Advanced Centre For Living Donor Liver Transplant at Fortis Hospital Bangalore

Living Donor Liver Transplant

Majority of liver transplants in our country are living donor liver transplants

Although every person has only one liver, liver's remarkable regeneration abilities make it possible for a person to donate a part of the liver for liver transplantation. However, it needs to be mentioned that in the case of living donors, only family members and relatives can donate. Besides, the person must undergo a series of blood and liver function tests, psychiatric evaluations, cardiac assessments, etc. to determine whether he/she is fit for donor transplant surgery. Patients need to seek approval from the authorization committee.

Liver transplant is a technically challenging and highly complicated procedure and the risk of the surgery are explained to both the donor as well as the recipient. However, if successful both livers will regenerate and grow eventually thus enabling the normal liver function for the donor and the recipient. The liver has two basic super properties:

• Even if a liver is functioning at 25-30 percent of its capacity, it is able to perform at optimum levels.

• Over time, a liver has the remarkable ability to regenerate up to 90 – 100 percent of its size over time – usually between 2-3 months.  

Thanks to these two properties, it's possible to harvest 50 and even 70 percent of the liver safely. While the liver can be extracted to this extent, a safety margin is usually maintained as a precaution. Usually, patients require a liver which corresponds to 0.8 to 1 percent of their body weight. This specification allows a person to fully recover once the surgery is finished. In addition, there is a segmental division of the donated liver which is usually bifurcated as the right lobe for an adult patient, left lobe for an adolescent and left lateral segment for a small child.

As compared to the west where livers are pre-dominantly (90 percent) harvested from brain-dead or deceased individuals, in India, nearly 80 percent of all transplants are derived from living donors. Although a complex surgery which is more challenging than a brain-dead or cardiac death procedure, the current rate of growth of successful living donor transplantations lays testimony to the success of this procedure in India. The evolution of living donor transplantations can be directly attributed to the establishment of premier health institutions and innovations in surgical techniques across the country. We have outlined some of the advantages of getting a living donor transplant. They are as below:

• Living donors usually go through a thorough health evaluation and need approval from a committee before being considered for donation. This rigorous process of selection ensures that recipients usually get to experience improved long-term outcomes as well as quicker recovery times.

• As living donors are usually immediate family members, the chances of organ rejection are minimal as there is an increased likelihood of organ acceptance owing to a genetic match.

• A living donor transplant is done as an elective procedure . Both the donor as well as the recipient can schedule surgery at a time that works for both people. Moreover, an elective and planned procedure makes it easier on severely ill individuals who are in need of stabilization before surgery.

• Living donor livers usually enjoy greater longevity as compared to those transplanted from a brain-dead donor.

• The nature of living donor transplants enables surgeons to perform an emergency transplant for patients suffering from acute liver failure as a life-saving measure.

• The quality of the liver graft is comparatively much better as it is harvested from a healthy donor. In addition, the cold ischemic time – referred to as the time a donated liver is without any blood supply – is also way shorter. As a result of this short cold time, we are able to achieve excellent outcomes in the living donor liver transplantation process.

• In other transplants, there is always the matter of a waiting period to negotiate which means the patient might have to wait for several months or years for their turn to finally come. In case of patients who are suffering from liver tumors, the wait is all the more excruciating as it might be a little too late by the time they get the donor liver they have been long waiting for. However, with the aid of living donor liver transplants, a patient can enjoy a fresh lease of life – while avoiding the life-threatening complications associated with the brain-dead transplants – as the operation can be scheduled at a time which suits both parties.

• Living-donor transplant helps save lives and most donors can experience a sense of happiness and self-worth knowing that their good deed made a huge impact on another person's life. This positive impact can go a long way in boosting self-esteem.

Preparation & Evaluation  For A Liver Transplant - Donor. Click Here                                                                                                                                         

Preparation & Evaluation  For A Liver Transplant - Recipient. Click Here

Precautions which are required to be taken while waiting for the transplant

Once the evaluation is complete, the waiting process begins. However, waiting for a transplant requires a certain level of preparation to be done in the interim. While waiting, it's important to regularly undergo a series of tests which helps in ascertaining that everything is well and no new complications have risen. It's also important to adhere to all appointments as every skipped appointment can push the waiting period forward. Apart from that, patients will be in close contact with the transplant team and will be required to report periodically about their health status while also listening to any dietary and health-related advice or suggestions.

