Liver Transplant: Types, Procedure, and Documents Required

30 September,2024

The liver is the largest and one of the most important internal organs in the human body, performing over 500 vital functions. Some of its fundamental roles include producing bile to help digestion, filtering toxins from the blood, metabolizing nutrients and medicines, and converting excess glucose to glycogen for storage. The liver's role in the human body has earned it the moniker of the body's "chemical factory." A person cannot survive for long without a healthy and functioning liver, as there are no viable artificial alternatives. Therefore, when the liver fails to carry out its functions, a liver transplant is the only option.

The first human liver transplant was carried out in 1963 by an American physician, Thomas Starzl. However, the patient did not survive. After repeated attempts, he performed the first successful liver transplant in 1967. Over the years, the procedure has undergone several developments to improve its success rates, making the liver the second most commonly transplanted organ after the kidneys. In 2022, out of 1,57,494 organ transplants worldwide, 37,436 were liver transplants. Countries such as India, Germany, and Thailand are pioneers in liver transplants.

This blog delves deeper into the liver transplant process, why it is needed, and the diseases it treats.

What is a Liver Transplant?

A liver transplant is a surgery that involves removing a diseased, non-functioning liver and replacing it with a healthy, functioning one obtained from a donor. It is also known as a hepatic transplant. A liver transplant is a last-resort treatment option for patients suffering from liver failure, which can be long-term, known as chronic liver failure, or short-term, known as acute liver failure. A liver transplant can also treat some types of liver cancers.

What are the Different Types of Liver Transplants?

The choice of liver transplant depends upon the patient's health, requirements, and organ availability. Depending on the type of donor, liver transplants are of two categories:

• Deceased Donor Liver Transplant (DDLT): A deceased donor liver transplant is when a healthy liver is obtained from a recently deceased donor. This procedure is also known as an orthotopic liver transplant. It is the most common type of liver transplant. This method is usually recommended when the patient requires a whole liver transplant. The deceased individual can be a pre-registered donor, or their family members can decide to donate their liver after their death.
• Living Donor Liver Transplant (LDLT): In this procedure, a healthy living individual donates a part of their liver to the patient. The liver has a distinctive ability to regenerate its lost tissue. As a result, both the donor and recipient livers can grow to their full sizes and resume full function in a few months. Living donors are usually the patient's family members, friends, or acquaintances willing to donate their liver. 

Other Types of Liver Transplants

Apart from living donor liver transplant and deceased donor liver transplant, the procedure can also be classified as:

• Split Liver Transplant: In a split liver transplant, a single liver from a recently deceased individual is given to two different patients. This method works when the recipients are an adult and a child. The adult receives the right lobe of the liver, as it is larger, whereas the child gets the smaller left lobe. A split donation benefits two patients at once and is especially useful when there is a shortage of donors.
• Domino Liver Transplant: A domino liver transplant is a rare type of transplant where a younger patient suffering from a metabolic disease such as familial amyloidotic polyneuropathy (FAP) receives a healthy liver. However, the diseased liver is not discarded but is transplanted into another patient who needs a liver as this liver is still functioning. The second recipient may develop symptoms of metabolic disease; however, it may take decades for that to happen. Therefore, doctors usually choose older patients as recipients who need a liver but may not develop symptoms in their natural life expectancy.

Why is a Liver Transplant Required?

The doctor will order a liver transplant when the patient undergoes liver failure, which means their liver has stopped functioning adequately. Liver failure is of two types: acute and chronic.

Acute Liver Failure

Certain diseases and conditions cause the liver to stop functioning rapidly, causing acute or fulminant liver failure. It is rare and can happen due to acetaminophen/paracetamol overdose, viral infections (hepatitis A, hepatitis B, and hepatitis E), acute fatty liver during pregnancy, and Wilson's disease. Other reasons for acute liver failure include: 

• Epstein-Barr virus
• Budd-Chiari syndrome
• "Death Cap" mushroom poisoning
• Sepsis
• Heat stroke

Chronic Liver Failure

A liver transplant is usually the preferred treatment for end-stage liver disease or chronic liver failure. Chronic liver failure occurs over a longer period, often years. The most frequent cause of chronic liver failure is cirrhosis. In liver cirrhosis, the normal tissue of the liver gets replaced with scar tissue over time. When too much scar tissue forms, it affects the regular functioning of the liver, causing liver failure.

