Liver transplant: From a patients perspective - process-types - costs - risks

 

Liver transplantation

A liver transplant is a procedure in which the liver of someone which has stopped or poorly working can be replaced with the healthy liver. This article explains what the indication for liver transplantation is and describes how it is performed. A liver transplant is a surgical procedure which replaces a disease-struck liver with a healthy, complete and healthy one of the patients. This article provides the latest indications on liver transplantation types, operations in general and immunosuppression required following transplantation.




Why do people need liver transplants?

Liver transplant is a way to manage patients with liver failure, although liver has the capacity to regenerate but in the events when chronic infections like hepatitis B & C, tumors, fatty liver or metabolic disorders lead to chronic liver damage or even acute events like poisoning, acute hepatitis leading to liver shutdown, often liver transplant is the only way to save lives. As currently there is no liver replacement therapy like dialysis in kidney disease.

 

What happens during a liver transplant?

Prior to liver transplantation, there is an entire evaluation process, during which patients that are candidates of liver replacement are evaluated in depth.

The transplant evaluation process

This evaluation is often done in steps, the first step is to establish how advanced is the liver disease, what are the complications, can the patient be managed medically or transplant is absolutely necessary. Your treating physician will take your detailed history to establish the stage of disease and what decompensations have occurred e.g. Ascites, Upper gastrointestinal bleeding, Encephalopathy, Jaundice, Liver tumors i.e. HCC , hepatorenal syndrome or hepatopulmonary syndrome. In addition, your doctors will look into your past medical history and evaluate for cardiac or pulmonary disease or any other contraindications to your surgery.

Apart from the history, you will get some blood works done to establish your blood group if not already known, and baseline liver tests to calculate your liver scores using scoring tool like Meld Na Score and Child Pugh score.

This follows an in-depth discussion by the transplant hepatologists with transplant surgeons alongwith discussion with the patient to decide future course whether to continue medical treatment for some time or liver transplantation has to be proceeded with. The risks and benefits of the surgery and post-op care and follow-up.

The next step involves extensive investigations to workup for any infections, any underlying diseases, cardiac fitness and liver imaging with C.T scans.

Patients are offered vaccinations for common infections e.g. pneumococcal, meningococcal and influenza prior to liver transplant.

The final step for the patient is to get fitness from relevant doctors in order to proceed with surgery, e.g. anesthesia evaluation will be done at this stage and decided whether patient is fit anesthesia or not similarly fitness evaluation is done by all concerned sub-specialties e.g. nephrology, cardiology, physiotherapy, psychiatry, pulmonology, infectious disease etc.

The above is a brief outline that entails the work-up process that occurs from the time patient is seen in clinic for transplant consideration to being listed for the surgery, minor variations or addition of steps might be present depending upon the hospital and local regulations and whether cadaveric or live donor liver transplant is being considered.

Liver transplant types: live vs cadaveric

For the countries where cadaveric liver transplant is commonly done e.g. USA, UK, ITALY, SPAIN, FRANCE etc, once the patient is evaluated he is put in the transplant waiting list and his surgery is proceeded with when his turn comes up depending upon the urgency of liver transplant and the availability of transplant organs.

For the countries where mostly Liver donor liver transplant is done i.e. most eastern countries like Pakistan, China, India and Korea. The potential donor evaluation is done simultaneously.

Liver donor evaluation process

The criteria established for liver donor by most centers is that, donor should blood group should match with the recipient. Positive and negative blood groups are not considered just the main group e.g. A, B, O is considered.

Donor should be medically fit and have no underlying medical condition.

Not be obese as fatty liver can’t be transplanted. Age should be around 18-50 years.

Similar to the patient the donor has to undergo medical tests and liver imaging e.g. c.t scans to assess his liver and plan re-section of liver along-with fitness evaluation for surgery.

Finally depending upon the institute / local regulations, permission from ethical review boards or transplant regulatory authority need to be taken.

 

Liver transplant surgery

Liver transplant surgery takes around 7-8 hours, patient is put under anesthesia, the diseased liver is removed followed by transplantation of the donor liver.

Patients are usually kept in ICU for 2 days following the surgery for observation followed by the next 10-14 days in the ward, where daily observation is made of patients wound, liver functions and optimization of immunosuppression medication.

Tell me the risk of liver transplant surgery?

Since the liver transplant surgery was established their has been excellent advances in the surgical techniques, pre and post op management and managing the immunosuppression after the transplant. Having said that, considering it’s a major surgery, the patients undergoing the surgery are mostly not in their best of health. There are some risks associated with surgery.

Overall the success rate varies from center to center but broadly speaking the average success rate for liver transplant surgery is 85 %.

In addition, about 20 % of the patients might face some adverse effects, most of which can be managed medically or via minimal invasive procedure.

·         Infections: These can occur during the immediate period or over the course as patient is on immunosuppressive medications.

·         Strictures: These are the narrowing of liver ducts mostly at the place where patient and donor organs are attached. If this occurs, this is managed via ERCP i.e. endoscopy.

·         Liver rejection: Finally the transplanted liver might not work at all, though this number is very very small, most patients might have to face deranged liver functions as a result of inadequate medication dose.

·         Relapse of primary disease: Some disease like autoimmune hepatitis might relapse and affect the transplanted liver.

Regarding donors:

The major risk is about 0.5 % i.e 1 in 200. Though similar to a recipient donors can face some minor complications e.g. infections, leakage from the surgery site, hernia and anesthesia related adverse effects.

 CAN YOU LIVE WITHOUT A LIVER

No, the liver is a major vital organ involved in the normal functioning of the body, whether, metabolizing the absorbed nutrients or detoxifying the harmful substances. Our body can’t function without a healthy liver.

But what about those donating the liver?

In liver donors, only a part of liver is removed not the full liver. After the surgery, the remaing portion of the liver increases in size to reach the pre-surgery level.

Liver transplant cost in USA

The approximate cost of liver transplant in USA ranges from $ 163,438 ( 145k to 180k). Cost varies depending upon the center and insurance coverage. In private setups full costs may reach $ 300,000 -  $600,000

 

Liver transplant cost in UK

Compared to the USA, liver transplant surgery is cheaper in UK. The exact value depends upon the center and nhs.

Approximate rate vary from 13-15000 GBP. Some sources quote $80,000.

 

Liver transplant cost in Pakistan

In Pakistan, liver transplant is done both in private sector and public sector hospitals.

Among the public sector hospitals the specialized centers doing transplant in bulk are

1.      PKLI, Lahore, Punjab

2.      Gambat Institute, Khairpur, Sindh

For the public sector hospitals, transplants are done on a discounted rate or even almost free of charge as well. The rate for liver transplant in PKLI as a private patient varies from Rs. 30,00,000 to 40,00,000.

Among the private sector institutes are Shifa hospital, Islamabad. Bahria hospital, Lahore and some other hospitals.

 

 Have any questions right below in the comment box.

 

 

 

 

 

 

 

 

 

 

 

 

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  1. Thanks for the useful overview, quite helpful as a patient.

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