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EDUCATION

How does the liver work?

The liver is the largest organ in the body (weighing about1.2 to 1.5kg). It is located on the right side of the abdomen, directly beneath the right lung, and is protected by the lower half of the rib cage. It performs many complex functions that are essential to life and good health.

Organ Donation

Functions of the liver

The liver performs a host of functions (well over 500) but the basic ones are:

Production of plasma proteins:
  • Factor 1 and 2: Clotting proteins that are responsible for ensuring that the blood can clot following injury
  • Plasma proteins namely the protein albumin which, amongst other things, keeps fluids within the blood vessels.
Storage of trace elements and vitamins:
  • Fats and fat soluble vitamins (A, D, E, K)
  • Iron
  • Glycogen, a product made by the liver as a method of storing energy that can be converted back at time of need to maintain the bloods sugar levels
Metabolism (breaking down) of substances:
  • Fats and fat soluble vitamins
  • Cholesterol
  • Proteins
  • Certain trace elements e.g. copper
Detoxification (rendering harmless):
  • Alcohol
  • Steroid and thyroid hormones
  • Drugs
Excretion (removal) of:
  • Copper and iron
  • Some drugs
  • Lactate (a substance produced by the body during metabolism)
Immunity
  • The liver cells contribute towards natural immunity by producing some antibodies. A special type of cell found in the liver called ‘Kupffer’ cells also help to clear unwanted substances from the body.

Common Symptoms of Liver Disease

The following are the most common symptoms

  • Jaundice
  • Dark Urine
  • Itching
  • Lethargy
  • Increasing tiredness
  • Altered sleep pattern
  • Vomiting of Blood
  • Confusion or talking irrelevantly
  • Drowsiness
  • Abdominal distension
  • Swelling of the feet
  • Weight loss
  • Loss of appetite

Liver Function Tests

Liver function tests (LFTs) measure various chemicals in the blood made by the liver. An abnormal result indicates a problem with the liver, and may help to identify the cause. Further tests may be needed to clarify the cause of the liver problem.

What are liver function tests?

As the liver performs its various functions, it makes chemicals that pass into the bloodstream and bile. Various liver disorders alter the blood level of these chemicals. Some of these chemicals can be measured in a blood sample. Some tests that are commonly done on a blood sample are called liver function tests (LFTs). These usually measure the following:

  • Alanine transaminase (ALT). This is an enzyme that helps to process proteins. Large amounts of ALT occur in liver cells. When the liver is injured or inflamed (as in hepatitis), the blood level of ALT usually rises.
  • Aspartate aminotransferase (AST). This is another enzyme usually found inside liver cells. When a blood test detects high levels of this enzyme in the blood it usually means the liver is injured in some way. However AST can also be released if heart or skeletal muscle is damaged.
  • Alkaline phosphatase (ALP). This enzyme occurs mainly in liver cells next to bile ducts, and in bone. The blood level is raised in some types of liver and bone disease.
  • Albumin. This is the main protein made by the liver, and it circulates in the bloodstream. The ability to make albumin (and other proteins) is affected in some types of liver disorder. A low level of blood albumin occurs in some liver disorders.
  • Bilirubin. This chemical gives bile its yellow/green colour. A high level of bilirubin in your blood will make you jaundiced ('yellow'). Bilirubin is made from haemoglobin. Haemoglobin is a chemical in red blood cells that is released when the red blood cells break down. Liver cells take in bilirubin and attach sugar molecules to it. This is then called 'conjugated' bilirubin which is passed into the bile ducts.
  • A raised blood level of 'conjugated' bilirubin occurs in various liver and bile duct conditions. It is particularly high if the flow of bile is blocked. For example, by a gallstone stuck in the common bile duct, or by a tumour in the pancreas. It can also be raised with hepatitis, liver injury, or long-term alcohol abuse.
  • A raised level of 'unconjugated' bilirubin occurs when there is excessive breakdown of red blood cells - for example, in haemolytic anaemia. The normal range of liver tests can often vary between different laboratories, so it is not always possible to compare results directly if they have been taken at different places. Also, the normal ranges of values for liver tests also are often different for men and women.
What are liver function tests used for?
  • To help diagnose liver disorders if you have symptoms which may be due to liver disease (such as jaundice). The pattern of the blood results may help to say which disorder is causing the problem. For example, depending on which enzyme is highest, it may point to a particular disorder.
  • To monitor the activity and severity of liver disorders.
  • As a routine precaution after starting certain medicines, to check that they are not causing liver damage as a side-effect.
Other tests of the liver

LFTs are useful, and are often the first marker of disease in the liver. However, other tests of the liver may also be done to confirm the diagnosis of a particular disorder, and/or to monitor the activity of the disorder and response to treatment.

