In the last decade or so, liver transplantation has become popular and successful in our country. Compared to other organ transplants (kidney, heart, lung, pancreas, intestine, face, hands), liver transplant has higher success rate, long term survival and needs the lowest quantum of medicines for follow up in the long run.
The path–resurrecting from the stage of End Stage Liver Disease (ESLD) to a new life through liver transplant with good quality of life–can be perilous, embedded with severe complications of ESLD, facing life- death situations often.
That said, there are also several misconceptions plaguing public imagination regarding liver transplantation. Those who undergo liver transplant have many queries and worries, regarding their long term health, quality of life, longevity, possible complications, social and financial concerns as well.
Here are some of them answered.
*What is the life span of a person who underwent liver transplant?
Post a transplant, many ask questions regarding survival and longevity of life. After a successful surgery, those who undergo regular medical follow up will get a productive long term survival. The nature of follow up matters a lot; there are many unscientific practices which preclude long term survival. Let us take it up in detail now-
People have lived more than 40 years after liver transplantation in abroad. In our country this treatment modality has come into vogue approximately 20 years back. As mentioned before, leading a productive life in the society is the core concept behind giving a new liver. There is a popular misconception that even after transplantation life span is constricted and the quality of life may not be that great. This is totally wrong!
After transplant the person can go back to his job, provided the job doesn’t have the risk of infections. Those who have a work from home arrangement, I have seen patients going back to work, working on their laptop from the second month after transplant. Those jobs requiring physical exertion can restart their work after six months. There are many who participated in sports; the Olympics gold medalist Chris Clugg is a wonderful example of the same. After transplant many lead a normal family life, women give birth to children.
For liver transplantation in the world over, 90 per cent success rate is quoted. The chance of a person living after transplant in the first year is 90 per cent, five years it is 85 per cent and 10 years it is somewhere between 60 to 75 per cent.
Let not these statistical figures misguide into thinking that due to liver transplantation the lifespan has come down. In fact, a patient’s age at the time of transplant, the diseases which the patient had other than liver disease at the time of transplant are the additional factors other than success of transplant surgery which determine lifespan after liver transplantation.
Usually the average age group of somebody undergoing liver transplant would be between 50 to 60 years. At this age, all other diseases which can happen in a person who has not undergone transplant would happen in the transplanted patient as well. A scientific regular follow-up is extremely important to ensure long-term lifespan. Doing liver function test (LFT) once in a while is not the way when it comes to ensuring long lifespan. Long-term lifespan is actually not determined by liver health, instead on the health of other organ systems; let us see what this means.
Organ rejection is a problem and we tackle this problem by giving anti rejection medicines. These medicines can induce diabetes, blood pressure, and high cholesterol. 30 to 40 per cent liver transplantation is done for a disease condition called Non Alcoholic Fatty Liver Disease (NAFLD). This condition has diabetes, high cholesterol and blood pressure disease associated with it. So, those who develop liver cirrhosis due to NAFLD and undergo liver transplant, obviously their diabetes, BP and cholesterol levels have to be controlled in a stringent manner. As mentioned, the rejection medicines can enhance these conditions. These conditions can promote ill-health of blood vessels culminating in heart attack and paralysis. Anti-rejection medicines very rarely induce certain cancers.
Managing these issues is what determines the lifespan and not the health of transplanted liver alone. If there are no major surgical complications after transplant surgery, generally the new liver would survive throughout the lifespan of an adult who underwent liver transplant at 50-60 years. This is the background of why it is said everything depends on a very systematic and scientific follow-up under a trained liver transplant physician who would monitor health of the grafted liver as well as health of other organ systems.
All follow-up medicines are monitored and any side effects which these medicines induce on the health of other organ systems is constantly monitored. There is another way of emailing blood tests to the transplant units and continuing medicines, which is a wrong follow up choice to make. It is not just unscientific but can be disastrous.
*What is the quality of life after transplant? How far can a transplanted patient live a normal life?
After transplant, it is possible to lead a normal life without compromising on the quality. Those who undergo transplant can engage in all activities which somebody of their age can perform. The patient can go back to the job they were doing before transplant. They can lead a family life, women can give birth. However, there are certain alterations which need to be incorporated in the lifestyle. Here are some of them:
- Infection control measures – During Covid times measures for Transplanted patients are similar to what we observe– maintaining hygiene of food and water, wearing an N 95 mask. Avoiding crowded places and visiting patients with fever are desirable
- Maintaining ideal body weight: Increase in body weight and obesity can be detrimental in liver transplanted patients. When suffering from liver cirrhosis, symptoms like lack of appetite, nausea and fatigue are common. They, however, disappear once after the transplant. Appetite returns and energy is revived. But this can also lead to overeating and possible obesity. Obesity and its associated conditions like BP, cholesterol and diabetes (collectively known as METABOLIC SYNDROME) are the basic reason behind shortened lifespan after liver transplantation. Thus, maintaining ideal body weight by following a healthy diet and regular aerobic exercise go a long way in ensuring long term lifespan post liver transplant.
