Experts Talk

Below are the excerpts from the interview

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Most of the liver diseases present with similar symptoms with some variations. Some of the common symptoms can be loss of appetite, nausea and vomiting, vomiting of blood, jaundice(yellowish discoloration of the eye), abdominal pain, itching, distension of abdomen( accumulation of fluid- ascites), swelling of lower limbs, weight loss, altered sensorium, confusion, and in a late stage- coma.

Liver is a crucial body organ which is responsible for processing essential nutrients from the food you eat, synthesizing bile and most importantly removing harmful toxins from the system. To ensure that your liver keeps performing its functions, you need to follow a healthy lifestyle.

Some of the liver diseases are metabolic and hence inherent at the time of birth and manifest later. However, some of the more common liver diseases are preventable like alcohol induced liver disease, fatty liver induced liver disease (NAFLD), Hepatitis A, B and C.

Liver transplantation is the treatment for end stage liver disease in both adults and children. In this operation, the diseased liver is removed and replaced by a healthy one. The success rate for the operation is high and terminally ill patient can return to normal lives.

The average cost of liver transplantation is Rs 18 to 20 Lakhs at Sahyadri specialty hospital, Pune Maharashtra. The cost of investigations of the donor and recipient is Rs 90,000. When patients are too sick and require prolonged stay following liver transplantation, the cost of treatment can escalate; hence it is advisable to patients to have the liver transplantation before they develop complications secondary to the liver disease (Cirrhosis).

Most of the patients seek help at a very late stage or referred late to a Surgeon. It is advisable for patients to seek the opinion of a Surgeon at a very early stage of the disease. The patient needs to take medicines for the rest of his life to prevent rejection of the new liver. The cost of medicines and the investigations in the first year is approximately Rs 10-15000/-. The number of medicines and the frequency of blood investigations are much less after the first year of liver transplantation.

The cost of liver transplantation in India is one twentieth when compared to USA, UK and other European Countries.

When a person’s liver is severely damaged and cannot function properly or complications may develop and liver transplantation should be considered. Conditions like hepatic coma, massive upper gastrointestinal bleeding, and liver cancer is best treated by complete removal of the liver (cirrhotic liver).

In general, when a patient needs a new liver, the earlier the operation, the higher the success rate is.

Urgent liver transplantation is recommended in patients who have acute liver failure and this could be due to many reasons. The common conditions are Hepatitis B, Hepatitis A, Hepatitis E and drug induced. In such patients liver transplantation is urgently needed in order to save the life of the individual.

A new liver can come from either of the two sources: A living donor or a brain-dead deceased donor.

Living donor transplantation:

It is technically feasible to remove part of the liver from a living person and transplant it to a patient who needs a new liver. The operation has now been done since 1989. Depending on the size matching of the donor and recipient, either the left side (about 35-40%) or the right side (60-65%) of the liver will have to be removed. The liver remnant in the donor will grow to its original size in 6-8 weeks time.

This process helps in an earlier transplantation before the recipients’ conditions deteriorates. It is a planned procedure whilst cadaver liver transplantation is an emergency procedure. It avoids the risk of death while waiting for a deceased donor liver graft(40% overall and 75% for patients in Intensive care units). The survival rate of a living donor transplant is over 90%.

There are risks like complications of the investigations and surgical procedures but the possibility of donor death rate is of 0.2-0.5%. Seventeen donor deaths have been reported in Brazil, France, Germany, Egypt, Hong Kong, Japan, USA and India.

Cadaver transplantation:

This is well established in the Europe and USA. Unfortunately, the availability of deceased donor liver is not very often in India. Depending on your blood group, you may have to wait for 0 to 6  months before you get a new liver.

During this waiting period, you may develop complications like spontaneous bacterial peritonitis (infection of the fluid in the abdomen) which, if repetitive may produce severe adhesions in your abdomen rendering liver transplantation difficult if not impossible.

It is important for everyone to register for organ donation, so that when we die, this noble act will help many people to lead normal lives. In the Western world the organ donation rate is between 15-18/million population where as in Indi it is less than 1/million.

The most important criteria is that the donation of portion of the liver is done voluntarily. The donor has to be less than 50 years of age, body mass index of less than 25 and is a near relative of the recipient. Both the donor and the patient should have the same Blood group or O Blood group.

