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SERVICES
& PROCEDURES |
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| Diagnosis of liver disease : |
Liver disease can be diagnosed early by simple tests |
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| Liver Function Test (LFT) : |
They are a set of blood test that indicate the status of liver function and include :
- Serum Bilirubin- Increased levels of bilirubin often indicate an obstruction to the out flow of bile or a defect in the manufacturing of bile by the liver cells (Hepatocytes).
- Serum Alkaline phosphatase - Elevated levels of this enzyme indicates a biliary outflow obstruction. Its also elevated in injury to the bile ducts and certain cancers.
- AST (Aspartate Aminotransferase) or SGOT (Serum Glutamic Oxaloacetic Transaminase)
- ALT (Alanine Aminotransferase) or SGPT (Serum Glutamic - Pyruvic Transaminase.
- AST and ALT are elevated during active hepatitis.
- GGT (Gamma Glutamyltransferase)
- LDH (Lactose Dehydrogenase)
- Serum Albumin - Low levels of albumin, are seen in many chronic diseases of the liver due to decrease synthetic functions of liver.
- PT (Prothrombin Time) : Prolong PT is indicative of defect of blood clotting due to advanced liver damage.
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| Viral Markers : |
Viral markers are done for various types of hepatitis to find out type of virus (B or C) responsible for liver cirrhosis |
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| Liver Imaging : |
The doctor might order an ultrasound, computerized axial tomography (CAT) scan or a scan of the liver using a radioisotope (a harmless radioactive substance that highlights the liver). These imaging modalities give information about gross structure of liver and detect any cancer in the liver. The doctor might also look at the liver using a laparoscope, an instrument inserted through the abdomen that relays pictures back to a TV screen.
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| Liver Biopsy : |
A liver biopsy will confirm the diagnosis. For a biopsy, the doctor uses a needle to take a small sample of tissue from the liver, then examines it for scarring or other signs of disease. Biopsy is risky when the disease is very advanced due to bleeding tendency.
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| Teatment of liver disease : |
 Liver damage from cirrhosis cannot be reversed but treatment can stop or delay further progression and reduce complications when detected and treated early. Treatment depends on the cause of cirrhosis and any complications a person is experiencing e.g. cirrhosis caused by alcohol abuse is treated by abstaining from alcohol. Treatment for hepatitis related cirrhosis involves medications used to treat the different types of hepatitis, such as Interferon, Lamivudine, Ribavarine for viral hepatitis and corticosteroids for autoimmune hepatitis Treatment will also include remedies for complications. For example, for ascites and edema, the doctor may recommend a low-sodium diet or the use of diuretics, which are drugs that remove fluid from the body. Antibiotics will be prescribed for infections, and various medications can help with itching. Animal Protein causes toxins to form in the digestive tract. Eating less protein will help decrease the buildup of toxins in the blood and brain. However complete avoidance of proteins is also bad for the health of the patient. The doctor may also prescribe laxatives to help absorb the toxins and remove them from the intestines.
When complications cannot be controlled or when the liver becomes so damaged from cirrhosis that it completely stops functioning, a liver transplant is indicated to save the life.
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| Liver transplantation : |
Orthotopic liver transplantation (OLT) has evolved over the last 35 years, and has now become established as the only and highly successful therapy for acute and chronic end-stage-liver disease with five years survival rate approaching to nearly 85%. Liver Transplantation (LT) in India is now an established therapy for acute and chronic liver failure. In the developed world, the formulation and acceptance of brain death criteria, establishment of dedicated transplant centres and availability of cyclosporine immuno-suppression resulted in a phenomenal growth in this area in the eighties. The refinement in surgical techniques, improvement in anaesthesia, perioperative care and access to newer immuno-suppressant drugs has now resulted in 1 year acturial survival rate of 90% and 5-8 year survival rate of 75%-80%. Shortage of donor organs continues to remain a significant problem and innovative surgical techniques of segmental transplantation, split liver transplantation and living related transplantation have been developed to address this problem.The success of paediatric LT in developed countries has increased the awareness and need for such procedures in the developing world.
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| Indications for liver transplantation |
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| Children : |
- Extra Hepatic Biliary Atresia
- Biliary Hypoplasia
- Hepatoblastoma
Metabolic disorders such as alpha-1antitrypsin deficiency, Wilson's disease
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| Adults : |
- Cirrhosis
- PBC
- Sclerosing cholangitis
- Liver cancer (selected cases)
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| Common to Paediatric and Adult patients : |
- Fulminant Liver Failure
- Cryptogenic cirrhosis
- Hepatitis B & C associated end stage liver disease
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| Absolute contraindications : |
- HIV
- Disseminated cancer (primary or metastatic)
- Unfit for Major Surgery
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| Selection of recipients and timing of transplant : |
Selection of patients for transplantation requires consideration of not only medical criteria (see above), but also the socioeconomic and educational background of the family. This is of paramount importance because in addition to the initial expenditure, receiving a transplant also involves a lifelong commitment on the part of the family to spend an average of Rs.12000/month on immunosuppression and to adhere strictly to the postoperative care protocol including anti-infection precautions and long-term medication.
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| Selection and timing for adults : |
The timing of LT is dictated by the natural history of the underlying disease, evidence of decompensation of liver function and worsening of quality of life. All patients suffering from chronic liver disease who have more than one of the criteria listed below should be referred for liver transplant assessment and listing at a liver transplant center.