*What are all the complications one can expect after liver transplantation?
There are a set of complications possible after liver transplantation. Fortunately in many Indian transplant centres rate of complications have come down over the years. Two or three decades back when liver transplantation was initiated in India, transplant surgeons were learning this new technology and historically if you look back, the success rate was low, death rate was high and complication rates were much more.
Since the learning curve has been crossed by many transplant centres, death rate/surgical failure has come down tremendously. Moreover, instead of liver transplant surgeon, handling the entire clinical activity, conjoint effort by liver surgical team along with liver medical team and Liver critical care team have certainly contributed to the high success rate and long-term outcomes in best of centres.
10 or 20 years back, transplant surgeons had no other choice but to do the entire medical and surgical activity on their own. Now, like in the western world we have various subsections or clinical specialities handling liver transplant patient. This has resulted in reduction of complications and increase in success rate. After liver transplant surgery, generally surgical complications happen during the first one or two months. Bleeding, leak from the bile duct, collection of pus due to infection inside the abdominal cavity are usual surgical complications seen in the first one or two months. From the third month onwards most complications are medically managed. A second surgery is needed rarely.
Among the medical complications, the new organ getting rejected is possibly the first and foremost. The patient’s immune system would consider the new organ foreign to the body and would try to reject it. It is, however, reassuring to note that chances of rejection in liver transplant are very less compared to other organ transplants. If at all rejection happens, it can be managed with medicines. Organ loss due to rejection is almost a rarity.
Liver Biopsy may be needed to ascertain the severity of rejection and then manage with medicines. Second medical complication is increased risk of infections. As mentioned before, anti rejection medicines reduce the immunity of patients. Because of this infections due to bacteria, virus and fungus are more in transplanted patients. The dose of anti-rejection medication is much more during the initial months and hence the chance of infection is also more. This risk is handled with anti-viral, antibacterial and anti-fungal medications. They are administered only in the initial months after transplant, beyond which lifestyle measures to control infection control are indicated.
When the new liver is attached to the patient’s body, various tubes are joined and complications are possible at these joining sites. Narrowing can happen and at times leak as well at the joining site of bile duct. If blood supply to the new liver is compromised, this can lead onto a serious condition called Hepatic Artery Thrombosis (HAT) which mostly occurs in the initial days and weeks after transplant. We regularly screen blood supply to the new liver using Doppler ultrasonogram. Blood vessels like portal vein and Hepatic vein also may get damaged very rarely -blood clot can form inside these vessels, rarely narrowing can occur at the joining sites. All these complications mentioned can be managed efficiently if detected early.
*How will the patient identify the onset of these complications?
Many a time the complications listed above need not give any difficulties or symptoms to the patient and hence regular blood tests as well as scanning are needed to identify this. Two most important symptoms are fever and generalised itching.
Fever in a transplanted patient should not be taken lightly. It occurs due to infection and the location of infection in the body has to be identified and appropriate treatment need to be given accordingly. The policy of giving paracetamol for a few days and then attending a hospital if that doesn’t work is a wrong decision when it comes to a transplanted patient.
The immune system is weak due to anti rejection medicines and a transplanted patient’s body may not handle fever or infection efficiently on its own. Regarding itching, the reasons can be many – dehydration of the skin, medications which the patient takes. Diabetes can be a reason for itching but a significant itching can either be a complication of bile ducts or a signal towards rejection; hence if significant generalised itching is present it has to be brought to the notice of liver transplant physician.
*Is there a high risk of cancer among liver transplanted patients?
In the human body prevention of cancer is done by the immune system. Some cells in our body undergo stealthy changes called mutations and if these mutated cells are allowed to grow, they evolve into cancer. Immune system is constantly watching mutated cells and then destroying them timely.
Because of anti-rejection medications given after liver transplant, the mutated cells get inefficiently tackled by the immune system and certain cancers can occur because of this. Skin cancers and rare types of lymphoma are the more common ones in the Western world. Among Asian patients, cancers of mouth, throat, stomach, food pipe may also occur. Since anti-rejection medication dose is much less in liver transplant as compared to other organ transplant, the chance of cancer incidence is also fortunately quite low.
