On the morning of November 20, 2020, when the country was engaged in a bitter battle against Covid-19, unsure whether it was winning or losing, a team of doc[1]tors were quietly winning on another front, and creating history at Kauvery Hospital, Chennai.
Dr. K. Elankumaran, Senior Consultant, Liver Transplantation and Hepatobiliary Surgery, and Clinical Lead - Liver Diseases and Transplantation Centre, was engrossed in an intricate liver transplantation surgery, along with a multidisciplinary team of doctors and medical professionals. With an impeccable record of performing 1200 liver transplantation surgeries since 2010, and armed with the support of an experienced and exclusive multidisciplinary team formed in November 2020, Kauvery Hospital, Chennai was heading for yet another grand success at a challenging liver transplantation surgery.
Creating History
The senior citizen who underwent this liver transplantation was over sixty years of age and had been living with liver disease for four years. During the last eight months, he had started exhibiting severe symptoms of liver failure. His visits to several hospitals and centres for evaluation and treatment came up with the same verdict- he should undergo a liver transplantation at the earliest. At Kauvery Hospital, Chennai, he underwent evaluation and was listed for ‘deceased donor’ transplantation.
Liver transplantation is the treatment option for both end-stage liver disease as well as acute, severe, liver failure. It involves replacement of a diseased liver with a healthy liver from a deceased or living donor. In the case of a deceased donor, the family of a brain-dead patient consents to donate organs of the deceased. In this case, the patient waited for a donor for six months and had to get admitted to the hospital multiple times for episodes of decompensating or exaggerated liver failure. His belly filled up with a lot of fluid, he started vomiting blood and various other life-threatening conditions started incapacitating him. Finally his daughter came forward to donate her liver. On evaluating her liver health, she was found to have more fat in her liver than the acceptable limit and was ad[1]vised diet and exercises. She returned fit for liver donation after working out intensely and observing a strict diet plan for a month. Dr. Elankumaran and his team were putting plans in place for the surgery when sudden complications set in. The patient’s kidneys started showing signs of dysfunction as it happens when a patient reaches terminal stages of liver failure, which affects multiple organs.
“On the day of the surgery he had a high level of kidney dysfunction and a lot of fluid had collected in his body. He was in no condition for surgery. He had to be put on dialysis for 36 continuous hours and 19 litres of fluid was recovered from his body! This is a rare instance in medical history. Internationally or nationally, never before had a patient with end-stage liver failure, and such a huge amount of fluid collection, been operated for a liver transplantation,” says Dr. Elankumaran.
Their multidisciplinary team stabilised the patient and went ahead with the surgery that turned out to be incredibly successful. The patient had an early and quick recovery and was discharged on the 7th day after transplantation. Three months later, when Dr. Elankumaran visited the patient in his home, they noticed that he was back to cycling, which was his passion before the liver disease. “This was a very heart-warming experience for us and proved once again that a person can get back to active life after liver transplantation,” he says.
Dr. Elankumaran has performed liver transplantation for many chronically ill patients with end-stage liver failure successfully. Many were indeed challenging. He narrates the case of a five year old who had acute liver failure. There were barely a few hours to save her life as the level of ammonia in her body was building up alarmingly, which could affect her brain. Yet, in less than 18 hours, they organized funds through crowd funding, evaluated a living donor from the family and managed a successful transplantation. It is three years now and the eight-year-old goes to school. She wants to undertake fasting for Ramzan!
Causes of Liver failure
◆ Alcohol
◆ Inappropriate use of alternative medicines
◆ Chemotherapy
◆ Smoking
◆ Diabetes
◆ Excessive salt intake
◆ Adulterated food containing pesticides, heavy metals
◆ Intestinal infections due to yeast Candida
◆ Overdose of Vitamin A
◆ Obesity causing non-alcoholic fatty liver disease
◆ Overuse of over-the-counter medications like painkillers, mood stabilizers, antidepressants, corticosteroids. Even Paracetamol, in doses more than 3 Gms per day, can cause acute liver failure
◆ Viral hepatitis A, B, C and auto[1]immune hepatitis
◆ Food poisoning eg Wild mushrooms
Symptoms of Liver disease
◆ Chronic fatigue
◆ Jaundice
◆ Abdominal pain and swelling
◆ Swollen legs
◆ Loss of appetite
◆ Nausea, vomiting
◆ Itchy skin
Donor is Divine
Dr. Elankumaran says the donor is the most important factor for success of any liver transplantation. Whether the healthy liver is obtained from a deceased donor or a living donor, both procedures are successful and have similar outcomes. Unfortunately, in India where there is a need for ten thousand liver transplantations a year, we hardly get 300 donors!
Living-donor liver transplant is resorted to when the waiting time for a deceased-donor is long and the patient’s health deteriorates in the meantime, developing life-threatening complications. Living-donor transplant is possible because the human liver regenerates and returns to its normal size soon. The first step involves identifying a healthy living-donor who is able to safely undergo a major surgical procedure. The doctors take into consideration the donor’s age, blood type and organ size to determine a match for the transplant. Usually living liver donors are close family members or friends.
Living liver donors undergo extensive evaluation procedures to ensure they are a match with the organ recipient. Harvesting of liver from a living donor is a major surgery that takes 6 -8 hours. The donor is kept in the ICU for a day and has a hospital stay of 5-7 days. In about a month, about 75% of their liver regenerates. Doctors advise adequate rest for a month. Following a review in a month, the donors can in[1]volve in normal activities.
Organ Recipient’s Journey
“The success rate of liver transplantation depends upon the patient’s condition and what led to the liver failure. In cirrhosis of liver, the success rate is 90-95%. If the liver disease leads to multiple problems affecting different organs, the success rate is lower,” says Dr. Elankumaran.
Since the nature of the human body is to reject foreign bodies, liver recipients have to be on immuno-suppressants life-long. While the initial doses for about 3-6 months are high, the doc[1]tors reduce the dose in about 6 months to one year.
Precautions to be taken by Liver Recipient
◆ No consumption of alcohol
◆ Medicines to be taken on time.
◆ Regular sleep
◆ Regular follow up and monitoring.
◆ Consumption of only home- cooked food.
◆ Regular aerobic exercises like brisk walking, jogging, swimming for 45 minutes.
Improving Liver Health
Avoid alcohol
◆ Prevent hepatitis infections by avoiding sharing of syringes, tattoos, unprotected sex, and transfusion of blood in dubious centres.
◆ Lifestyle changes for those with fatty liver include reduction of carb intake, increased proteins, veggies and fruits, vitamins, green tea and coffee.
◆ Hepatitis vaccines are advised for persons whose occupation puts them at risk of infection- eg: health workers
Need for Awareness
According to Dr. Elankumaran, unlike cardiac health, awareness about liver diseases among the public is low. Alcoholism is a rapidly growing threat to liver health. Many people approach practitioners of alternate medicine for jaundice, which may cause liver damage. Liver diseases are serious and may lead to life-threatening conditions and need immediate attention. The public should also develop faith in the success of liver transplantations. We also have problems of donors. More people should come forward to donate organs. Deceased Donor Liver Transplantations are under the aegis of state coordinating body, which allocates donated livers to licensed centres within the state in a fair and transparent manner.
