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Liver transplantation involves removal of the old diseased liver which is replaced with a new one. This involves the need for a donor. This procedure comes under the purview of the law governed by the Transplant of Human Organ Act, 1994 of India. This is a law mainly for the protection of organ donors so that they are not made victims of coercion in various social circumstances.

Liver has a large reserve of function and it is not until more than 80% of functional liver cells have died due to various diseases that signs and symptoms of liver failure begin to appear. Such diseases may ultimately overwhelm the inherent capacity of liver to recover from injury and the liver fails. In such conditions, liver transplantation offers not only the realistic hope of survival but also the possibility of cure.

Liver failure may develop either suddenly (acute) or slowly (chronic). Acute or Fulminant Liver Failure may develop commonly due to infections with viruses (Hepatitis A, E) or Drugs (drugs for tuberculosis, high doses of paracetamol) intake. Such a liver failure develops suddenly (in matter of hours to days), progresses very rapidly often leading to death due to swelling of the brain or failure of other vital organs. A timely liver transplantation offers the only realistic hope of survival in these patients. Chronic liver failure (disease), on the other hand, develops slowly (over a period of months) and is a result of continuing slow damage to the liver.

Common causes of such slow damage of liver include viral infections (Hepatitis B or C), regular intake of alcohol etc. Signs that the liver is beginning to fail include jaundice, excessive tiredness, ascites (accumulation of fluid in the tummy), encephalopathy (drowsiness and confusion), vomiting of blood rupture of distended veins into the food-pipe and effects of liver disease on other vital organs like kidneys, lungs etc. leading to their dysfunction. Some patients with liver cancer are also candidates for liver transplant.

Cancer often develops in those who have cirrhosis already and extensive surgery to remove the tumour is not possible in such cases. Besides, there are genetic disorders which affect the liver and result in liver disease such as Crigler-Najjar Syndrome or Progressive Familial Intra-hepatic Cholestasis which might need liver transplantation. Finally, there are also genetic disorders which do not cause liver disease but are cured by a liver transplant such as Primary Hyperoxaluria, Familial Amyloid Polyneuropathy, Maple Syrup Urine Disease etc.

A team of doctors including called liver transplant surgeons; hepatologists; a transplant coordinator and nurses among other health care professionals all working using a multi-disciplinary team approach. The transplant team will begin by running a series of blood tests, an x ray, and other investigations to help decide the benefits from a transplant. The transplant team will also check to see if

the patient’s heart, lungs, kidneys, and immune system are strong enough for surgery
the patient is mentally and emotionally ready for a transplant
the patient has a support system with family members or friends who can care before and after the transplant
the patient has the finances to cope with the long term care needed post transplantation

The new liver usually comes from either a brain-dead (cadaveric or deceased) donor or a willing living family donor. In India, it is usually a willing healthy living near relation who donates a part of his or her liver to the patient needing a liver transplant. This donor is usually an immediate family member- related emotionally to the patient. All living donors are subjected to several tests before transplant surgery. These include Blood tests, CT Scan, MRCP, Viral tests, Chest X-ray etc. These tests will ascertain the donor’s blood group compatibility with the recipient. These tests will also confirm that the part of the liver to be donated will be adequate for the recipient without risking a donor’s well-being. In addition to this, clearances are also needed for the donor from the Cardiologist, Pulmonologist and Gynecologist (if the donor is female). Besides making sure that the donor’s liver will work as it should, it is also important to establish that the donor has no other pre-existing disease. Transplantation involves a multi-disciplinary team approach wherein each case is put forward before a transplant board and discussed thread bare to ensure the best possible results.

The liver has two qualities which make it possible for a donor to donate part of the liver. The first is ‘reserve’. The liver has enough functional reserve that up to 75% of the liver can be removed if required (in liver donors we restrict it to 70% in order to have a margin of safety). The remaining 25% is enough to perform the functions required of the liver. The other quality is the ability to ‘regenerate’. After removal of part of the liver, the remaining liver rapidly grows back to its full size in a few weeks.

