Liver Transplant Surgery, Cost, Type, Fact And Success Rate In India

Replacement of a dead, damaged or failed liver with a healthy liver from a deceased donor or a part of liver from a healthy living donor done through a surgical procedure is known as liver transplant.

Liver is the largest largest internal organ and works to perform several critical functions, which includes:

• Processing of nutrients, medications and hormones
• Production of bile, to help body absorb and metabolise fats, cholesterol and fat-soluble vitamins
• Production of important proteins
• Filtering of blood of bacteria and toxins
• Managing immune responses and fighting infections

Liver transplant is usually done in people who suffer from major complications arising due to end-stage chronic liver disease. Liver transplants are also done in sudden liver failure cases which usually happen in younger cases.

All over the world more number of patients with failed liver are waiting for a deceased donor than its available.

Living-donor liver transplant is a better alternative to waiting for a deceased-donor liver as when a part of the liver is removed from the donor, it regenerates and returns to its normal size shortly after surgical removal.

India is one of the major centers for liver transplant in the world. In india all Liver transplants are done in JCI accredited hospitals by an internationally trained and experienced team of surgeons who follow internationally accepted protocols.

Types of Liver Transplant

1. Living Donor liver transplant

Cut a section of a normal liver and cirrhotic liver

Liver transplant is done in people whose symptoms due to liver failure cannot be controlled or who have liver cancer.

Liver failure can be acute or chronic depending upon progress of disease or symptoms. In acute cases failure occurs quickly within a matter of weeks. It is not a common condition and happens usually as a result of complications of medications, drug overdose or ingestion of toxins or heavy metals.

Chronic liver failure is much more commoner and occurs over a period of months or years. Chronic liver failure is usually caused by a plethora of conditions. When non-functional scar tissue replaces the normal tissue of the liver is called cirrhosis. Cirrhosis is the most common cause of chronic liver failure and liver transplant.

Major causes that lead to cirrhosis of liver and liver transplant include:

• Chronic infection with Hepatitis B and C.
• Excessive regular alcohol consumption for a long period of time.
• Pathological fatty deposition in the liver is called non-alcoholic fatty liver disease, causing inflammation and liver cell damage.
• Hemochromatosis, Wilson’s disease and other genetic diseases causing excessive deposition of metals in the liver.
• Inborn, acquired and chronic infectious disease of bile duct.

Liver transplant  can treat acute liver failure, but it is more commonly to treat chronic liver failure. Liver transplant is also a good treatment option for certain cancers that originate in the liver.

Risks in Liver Transplant

Risks in liver transplant can be due to the surgical procedure or  with the drugs that need to be given to prevent rejection of the donor’s liver.

Risks in the surgical procedure include:

• Leakage, blockage or contraction of bile duct
• Excessive bleeding
• Thrombosis or blood clots formation
• Failure of survival of donated liver
• Infection
• Rejection of donated liver

In few conditions if the underlying disease is not treated or controlled properly there may occur recurrence of liver disease in the transplanted liver.

Anti-rejection medication side effects

After a liver transplant, immuno-supressant medications are needed for the rest of life to prevent rejection of the transplanted liver by the patient’s immunity. These anti-rejection medications can cause:

• Bone loss or thinning
• Loss of blood sugar control or diabetes
• Loose motion
• Increased blood pressure
• High cholesterol

Immuno-suppresants also increase risk of infection as well.

Evaluation

Patient needs to be evaluated prior to final decision for transplant:

• To understand if patient is healthy enough to undergo transplant surgery and will be able tolerate lifelong anti-rejection medications
• To manage any medical conditions that may interfere with transplant success

Specific tests, procedures and consultations prior to transplant surgery:

• Laboratory tests, like blood and urine tests to assess the general condition of body, including the liver
• Imaging studies, like an ultrasound
• Heart tests which may be ECG and Echocardiogram for assessment of cardiovascular system
• A general health exam, to check for other illnesses that may affect liver transplant

Other evaluations can be:

• Nutritional assessment and counseling with dietitians
• Psychological evaluation
• Addiction testing and counseling

Waiting for a new liver usually takes a heavy toll on the patient and family in terms of finances, socialization, and mental health as well. Most countries have a long waiting list depending upon the severity of the disease and the availability of donors.

Liver transplant in India if a patient’s relatives are willing to donate has no waiting and can be performed in any of the top JCI accredited hospitals.

Complications due to end-stage liver failure are serious, and patients may need to be frequently hospitalized.

Living liver donors

A small portion of liver from the donor is transplanted into the recipient by a surgical procedure. Eventually the liver portions in both the donor and the recipient grow to normal size within a few weeks.

