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Liver Transplant in India

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The article Liver Transplant in India comprises of information regarding liver functioning, signs of liver failure, liver donation, Liver surgery. Hope this article can bring awareness regarding liver transplant to all readers. – PowerPoint PPT presentation

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Title: Liver Transplant in India


1
Liver Transplant in India Liver is a vital part
for humans it plays a crucial role in metabolism
process. If the liver is damaged by any means
the victim cannot survive. The best option for
him/her would be Liver Transplant. The article
Liver Transplant in India comprises of
information regarding liver functioning, signs of
liver failure, liver donation, Liver surgery.
Hope this article can bring awareness regarding
liver transplant to all readers.
LIVER FUNCTION The liver is a vital organ, which
means that you cannot live without it. The liver
performs many critical functions, including the
metabolism of toxins and drugs, the elimination
of degradation products of normal metabolism
(eg, the removal of bilirubin and ammonia from
blood), and the synthesis of many enzymes and
proteins (blood coagulation factors). Blood
enters the liver from two channels, the portal
vein and hepatic artery, providing nutrients and
oxygen to liver cells, also known as hepatocytes,
and other name is bile ducts. The blood leaves
the liver through the hepatic veins that flow
into the inferior vena cava that immediately
enters the heart. The liver produces bile, a
liquid that helps to eliminate metabolic waste
and toxins through intestine and dissolve fats.
Each hepatocyte creates bile and excretes it into
microscopic channels that join to form bile
ducts. Like tributaries that join to form a
river, the bile ducts join together to form a
single hepatic duct that brings bile into the
intestine.
WHO NEEDS A LIVER TRANSPLANT? Liver
transplantation surgically replaces a diseased or
failing liver with a healthy, normal liver.
Currently, transplantation is the only cure for
liver failure because no machine reliably
provides all the functions of the liver. People
who need a liver transplant usually have one of
the following conditions.
ACUTE HEPATIC INSUFFICIENCY Acute liver failure,
also known as fulminant hepatic failure, occurs
when a previously healthy liver is massively
injured with clinical signs and symptoms of liver
failure. A number of things can lead to acute
liver failure, but the most common causes are
ingestion of a toxin such as fungi poisonous or
an idiosyncratic reaction, overdose of
acetaminophen, viral infections.
The characteristic of this condition is the
development of confusion (encephalopathy) within
eight weeks after the onset of yellowing of the
skin (jaundice). The confusion occurs because the
toxins
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usually metabolized by the liver accumulate.
Patients with acute liver failure can die within
days if not transplanted. These patients are
classified as absolute priority (status I), which
places them at the top of the waiting lists for
the liver of a donor.
CHRONIC HEPATIC INSUFFICIENCY The liver has a
remarkable ability to repair itself in response
to an injury. Nevertheless, repeated lesions and
repairs, usually over many years and even
decades, heal the liver permanently. The final
stage of healing is called cirrhosis and
corresponds to the point where the liver can no
longer repair itself. Once a person has
cirrhosis, they may begin to show signs of liver
failure. This is called decompensated liver
disease. Although medications can reduce symptoms
caused by liver failure, liver transplantation is
the only permanent cure.
SIGNS OF LIVER DAMAGE Gastrointestinal bleeding
As the liver becomes more resistance, scarred to
portal blood flow increases, resulting in
increased pressure in the portal venous system.
This portal hypertension requires alternative
ways for the blood to return to the heart. The
small veins in the abdomen, but outside the
liver, then become enlarged and thin-walled
because of the abnormally high amount of blood
that passes through them under increased
pressure. These fragile veins, called varicose
veins, often line parts of the gastrointestinal
tract, especially the stomach and esophagus, and
are likely to rupture and bleed. When bleeding
takes place in the intestinal tract, it can be
fatal.