Individuals are also advised to build a strong support system around themselves during this crucial period. It's important to surround oneself with friends and family as they can be a powerful source of information and much-needed support. That being said, here are a few precautionary steps which should be followed to avoid any unnecessary complications and infections while waiting:

• Practicing good hygiene is step one. Infections can come from all possible avenues and one way of preventing them is by washing hands regularly. Washing hands every now and then with warm water and soap can help keep disease-causing germs at bay while helping avoid one from falling sick. If soap and water aren’t readily accessible, then carrying a hand sanitizer can also help fight germs efficiently and conveniently.

• In the case of malnourished or underweight individuals, it's important to gain weight as a low BMI can increase the risk of mortality. Medical nutrition therapy is usually recommended as it can help patients reached a desired healthy weight for surgery. In addition, consuming a low-fat, protein-rich diet comprising of foods such as eggs, meat, fish, and soy can assist in building up the muscles.

• Similarly, in the case of overweight patients and donors, it is recommended that they try and lose a few kilograms once the waiting period begins. Excessive weight can cause additional strain on the liver once the surgery is completed. Losing even a little weight can help in easing the recovery process.

• Studies have revealed that regular physical activity prior to the surgery has a positive effect on transplant patients. Staying active by performing light exercises like aerobics, yoga, walking has proven to improve functional capacity while helping patients recover more easily afterward. That being said, one should not try and engage in heavy lifting as it could strain the veins present in the liver.

• One should take adequate rest.

• It's equally important that the patient sticks to the prescribed dose of medications and not try and experiment with new forms of medications or supplements. Even vitamins, herbs, or supplements should not be consumed unless given the go-ahead by the transplant team.

• In case of patients who aren’t able to absorb the required limit of proteins or calories in their diet, then nutritional supplements may be prescribed after consultations with the dietician in our team.

• Skip alcohol. If you need a new liver, don't drink or take recreational drugs. Even a little alcohol can make liver diseases worse. If you're getting a liver transplant because of alcohol abuse, you may need to pledge to never drink again after the operation.

• A liver transplant is a lifetime commitment. One should strictly abstain from alcohol consumption and/or illicit drugs as it could unnecessarily create a host of health complications. Moreover, one of the pre-requisites before a transplant is that the recipient has to commit to a lifetime of sobriety. If the transplant team has a reason to believe that the patient has violated this agreement, they may subject the patient to random blood screenings or urine tests to check for the presence of alcohol. If found positive, there’s a high likelihood of the patient being delisted from the waiting list. Even donors should abstain from drinking alcohol from the moment the surgery is set.

• Besides laying off alcohol and illicit drugs, patients should quit smoking as well. Smoking can lead to lung infections, decrease the amount of oxygen in the body and prolong ventilator usage post-surgery.

• The patient should make it a point to keep the transplant team in the loop of any changes they might notice in their body or in their health. If there are new developments such as fever, drowsiness, fatigue, loose stools or presence of blood in stools, vomiting, etc. or if the person has been hospitalized for whatever reasons, the transplant team should be notified at the earliest.

• In the case of children, they should get themselves vaccinated (appropriate for their age) before the surgery. This is because the patient will not be able to receive any new vaccines once the transplant has been completed.

• Ascites described as an accumulation of fluid in the abdomen is an uncommon but serious complication that can occur after the transplant. In order to avoid this from happening, one should follow a low-sodium diet, adhere to liquid-intake restrictions along with diuretic treatment (if prescribed)

• While in most cases, patients on the waiting list will be able to continue working and traveling, there are times when the transplant team might consider it unsafe. This is entirely dependent on the prevailing circumstances. If the patient has been diagnosed with low platelet counts, INR higher than the recommended range, suffers from gastrointestinal hemorrhage, or encephalopathy to travel – then the transplant team may suggest taking a break from work and rest instead. In any case, if the patient seeks to travel, he/she should inform the transplant team while doing so. The patient should also provide numbers of any emergency contacts if he/she can't be reached. Additionally, they should ideally try and locate a local doctor as a precaution in case any complications were to pop up while traveling.

• Patients are advised to learn the relevant medical terms, abbreviations, and acronyms associated with liver transplants while waiting. This way, they will find themselves in a much better position to navigate the tricky landscape of medical science.

Getting admitted to the hospital for a transplant.

Once the liver has been allocated, the next logical step involves getting admitted to the hospital to prepare for the transplant. In case of living donor transplants, as these surgeries are planned in advance, both the donor as well as the patient are prepared for surgery by getting admitted to the hospital at least a day in advance to the surgery. It needs to be mentioned that neither the patient nor the donor is allowed to consume any food or drink any liquid after midnight prior to the surgery. Eating or drinking too close to the scheduled surgery may require rescheduling of the transplant surgery altogether.

