Liver Failure (Cirrhosis) And Transplant

Hello everyone,

My name is Dr. Siddharth here. I am a multi-organ abdominal surgeon and I am working as a consultant for liver transplant. Today I thought I will talk about something which a lot of my patients have common as questions. A lot of my patients who come to me are having advanced liver disease and most of the questions are pertaining to what is liver failure what is cirrhosis and why do they need a liver transplant. So I thought I will talk briefly about it today on a common forum so starting with what is cirrhosis and what is liver failure. So first we have to understand that liver though it is a solid organ it is a soft organ and when a liver disease sets in cirrhosis sets in for any particular cause. With cirrhosis we mean that the liver is getting hard and firm and shrunken. And a lot of patients with cirrhosis may not immediately need a transplant if the cirrhosis is in the early stages. Cirrhosis simply we can divide based on a few tests and patient’s clinical condition as A B & C. A B the least severe and C the most severe. When patients are in stage A they may not require transplant when they enter B or C most of them do require transplant & benefit from transplant.

And we say that the patient has liver failure when the signs of liver failure in a cirrhotic patient start appearing. So what are the signs of liver failure? Liver failure most of the signs appear because the functions that the liver normally does are not able to be performed in the body and second is something because what you call as portal hypertension. Portal hypertension simply means that there is a portal vein which normally drains blood into the liver from the intestines. Now, this soft organ soft liver which has become hard and shrunken provides a lot of resistance to the portal vein and blood is under a lot of pressure now. So these small veins which come from the intestine and form the big portal vein they fall under a lot of pressure and then because of the increased pressure they can burst and bleed at some point and it can present as bleeding with vomiting. So this is one of the features of portal hypertension. Other features of portal hypertension are forming an Ascites that is fluid in the abdomen.

We have to just remember that it can affect because the liver has so many functions that it can liver failure can practically affect all organs. It can cause encephalopathy that is drowsiness or seizures or even coma because it can affect the brain it can affect the lungs it can cause a lot of fluid accumulation around the lungs. It can cause difficulty in the oxygenation of the blood itself which is it goes to the lungs to get oxygenated. In advanced cases and in a very minority of cases it can also affect the heart in certain ways. One of the most common organs to get affected by liver disease is kidneys. People may have normal kidneys but because of the liver the kidney starts getting affected. Yes, there is pooling of fluid which is known as Ascites in the abdomen and this Ascites itself poses a risk of renal failure and poses the risk of getting infected. And once the Ascites gets infected it also becomes a life-threatening condition. So coma heavy bleeding infection in the Ascites renal failure all these are present signs of renal failure and they all can be life-threatening.

So when these signs start appearing that is a time patient will get benefited from liver transplantation. In common terms what is liver transplantation. Well we are taking out the diseased liver and we are putting in a new liver. So this is liver transplantation in very simple terms. A new healthy liver is replaced by an old diseased liver. So let us just briefly discuss about what are the common causes for liver failure. As you must all heard about Hepatitis B & Hepatitis C. alcohol is something that we all are aware is a common cause for liver failure. What I would like to touch on today is something called NASH which is non alcoholic steatohepatitis something it is different in terms from other causes is that it is neither a toxin nor an infection. Hepatitis B & Hepatitis C are infections. Alcohol is a toxin. NASH is something which happens because of bad metabolic condition or something called metabolic syndrome as obesity diabetis thyroid disorders deranged lipid profile or deranged cholesterol levels. So all these add as a risk factor for liver to have initially fatty liver which will turn over the years or decades can turn in to cirrhosis and liver failure. And this in developing countries like India and in developed countries is probably one of the fastest growing causes for liver disease. So next we come to what is the treatment.

So in early cases of the liver disease where the cirrhosis has not set in or the patient has a child a there is certain in fact most of the causes for liver failure can be treated. Liver is one organ where most of the causes for instage failure are actually are preventable and if identified at an early stage are curable. We have very good medicines for Hepatitis B treatment for Hepatitis c treatment NASH I said is not an infection or toxin it is just probably our poor lifestyle habits poor diet and chronic conditions like diabetes thyroid disorders that over a long period of time can cause this disease. Once if we try to prevent these diseases we can prevent liver failure from happening. Alcohol as a toxin can be avoided by a person if taken in moderation or small amounts it may not cause liver failure but it causes liver failure only when taken in heavy amounts for a long duration. So most of the liver failure causes the common causes are very easily preventable. But once this treatment or medical treatment may be limited to conditions as I said in early liver disease but once the liver diasease becomes fairly advanced where all these signs that are discussed earlier start becoming evident and keep happening over the course of time. This is the best indicator that patient now needs a liver transplant.

We have objective markers scorings where we can calculate even the patient’s proposed survival or predict patient survival over 90 days based on how advanced the liver disease is. Once the liver disease is advanced to a certain degree that it poses threat to life and liver transplantation will eliminate that risk – that is the time when patient will benefit from the surgery. And it is proposed only to these subsets of patients where this liver disease is very very advanced. Next common question is what are options for liver transplantation. Options for liver transplantation are common of 2 types – there are 3 or 4 different types of options but the common option needs a live donor and a cadaveric or a deceased donor. Live donor is one where a life donates part of their liver. And cadaveric or deceased donor is where there is a person who is brain dead is in the ICU setting. Brain dead commonly because of a road traffic accident or a stroke where all other organs are functioning normally but the recovery of brain has been ascertained to be irrecoverable. And if the family members of these brain dead patients can consent then these organs can be utilized for people who need those organs for transplantation. Both kinds of liver transplants do happen in our country so the next common question for patients with advanced liver disease who needs a transplant is what are the options for transplantation.

The 2 common options are live donor transplantation and cadaveric transplantation or organs from a brain dead patient. Live donation is where somebody is live donates part of their liver. In India what is allowable is that they have to be a blood relative or a close contact of that patient. Live donor is safe in the terms of donor safety and the recipient safety and the liver is unique in the capacity that it grows back to its normal size 4 to 6 weeks for the donor and the recipient and they both end up with a complete liver after 6 weeks. And donor can live a normal life. They don’t need any lifelong medications, there is no restriction on physical work mental work or any kind of work that they may like to do in the long term. So the next option is cadaveric transplant where a brain dead patient donates organs. These patients are usually those who had a road traffic accident or a stroke and their brain has received damage which cannot be reversed or the recovery is not possible but all the organs are in working condition, the heart is pumping, the blood circulation is there and the major organs like lungs kidneys liver bowel and all other major organs are in working condition.

So these patients are usually in the ICU they are usually on a ventilator. When their family or next of kin gives consent then these organs can be used for patients who need it for transplantation. So these are the 2 broad categories – live versus the deceased. In terms of outcomes, the outcome of both types of transplantation is comparable. In long term yes in live donors patients because they are receiving a part of liver the initially the hospitalization period may be a little longer by a few days to a week or so but in the long term they both types of recipients live and cadaveric they both do similarly. So in nutshell is what is liver disease and who are the patients who require liver transplant and what are the options and if you need any further clarification you can always get in touch with me through Lybrate or through my email id. I will be more than happy to answer any questions.

Thank you!