FLUID RETENTION A function of the liver is to
synthesize many of the circulating proteins in
the blood, including albumin. Albumin and other
proteins in the blood stream retain fluid in the
vascular space by exerting what is known as
oncotic (or osmotic) pressure. In case of hepatic
insufficiency, the low albumin levels cause the
liquid to come out of the blood which cannot be
reabsorbed. The fluid accumulates in the
body cavities and tissues, most often in the
abdominal cavity, called ascites. The fluid can
also accumulate in the thoracic cavity or in the
legs. Fluid retention is treated first of all by
a strict limitation of the dietary salt supply,
then by drugs (diuretics) which force the loss of
salt and water by the kidneys and finally by
intermittent drainage by insertion of a needle in
the abdominal or thoracic cavity.
ENCEPHALOPATHY
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The inability of the liver to remove ammonia and
other toxins from the blood allows these
substances to accumulate. These toxins cause
cognitive dysfunction that ranges from sleep-wake
cycle disorders to mild coma confusion.
JAUNDICE One of the main functions of the liver
is to eliminate the breakdown products of
hemoglobin. Bilirubin is one of those
degradation products treated and excreted by the
liver. In cases of hepatic failure, bilirubin is
not eliminated from the body and bilirubin levels
increase in the blood. The skin and all the
tissues of the body then take on a yellow color.
CAUSES OF CHRONIC LIVER INJURY VIRAL HEPATITIS
HEPATITIS B Around 5 of all liver transplants in
India happens because of hepatitis B but
represents a higher proportion of liver
transplants in other parts of the world,
including Australia / New Zealand.
HEPATITIS C Most of the liver transplants in
India happens because of hepatitis C, affecting
nearly 50 of all liver transplant recipients.
ALCOHOLIC LIVER DISEASE Hepatic impairment due to
alcohol abuse is the second most common
indication of liver transplantation in India.
Most centers require a minimum of six months of
abstinence, often as part of a recognized
addiction treatment program such as Alcoholics
Anonymous, as a condition of registration for
transplantation.
METABOLIC LIVER DISEASE Nonalcoholic
Steatohepatitis (NASH) Deposition of fat in
liver cells can lead to inflammation that injures
and heals the liver. Risk factors for the
development of fatty liver and NASH include
obesity and metabolic conditions such as
diabetes and hyperlipidemia (increased
cholesterol). The percentage of patients
transplanted for this disease has increased
35-fold between 2000 and 2005.
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HEPATOCELLULAR CARCINOMA Hepatocellular
carcinoma (HCC) is a primary liver cancer, which
means that it comes from abnormal liver cells.
CHC rarely occurs in a normal, non-cirrhotic
liver. Its incidence is, however, remarkably
increased in the context of cirrhosis and, in
particular, certain types of liver diseases
leading to cirrhosis. Although cancer begins in
the liver first, as it grows, it can spread to
other organs of the victim, a process called
metastasis. Hepatocellular carcinoma is most
commonly spread to the bones or lungs. The risk
of spreading out of the liver increases with the
size of the cancer.
Liver transplantation definitely cures a patient
with HCC, provided that the tumor has not spread
beyond the liver. Because there are many more
people in need of liver transplants than organs
available, so specific guidelines called the
Milan Criteria have been established to define
which HCC patients can be transplanted. These
criteria define the limits of the number and size
of tumors that ensure a very low probability of
cancer spreading outside the liver.
WHO ARE NOT CANDIDATES FOR A LIVER
TRANSPLANT There are many people with
decompensate liver disease and cirrhosis, but not
all are suitable candidates for liver
transplantation. A patient should be in a
position to survive the operation and also
potential postoperative complications, reliably
take drugs that prevent infections, travel to the
clinic regularly, and undergo laboratory tests
and stop drinking alcohol. The conditions listed
below are generally considered absolute
contraindications to liver transplantation.
Life expectancy may be reduced due to Serious and
irreversible illness Severe pulmonary
hypertension Cancer that has spread to other
organs outside the liver Uncontrollable or
Systemic infection Abuse of active substances
(alcohol and / or drugs) Unacceptable risk of
substance abuse (alcohol and / or drugs) History
of incompletion or adoption to a strict medical
course. Uncontrolled and Severe psychiatric
illness TYPES OF ORGAN DONORS
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BRAIN DEAD DONOR ORGANS Most livers used for
transplantation come from dead brain patients.
