LIVER TRANSPLANTATION
Dr. Nilesh H. Doctor
Consultant- Hepato Biliary Surgeon
Jaslok Hospital & Bhatia Hospital
INTRODUCTION
The first Orthotopic Liver Transplantation (OLT) in the world was performed in the US in the
late sixties. In the decade before this, the introduction of ICU's and assisted ventilation had
led to the identification of brain death. A small number of patients seemed to have
irreversible loss of brain function, but a beating heart, which ensured perfusion to vital
organs. The artificial ventilation provided the oxygenation that would not have occurred in
these otherwise apneic patients, who had no brain-stem reflexes. Also, it was seen that
subsequent to the cessation of brain-stem function, there was an inevitable stoppage of
cardiorespiratory function within 48 to 72 hours. Hence, there was a window period during
which there was perfusion of organs in the cadaver, during which they could be harvested
and used for implantation.
There were pioneering efforts on both sides of the Atlantic, with Professor Thomas Starzl in
the US and Prof. Roy Clane in the UK trying to make Liver Transplantation a reality. Finally,
Prof Starzl performed the first transplant. These initial efforts were not followed by a dramatic
rise as the operation was technically demanding and there was a high rate of rejection due to
the lack of good immunosupression.
Prof. Calne pioneered the use of cyclosporine, which led to a dramatic reduction in rejection
of donor organs and results showed a steady improvement, such that by the Eighties, OLT
was performed in many centers in Western Europe and U.S.A. Another significant
improvement that led to better usage of organs was the development of organ preservation
solutions. UW solution, developed at the University of Wiscons in, allowed excellent cell
preservation and good organ function after 18 hours of cold ischaemia. This meant that the
organ could be retrieved in one place and used in another. This rapidly led to the
establishment of a central org-in registry where optimal organ sharing could be done based
on the urgency of requirement.
The Indian scenario
Liver Transplantation in India did not take off till very late. Transplantation is the culmination
of the advancement in many specialties including Hepatology, Immunolog y, Infectious
Diseases, Intensive Care and Anesthesiology, apart from the technical advances in surgery
that require special training. In many ways, this was not a priority area for the Indian health
sector.
In the last few years there has been in influx of well-trained persons in this field.
Also
the brain death Law has been passed by an Act of Parliament in 1994.
Slowly the infrastructure required for transplantation has been made available in a few
hospitals. Problems of OLT in India:
1. The donor:
After the passage of the Human Organ Transplantation Act, trading in organs has been
banned and Brain Stem death has been legalized. However, awareness of this fact is not
widespread and there has been no great effort on the part of the Government to create
awareness. There needs to be a concerted effort on the part of the Government, NGO's and
the medical bodies to start a massive awareness programme through the media to educate
the doctors, ICU personnel, and the lay public about Brain Death and the potential of a brain
dead individual to donate organs. This can be done through films, seminars, workshops, and
the distribution of Donor Cards, which helps a person decide during his or her lifetime about
organ donation. Religious leaders can also help by clarifying the compatibility of organ
donation with religious beliefs and their essentially altruistic nature.
Once there is some level of awareness amongst the lay public, any request for organ
donation from a brain dead relative is likely to be treated with les s hostility by the aggrieved
family members.
2. It is essential to have specially trained personnel, usually Medical Social Workers, to deal
with the families of brain dead individuals. First of all, they have no vested interests in
transplantation and are seen as grief counsellers. Secondly, they are trained in the various
psychological aspects of families dealing with death. A sensitive approach and awareness of
the emotional stages through which the family members go through helps to make the
request for organ
donation attherighttime.
3. The recipient: there is a large pool of patients with end-stage liver disease who deserve OLT.
However, since it a new area of development, it is seen as an experimental procedure.
