Liver Transplant - Indian Perspective

Located in Ahmedabad, Zydus Hospitals is a 550 bedded super-specialty hospital that boasts of having highly sophisticated medical equipment that enables it to offer varied medical treatments & services such as investigations, diagnostics, rehabilitation, and physiotherapy care, all under one roof.

The Transplantation of Human Organ Bill was passed in 1994, became a law in 1995 and has been amended in 2011. The first successful liver transplant was performed at Apollo hospital, New Delhi in 1998. India has come a long way in the last 2 decades, liver transplantation (LT) is now being offered as a lifesaving procedure in many centers, and as the expertise is increasing, every year more centers are getting established. Initial attempts at performing deceased donor liver transplants (DDLT) were met with disappointment due to lack of deceased donors. Also, LT is a technically complex procedure, requiring huge amount of resource, and is associated with a formidable cost, hence the initial enthusiasm in public sector was ill-sustained. As the number of patients on waiting list increased with hardly any increase in the organ donation rates, the emphasis shifted to living donor liver transplants (LDLT) and to the private sector.

Beginning of LT in India had an optimistic approach, a hesitant beginning, and has a gratifying present, which has put the country at forefront globally. There are about 110 LT centres in our country(active centres about 40), however the gap between the number of LTs needed (about 50,000 livers) and the number of LTs being performed (about 2000-2750 per year), is still wide and it will require the efforts of all concerned in the transplant community, to bridge it up.

It is important that the interval between the harvesting of the liver to the restoration of circulation in the recipient is kept as short as possible, ideally less than 10 hours

The most common indication for LTin our country is end stage liver disease secondary to alcoholic liver disease, hepatitis B and C related liver disease, non-alcoholic steatohepatitis, and cholestatic liver disease. Emergency LT is required in patients with acute liver failure due to viral infection (Hepatitis A, E, B), idiosyncratic drug reaction (anti-tubercular drugs, anticonvulsants etc.), once they fulfill criteria for the same. Patients with hepatocellular cancer confined to the liver are also offered LT as a curative treatment. In children commonest indication for LT is biliary atresia, others being inborn errors of metabolism, like Maple syrup urine disease, primary hyperoxaluria where combined liver and kidney transplant is required.

There are two types of transplants as mentioned above, one is with deceased / brain dead donor (DDLT) and the other is with living donor (LDLT). Brain dead donors are matched according to the blood group, size and liver functions apart from other test to decide whether the liver is suitable or not for donation. Once the organ is available it is allocated to the patient and the system of organ allocation is different in different states and there is generally a neutral body which regulates this. In our country, we still do not have a central system of organ allocation, unlike UNOS and NHSBT in US and UK, respectively. There is lot of work being done on this front and we hope to have a system in place for every State soon.
Vibha VarmaConsultant - HPB & Liver Transplant SurgeonZydus HospitalThe retrieval of organs and preparation of the patient goes hand in hand rapidly, with the multidisciplinary team (surgeons, physicians, anesthesiologists, nursing staff, coordinators, intensive care team, etc.) in action organizing the whole process. It is important that the interval between the harvesting of the liver to the restoration of circulation in the recipient is kept as short as possible, ideally less than 10 hours. This requires team approach with every individual member being aware of the responsibilities. In LDLT, the transplant is planned in advance and the donor is identified from the family. The donor had to be blood group compatible, between 18-55 years, healthy, in sound state of mind and most important willing for donation. They are assessed for liver donation in different stages, the initial stages are required to look for the suitability of the liver for donation and later stages are for confirming the fitness for surgery and to rule out any risk factors for the donor. As the liver has unique property of regeneration, has two lobes/divisions, and only a quarter of normal functioning liver is required for sustaining life, one can donate up to 70 percent of liver safely. In all the endeavor of LDLT, the idea is to do no harm to the donors, hence donor selection and acceptance is very important step and repeated counselling along with assessment helps us in achieving this goal. The donor surgery is safe in experienced hands with the risk of surgery for donors is 0.2-0.5 percent.

Transplant surgery involves removal of the entire diseased liver from the patient and replacing it with a new liver(whole liver or partial liver depending upon the donor – deceased or living). Generally, the operation in the patient lasts for 8-10 hours and after the surgery the patient remains on machine ventilation for the night and is woken up on the first day following surgery. Patients are started on immunosuppressant drugs for helping them in accepting the new liver. These medicines require dose adjustments depending upon the liver functions and their drug levels. Patients are discharged following transplant in 2-3 weeks and are called for follow-up on regular basis. The success of LT surgery is 90-95 percent depending upon the pre-transplant condition of the patient. The important complications post LTwhich can occur is infection and rejection. The risk of infection is highest in the initial three months of surgery when the dose and number of immunosuppression is high. Liver is a tolerant organ and rejection episodes are easy to treat, severe rejection leading to graft failure and re-transplantation is very rare (five percent).

In the last decade there has been a slow but steady increase in the organ donation rates and the number of DDLT. Organ donation rates are still very dismal ranging between 0.3-1.3/million population. If we have to help the patients on the waiting for transplant this rate needs to go up to at least 5-10/million. At present the transplant programs all over the country are predominantly performing LDLT (ratio of LDLT to DDLT varying from 95:5 to 70:30 with very few centers performing only DDLT). The results of LTs in India in many centers are as good as those in the West with 1, 3, and 5-years survival being 90 percent, 85 percent, and 70 percent respectively.