a patient with alcoholic liver disease get a transplant?

Hepatocellular carcinoma, which are confined to the liver can be treated by liver transplantation

Are people with liver cancer considered for transplantation?

Patient needs medication to protect the new liver from rejection

These medications however reduce both in dosage and number as time passes and the immune system gets used to the new liver

Will the patient have to depend on lots of medication for the rest of life?

Most liver transplant recipients are able to return to a normal and healthy lifestyle

Most report that they feel re-energized, have an improved quality of life and enjoy everyday activities once more

Liver transplant recipients are able to participate in normal exercise after their recuperation and women are able to conceive and have normal post-transplant pregnancies and deliveries

QOL after tx

Donation after brain death Living related donor

Where does the liver come from?

Organ donation in India

1.3 billion population HOTA (Legal Act)

since 1994 Liver used in only

40-50% Donation< 0.03 per

million (20-35 per million – west)

No. of deceased donors per year

Till then …Living related liver transplant

Any person above the age of 18 years can legally donate his part of liver however in India as per Human Organ Act 1994, liver donation is restricted to family members(brother, sister, father, mother, son daughter) or close relatives (Uncle, aunt, cousin, brother-in-law, sister-in-law, grand parents)

Medically the liver donor should have a compatible blood group and should be me medically fit and psychologically sound

Who can be a living donor?

Liver transplantation

is possible due to the

amazing regenerative

capacity of human

liver

Both donor and

recipient eventually

lead normal lives post

procedure

How will I live once they remove my whole liver out?

Right hepatectomy complex surgery

Bile leak well recognized complication

Wound pain quite common

Psychological trauma in case of recipient death

Overall risk -0.1-0.2%

The risk to living liver donor

Donor usually discharged within 7-10 days Donor can resume his normal activity within

3-4 weeks and resume his job within 6 weeks time

No special precautions are needed for donor after about 4-6 weeks and he lives a normal life thereafter

When can donor resume work following a surgery?

Don’t drown me in alcohol

Watch those drugs, can harm me. No medications without consulting doctor

Don’t eat too much of fatty food.Get Shots against

Hepatitis A and B

Don’t have unsafe sex, don’t share needles/syringes, personal items like razors.

OLTx for biliary atresia w/HCC: 41 year survivor

“The Great One”

Pledge your organs

Save a life

Don’t Take me to heaven, no one needs me there!