In case of deceased or brain-dead donor transplants, most surgeries are emergency situations as the operation is entirely dependent on when a cadaveric liver becomes available for a transplant. Once a cadaveric liver becomes is available, the patient or his/her family is contacted immediately following which he/she needs to reach the hospital on an urgent basis. This call can be made at any time – day or night – which is why it’s important to provide a number which is always accessible. Upon reaching the hospital, a series of tests along with a comprehensive review of the patient’s current health status will be carried out. These tests will help in determining whether the patient is ready and able to undergo a liver transplant. Care should be maintained to ensure that the patient doesn’t consume any food or liquids once the patient or their family have received intimation for the liver transplant.

The next step after being admitted involves discussions with the transplant team. The team will discuss with the patient and his/her family members about the logistics involved in the surgery, the various risks, along with the quality of the liver which has been made available for the transplant. Thereon, the required set of consent forms will also be needed to be signed by the patient so as to confirm he understands the surgery, post-operative care and all the risks associated with it.

It’s the patient’s responsibility to keep the transplant team notified about any pre-existing health problems, their current health status, current medications while also keeping them informed about any known drug allergies. This is important as it helps in preventing any accidental drug use, infections, and surgical complications after interaction with transplant medicines. If any unexpected or new developments are discovered during the review such as the onset of a fever or an unforeseen change in the health status vis-à-vis the previous medical report, then the appropriate treatment may be suggested and the transplant might need to be postponed as well.

The Surgical Operation

Both operations – donor as well as the recipient – are scheduled concurrently to make sure that the risk of ischemia (damage during storage) is minimized. As mentioned before, in the case of deceased donor transplants, surgery can be initiated only once the donor's liver has been examined and deemed suitable for the recipient. The surgery does not commence immediately once the patient has been taken into the operation theater though. There are a set of precautionary procedures that need to be followed and prep-work which requires to be scheduled before the operation can take place – a process which might take up to two hours. This process also involves placing certain monitors to various parts of the body to measure the pulse, oxygen level, blood pressure, and other vital parameters.

Both the recipient as well as the donor will be administered general anesthesia, following which they are put on a ventilator. Once both are asleep, a tube called a catheter may be placed in the bladder to drain urine along with several other lines including arterial line, central line, endotracheal tube, nasogastric tube, etc. which facilitate the rapid administration of blood products, intravenous fluids, and medications. In addition, several tests including blood tests might be performed in conjunction with the surgery.

The Surgical Operation – Donor operation

In the case of living donor operations, depending on which part of the donor's liver is removed, different types of incisions will be made. The incision could either be straight up and down or possibly, a 4-inch cut across the bikini line. The type of incision to be made will be determined at the time of surgery and the best course of action will then be chosen.

During the pre-operative process, the liver will be divided into two separate segments and one portion will be removed for the recipient. The other part of the donor will be left intact along with the respective blood vessels and bile ducts going in and out of the lobe. In case of a full right lobe and left lobe donation, the gallbladder is always taken out as it’s stuck to the undersurface of the liver. The surgery usually takes anywhere between six to eight hours for completion. Any bleeding will be monitored with the help of a drain tube which is attached to the abdomen. Upon completion of the surgery, the incision line is closed with the help of self-absorbing sutures or staples. Further, the donor is taken off the ventilator and shifted to the ICU for overnight observation. The liver starts healing almost immediately and the regeneration process takes around six to eight weeks for full regeneration.

The Surgical Operation – Recipient operation

For the recipient, surgeons work in tandem to remove the cirrhotic or damaged liver and prepare for the implantation of the new organ. The cirrhotic liver may be slightly shrunken and stiff and there are chances of it being stuck to the nearby organs which is why it’s removal needs to be done carefully and at a slow pace to minimize chances of bleeding. The gall bladder will also need to be removed to make space for the new organ. The liver has several key connections which need to be re-connected to ensure that all blood vessels allow for blood circulation while ensuring the bile drains from the liver as well. Some of these connections include the hepatic artery, portal vein, inferior vena cava, and the bile duct. There are different methods used to reestablish the connection and it entirely depends on a case-to-case basis.

Once all connections have been established, the liver starts functioning almost immediately. Similar to the donor’s operation, bleeding will be monitored through a drain tube attached to the abdomen while the incision is closed with the help of self-absorbing sutures or staples. More often than not, the surgery takes anywhere between eight to twelve hours to complete, depending on the nature of the surgery and complications. In addition, around ten units of blood and blood products are reserved for the surgery which mayalso increase during or after surgery

Upon completion of the surgery, the recipient is allowed to recuperate in the ICU while still on a ventilator. Family members are allowed to wait in the waiting lounge are where they will be duly informed by members of the transplant team regarding the patient’s condition at the end of the surgery.

