Question 1

What is the survival rate after liver transplantation?

Dr. Ashish George · Accepted Answer

In terms of short- and long-term survival, more than 90% of patients who undergo liver transplant are alive at 1 year, more than 80 to 85% at 3 years, more than 75% at 5 years and more than 65 to 70% at 10 years. A liver transplant does not have an expiry date. That is the beauty of the liver: it can regenerate. A small insult will not harm it; some cells may die and then regenerate. That is why patients who undergo liver transplant and follow their treatment properly live for a very long time.

Question 2

Is liver transplantation a cure, or a treatment or therapy?

Dr. Ashish George · Accepted Answer

It is a cure, in the sense that the patient's symptoms completely abate after transplant. However, the patient needs to continue on immunosuppressants lifelong, so he will be on medication and will need to stay in touch with us lifelong, but his disease will go away.

Question 3

Is it advisable for patients with chronic hepatitis to undergo liver transplantation, given that the ongoing infection could infect the transplanted liver as well?

Dr. Ashish George · Accepted Answer

Yes. If a patient with chronic viral hepatitis, most commonly hepatitis B or hepatitis C, develops chronic liver failure and decompensates, he should undergo liver transplant. After transplant, patients with hepatitis B in particular are kept on lifelong antivirals, which keep the virus suppressed and ensure the new liver suffers no injury. Hepatitis C is now completely treatable with directly acting antivirals, which can be given pre-transplant and in a few cases even post-transplant. Chronic viral hepatitis therefore poses no major challenge to offering liver transplantation.

Question 4

How do factors such as donor liver quality and the recipient's health condition affect the success of, and recovery after, a liver transplant?

Dr. Ashish George · Accepted Answer

For a patient and donor pair being evaluated for a living donor transplant, both undergo extensive evaluation. The donor evaluation is two-pronged: first, that the surgery itself poses no major risk to the donor; second, that the liver is of good enough quality to work well when part of it is placed in the recipient. The chance of the liver not working in a living donor transplant, called primary non-function, is less than 1 to 2%. Sometimes the liver takes time to function well, called early allograft dysfunction, which may happen in about 5 to 10% of patients. With a marginal donor it is a spectrum: we usually consider donors aged 18 to 55, and a younger donor with a non-fatty liver will have better liver quality than an older donor whose liver has a little more fat. Once we declare a donor fit for donation, we have already evaluated both aspects: the risk to the donor is minimal and the liver quality is good enough.

Question 5

Who is eligible to donate a liver?

Dr. Ashish George · Accepted Answer

There are two aspects. Legally, whoever is evaluated to donate has to be a relative of the patient. Medically, the best donor is a blood-group compatible donor, following the same compatibility rules as blood donation: for a group A patient, A and O donors are compatible; for group B, B and O; a group AB patient is a universal recipient; and a group O patient needs an O donor. Rh positive or negative does not matter in liver transplant. If the family has no blood-group compatible donor, we can evaluate an incompatible donor, but the patient needs preparation, the preparation takes slightly longer, and there is added cost along with a slight increase in risk.

The donor should be 18 to 55 years of age and otherwise healthy: no diabetes, and no advanced pulmonary problems or other uncontrolled conditions that pose a risk to life. Mild hypertension is not a problem. Previous abdominal surgery is usually not a problem. Benign gynaecological problems, mild bronchial asthma and a seizure disorder controlled on medication are not a concern.

Question 6

Is there research correlating liver transplantation with COVID-19 survival, and what are the nutritional considerations before, during and after liver transplantation?

Dr. Ashish George · Accepted Answer

There is now significant data that many patients who develop COVID-19 after transplantation get only mild disease, probably because the body cannot mount a very severe response against the virus, and it may be just like flu. But patients who develop severe COVID-19 may have poor survival because, being immunosuppressed, they are at risk of superadded secondary infections.

Nutrition before and after transplant are two separate questions. Patients with liver cirrhosis usually lose a lot of muscle mass, called sarcopenia, so while they wait for transplant we put them on a high-protein, high-calorie diet to reduce muscle loss as much as possible. After transplant, sarcopenia usually reverses very soon because the underlying disease has been addressed. Because the patient is on immunosuppressive medication, there are a few restrictions. We prefer that they eat only freshly cooked meals, because food kept in the refrigerator and reheated may carry infections that are harmful to an immunosuppressed patient. They should ensure the water they drink is clean. Uncooked fruits and vegetables should be ones that can be washed, peeled, cut and eaten immediately; anything that cannot be peeled is ideally avoided, because even with thorough cleaning bacteria or parasites may remain. Finally, red meat should be eaten less often, because these patients carry a long-term risk of cardiac disease.

Question 7

How long does it take for a donor's liver to regrow after donation, is it true that a donor has only about 10 years to live afterwards, and what is the age limit for donating?

Dr. Ashish George · Accepted Answer

In adult living donor transplantation about 60% of the liver is taken, so about 40% remains in the donor, and it grows very fast. Experimental data in rats and radiological imaging in humans show that growth is fastest in the first 2 to 4 weeks, with almost 70 to 80% of growth happening in that period. It continues to grow for about 3 to 6 months, and by the end of 6 months almost 95 to 97% of the original size has been regained, with normal function well before that. That is the beauty of the liver as an organ. When a kidney is donated, the nephrons left in the remaining kidney have to work overtime, and their number does not increase. The liver is like a tree: prune 70 to 80% of its branches, give it sunlight, manure and water, and in 3 to 6 months it is whole again and you would not know it had been pruned.