A liver transplant can be said to be successful when the patient returns to a normal productive life. Like the best centers in the world, the success rate of Liver Transplantation at BLK Superspeciality Hospital (New Delhi)is over 90% at one year after transplantation. After one year the rate of complications decreases to close to that of normal people of similar age and general health and life returns to close to normal. Some precautions and some medications have to be taken life-long.

Like any operation the Living Donor Hepatectomy carries a certain risk. Our priority is always to reduce the risk to the donor. However despite all precautions, there is a 10 to 15% chance of a complication that would require treatment or prolong the hospital stay (normally a week or less). The most common complication is development of some fluid around the lung. Usually this requires no treatment other than breathing exercises but occasionally it may need to be drained under ultrasound guidance. Sometimes there may be leakage of bile from the cut surface of the liver or elsewhere. Usually this too does not require anything more than keeping the abdominal drain longer than usual. Sometimes it requires ultrasound guided drainage. Rarely temporary endoscopic stenting of the bile duct is required. Besides, like any operation, there is a small risk of death as a consequence of the operation. All over the world the donor mortality is in the region of 0.2% (just a little higher than the risk of mortality from driving a car on the streets of Delhi). 

The hospitalization for the donor is typically about a week. However, it takes about a month before the donor feels recovered enough to return to work. For 3 months after the operation the donor has to avoid lifting heavy weights as with any abdominal surgery, after which there are no restrictions on activity. Long term problems are rare and these can occur after any abdominal surgery. Life is otherwise normal; there are no medicines to be taken in the long term and no dietary restrictions.

What is the course of patient in the hospital after the operation?
After operation, the patient needs to stay in the hospital for about 30 days to be sure that the new liver is working. Medicines need to be taken to prevent infections and the body rejecting the new liver. The team of doctors will check for bleeding, infections, and liver rejection. During this time, a patient will learn how to take care of himself/herself as part of preparation for care at home including information about the medicines that are to be taken life-long.

• The new liver may not work
• The new liver may be rejected by the recipient’s body
• Blockage of blood vessels going into or out of the liver is possible
• Leak or blockade of the bile ducts might occur
• Patient may develop infection

The immune system is our body’s natural defense mechanism. It is programmed to recognize and destroy anything unfamiliar. This includes the cells of a transplanted liver as well as the bacteria and organisms that cause infection. Rejection occurs when patient’s own immune system fails to recognize the new liver as its own, reacts to it and attacks the new liver. After surgery patient is started on medications (Immunosuppressants) to prevent the patient’s own body reacting to the new liver and rejecting it. However, these medicines make the patient susceptible to infection and the patient is also given prophylactic antibiotics and anti-fungals and sometimes anti-virals as well. Over a period of time the requirement of these medicines comes down and they are gradually withdrawn. At least one immunosuppressant medicine continues lifelong in a small dose. Episodes of rejection occur in 10 to 30% of patients who have undergone a liver transplant. These are usually easy to recognize (from periodic blood tests) and easy to treat (by increasing the dose or adding immunosuppressive medicines). Rejection that does not respond to treatment and leads to loss of the liver is very rare.

Immunosuppressive medication can have many side effects. Because these medicines weaken the immune system, one is more infection prone.
Other possible side effects include

• Weight gain
• High blood pressure
• High blood cholesterol
• Diabetes
• Brittle bones
• Kidney damage

The doctor and the transplant team will watch for and treat any of these side effects observed. In general, the life of a liver transplant patient is similar to that of a patient with a chronic but controllable medical condition like high blood pressure in that periodic (once in 3 months long term) checkups and adjustment of medication is required.

Rejection might make the patient feel tired along with loss of appetite.
Other signs might include having

• Fever
• Pain around the liver
• Jaundice
• Dark-colored urine
• Light-colored stools But rejection doesn’t always mean feeling ill.

The doctors will check through blood tests for signs of rejection. A liver biopsy is usually needed to confirm rejection. This is a procedure that involves taking a small piece of the liver for observation under the microscope.