After many years from liver transplant, it is prudent to look for any signs or symptoms of cancer and that is where the importance of performing screening tests on transplanted patients lies. For example, in the USA, those above 55 years of age, has to undergo a test called colonoscopy. Large intestinal cancer or colon cancer evolves from pre-runner lesions called polyps. By screening colonoscopy these polyps can be picked up and be removed through colonoscopy without surgery, before those evolve into cancer. Breast cancer, uterine cervical cancer all have screening techniques like mammogram, PAP smear test and tumour marker blood test panels. After liver transplantation, cancer surveillance is important.
*When we talk about lifestyle modifications after transplant, infection control measures are very important. What are all the aspects which should be taken care of? Do lifestyle measures for infection control change over time?
Rejection of the new organ is prevented by reducing immunity with the help of anti-rejection medicines. The dose of anti rejection medicines would be high immediately after the transplant and over time, the dose can be brought down step by step.
We even measure the level of anti-rejection medicine in blood and that is how the dosages are adjusted. Immediately after transplant surgery, the risk of infection is much higher, but at the same time over years the risk comes down commensurate with the reduction in dosage of anti-rejection medication. Although the risk of infection comes down with time, infection control measures should not be neglected totally.
Bugs get into the body through the water we drink, the food we consume as well as the air we inhale. Uncooked food of any sort is better avoided whatever be the duration from transplant surgery. Green salad, half cooked chutneys, half cooked meat, fish etc should not be consumed at all.
Water source should be a reliable. Preferably use boiled water. Installing a water purifying system in individual households is desirable. Eating out from restaurants should best be avoided, especially in the initial years. Most Indian cities have the risk of atmospheric pollution. Crowded places run more chances of getting respiratory infection. Theatres, shopping mall, crowded market, festivals, large scale gatherings, places of worship and other public places with a lot of people should be avoided.
In public places, wearing a mask should be practised. N 95 mask is far superior to cloth mask or the layered surgical mask. In summary, the risk of infection is high in the initial months after transplant. This is lessened over time but awareness about infection control and the practises should be followed lifelong.
*What is the logic behind saying that increased body weight is harmful to the liver transplanted patient? What is the significance of maintaining ideal body weight after transplant? What is metabolic syndrome?
Lifestyle measures aimed at maintaining ideal body weight is the most important aspect which would ensure long-term lifespan. As mentioned before, 30 to 40 per cent of those who get transplanted have liver cirrhosis due to NAFLD which has associated BP, Diabetes and raised cholesterol issues.
This might get exacerbated if body weight goes up. Those who do not have any of these prior to transplant might develop this because of the immuno suppression medications namely Tacrolimus and Everolimus. Maintaining body weight is important to prevent the combination of diabetes, BP, cholesterol which is collectively known as “Metabolic syndrome”.
Metabolic syndrome in the transplanted patient reflects on the health of blood vessels. Blood circulation gets affected and can result in heart attack and paralysis. In short, regular physical exercise and a proper food auditing aimed at maintaining ideal body weight has immense importance in prolonging life span after liver transplant
*Briefing about medications used after liver transplant
There are a lot of questions around medication use after liver transplant. During the initial weeks and months after transplant surgery, the number of tablets can be as high as 20 or even 30 per day but over weeks and months the number comes down progressively and ultimately by second year generally there is only one type of tablet to be taken twice daily.
In the first four months there are three types of anti-rejection medications- Tacrolimus, Mycophenolate, steroids, and rarely a medication called Everolimus. Steroid medication is generally stopped after the second month or third month; this initial 2 to 3 months when the patient takes steroid tablets an increase in blood pressure and derangement of blood sugar should be monitored strictly.
Mycophenolate is stopped after completion of one year. From second year onwards generally only Tacrolimus alone is given either once daily formulation or twice daily. In addition to these immunosuppressant medications mentioned above, in the initial 3 to 4 months some anti bacterial, anti-fungal and antiviral medications are also used. If the transplant is done for liver disease due to hepatitis B, then medication aimed at controlling Hepatitis B also needs to be taken.
Whether medications can be stopped is a question I face quite frequently. Research is going on in this direction whereby, after many years of transplant, 20 per cent of transplanted patients may not require medicines. Why does this happen? Liver is very tolerant and the body’s immune system ultimately accepts the new organ. Because the liver gels well with the new body and its immune system, the chance of rejection comes down and ultimately one fifth of the transplanted patient population may not even need any medications.
The technical term for this is Clinical Operational Tolerance (COT). But we need to realise that this is only an undergoing research and as of now the option is to continue with medications and get the regular check ups done.