Other causes that lead to chronic liver failure include:

• Alcohol abuse (alcohol liver disease)
• Hepatitis B and Hepatitis C
• Autoimmune hepatitis
• Biliary cirrhosis
• Primary sclerosing cholangitis
• Biliary atresia (in newborns)
• Liver cancers (e.g., hepatocellular carcinoma)
• Nonalcoholic fatty liver disease (NAFLD)
• Hemochromatosis

What is the Success Rate of a Liver Transplant?

The success of a liver transplant can differ based on variables such as the patient's health, type of liver disease, and post-treatment care. On average, the one-year survival rate for a liver transplant is about 88%, and the five-year survival rate is around 75%.

How are Patients Selected for a Liver Transplant?

Although a liver transplant is the recommended treatment for liver failure, not every patient with end-stage liver disease will qualify for a transplant. There is a shortage of healthy liver donors, so careful selection of cases is extremely important. Liver transplants are contraindicated if the patient has:

• Cancer that has spread outside the liver
• Uncontrolled infections
• Active alcohol or drug use
• Severe heart and lung disease
• Non-compliance or inability to follow the treatment plan.

The doctor will conduct diagnostic and blood tests to evaluate the patient's health. The surgeon will schedule the surgery once the patient is deemed eligible for a transplant and a donor is readily available. If a donor is unavailable, the patient will be put on a waiting list.

What is a Liver Transplant Waiting List?

A liver transplant waiting list is a system devised to ensure that patients who need a liver more urgently get top priority when a donor becomes available. The list categorizes patients by blood type, body size, geographical area, and type of liver disease. Along with these categories, a scoring system known as the "model of end-stage liver disease," or MELD in adults, and "pediatric end-stage liver disease," or PELD in children, is used to assess the severity of chronic liver disease. The scores are determined based on three laboratory tests: serum bilirubin, serum creatinine, and international normalized ratio for prothrombin time (INR). The score for the test ranges between 6 and 40. The higher the score, the more urgent the requirement is, thus placing them higher on the transplant list. When a donor liver becomes available, it is offered to those at the top of the list first.

It is difficult to predict how much time a patient might have to spend on the transplant list. Getting a new liver depends on several factors, such as:

• If the patient's condition deteriorates, their score increases, and they move higher on the list.
• If two people have the same MELD score, the recipient is decided based on the time spent on the transplant list.
• Patients with acute liver failure are usually moved to the top of the list as their requirement for a liver is more pressing.

Who can Donate a Liver?

Living liver donors are usually the patient's immediate family, such as parents, siblings, or children. Extended family members such as uncles, aunts, nephews, nieces, or first cousins can also donate their liver if immediate family members are unavailable or not a good match.

• The donor must be willing to donate their liver and ideally between 18 and 60 years of age.
• The donor and recipient blood groups need not be exact matches but must be compatible.
• Ideally, the donor and recipient should be of a similar size by height and weight.
• The donor must be physically healthy with no diseases, such as hepatitis, diabetes, heart, kidney, or lung disorders, autoimmune disorders, HIV/AIDS, cancer, and hypertension.
• The donor must not have a history of or excessive active consumption of alcohol and illicit drugs.
• Pregnant women cannot donate their liver.

For a deceased donor liver transplant, the donor might have suffered a head injury in an accident. Although their heart continues to beat, their brain has permanently stopped functioning, rendering them brain-dead.

What is the Procedure for a Liver Transplant?

Once a donor liver is available, the hospital will contact the patient to schedule surgery. In the case of living donor transplants, the donor and recipient can schedule their surgeries in advance.

Before the Surgery

Before scheduling the surgery, the doctor will explain the procedure to the patient and review their medical records. They will also conduct a few tests to assess the health of the patient, including:

• Blood tests
• CT scans
• Chest X-rays
• Doppler ultrasound
• Echocardiogram
• Pulmonary function test

During the Surgery

Once the donor's liver is approved and the patient is fit for surgery, the surgeon will proceed with the transplant. The surgery will differ depending on the donor type and may take 6 to 12 hours to complete.

Deceased Donor Liver Transplant 

• The surgeon will put the recipient under general anesthesia and sterilize the site of the incision.
• Then, they will make an incision on the abdomen just under the ribs to reach the liver. 
• They will separate the liver from the neighboring organs and clamp its arteries and veins to restrict blood flow.
• Then, they will remove the non-functioning liver and place the healthy donor liver in the same anatomical position.
• The surgeon will reattach the arteries and veins and ensure blood flow to the new liver. The bile ducts are also attached to the new liver.
• If there are no complications during the surgery, they will close the incision with stitches.