Follow-up visits at the hospital will be needed to ensure that the new liver is working well. There will be a need for regular blood tests to check that the new liver is not being damaged by rejection, infections, or problems with blood vessels or bile ducts. Common tips for those who have had a liver transplant include:
• Avoiding people who are ill and report any illness, no matter how small
• Taking a healthy diet and exercise
• Not smoking cigarettes or drinking alcohol
• Taking all prescribed medicines as directed
• Consulting the doctor before taking any medicines other than those prescribed.
• Following the doctor’s instructions on how to take care of a new liver
• Having blood tests and other tests prescribed by the doctor

Some activities that may raise questions include:
Work: After recovery, most people are able to return to work.

Diet: Most people can eat a normal, regular meal. Some medicines prescribed post-transplant may cause weight gain and others may cause diabetes or raise cholesterol. So, eating a balanced, low-fat diet can help maintain a healthy lifestyle.

Exercise: Most people can be physically active after a liver transplant.

Sex: Most people can have a normal sex life after a liver transplant. For women, avoiding pregnancy in the first year after a transplant is recommended. Checking with the doctor when it is alright to have sex again or getting pregnant is a good idea.

After a successful liver transplant, most people can go back to their normal daily activities, and return to work. Getting strength back may take months, especially if one was very sick before the transplant. The doctor will update you on the recovery period at follow-up.
What precautions I need to take regarding Medications after Liver Transplantation?
• Do not take any other medications, including “over-the-counter” medications you can buy at the Pharmacy.
• Do not take any herbal supplements or remedies.
• Take only the medications ordered by your transplant doctor
• Do not stop taking any of the medications, unless your transplant doctor tells you to
• If you go to another doctor, tell him or her what medications you are taking

Tacrolimus
Cyclosporine
Prednisone
Mycophenolate (MMF)
Fluconazole
Acyclovir / Valcyclovir
Cotrimoxazole

Tacrolimus
Brand name: Prograf /Pangraf / Seegraf Appearance: Cap (0.5mg, 1mg, 2mg, 3mg, 4mg)
Why this medication is used:
Tacrolimus is an immunosuppressive drug that is mainly used after organ transplant to reduce the activity of the patient's immune system and so lower the risk of organ rejection. This drug is also used for treating acute rejection episodes.
How to take this medication:
• Tacrolimus is usually taken twice a day; at breakfast and dinner time. This medication works best when it is taken at the same time each day.
• The dose of tacrolimus will be adjusted, depending on the amount of tacrolimus in your blood. If you are coming to the clinic for blood work in the morning, do not take your tacrolimus that morning. Bring it to the hospital and take it after your blood work. If you are having blood work after 11 am, take your morning dose as usual.
• Do not eat grapefruit or drink grapefruit juice while taking this medication. Grapefruit increases the amount of tacrolimus in the body.

Special precautions
• Tacrolimus reduces your body’s ability to fight infection. Follow the precautions we guided with above to help prevent infections. Watch closely for signs of infection.
• Tacrolimus may cause tenderness, swelling or bleeding of the gums. Brush your teeth gently. Visit your dentist regularly.

Side effects:
Some common side effects do not need medical attention. They may lessen or go away as your body gets used to the medication. See your doctor if these effects become bothersome:
• Swollen, tender or bleeding gums – The gums seem to “grow” and cover more of the teeth.
• Trembling or shaking of the hands
• Cramps in your legs
• Hair growth – Hair on the face and arms may become thicker and darker. This new hair will fall out after you stop taking cyclosporine.
• Headaches or changes in your vision
• Seizures- This is very rare though one should be aware of this side effect.
Call your doctor right away if you have any of these side effects:
• signs of infection – fever, chills, sore throat, cough, painful urination
• seizures
What to do if you miss a dose
If you miss a dose, take it as soon as you remember. However, if it is within 6 hours of your next dose, do not take it. Skip the missed dose and take the next dose at the regular time.
Do not take a double dose.

