What is Liver transplantation?
Liver transplantation is a surgical procedure performed to replace a diseased or damaged liver with a healthy one that functions properly. The most commonly used technique is called Orthotropic liver transplantation, where the entire liver is removed and replaced with a donated liver.
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Liver transplantation is the standard treatment for end-stage chronic liver disease or cirrhosis and is a life-saving procedure for patients with acute liver failure. A donated liver can come from either a living donor or a deceased (brain-dead, cadaveric) donor.
Who is eligible for a liver transplant?
The severity of liver disease and its impact on the patient’s health, as indicated by signs, symptoms, and blood tests, is used to determine the need for a liver transplant.
Some patients may have irreversible liver disease that does not require a transplant, while others may be too ill to benefit from a transplant. Specialized doctors in liver diseases, such as liver transplant surgeons and hepatologists, are best suited to assess the need for transplantation. A liver transplant is only offered if the benefits outweigh the risks.
Liver transplant is not recommended for patients with current alcohol abuse problems, uncontrolled active infections, widespread cancer, or severe untreatable diseases of the brain, heart, or lungs.
Types of liver transplants
There are two types of liver transplants based on the source of the liver:
Deceased donor transplant: This type of transplant involves using a liver from a deceased donor. Brain death resulting from accidents, brain hemorrhages, or strokes with irreversible brain damage is the usual cause. A single deceased donor can provide organs for multiple transplants, saving many lives.
Living donor liver transplant: In this more technically complex procedure, a healthy liver is taken from a living donor and transplanted into the recipient. Living donors undergo a thorough evaluation process to ensure they are suitable candidates. Living donor transplants have advantages such as minimal risk of liver dysfunction since the donors are healthy individuals with fully functioning livers, and there is a better genetic match between the donor and recipient, reducing the risk of organ rejection.
Evaluation and preparation for liver transplant
The evaluation process begins with assessing the recipient’s suitability for transplantation. If there are potential donors within the family, their blood groups are checked, and a compatible donor undergoes evaluation. Once a suitable donor is identified, the authorization committee clearance is obtained, and the transplant is scheduled. Living donor liver transplants can typically be performed within 2-3 weeks.
Recipient evaluation includes various tests, such as blood tests, CT scans, and assessments by specialists to determine the severity of liver disease, its impact on other organ systems, and the patient’s ability to tolerate the surgery. The evaluation also includes checking for liver tumors and assessing the condition of other organs like the heart, lungs, and kidneys. The evaluation process usually takes around 7-10 days as an outpatient.
Donor evaluation includes compatibility checks, liver function tests, liver volume assessment, and, in some cases, a liver biopsy to ensure the quality of the liver. Donors undergo thorough medical and psychological evaluations and receive counseling during the process. Donor evaluation also takes about 7-10 days as an outpatient, usually done alongside the recipient evaluation.
Authorization committee clearance is required for living donor transplants. The committee reviews all cases that have completed both recipient and donor evaluations to ensure the suitability for transplant. The transplant date is scheduled only after clearance by the authorization committee.
Financial arrangements for liver transplant are offered as packages, including pre-transplant workup fees, operation charges, and lifelong consultation charges for both the patient and the donor. Patients with additional risk factors or specific conditions may require additional expenses, which should be discussed with the pre-transplant coordinator. Insurance coverage and payment arrangements should be coordinated with the appropriate authorities.
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Alternatives for patients without suitable living donors
Patients who do not have a suitable living donor or are unlikely to receive a deceased donor transplant in time for their disease severity may benefit from alternative procedures:
Swap transplant: When a family member is willing to donate but not a suitable match for the patient, a paired donation or swap transplant can be considered. This involves exchanging donors with another family in a similar situation, allowing both patients to receive suitable livers. Swap transplants require careful planning and can only be performed by experienced transplant teams.
Dual lobe liver transplant: If a potential living donor’s liver volume is inadequate for the recipient, two or more suitable donors from the same family can donate a portion of their livers. The partial livers from multiple donors can be combined to provide an adequate liver volume for the patient. This complex procedure requires simultaneous operations on the recipient and multiple donors.
ABO-incompatible (ABM) transplant: Typically, liver transplants are performed using blood group-compatible donor livers to minimize the risk of organ rejection. However, with specific immunosuppressive medications and measures, it is possible to reduce antibody levels before transplant, allowing for ABO-incompatible transplantation and preventing organ rejection.
A deceased donor transplant is the usual route for patients who have completed the evaluation process and are medically fit for transplant. They need to register their names on the waiting list through the appropriate state-wide authority. When a potentially deceased donor liver becomes available, the patient is alerted and called to the hospital for preparation.
The liver is carefully assessed for suitability before transplant. Patients should discuss the quality of the liver and associated risks with the transplant team before accepting or rejecting it. In case of cancellation or unsuitability, patients return home and continue waiting for the next opportunity, ensuring patient safety and increasing the chances of a successful transplant.
In conclusion, liver transplantation is a critical surgical procedure for patients with severe liver disease or acute liver failure. With careful evaluation, suitable donors, and appropriate preparation, liver transplants can save lives and improve the quality of life for those in need.
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