What is the preparation required for transplant?
It is important to accept transplantation with a positive attitude because it is a big step and although its preparation is cumbersome, waiting period unpredictable (for DDLT), operation complex and recovery prolonged, most patients do well after transplant and lead an excellent quality of life.
The preparation starts with recipient’s evaluation. Once the patient is found suitable for transplantation, any potential donors in the family should have their blood group checked and one who is compatible should undergo donor evaluation. If the donor is suitable, authorization committee clearance is obtained and transplant is scheduled. Patients planned for a living donor liver transplant can generally undergo the same in about 2 – 3 weeks.
If a suitable family donor is not available, after the recipient evaluation is found satisfactory, the patient is registered on the waiting list for a deceased donor liver transplant.
Patients should make adequate arrangements for blood products well in advance before surgery.
While preparing for a transplant, all doubts should be clarified and understood. Patients and the donors are encouraged to meet other patients and families who have undergone the operation and willing to share their experiences.
Pre-transplant recipient (patient) evaluation
Once ESLD (end stage liver disease) is diagnosed and need for a transplant is perceived, patients undergo a formal evaluation, which involves blood tests, CT and other scans, tests for heart, lungs and other organ systems and assessment by various specialists. Evaluation is performed with the following goals:
- To establish the diagnosis and find the cause of cirrhosis / ESLD
- To determine the severity of liver disease and its effects on other organ systems such as kidneys, lungs, etc. and thus determine urgency of transplant.
- To actively look for liver tumor.
- To evaluate the condition of other organ systems such as heart, lungs, kidneys, etc. and determine patient’s ability to tolerate this major operation.
- To evaluate difficulty, technical feasibility and risk of surgery (previous abdominal infections, surgery, thrombosis of liver blood vessels)
Evaluation generally takes about 7 – 10 days and is done on outpatient basis. The evaluation period may be very hectic and stressful. Patients are advised to relax between tests and follow the instructions for each test carefully for accurate results. The transplant coordinator is the main contact person during evaluation and will fix appointments for any tests or procedures. At every stage of evaluation, the plan for further tests may change depending on your reports; therefore, it is important to visit the transplant clinic routinely for review by the transplant team. Patients who are sick may be advised to undergo evaluation in the hospital. If unexpected / incidental problems are discovered on evaluation such as cardiac disease, thyroid disease, infection, etc. these might have to be treated before transplant.
Patients with other co-existing disease such as uncontrolled blood pressure, diabetes or untreated cardiac problems, might have to wait until they are corrected. Liver transplant can even be performed after successful cardiac angioplasty or with heart bypass surgery.
Who can be a living liver donor?
A living donor should meet the following criteria:
- Compatible blood group with the recipient (refer table 1 below)
- A family member (wife, husband, mother, father, brother, sister, son, daughter, grandfather, grandmother, grandson, granddaughter) or close relative of the patient as defined by the Act.
- We do not accept family friends, well-wishers, staff or neighbors as donors
- Age group 18-55 years
- Not overweight, because people who are overweight may have fatty liver
- The donor liver should be large enough to provide adequate volume for the recipient (patient) as well as for the donor
- Donor should be in good overall physical and mental health and undergo a thorough medical and psychological evaluation and volunteer for donation after fully understanding the risks of surgery.
Table 1: Compatible Blood Group
* Rh factor (+ve or -ve) is not important
The decision to donate can be changed at any stage of the evaluation, before or after the tests are done or any time before the surgery.
Pre-transplant donor evaluation
Donor evaluation is performed in four phases, with more expensive and invasive tests reserved for later phases. The teABO incompatible (ABOi) transplant: Generally, liver transplant is performed with blood group compatible donor livers, because ABO (blood group) incompatible transplantation triggers production of antibodies against the transplanted liver causing organ rejection. However, if some special immunosuppressive medicines and measures are used, antibody levels can be reduced before transplant and organ rejection prevented. In small children, the antibody levels are very low and ABOi transplant can be performed with less preparation and better success. Since very few centers have experience with ABOi liver transplants, it is offered only at experienced centers.sts take about 7 – 10 days and are done on an outpatient basis, commonly along with the recipient evaluation.
Fatty liver (steatosis) is quantified by Liver Attenuation Index (LAI) and liver volumes is calculated by the second (tri-phasic) CT scan. The tri-phasic CT also gives surgeons a detailed view of the liver, its blood supply and anatomy. Few donors might need a biopsy to study liver quality in more details, where a tiny piece of liver is examined under a microscope. Most donors with a non-fatty liver and adequate volumes i.e. donors who have cleared phases I & II, have a high chance of being accepted for donation. When potential donors are rejected, it can be stressful for the family, but this is done for the safety of the donor and success of transplant, an alternative donor should then be identified.