Living-donor liver transplants are a better alternative to waiting for a deceased-donor liver as it:

• Prevents the hazardous health complications of living with a failed liver.
• Prevents financial losses to the patient and family
• Survival and success rate of Living liver transplant is better than a deceased liver transplant.
• Prevents psychological and mental health issues.
• Prevents damage to other organs including brain from unmetabolized toxins building up in the body

Usually living donors are close family members or friends. It is always advised and better to find willing family members for liver transplant.

Apart from some surgical risk to the donor, advantages of living liver transplant greatly outnumbers deceased donor liver transplant.

Domino liver transplant is a less common living liver donor transplant type where the donor already suffers from a condition called amyloidosis. Amyloidosis liver causes abnormal deposition of proteins in the body organs causing their damage, but the liver functions well. So the donor receives a normal liver from another donor or deceased person and in turn donates his amyloidotic liver to another person. The recipient of the amyloidotic liver will also eventually suffer from amyloidosis but that takes decades. This type of liver transplant is reserved for elderly patients.

2. Deceased donor liver transplant

Is a more common procedure due to unavailability of living donors because of various social, psychological, mental and other issues. In this type of liver transplant a liver is harvested from a brain dead victim whose still might be pumping blood to the organs including liver. The liver is harvested from the body with either relative’s consent or if the dead person prior to the death had pledged to donate organs. In such cases multiple organs can be harvested and one dead donor can give life to many.

The harvested liver is then surgically transplanted into the recipient very similar to the living donor liver transplant.

Cost of liver transplant surgery

Liver transplant is a very complex and specialised surgical procedure and can only be performed in hospitals with top of the line infrastructure. Huge investments in infrastructure and high cost of training of the transplant team results in a whopping high cost of liver transplant surgery.

Cost of liver transplant surgery in the western world can be as high as USD 300000. But in the asian countries like India the cost of liver transplant in a JCI accredited hospital with an internationally trained and qualified transplant team is almost 10% of the cost of western countries. On an average the cost in India is about USD 35000-40000. Given the cost benefit and the success rate as good as the western countries, India is the most cost-effective country for liver transplant surgery.

During the procedure

Living liver donor procedure

Living-donor liver organ regeneration

During the transplant surgery the surgical team starts by harvesting the donor liver from the donor. For this surgeon makes an incision in the abdomen to access your liver. After harvesting a part of the donor’s liver the incision is closed with stitches.

By this time another surgical team removes the diseased liver from the recipient and places the donor liver in its place and secured. Then blood vessels and bile ducts are connected to the donor liver. Surgery can take several hours up to 12 hours.

After closure of the incision with stitches, the recipient will need to stay in ICU for upto couple of days.

The transplanted liver portion in the recipient’s body and the left chunk of liver in the donor’s body regenerate rapidly. They regenerate to normal volume in several weeks.

After a liver transplant

• Few days of stay in the intensive care unit (ICU) for monitoring patients and looking for early signs of complications.
• A total stay in hospital for 7-10 days
• Frequent follow-ups after discharge from hospital during the first month.
• Continue medications for the rest of the life to prevent rejection of the transplanted liver.

A recipient can resume normal activities and go back to work within a few months after liver transplant. But complete recovery from a liver transplant can take upto six months which depends upon the general condition and health of the patient prior to the surgery.

Results

A successful liver transplant depends on many factors, but the most important of which is the health condition of the recipient prior to the transplant and other organs involvement. The higher the involvement of other organ functions and longer the wait period before transplant the lower the chances of success. The world over overall survival rates of recipients after liver transplant at 5 years is 75%. Indian Doctors and hospitals very well match the success of liver transplant in the developed countries and have similar at 5 years survival rate.

It has been researched that people who receive living donor liver transplant  have better short-term survival rates than compared to those who receive a deceased-donor liver.

Diet and nutrition

A healthy well-balanced diet after a liver transplant is very important for recovery and keeping the transplanted liver healthy.

A discussion with a dietician regarding food habits and diet chart helps maintain a healthy diet. The important things include:

• Well balanced diet low in salt, cholesterol, sugar and fat
• Avoid alcoholic beverages and use of alcohol in cooking
• Fruits and vegetables must form a big portion of daily diet
• Grapefruit and grapefruit juice affect post transplant medications and must be avoided
• Processed food to be avoided and whole grain foods should be preferred
• Foods must be high in natural fibres
• Dairy products should be low-fat or fat-free to maintain optimal calcium and phosphorus levels
• Stay well hydrated with plenty of water and fluids
• Lean fat free meats like fish or poultry can be consumed in limited amounts.

Exercise

In the post liver transplant period habit exercise and physical activity should be developed to help improve overall well being.

Walking regularly is a good activity and can be started in the immediate post transplant period. It improves physical as well as mental health.

Walking, bicycling, swimming, and other low-impact strength training and physical activities can immensely modify lifestyle.