Principal Consultant & Unit Head, Liver Transplant, Fortis Hospital, Shalimar Bagh, New Delhi, India
Part 9 of 12 in Liver Transplant
Re-Transplantation: When and How Often It's Possible
August 11, 2024
Asked whether a patient who already had a liver transplant can receive another, Dr. George confirmed re-transplantation is possible, needed in around 5-7% of patients, whether from disease recurrence, chronic rejection, or other causes.
A more challenging but feasible surgery
Re-transplant is technically more demanding than a first transplant, but achieves equal long-term results and survival when performed by a skilled team. Some patients have undergone two, three, or even four transplants over the years for recurring reasons such as chronic rejection.
What changes the calculus for a repeat transplant
The reason behind the need for re-transplant matters. A patient who stopped taking immunosuppressant medication raises the question of whether they will adhere the second time; a patient whose liver failure recurred because they returned to drinking alcohol raises the same concern about post-transplant abstinence. Outside of these adherence-related cases, most patients needing re-transplant for other reasons require no major additional evaluation beyond what was needed for their first transplant.
This article is based on a Jivo Masterclass session conducted by Dr. Ashish George, Principal Consultant & Unit Head, Liver Transplant, Fortis Hospital, Shalimar Bagh, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
Looking for a liver transplant consultation or a second opinion? Get in touch with the Jivo team
This guide is based on a live Jivo Masterclass: Dr. Ashish George taught doctors across Africa on August 11, 2024.
FROM THE LIVE Q&A
Moderator
Is it possible for a healthy person without liver disease to have a partial hepatectomy stored, so that if they develop liver disease later it can be transplanted back to them?
Dr. Ashish George
No, this has not been thought of or done. Only a very small subset of the general population ever needs a liver transplant, so removing a healthy liver segment as a major surgery isn't advisable, and there is no method to preserve a graft for years, only for hours to a few days using specialised machines.
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Frequently Asked Questions
What is the time limit for liver cells to survive outside the body before transplant, and what is the recommended alcohol limit for a patient after liver transplant given a history of alcohol use?▼
A deceased-donor liver can be preserved up to 16 hours in solution, though shorter is always better. Living donor transplant avoids this almost entirely since donor and recipient surgeries happen side by side, keeping the liver outside the body for only half an hour to two hours. The prescribed alcohol limit after transplant for alcoholic liver disease is zero, and at least six months of abstinence is recommended before transplant, and none at all afterward.
On immune monitoring and tolerance after liver transplant, there is evidence of adverse effects including cardiovascular disease, osteoporosis, infection and renal failure. How can these risks be minimised to improve outcomes for patients?▼
Post-transplant medications do carry a risk of cardiac problems, hypertension, diabetes and renal dysfunction, and a modestly elevated cancer risk versus the general population. But comparing 100 transplanted patients against 100 similar patients who are not transplanted, more of the transplanted group are alive at one, three and five years. Doses are actively managed and medications changed where complications arise to minimise risk over time.
What is the survival rate of liver transplantation?▼
More than 90% of patients are alive at 1 year, 80-85% at 3 years, more than 75% at 5 years, and 65-70% at 10 years. Liver transplant does not have an expiry date because the liver can regenerate.
Is liver transplantation a replacement, a like-for-like graft, or a therapeutic treatment, essentially a cure versus a therapy?▼
It is a cure in that the patient's symptoms completely resolve. However, because the patient needs lifelong immunosuppressant medication, they remain in medical follow-up indefinitely even though the disease itself is gone.
Is it advisable for patients with chronic hepatitis to undergo liver transplantation, given the risk of the new liver becoming infected too?▼
Yes. Patients who develop decompensated chronic liver failure from hepatitis B or C should undergo transplant. Hepatitis B patients are kept on lifelong antivirals post-transplant to suppress the virus; hepatitis C is now completely treatable with directly acting antivirals given before or after transplant. Chronic viral hepatitis does not pose a major barrier to offering transplant.
How often is liver re-transplantation needed?▼
In about 5-7% of patients, due to disease recurrence, chronic rejection, or other causes.
What makes doctors hesitant to offer a repeat transplant?▼
Cases where the first transplant failed due to non-adherence to immunosuppressant medication, or a return to alcohol use, since these raise doubts about post-transplant adherence the second time.
In This Series: Liver Transplant
- 1.Liver Transplant
- 2.Indications for Liver Transplant: Acute and Chronic Liver Disease
- 3.Liver Transplant for Liver Cancer: HCC, the UCSF Criteria and Downstaging
- 4.Contraindications and the MELD-Sodium Score for Timing Transplant
- 5.Survival Rates After Liver Transplant, and Why It's a Cure, Not Just a Therapy
- 6.Living Donor Evaluation: Compatibility, Safety and Liver Regeneration
- 7.Who Can Donate a Liver: Eligibility, Compatibility and the Ten-Year Myth
- 8.Hepatitis B and C in Liver Transplant Candidates
- 9.Re-Transplantation: When and How Often It's Possible
- 10.Nutrition Before and After Liver Transplant
- 11.Immunosuppression After Transplant: COVID-19, Cardiovascular and Renal Risk
- 12.Cold Ischemia Time and Post-Transplant Alcohol Limits