Absolute Contraindication for Early Liver Transplant Surgery

Introduction

Liver transplantation (LT) is the treatment of choice for the end stages of acute and chronic liver disease. Liver transplant is characterized by five-year survival rates of more than 80 percent and results in excellent health-related quality of life. Survival is not significantly different from that of the general population in terms of age and sex after the first year post-transplant. Excellent health-related quality of life is also present in the majority of liver transplant recipients. Professional occupation is directly impacted by the quality of life. Thus, within 3 to 6 months of surgery, a significant number of liver transplant recipients are able to return to their prior profession or occupation fully or at least part-time.

What Is Liver Transplant?

A diseased or damaged liver is replaced surgically with a healthy liver from a donor during a surgery known as a liver transplant. The liver is the largest organ in the body and is responsible for many essential functions, such as producing bile to aid in digestion, storing nutrients, and filtering toxins from the blood. When the liver is severely damaged, it can no longer perform these functions, leading to liver failure. Liver transplantation is usually recommended for patients with end-stage liver disease, which is a condition in which the liver is damaged beyond repair and cannot function properly. End-stage liver disease can be caused by a variety of factors, including chronic hepatitis B or C infection, alcoholic liver disease, nonalcoholic fatty liver disease, autoimmune liver disease, and liver cancer.

How Liver Transplant Is Performed?

Liver transplantation can be a lifesaving procedure for patients with end-stage liver disease. However, it is a complex surgery that carries significant risks and requires careful evaluation and preparation. Patients who undergo liver transplantation must commit to a lifelong regimen of medications and monitoring to ensure the long-term success of the transplant.

• During a liver transplant, the diseased liver is removed from the patient and replaced with a healthy liver from a deceased or living donor.

• The donor's liver is carefully matched to the patient's blood type and body size to reduce the risk of rejection.

• The transplant surgery typically takes six to 12 hours, and the patient is placed under general anesthesia for the procedure. The patient will be closely watched in the hospital for a few days to a few weeks following the procedure. The patient will need to take immunosuppressant medications to prevent the body from rejecting the new liver. These medications suppress the immune system, reducing the risk of rejection but also increasing the risk of infection. The patient will need to follow a strict medication and monitoring regimen for the rest of their life to ensure the success of the transplant.

What Are the Indications of Liver Transplant?

A liver transplant is a life-saving procedure for patients suffering from severe liver disease. The following are the indications of a liver transplant:

Chronic Liver Disease

• Ascites - Ascites are the buildup of fluid in the belly, often due to severe liver disease.

• Encephalopathy - A condition that affects brain structure or function. It causes brain degeneration.

• Portal Hypertensive - Portal hypertension is the condition in which the pressure elevates within the portal system.

• Bleeding - A liver transplant is necessary for excessive bleeding of the liver.

• Jaundice - The condition in which yellowing of eyes, skin, and nails occur due to abnormal bilirubin level in the liver.

• Hepatocellular Carcinoma - The condition which causes cancer of the liver cells is called hepatocellular carcinoma.

Acute Liver Disease

• Hepatitis B - Patients with end-stage chronic hepatitis B virus-related liver disease are appropriate candidates for liver transplantation.

• Hepatitis C - Patients with end-stage chronic hepatitis C virus-related liver disease are appropriate candidates for liver transplantation.

• Alcoholic Liver Disease - Selected patients with end-stage alcohol-related liver disease should be considered for liver transplantation. Alcohol dependence should be differentiated from alcohol misuse.

Cholestatic Liver Disease

• Primary Biliary Cirrhosis - The condition in which the bile ducts get damaged is called primary biliary cirrhosis.

• Primary Sclerosing Cholangitis - The condition in which the degeneration of the liver and gallbladder occurs which is characterized by inflammation and scarring of the bile ducts.

• Autoimmune Hepatitis - The condition in which the body itself starts attacking liver cells is called autoimmune hepatitis. It is characterized by inflammation of the liver.

Hereditary Liver Diseases

• Hemochromatosis - The condition in which excess iron accumulates in the body which causes organ damage.

• Wilson’s Disease - The condition in which excessive accumulations of copper occur in the body.

• Alpha-1-Antitrypsin Deficiency - It is a genetic disorder of the liver.

• Liver Tumors - Tumors are the cells that divide rapidly, which occur in liver cancer.

• Liver Metastases - The condition in which liver cancer spreads to the different parts of the body.

What Are the Contraindications of Liver Transplant?

The contraindications of liver grafting must be fully understood by the healthcare providers. There are two categories of contraindication:

• Absolute Contraindication - A patient with a fatal disease additional to the liver condition is absolutely unsuitable for a liver transplant. For example, a patient with malignancy disseminated in the body or a patient with brain damage too severe for an independent existence should not receive a transplant.

• Relative Contraindication - The first type of relative contraindication is found in patients with a disease that is likely to recur in the grafted organ.

The following are the relative contraindications of the liver transplant:

1. Hepatitis virus of the B and C types.

2. Malignant disease (cancer) in the liver.

3. Destruction of the liver in the act of attempted suicide.

4. Liver disease due to alcohol in patients who continue drinking and autoimmune disease that might affect the transplant.

5. Autoimmune diseases.

6. Acute depression.

7. Young patients.

8. Patients who are too ill. Initially, they may have been considered satisfactory patients, but by the time an organ becomes available, the patient may have deteriorated to an irreversible state. It is very difficult to tell the patient and the relatives that this is the true and unfortunate consequence of waiting for an organ. Deterioration often progresses rapidly within hours, ending with irreversible brain damage and death.

9. Patients who are too well. The patient may have irreversible and advanced liver disease but still be capable of a reasonable lifestyle. Doctors may discuss the expected prognosis truthfully with the patient and make assessments at regular intervals, but it is better to manage such patients’ cases conservatively until they really need a graft.

Conclusion

Liver transplant surgery is a complex procedure that can save the lives of patients with end-stage liver disease. However, there are situations in which liver transplant surgery is not recommended due to the increased risk of complications or failure. Doctors must carefully evaluate the patient's medical history, comorbidities, and risk factors before deciding on liver transplant surgery. Absolute contraindications must be considered to ensure the best possible outcome for the patient.