Living Donor Liver Transplant

• In a living donor transplant, the surgeon operates on the donor first. The required part of the liver is taken from the donor. The rest of the liver is left as it is to regenerate.
• Then, the surgeon removes the recipient's liver and replaces it with the portion of the donated liver.
• They reattach the blood vessels and bile ducts to the new liver and ensure it receives blood.
• Finally, they will stitch up the incision to close it.

What Happens After a Liver Transplant Surgery?

Immediately after the surgery, the patient is moved to an intensive care unit (ICU) under observation for post-surgical complications. Their vitals are also monitored.

• Once the doctor declares the patient stable enough, they are moved to their hospital room to recover. 
• After the surgery, the patient must stay at the hospital for about two weeks. 
• The donor must remain at the hospital for about four to seven days and can go home once the stitches are removed.
• The patient might have to visit the hospital frequently for follow-up.
• The recipient's immune system might perceive the new liver as a foreign entity and try to reject it. Therefore, they have to take anti-rejection medicines or immunosuppressants for the rest of their lives.
• The patients must keep checking for symptoms of complications and contact their doctor if they experience any.

A full recovery from a liver transplant may take over six months, after which patients can slowly resume their daily activities.

What are the Complications of a Liver Transplant?

A liver transplant is a complex procedure. Therefore, it has certain risks and complications attached to it. Some complications of a liver transplant include: 

• Organ rejection
• Infections
• Leakage or shrinkage of bile ducts
• Failure of new liver
• Blood clots (thrombosis)
• Infection at the site of surgery
• Bleeding
• Recurring liver disease, such as primary sclerosing cholangitis, hepatitis C, or fatty liver disease
• Post-transplant lymphoproliferative disease (PTLD)
• Higher susceptibility to skin cancers

Patients with liver transplants have to take immunosuppressants for the rest of their lives. These drugs not only increase their risk of infections but also cause some adverse effects, such as diabetes, hypertension, bone loss, high cholesterol, weight gain, and kidney damage.

What Documents to Submit for a Liver Transplant?

Both the donor and the recipient have to submit certain documents to get approval for a liver transplant.

Documents for First Degree Relatives (Parents/Siblings/Children above 18 years/Grandparents)

• Donor and recipient's passport and medical visa
• Detailed family tree
• Original birth certificates of donor and recipient
• National ID cards of donor and recipient
• Declaration affidavits (in domestic language and English translated) by donor and recipient
• No Objection Certificate (NOC) from the donor's immediate dependents
• Death certificates, if the donor or recipient's immediate dependents are dead
• Letters from the Health Ministry
• Ten passport-sized photographs of each of the donor and recipient
• Two family group photographs with the donor, recipient, and their immediate family visible

Documents for Spousal Donation

For a liver transplant between spouses, all documents for first-degree relatives have to be submitted, along with:

• Marriage photographs
• Marriage certificate
• Birth certificates of children

Documents for Second Degree Donations (Uncle/Aunt/Niece/Nephew/In-laws/Cousins)

For second-degree donations, all documents submitted for first-degree donations are applicable, along with:

• Medical records and proof of why first-degree relatives are not available for donation
• Donor and recipient's bank statement for the last three years and their occupational details, if they are working

Medical Records Required From Donors and Recipients

The donor and recipient must submit essential medical records before a liver transplant. These include:

• Donor: Blood group, glucose tolerance test, urine analysis, renal function tests, abdominal ultrasound, cross-matching, hepatitis B and C virus test (HBsAg and HCV antibody), HIV 1 and 2, height and weight
• Recipient: Blood group, renal function tests, hepatitis B and C virus test, HIV 1 and 2, abdominal ultrasound, ECG, echocardiography, cross-matching, height and weight

Takeaway

A liver transplant is a life-saving procedure for patients with end-stage liver disease. In this procedure, a diseased liver is replaced with a healthy one. The liver can come from a deceased or living donor. However, there is a shortage of organ donors worldwide. Therefore, many patients end up on a transplant waiting list. With the development of new techniques and treatment options, the gap between the number of donors and recipients can be bridged, thus saving more lives.