Both the patients and donor’s emotional health and willingness for transplant is important for the operation and they would be counselled by a psychologist during evaluation.
HLA testing and matching is performed before the authorization committee meeting.
Authorization committee clearance
All patients planned for living donor transplant need clearance by the government appointed authorization committee. Our administrative staff will help patients and their families understand and prepare various legal forms, affidavits (statements under oath) and supporting documents. Proof of identity, residence and donor-recipient relationship have to be submitted with the application to authorization committee. Donors who are not near relatives and foreign nationals have to obtain a no-objection certificate (NOC) from the state of domicile (residence) or embassy. The transplant team is independent of the authorization committee and cannot influence its decision. Falsification of documents or other efforts to provide false information / mislead the authorization committee constitutes violation of the law and carries heavy penalty.
All cases who have completed both patient and donor evaluations are reviewed by the multi-disciplinary transplant team, where their suitability for transplant is discussed and tentative date for transplant decided. The transplant is scheduled only after clearance by the authorization committee.
Arrangement of blood and blood products
Once the medical decision for transplant is made, patient’s family is advised to donate about 18 units of blood (any blood group, unless the patient has a rare blood group), well before the date of surgery and prepare 3 platelet donors (same group as the patient). Platelets have a short shelf-life and therefore should be donated only one day prior to surgery. If the surgery is expected or found to be difficult, additional blood donations may be required before surgery or may have to be replaced after surgery, as and when notified by the transplant team.
Liver transplant is offered as a package at Columbia Asia Hospital. It includes pre-transplant workup fee, operation charges and life-long consultation charges for both patient and the donor. The transplant coordinator will explain expected expenses at various phases, mode of payment, inclusions and exclusions of the package.
Patients with additional risk factors such as kidney or cardio-respiratory problems, those expected to undergo a complex operation, need prolonged ICU care or hospitalization might be offered the high-risk package. Patients undergoing combined liver-kidney transplant, dual lobe transplant, ABO incompatible transplant or have hepatitis B or other diseases require use of additional expensive medicines, they should discuss the package applicable to them with the transplant coordinator.
Patients whose expenses for transplant and post-operative medical care will be borne by insurance company, employer or embassy should discuss the same with the patient financial liaison or TPA helpdesk, who will guide patients with required paperwork. Some insurance companies only pay part of the package and the remaining amount has to be arranged by the patients’ family.
What if a patient does not have a suitable living donor?
Patients who do not have a suitable living donor or are unlikely to get a deceased donor transplant in time for their disease severity might benefit from one of the following innovative procedures.
Alternative in living liver transplant
Swap transplant: When one of patient’s family members is suitable and willing for donation, but is not a good match for the patient, a paired donation or swap transplant may be considered. In this type of transplant, two families with suitable living donors exchange their donors because they are not a good match for their own patient, but are appropriate for each other’s patients.
Swap transplant is commonly done for blood group mismatch, e.g. if donors and patients of one family have blood groups A and B and that of the second family B and A, respectively, these donors are not suitable for their own recipient. However, if donors are exchanged, both patients can undergo transplantation. Both transplants are performed simultaneously and therefore can only be done by a large experienced transplant team after careful planning.
Dual lobe liver transplant: When a potential living donor’s liver volume is found inadequate for the recipient on pre-operative CT scan, they may be rejected and another donor evaluated. It is common that in one family two or more people might have been rejected for donation each because of low liver volumes, who were otherwise suitable. If partial livers from both donors are combined; it is often adequate for the patient. In such a transplant, three operations (one recipient and two donors) are performed simultaneously. Dual lobe transplants are technically complex and offered by few centers only.
ABO incompatible (ABOi) transplant: Generally, liver transplant is performed with blood group compatible donor livers, because ABO (blood group) incompatible transplantation triggers production of antibodies against the transplanted liver causing organ rejection. However, if some special immunosuppressive medicines and measures are used, antibody levels can be reduced before transplant and organ rejection prevented. In small children, the antibody levels are very low and ABOi transplant can be performed with less preparation and better success. Since very few centers have experience with ABOi liver transplants, it is offered only at experienced centers.
