Liver Transplantation

There are two types of liver transplants depending on the source of liver:

1. Deceased donor liver transplant (Cadaveric liver transplant)

Brain death is sudden death after an accident, brain haemorrhage or stroke with irreversible brain damage that is not compatible for life. Donation by a single deceased donor can allow as many as nine lifesaving organ transplants and numerous life-enhancing tissue replacements.

2. Living donor liver transplant 

This is technically more complex than deceased donor liver transplantation, but can be safely performed by an experienced team with a well-established setup. A few advantages of living donor transplants are:

• Living donors are healthy people with a perfectly healthy liver and go through a rigorous process of evaluation; therefore, the chances of liver not working after transplantation are very minimal
• Better genetic match between living donors and candidates may decrease the risk of organ rejection

1. Recipient

The preparation starts with the recipient's evaluation. Once the patient is found suitable for transplantation, any potential donors in the family should have their blood group checked, and if found compatible, they should undergo donor evaluation. If the donor is found to be suitable, authorisation committee clearance is obtained, and the transplant is scheduled. Patients planned for a living donor liver transplant can generally undergo the same in about 2–3 weeks.

Evaluation
Once end-stage liver disease (E.S.L.D.) is diagnosed and the need for a transplant is perceived, the patients undergo a formal liver disease evaluation, which involves blood tests, computed tomography (C.T.) and other scans, tests for heart, lungs and other organ systems, and assessment by various specialists. Evaluation is performed with the following goals:

• To establish the diagnosis and find the cause of cirrhosis / E.S.L.D.
• To determine the severity of liver disease and its effects on other organ systems such as the heart, kidneys, lungs, etc. and thus determine the urgency of transplant
• To actively look for liver tumour
• To evaluate the condition of other organ systems, such as the heart, lungs, kidneys, etc. and determine the patient's ability to tolerate this major operation
• To evaluate difficulty, technical feasibility and risk of surgery (previous abdominal infections, surgery, thrombosis of liver blood vessels)

Evaluation generally takes approximately 7–10 days and is conducted as outpatient services.

2. Donor

A living donor should meet the following criteria:

• Compatible blood group with the recipient
• A family member (wife, husband, mother, father, brother, sister, son, daughter, grandfather, grandmother, grandson, granddaughter) or close relative of the patient
• We do not accept family friends, well-wishers, staff or neighbours as donors
• Age group range: 18–55 years
• Should not be overweight because people who are overweight may have fatty liver
• The donor liver should be large enough to provide adequate volume for the recipient (patient) as well as for the donor
• Donor should be in good overall physical and mental health, undergo a thorough medical and psychological evaluation and volunteer for donation after fully understanding the risks of surgery

The decision to donate can be changed at any stage of the evaluation, before or after the tests are performed or any time before the surgery.

Evaluation 
Liver donor evaluation usually takes about 7–10 days and is performed as outpatient services, most often along with the recipient evaluation. Donors usually undergo liver function and liver volume tests to evaluate the organ in first phase. Few donors might need a biopsy to study the liver quality in more detail, where a tiny piece of liver is examined under a microscope.

When potential donors are rejected, it can be stressful for the family, but this evaluation is performed for the safety of the donor and success of transplantation; an alternative donor should then be identified. Both the patient’s and donor’s emotional health and willingness for transplant is more important for the operation and they would be counselled by a psychologist during evaluation.

3. Alternatives for living donor

Patients who do not have a suitable living donor or are unlikely to get a deceased donor transplant in time for their disease severity might benefit from one of the following innovative procedures:

• Swap transplant
  When one of the patient's family members is suitable and willing for donation but is not a good match for the patient, a paired donation or swap transplant may be considered. In this type of transplant, two families with suitable living donors exchange their donors because they are not a good match for their own patients but are appropriate for each other's patients. Both transplants are performed simultaneously and, therefore, can only be performed by a large, experienced transplant team after careful planning.
• Dual lobe liver transplant
  When a potential living donor's liver volume is found inadequate for the recipient on pre-operative CT scan, they may be rejected and another donor evaluated. It is common that in one family two or more people might have been rejected for donation because of low liver volumes, who were otherwise suitable. If partial livers from both donors are combined, it is often adequate for the patient. In such a transplant, three operations (one recipient and two donors) are performed simultaneously.
• ABO-incompatible (ABM) transplant
  Generally, a liver transplant is performed with blood group compatible donor liver because ABO (blood group) incompatible transplantation triggers the production of antibodies against the transplanted liver, thereby causing organ rejection. However, if some special immunosuppressive medicines and measures are used, antibody levels can be reduced before transplant and prevent organ rejection.
• Deceased donor transplant
  Once the recipient evaluation is completed and patient is found medically fit for transplant, the prescribed forms have to be completed and submitted through the hospital to the state-wide appropriate authority for registering their names on the waiting list for a deceased donor transplant.
  When a potential deceased donor liver is available, patients are alerted immediately and called to the hospital. While one team prepares the patient for transplant, another team retrieves the donor's liver. The liver is carefully checked for its suitability for transplantation. Liver from donors may be considered high risk if they had previous hepatitis B or hepatitis C infection and possess risk factors for HIV infection, active infection or cancer. Patients should discuss the quality of liver and associated liver transplantation risks with the transplant team before accepting or rejecting it. If the transplant team finds the liver unsuitable, the donor family withdraws their consent to donate, or for any other reason, the transplant is cancelled; patients will have to return home and continue waiting for the next donor. While such "false alarms" could be stressful, these decisions are always taken in the interest of patient safety and to optimise the chances of a successful transplant.