Awareness needstobecreatedthatOLTisnowfirmlyintherealmofpreferredtherapyforendstageliverdisease. There are many scoring systems which can give a reasonably accurate idea of
the prognosis of the patient. Once it is seen that the survival is unlikely to be beyond sixmonths
orayear, it is obvious that
OLTwouIdbelifesaving.Thebenefittothepatientmustbebalancedagainsttherisksof4heoperation and
the life-Iong immunosupressionthatis needed .Also,in the absence of third party payments ,cost
assumes a very significant role. Currently, the various health insurance schemes do not cover
OLT and thissituation also needs tobe remedied. Gastroenterologists are also
reluctanttoreferpatients for OLT due to the low number of transplants performed. Hence, a vicious
circle slowly gets established wherein the fewer patients that get transplanted, there is increased
reluctance for referral. This leads to a small number of patients on the Waiting list and a potential
situation where there may bed on ors butn or ecipients.
4. Central Registry: formation of a central body to co-ordinate the various activities relating to
transplantation is essential forthe optimal utilization of organs. This body, called the ZTCC(Zonal
Transplantation Co-ordination Committee in Maharashtra), is responsible for all the rules and
regulationsthatwouldregulatetransplantationactivities.theywouldmaintainalistoftherecipients,
organize the distribution of donor organs as per pre-decided guidelines, help hospitals with the
creation of awareness about brain death, create mass awareness campaigns for cadaver
transplantationandactasaredressalforumforthevariousrepresentatives.
5.
Donormaintainenceahemaintainenceofabraindeaddonorrequiresagreatdealofattention.The
hemodynamic status, sepsis and indices of function of the various organs are important
determinants of organ function after implantation. It is essential to have an experienced Intensivist
aggressively helping with donor maintainence in a proactive manner with inotropic support if
necessary if the recipient functionis to be improved.
6. Living Related Liver Transplantation(LRLT): LRLT was started mainly for children due to the
shortage ofchild donors. With anexcellent donor safety profile andvery good long-term results, it is
now a well-established therapy for end-stage liver disease in children. As the shortage of donors
became more a cute for adults, and with thefailure of cadaver transplantation totake off in Japan,
it became apparent that LRLT had potential for adults as well. With initial successes, it soon
became widespread. In India, this modality appears very attractive forvarious reasons. With the
time taken for cad averic OLTtodevelop in India, it might be possible to convince patients, as they
don't have to keep waiting for a nindefinite period of time. Also, it can be planned as a nelective
procedure, solving some of the logistic problem sthatmightleadto last-minute has sles with the
recipient .Also ,it avoids a lotofthesocialandethicalissuesthatarelinkedtocadavertransplantation.
7. The Hospital: The different hospitals that have promoted cadaver transplantation belong to
different categories: Government hospitals, Trust Hospitals and Private hospitals. It is important
that OLTisofferedtoallsectionsofsocietyandisnotseenastreatmentoftheelite.Thisislikelytohamper its
development. This will involve massive investments by the government, which seems unlikely.
SomeefforthasbeenmadebyTrusthospitalstosubsidiseOLTsothatawidecross-sectionofsociety can
benefit.
It is important for hospitals to realize the various needs of the Transplant team and ensure coordination of the various departments that is such a vital part of the success of OLT. The hospitalbasedsocialworkershouldbethekeypersontoco-ordinateanyeffortatthehospitallevel.Rightfrom
theprocessofconsentofthedonorfamilytoorganizingtheretrievalandensuringproperdistribution
oftheharvestedorgans,thesocialworkershouldbethecentralfigure.Theyshouldalsoco-ordinate
the
efforts for the recipient and provide a constant link and support for the recipient family in the peri
transplant period.
There should be a constant re-appraisal bythe hospital and efforts to educate the ICU
personnelto declare brain death.
!t can be seen from the above that OLT is a major undertaking that involves many departments in
a hospital, involves many social and ethical issues apartfrom medical ones, and involves
significant short-term and long-termcosts. Hence, amulti-ponged approach to simuitaneously
tackle all these problem sisessential to establish it in lndia.