Resuming life after transplant

Taking care of yourself as well as your transplanted liver entails a commitment of a lifetime. At Fortis, our goal is to help you fulfill that commitment so that you can continue living your life to the fullest. In that regard, our transplant team will there every step of the way by carefully monitoring your condition for any signs of rejection or infection. Our ultimate aim is to help achieve an optimal transplant outcome for you and everyone involved.

Postoperative Care & Recovery after Liver transplant (Donor & Recipient). Click Here

Alternates to Living Donor Liver Transplants. Click Here

Liver Transplant FAQ

How many years will my transplanted liver last?

If you follow the various guidelines and instructions relayed to you by the transplant team, a transplanted liver can last you a lifetime. It’s imperative that you attend all follow-up visits and take care of your new liver by taking all prescribed medications on time. This will allow you to enjoy years of good health and lead normal lifestyle even years after getting a transplant.

What is the law about transplant in India? What is the procedure for cadaver donation? Can the hospital make arrangements for a living donor if I pay money?

In order to prevent organ trafficking, the Transplantation of Human Organs Act, 1994 established the definition of ‘brain-stem death’ (commonly referred to as ‘cadaver’). Thereon, using specified criteria, authorized doctors diagnose the nature of the brain-stem death and accordingly approve the liver donation. Thanks to these donations, thousands of patients with end-stage organ failure are able to acquire a new liver and with it, enjoy a new lease of life.

For any living donors, the law has laid down stringent rules and procedure to avoid malpractices and fraudulent activities. Anyone in violation of these laws is faced with severe punishment and penalties. Each and every case of living donor transplantation is scrutinized carefully, reviewed in detailed and only if all conditions are met, approved for transplantation by a government-appointed authorization committee. The guidelines for living donor transplantation entails that the donor requires to be a family member of the patient. Donors cannot be ‘bought’ by simply paying them money. Thanks to the prevalence of this law and government efforts, the illegal unrelated transplantation trade has been effectively curbed.

Where can I get more information about liver transplant?

In case you’re seeking more information on liver transplant, arguably the best place to start your search is by getting in touch with our transplant team or former patients who have undergone a transplant in the past. Alternatively, there’s plenty of information available on the internet as well which can help you get the information you need. Government websites such as NOTTO(National Organ and Tissue Transplant Organisation,India) UNOS (United Network for Organ Sharing, USA), European Liver Transplant Registry (ELTR) are very helpful in that regard while also being a reliable source of information.

There are also tools available online such as liver disease scoring systems which act as a reliable outcome prediction tool for patients suffering from liver disease. Some of the popular tools are Model for End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP). You can also visit forums, read through blogs or visit chat support groups which can point you in the right direction. That said, not everything you read online is accurate and there might be misleading facts published on personal blogs. Any information found on the web should be double-checked for its credibility. If you still seek more information or if you have any doubts that need clarification, feel free to reach out to our transplant team.

The Multi-disciplinary Liver transplant team at Fortis

Before undergoing any major surgery, such as a liver transplant, one needs to be aware of the procedures and various risks involved. At Fortis, we always keep you in the loop so that you remain on top of things at all times. We not only empathize with our patients but also give every operation, the utmost priority while maintaining the highest level of professionalism and respect in our liaisons with them.

We offer the full scope of treatments and all our surgeries are undertaken by our experienced and highly skilled team comprising of Liver transplant surgeons, Transplant Hepatologists (liver physicians), Anesthesiologists, Critical care specialists (ICU doctors), Radiologists (diagnostic and interventional specialists), Transplant coordinators, Operation theatre staff and nurses, ICU and ward staff and nurses, Cardiologists, Blood bank personnel, Pulmonologist (lung specialist), Psychiatrist, Nutritionist and Dietician, Physiotherapists / Play therapists (for children), as well as Hematologists, Biochemists, Pathologists and Microbiologists.

We use only the most advanced equipment and the best techniques in a top-notch operation theatre, with minimum invasive techniques. Our panel of doctors are best in their field and are well equipped to deal with every situation. We believe that life is of prime importance and therefore ensure that our patients always have access to the best expertise while following the highest standards in health care.

To ensure there are no malpractices, all our living donor cases are subject to approval by the Transplant Ethics Committee. We also carry out strict investigations for both the recipient as well as the donor to make sure that the surgery is safe for both while ensuring that the recipient receives the best graft. We are proud to state our team has successfully performed over hundreds of transplants to date with consistently good clinical outcomes.