The claim that a donor has only 10 years to live is absolutely false. Whatever risk the donor carries is around the time of surgery, because it is major surgery. Once recovered, 95% of our donors are discharged by five to six days, and by the end of one month most fly back home and need no further follow-up with us. Whatever life they lived before donation, they continue to live after. The donor is not on any long-term medication. The scar takes about 3 months to reach its normal strength, so we tell donors not to lift heavy weights for 3 months. Apart from that there are no restrictions: food habits, social life, family life, life expectancy, work, sexual life and having children do not change.

Question 8

Can someone donate part of their liver twice?

Dr. Ashish George · Accepted Answer

No. You can only donate once.

Question 9

For someone who has already had a liver transplant and needs another, what are the possibilities, and how many times can a transplant be repeated?

Dr. Ashish George · Accepted Answer

It is possible. Perhaps 5 to 7% of patients who undergo liver transplant may need a re-transplant, for reasons that could include recurrence of the disease, chronic rejection or other causes. Re-transplant is technically more challenging than a first transplant, but it is feasible and gives equal results and long-term survival to a first transplant. How many re-transplants a patient may have is debatable: there are case reports of patients who have undergone two, three or even four transplants over the years, for example after chronic rejection. Re-transplant is possible when required in this small subset of 5 to 7%, and results are very good when it is done by a skilled team.

Question 10

Are there additional requirements for a repeat transplant, or do the same rules apply to everyone?

Dr. Ashish George · Accepted Answer

Similar rules apply to most patients, but we have to look at why the patient needs a re-transplant. If a patient stopped taking his immunosuppressant medication, how confident are you that he will take it the second time around? Those questions need answers before we offer re-transplant. Patients whose liver failed again because of recidivism, meaning a return to alcohol, need rethinking on whether they will maintain the abstinence required after transplant. Otherwise, if the disease has recurred for other reasons, most patients can undergo re-transplant without any major evaluation beyond what the first transplant required.

Question 11

Is it possible for a healthy person without liver disease to have a partial hepatectomy and store the liver tissue, so that if they develop liver disease later it can be transplanted back to them?

Dr. Ashish George · Accepted Answer

No. This kind of treatment has not been thought of or done. Most of the general population will never need a liver transplant: only a very small subset develops liver disease, and of that subset only some go on to chronic liver failure requiring transplant. A hepatectomy is itself major surgery, so doing it in a healthy person is not advisable. There is also no method to keep a graft for years. A graft can probably be kept outside the body for a few hours, and machines can keep deceased-donor organs for a few days, but nothing beyond that. So this is not an option.

Question 12

How long can the liver survive outside the body between removal from the donor and transplantation into the recipient, and what is the recommended alcohol limit after liver transplant for patients used to drinking?

Dr. Ashish George · Accepted Answer

A deceased-donor liver, taken whole from a brain-dead donor, can be kept in preservative solution for up to 16 hours and still be transplanted successfully. We want this cold ischaemia time to be as short as possible, because the longer the liver is outside the body without blood, oxygen and nutrients, the more cells die. This problem does not arise in living donor transplant, because the donor and recipient operations run side by side in adjacent theatres. The liver is outside the body for perhaps half an hour to one and a half or two hours, the time needed to prepare it for implantation. That is the benefit of living donor over deceased donor transplant.

For patients transplanted for alcoholic liver disease, the prescribed alcohol limit is zero. Ideally there should be 6 months of abstinence between stopping alcohol and being offered transplant; this can be reduced to three months. Where the patient is very sick, with no period of abstinence, we discuss with the family whether to operate, because transplant is lifesaving. After transplant the patient must not go back to drinking, because the new liver cannot sustain the metabolic stress of alcohol. We advise patients not to drink at all: once you start, one drink becomes two, then four, then a habit again. The best way is to stop completely and not think of alcohol again.

Question 13

Research shows that patients living after liver transplant develop adverse effects including cardiovascular disease, osteoporosis, infection, renal failure and malignancy. How can these be minimised so that patients are better off after transplant?

Dr. Ashish George · Accepted Answer

Take a patient with chronic liver disease that is not decompensated: not much ascites, no encephalopathy, kidneys not significantly affected, jaundice not very high. If his MELD-sodium score is 14 or less, he should continue on medicines and follow up with us, because his risk of dying from the transplant or from the complications of the medications you mention is higher. If the score is 15 or more and he is kept on medical management rather than transplanted, more of these patients will die than of those who are transplanted. This has been studied in more than 16,000 patients.

So yes, post-transplant medications carry a risk of cardiac problems, hypertension, diabetes and renal dysfunction, but that risk is much lower than the risk of not transplanting. Because patients stay in contact with us, we keep medication doses such that these complications are reduced or do not arise, and if a complication does occur we can switch one medication to another. Immunosuppression does carry a risk of cancer: higher than in the general population, but not very high overall. To summarise: take 100 patients with advanced liver disease who are not transplanted and 100 who are. At one, three and five years, more of the transplanted patients will be alive.

Live Discussion with Dr. Ashish George