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Refractory ascites
One or more episodes of bacterial peritonitis (SBP)
Serum Albumin level below 3 gm/dl
Prothrombin time 5 seconds > control
Progressive cholestasis (PBC)
Severe Portal Hypertension (GI Bleed)
Encephalopathy
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Delay in referral adversely affects immediate and long-term outcome after LT and increases the cost of treatment. |
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| Selection and timing for pediatric patients : |
Optimal timing of liver transplantation is important to ensure the best chances for survival. All children with chronic liver disease with growth retardation and/or an expected survival less than one year should be considered for transplantation. Such a prognosis may be indicated by the presence of refractory ascites. Spontaneous bacterial peritonitis, gastrointestinal bleeding not controlled by conservatives measures, prothrombin ratio (INR) >1.4, indirect bilirubin >6 mg/dl, hypoxia, and encephalopathy. All children with advanced liver disease should be referred to the transplant center to ensure timely assessment and pre-transplant management.
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| Fulminant hepatic failure : |
All patient with fulminants hepatic failure should be managed in specialized liver units in close consultation with the transplant team, since a significant proportion of them will need life-saving emergency liver transplantation. Urgent liver transplantation should be considered in the presence of poor prognostic indicators. The poor prognostic indicators are age under 10 or more than 40 years, non-A, non-B, non-C hepatitis, rising prothrombin time (>30seconds), rising bilirubin (>10mg/dl), worsening encephalopathy (Grade II or higher hepatic coma) , a shrinking liver, worsening renal function and hypoglycaemia requiring increasing percentage of IV dextrose. The mortality without transplantation is 90% if the international normalized prothrombin ration (INR) is greater than 4.0
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| Liver for The Transplant : : |
The Liver for transplantation can be obtained from two sources:
- Brain dead Cadaver:
- Live donor: a part of the donor liver
There is no need for tissue typing in liver transplant, only the donor and recipient should have same or compatible blood group.
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| Orthotopic whole liver transplantation : |
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From the cadaver one obtains the whole liver graft and transplantation operation usually lasts for 6-8 hours and involves multiple vascular & biliary anastomoses. The blood loss during the operation is on an average 1 to 3 litres. The patient is usually ventilated post operatively for 24-48 hours. The patient is weaned from the ventilator and fed by 72 hours, if everything goes on smoothly. The average hospital stay is 2-3 weeks.
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| Living - related liver transplant : |
There is high-incidence of deaths on liver transplant waiting lists due to a shortage of cadaver donors all over the world. This problem is especially grim in Asian countries where donation rates are very low due to social and cultural reasons and also lack of awareness among public. Live donation though a major operation, can be undertaken safely. The donors can be discharged from the hospital within 10 days, and majority of them do not even require blood transfusion. In addition, liver has a large reserve functional volume and one can safely remove as much as 70% of the healthy liver without precipitating liver failure. Living donation only involves removal of 30% for paediatric recipients and 50-55% in the case of adult recipients. The advantages of LRLT are many. It almost guarantees an organ for each child with a suitable parent donor, and now with the right lobe transplants technology, many adults who can not wait for cadaver donor, can be safely transplanted.
The implanted liver shows better early function since the organ preservation times are short. We can choose an elective date of the operation, so that the patient receives it in good condition. The risk to donor with strict selection is small. The blood group must be the same or compatible to that of the patients own group. The comforting fact is that the liver regenerates to 90% of the initial volume within three months in both recipients and the donor.
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| Criteria for live donation : |
The living donor should be a relative with compatible blood group and similar body weight. The proposed donor should be medically fit and in the age group of 18-55 years. The donor is also thoroughly evaluated for fitness. The most important test is the volume of the two lobes of the liver as estimated by CT volumetry.
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| Pre transplant - assesment / counselling : |
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This involves assessment of : :
- Liver disease
- liver function tests
- Doppler Ultrasonography/ CT scan/MRI
- Esophago - Gastro - Duodenoscopy
- Liver Biopsy (selected cases )
- Infection/cancer markers
- Infection screening
- Nutritional and electrolyte status
- Cardiac, Respiratory and Renal function
- Surgical & Anaesthetic risks
- Social, Psychological and Economic issues
- Patient and family counseling
This is a very important aspect of the pre-transplant process. The aim of this phase is three pronged - 1. To identify the cause of liver failure, 2. To rule out contraindications for the transplant and 3. To assess the fitness of the patient for the procedure.
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| Outcome - and results after liver transplant : |
Early complications following OLT include primary non-function, vascular thrombosis, sepsis, biliary leak/ obstruction and acute rejection. Late complications include biliary stricture, chronic rejection, infections and occasionally malignancy. Recurrence of primary disease may be a problem in patients with hepatic tumours and hepatitis C infection. Hepatitis B recurrence is rare after transplantation for fulminant liver failure. In those with positive Hepatitis B status and chronic liver diseases, recurrence can be reduced to 10-15% from 70% with the peri and postoperative use of anti-Hepatitis B Immunoglobulin and antiviral agents. World over, liver transplantation remains a high risk procedure with a mortality of 15-20% with high perioperative morbidity. Most patients who cross one year survival will live up to their normal life expectancy. They will lead an excellent quality of life with no functional disability.
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| Quality - of life after liver transplant |
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The change in the quality of life of a patient after a transplant is truly amazing. Most people resume their normal activities including work within three months of the transplant. Apart from the fact that they need lifelong immunosuppressive medication (as is the case with any organ transplant) to prevent rejection of their new liver, they can expect a life which is normal in all respects including longevity, reproductive function and physical activity. Most women have normal pregnancy after liver transplant. In the case of children, those with growth failure secondary to liver disease will resume growing and that there appears to be a general improvement in lifestyle. |
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