Cyclosporine
Brand name: Sandimmune / Neoral Appearance: Cap (25 mg, 50 mg, 100 mg)/ Liquid (100 mg/ml)
Why this medication is used:
Cyclosporine is an immunosuppressive drug that is mainly used after organ transplant to reduce the activity of the patient's immune system and so lower the risk of organ rejection. This drug is also used for treating acute rejection episodes.
How to take this medication:
• Cyclosporine is usually taken twice a day; at breakfast and dinner time. This medication works best when it is taken at the same time each day.
• The liquid is oily and is usually taken with a small amount of juice/ chocolate milk.
• The dose of cyclosporine will be adjusted, depending on the amount of cyclosporine in your blood. If you are coming to the clinic for blood work in the morning, do not take your cyclosporine that morning. Bring it to the hospital and take it after your blood work. If you are having blood work after 11 am, take your morning dose as usual.
• Do not eat grapefruit or drink grapefruit juice while taking this medication. Grapefruit increases the amount of cyclosporine in the body.
Special precautions
• Cyclosporine reduces your body’s ability to fight infection. Follow the precautions we guided with above to help prevent infections. Watch closely for signs of infection.
• Cyclosporine may cause tenderness, swelling or bleeding of the gums. Brush your teeth gently. Visit your dentist regularly.
• Do not take any products that contain magnesium (such as antacids or magnesium supplements). This can cause diarrhea, which may be confused with a sign of GVHD.
Side effects
Some common side effects do not need medical attention. They may lessen or go away as your body gets used to the medication. See your doctor if these effects become bothersome:
• Swollen, tender or bleeding gums – The gums seem to “grow” and cover more of the teeth.
• nausea or vomiting– Some patients may need to take Domestal /Emeset 30 minutes before each dose
• trembling or shaking of the hands
• cramps in your legs
• hair growth – Hair on the face and arms may become thicker and darker. This new hair will fall out after you stop taking cyclosporine.
• headaches or changes in your vision
Call your doctor right away if you have any of these side effects:
• signs of infection – fever, chills, sore throat, cough, painful urination
• seizures
What to do if you miss a dose
If you miss a dose, take it as soon as you remember. However, if it is within 6 hours of your next dose, do not take it. Skip the missed dose and take the next dose at the regular time.
Do not take a double dose.

Prednisone
Brand names: Prednisolone (Wysolone / Omnacortil)
Why this medication is used: Prednisone is a steroid medication and an immunosuppressive drug that is mainly used after organ transplant to reduce the activity of the patient's immune system and so lower the risk of organ rejection. This drug is also used for treating acute rejection episodes..
How to take this medication
• Take prednisone with a full glass (250 ml or 8oz) of water.
• If prednisone upsets your stomach, try taking it with food or milk.
• If you are to take prednisone once a day, take it in the morning with breakfast. Avoid bedtime.
• The doctor will change the dose of prednisone depending on your body’s response to the medication.
Special precautions
• Prednisone may increase the risk of infection and hide some of the signs. Watch closely for signs of infection.
• Do not drink alcohol while taking prednisone.
Side effects
Some common side effects do not need medical attention. They may lessen or go away as your body gets used to the medication. See your doctor if these effects become bothersome:
• Nausea
• Restlessness or trouble sleeping
• Increased appetite
• Dizziness
• Headache
Call your doctor right away if you have any of these side effects:
• signs of infection – fever, chills, sore throat, cough, painful urination
• swollen face, lower legs or ankles
• unusual weight gain
• changes in vision
• increased thirst, frequent urination
• anxiety or mood changes

Mycophenolate (MMF)
Brand name: Cellcept / Mycept
Why this medication is used: Mycophenolate is an immunosuppressive medication. It reduces the body’s immune response.
How to take this medication
• Mycophenolate is usually taken twice a day. It works best when taken at the same time daily.
• Take mycophenolate on an empty stomach. This means 1 hour before or 2 hours after meals.
• Swallow the tablets or capsules whole. Do not cut, crush or chew them.
Special precautions
• Mycophenolate reduces your body’s ability to fight infection.
• Mycophenolate can harm an unborn baby. Two forms of birth control must be used if there is any chance of pregnancy.
Side effects
Some common side effects do not need medical attention. They may lessen or go away as your body gets used to the medication. See your doctor if these effects become bothersome:
• constipation or diarrhea
• headache
• heartburn or stomach pain
• nausea or vomiting
• muscle joint or back pain
• trouble sleeping
Call your doctor right away if you have any of these side effects:
• Signs of infection – fever, chills, sore throat, cough, painful urination
• Tremor – uncontrollable shaking of the hands
What to do if you miss a dose: If you miss a dose, take it as soon as you remember. However, if itis within 6 hours of your next dose, do not take it. Skip the missed dose and take the next dose at the regular time. Do not take a double dose.