Besides, the potential donor should understand clearly that

• The donor operation carries complication rate of 10-15%.
• The recipient is successful in 90-95%, which means that there is 5-10% chance of dying.
• The donation is done out of his/her own wish and without any coercion.
• There is no financial gain related to the act of donation.
• The donor has the right to withdraw at any time without the need of giving any reasons to do so.

Patients who have cancer in another part of the body, active alcohol or illegal drug abuse, active or severe infection in any part of the body, serious heart, lung or neurological conditions or those who are unability to follow doctors’ instructions are excluded generally.

The overall success rate of liver transplant is over 94% and the majority of recipients can return to normal activities and achieve 95% of their quality of life which they had prior to liver disease. Since the recipients’ body may reject the new liver, it is essential for them to take immunosuppressive medications and continue follow up at the liver transplant clinic. They will need to continue these medications for life, at a reducing dosage.

The risk for the recipient is the return of the original problem that necessitated the liver transplant in the first place, e.g. hepatitis C, recidivism (return to alcoholism), noncompliance of medications. The other complications that can arise are thrombosis of blood vessels going into or out of the liver, primary or delayed graft non-function, bile duct complications, renal failure and other infections.

After a successful liver transplantation (95% of patients) – the patient is advised to take care of infections and to take anti-rejection medicines for life. The patient can return to normal quality of life and can return back to work in three months time. The patient has to regularly follow up with the surgeon in the first year and later at regular intervals as advised by his doctor. He will require blood tests to determine that his liver functions and to adjust his medications in the beginning and later the tests are infrequent. The patient is advised not to take any herbal or alternative drug treatment.

The transplant patient is assessed regularly for various complications like rejection, infection, narrowing of blood vessels etc., and appropriate treatment is initiated. Post transplantation, he is under the guidance of his doctor throughout his life. Any health problems that do come up have to be investigated and treated, though they are infrequent.

Diabetes is a silent killer. There are approximately 90 million diagnosed diabetics in India, of which Type 1 diabetes contributes to 10% of the total. It has a major impact on a variety of body functions including the eyes (retinopathy), the kidneys (nephropathy), the nerves (neuropathy) and the circulation (peripheral vascular disease, stroke and heart attacks).

There are two types of diabetes. Type-1, where there is no production of insulin in the body, and Type-2, where there is either ‘small for body mass’ production of insulin or there is peripheral insulin resistance.

Conventionally, diabetes can only be ‘treated’ with insulin. A ‘cure’ is possible only through a transplant procedure called a pancreatic transplant that is still rare in India.

Pancreas transplantation is carried out in three forms:

Simultaneous Pancreas-Kidney Transplantation (SPK): This is for a diabetic patient on or approaching dialysis. Here a pancreas and kidney from the same brain dead donor is transplanted into a patient that fits the above criteria. This can also be extended to include a Simultaneous Pancreas (cadaveric)-Kidney (Living donor) operation.

  • Pancreas after kidney transplant (PAK): This is for a diabetic patient who has had a successful kidney transplant but has on going complications from diabetes.
  • Pancreas Transplant alone (PTA): Will benefit a patient with diabetic complications in the eyes, nerves as well as loss of warning signs for low sugars.

Inclusion criteria for SPK:

  • 18 years or older.
  • Have Type 1 or Type 2 diabetes (without peripheral insulin resistance) along with kidney failure.
  • Deemed fit for surgery by a multi-disciplinary team.

Exclusion Criteria for SPK:

  • Active cancer
  • Does not follow treatment protocols
  • Substance abuse problems
  • Severe mental retardation
  • Severe heart disease and/or severe blood vessel disease.

Is it possible to have kidney and pancreas transplants at different times?

Yes. Sometimes, a patient who has kidney failure because of diabetes may have a kidney transplant first, followed by a pancreas transplant at a later date (PAK).

How successful is a SPK?

The graft survival rates for SPK in adults is more then 94% at one year and 80% at the end of ten years.

What care should I take after SPK transplant surgery?

The care after a SPK is very similar to a kidney transplant alone with adherence to immunosuppressive or anti-rejection medications, to help prevent your body from rejecting your transplanted organs. You need to take these medicines exactly as the doctor prescribes for the rest of your life.

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