Deceased donor transplant
Once recipient evaluation is completed and patient is found medically fit for transplant, the prescribed forms have to be completed and submitted through the hospital to the state-wide appropriate authority for registering their names on the waiting list for a deceased donor transplant. Patients may register at more than one hospital, even in different states (Maharashtra, Gujarat and Karnataka). After listing, patients should undergo periodic testing and review with the transplant team and also inform them of any significant changes in patient’s medical condition.
When a potential deceased donor liver is available, patients are alerted immediately and called to the hospital. The contact information of the patient should be updated with the coordinators so that the transplant team can contact the patient and the family when a liver is available any time of day or night. The coordinators should be informed if the patient is going out of country.
Patients not living in the same city should pre-plan for the emergency trip well in advance. They should also have flight options and important phone numbers handy and plan on getting to the hospital quickly. They should alert their employer about sudden leave in advance. They should designate someone who will take care of their family and home in their absence and maybe make a power of attorney for their business. The waiting period is highly variable, ranging from weeks to months.
While one team prepares the patient for transplant, another team retrieves the donor liver. The liver is carefully checked for its suitability for transplantation. Livers from donors may be considered high risk if they had previous hepatitis B or hepatitis C infection, had risk factors for HIV infection, had active infection or cancer. Patients should discuss the quality of liver and associated risks with the transplant team before accepting or rejecting it. If the transplant team finds the liver unsuitable, the donor family withdraws their consent to donate or for any other reason the transplant is cancelled; patients will have to return home and continue waiting for the next offer. While such “false alarms” could be stressful, these decisions are always taken in the interest of patient safety and to optimize chances of a successful transplant.
Preparing for an emergency liver transplant
Patients with acute liver failure are very critical in the ICU, often on a ventilator, may have a rapidly progressive worsening disease and might need an emergency transplant. Although the preparation required is similar, all tests, and arrangements have to be done in a very short duration. Recipient and donor evaluations are done emergently within few hours to days. Recipient evaluation is similar, although neurological evaluation, including a CT scan of the head may sometimes be required. Donors also simultaneously undergo a rapid evaluation; all tests being done in less than 12 – 24 hours. An emergency legal authorization committee clearance is also required. If a suitable living donor is not available, patients are enrolled on the waiting list, where they are given priority on the cadaver list.
Precautions to be taken while waiting for the transplant
While waiting for the transplant, it is important that patients undergo regular tests, adhere to all appointments and medical advice, and comply with treatment and dietary restrictions. In order to remain healthy, prevent any infections, prevent any complications, enable early identification of any problems or significant change in condition and allow prompt treatment before transplant, some simple precautions can be taken.
- Hand washing and scrubbing for at least one-minute using soap and water including between fingers, under the fingernail and around the nail beds before eating after using the bathroom or when they are dirty.
- Using anti-septic hand-rubs frequently
- Malnourished patients may be advised few weeks of medical nutrition therapy.
- Perform light exercises, walk and remain active (as much as possible).
- Getting enough rest
- Taking only the prescribed medicines. Do not take any new medicines, including vitamins, herbs or supplements without discussion with the transplant team.
- Children are advised to undergo all vaccinations appropriate for age, because they cannot receive live vaccines after transplant
- Eating low salt diet, as prescribed and adhering to liquid intake restriction. This will help in controlling ascites (fluid in the belly)
- Eating smaller meals, low-fat, high protein adequate calorie diet, keep the muscles strong
- Patients can consider taking nutritional supplements if they are unable to get enough calories or proteins in their diet, as advised by the dietician
- The transplant team should be informed about any significant change in the health or any hospitalizations
- No alcohol intake, if the transplant team has any doubt about lifetime commitment to sobriety or abstinence from alcohol or illicit drugs, they can perform random screening blood or urine tests for the same and if found positive, make the patient inactive on the waiting list
- Patients should quit smoking before transplant, because it can cause lung infections after surgery and prolong recovery from ventilator after surgery.
- The transplant team should be notified of any the unexpected change in health such as blood vomiting or black stools, changes in mental condition, excessive sleepiness (drowsiness), confusion, nose bleeding, weight gain, swelling in abdomen or arms and feet, severe or sudden abdominal pain, fever, fainting spell, severe vomiting or loose motions.
- Patients may be able to continue to work and even travel while on the waiting list after discussing the same with the transplant team. It may not be safe for patients with very low platelet counts, high INR, history of GI bleed or encephalopathy to travel. While travelling, the co-coordinators should be updated with the contact numbers. Patients should also identify a doctor locally who can take care of any urgent problems while travelling.
- Patients should keep the phone numbers of their family members and the transplant team handy to deal with any urgent situations.