Fluconazole
Brand names: Forcan
Why this medication is used: Fluconazole is used to prevent or treat fungal infections.
How to take this medication
• This medication works best when it is taken at the same time each day.

Acyclovir / Valcyclovir
Brand names: Acivir/Valcivir
Why this medication is used: Acyclovir is used to prevent or treat certain viral infections.
How to take this medication
• Acyclovir is usually taken twice a day. Take tablets with a full glass (250 ml, 8 oz) of water.

Cotrimoxazole
Brand names: Septa-DS
Appearance
Tablets (sulfamethoxazole 400 mg and trimethoprim 80 mg)
• Double strength (DS) tablets (sulfamethoxazole 800 mg and
trimethoprim 160 mg)
Why this medication is used: This medication is used to prevent a lung infection called PCP pneumonia.
How to take this medication
• Take tablets with a full glass (250 ml or 8 oz) of water.
• This medication is usually taken once a day, but only 2 days a week (Monday, Thursday).

It can help to limit the number of visitors you have (only 2 or 3 at a time). Avoid close contact with anyone who is ill. Sometimes, close contact is unavoidable, such as when someone in your home has a cold. A person with a cold can reduce the spread of germs by washing their hands often, sneezing or coughing into disposable tissues and wearing a procedure mask. You may want to wear a procedure mask when you are in the room with a person who is sick. Remember to wash your hands if you touch the person or touch an object he or she has used such as the telephone. Washing your hands is the best way to prevent infections. It is important that you, your family and visitors wash their hands well. This means washing your hands, fingers and nails with antimicrobial soap and warm water. Then, rinse with water and dry with a clean towel. If soap and water are not available, you can use water-less soap (sanitizer). Take a shower every day and wash with a mild soap, such as baby soap. Wash under your arms and in the groin area very well. If you have dry skin, apply a mild moisturizer to your skin to keep it coated and protected.

With time you can expect to return to all your daily activities. You will need to pace your activities for the first few months, so that you do not tire yourself out. Start with a little exercise each day. You may tire easily at first, so remember to balance rest with activity. Gradually increase your activity and exercise. This will help you regain strength and endurance. Walking is an excellent way to get exercise each day. Start with short walks, 2 to 5 minutes, a few times and a day. Do not push yourself if you feel tired or uncomfortable. Gradually take longer walks. It may take several weeks or even months to go longer distances. But each walk will benefit you; so don’t give up. Gradually increase your walking up to 30 minutes, 4 to 5 times a week.
To prevent infection when you go outside, wear a procedure mask until at least first 3 months after Liver Transplantation. While you are recovering, there are some activities and places you should avoid:
• For the first 3 months you should avoid crowded places, such as the grocery store, movie theatre, public elevators or shopping malls. In crowds, you are more likely to have contact with people who have respiratory or other illnesses.
• Do not do activities such as gardening
• Avoid dusty areas, such as construction or excavation sites.
• Do not go near chicken coops or other places where birds roost.

Healthy eating is good for you and helps you recover. When you leave the hospital, you may feel tired and have less appetite. This can make it harder for you to get the nutrition you need. You will need to choose foods and drinks that help you regain your strength. To prevent infection, you must choose and prepare foods carefully for 3 months after your transplant and until you no longer take immunosuppressive medications (for example: cyclosporine or steroids). It is important that you continue to drink enough fluids at home. We recommend that you drink 2 litres (8 cups) of fluid each day. Some cautions about fluids:
• Limit fluids that contain caffeine (such as coffee, tea and cola) to no more than 500 ml (2 cups) a day.
• Check with your doctor before drinking any alcohol. Alcohol can affect your liver and interfere with medications such as prednisone.
• Do not drink water that is not chlorinated.
• Do not drink unpasteurized milk, fruit or vegetable juices.

Delhi Liver Transplant: Best Liver Transplant Hospital, Doctor, Surgeon in Delhi India