Brain death is usually due to a major stroke or
massive head trauma caused by a penetrating
injury (eg example a gunshot wound) or a blunt
injury (for example, accidents). The trauma has
stopped all brain functions, although other
organs, including the liver, can continue to
function normally.
There are strict definitions as to what
constitutes brain death based on the complete
absence of any kind of brain function. Because
patients who meet the criteria for brain death
are legally dead, they are appropriate tissue
and organ donors. In countries like United
States, the family of someone who is brain dead
must give consent for organ and / or tissue
donation and in France, consent to organ donation
is presumed and allowed, but the family members
have right for objection.
Typically, transplant centers whose patients will
receive organs from a particular donor will send
a team of surgeons to procure the appropriate
organ. The organ harvesting procedure takes place
in an operating room of the donor hospital. The
organs are removed and stored in order to
optimize their state during the period of
storage and transport. Each acquired organ is
then transported to the hospitals where the
designated recipient is waiting for it.
ORGAN DONORS OF CARDIAC DEATH Sometimes a patient
has a poor neurological prognosis and a
devastating brain injury, but does not meet the
strict criteria for brain death in that there is
still detectable brain function. In these
situation, the patients family may decide to
withdraw lifesaving medical support and allow him
to die. In such type of cases, death is treated
as cardiac death but not as brain death. Organ
donation can happen after cardiac death but make
sure family members must accept it.
It is only after the familys decision to
withdraw support that the patient can be
considered for an organ donation after his
death. In this senario, support is withdrawn,
according to the wish of family members and
managed by the patients physician, and then the
patient is allowed to die. The patients
physician, who is not involved in any aspect of
the organ transplant, is present to determine
when the heart stops beating and the circulation
is stopped so that the patient has no sign of
life . He or she then declares the patients
death.
An urgent operation is then performed to preserve
and remove organs for transplantation. This mode
of cardiac death, unlike brain death, causes an
increase in organ damage during two periods. The
first
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period is that between the withdrawal of support
from life and death. As the donors breathing and
circulation deteriorate, the organs may no
longer receive enough oxygen. The second period
is minutes immediately after death and until the
organs are rinsed with the preservative solution
and cooled. As a result, livers obtained from
cardiac death donors are associated with an
increased risk of primary malfunction or
dysfunction of the early organs, thrombosis of
the hepatic arteries and biliary complications.
LIVING DONORS Although each person has only one
liver and would die without it, it is possible to
donate part of the liver for transplantation to
another individual. Segmental anatomy (see figure
below) allows surgeons to create grafts of
varying size, depending on the recipients
requirement for liver tissue. Partial livers in
the recipient and donor will develop to provide
normal liver function for both individuals.
THE LIVER TRANSPLANT OPERATION A liver transplant
involves the removal and preparation of the
donors liver, the removal of the diseased
liver, and the implantation of the new organ. The
liver has several important connections that must
be re-established so that the new organ can
receive blood flow and drain the bile from the
liver. The structures to be reconnected are the
the bile duct, the hepatic artery, the portal
vein and inferior vena cava. The exact method of
connecting these structures varies depending on
the specific anatomy of the recipient and the
anatomy of donor and, in some cases, the
recipients disease.
For a person undergoing liver transplant surgery,
the series of events in the operating room is as
follows
Incision Evaluation of the abdomen for
abnormalities that would prevent liver
transplantation (eg, undiagnosed infection or
malignancy) The native liver is
mobilized.(dissection of hepatic attachments to
the abdominal cavity) Isolation of important
structures (hepatic artery, common bile duct,
portal vein, behind and below the liver,
inferior vena cava above) Transaction of the
structures mentioned and removal of the native
sick liver. Sewing in the new liver First,
venous blood flow is restored by connecting the
inferior vena cava and the portal veins of the
donor and recipient. Then, the arterial flow is
restored by sewing the recipient and
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donor hepatic arteries. Finally, biliary drainage
is done by sewing the common bile ducts of the
recipient and donor. Bleeding need to be
controlled The incision is closed.
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