Other blood tests which may be done include:
  • Blood clotting tests. The liver makes many of the proteins needed to make blood clot. In certain liver disorders the liver cannot make enough of these proteins and so blood does not clot so well. Therefore, blood clotting tests may be used as a marker of the severity of certain liver disorders.
  • Gamma-glutamyltransferase (GGT). This is another enzyme that occurs in liver cells. A high level of this enzyme is particularly associated with heavy alcohol drinking
  • Immunology. Blood tests may be done to detect
  • Viruses and antibodies to viruses. Various viral infections can cause hepatitis for example, hepatitis A virus, hepatitis B virus, etc.
  • Auto-antibodies. These are antibodies which attack a part of your own body and occur in autoimmune disorders. The most common autoimmune disorders of the liver are:
  • Primary biliary cirrhosis (associated with anti-mitochondrial antibodies).
  • Autoimmune hepatitis (associated with smooth muscle antibodies).
  • Primary sclerosing cholangitis (associated with antinuclear cytoplasmic antibodies).
  • Other types of protein in the blood can point to specific liver diseases - for example:
  • Ceruloplasmin is reduced in Wilson's disease.
  • Lack of 1-antitrypsin is an uncommon cause of cirrhosis.
  • A high level of ferritin is a marker of haemochromatosis.

Note: Normal LFTs do not always exclude liver disease.

Ultrasonogram

USG abdomen is the most widely use screening/diagnostic investigation which is safe and relatively inexpensive. It can be used to visualize all the internal solid organs of the abdomen. The shape, surface, presence of fat in the liver, stones and tumours can be diagnosed. Presence of fluid(ascitis) can also be diagnosed. It can always be combined with fluid aspiration or biopsies if required.

CT/MRI

Computerised tomography (CT) or Magnetic Resonance Imaging(MRI) are two different types of investigations used to diagnose Liver Pathologies. Thin cross sectional images of the abdominal organs are obtained by the scanner and they are captured in a computer and reformatted to produce precise information of the internal organs.

Donate Organs, Save Lives

Why is it important to donate organs and tissue?

On any given day, thousands of patients are waiting for critical organ transplants across the country. Sadly, hundreds die each year waiting. One person donating their vital organs and tissue can save the lives of as many as eight other people, and make a difference in the lives of many more

What should I do if I want to donate?

The most important thing to do is let your family know. You can also sign an organ donor card and keep it in your wallet.

Why does my family need to know?

You next of kin must sign a written consent form before organ or tissue harvest is done.

Can I choose which organs and tissue I wish to donate?

Yes.You can choose to donate all of your organs and tissues, or simply select the specific ones.

Myths and Facts

Myth: Brain Death and coma means one and the same

Fact: No. Coma is a long term unconscious state of the brain, in which the brain and other vital organs keep working. Brain death is a condition in which the brain stops functioning & this condition is irreversible leading to death of the person.

Myth: I have always understood that when an individual dies, the heart stops beating. Since my loved one's heart is beating, he is still alive.

Fact: The heart has its own pacemaker independent of the brain. As long as it has oxygen, it continues to beat. The heart could actually be removed from the body, placed in a saline solution, given oxygen and it will continue to beat for a few minutes. Eventually, the heart will stop, despite being on maximum life support machines

Myth: May be I wont really be dead when they sign my death certificate.

Fact: Although its a popular topic in the tabloids, in fact, people dont start to wiggle their toes after they're declared dead. In fact, people who have pledged organ donation are subjected to exhaustive range of tests to confirm their death.

Myth: If I agree to donate my organs, the hospital staff wont work as hard to save my life.

Fact: When you go to the hospital for treatment, doctors focus on saving your life and not somebody else's. So there is no prejudice in this aspect.

Myth: My religion discourages organ donation.

Fact: There are 22 major religions in the world and none of them discourage organ donation. In fact, most of the religions in India support organ donation and consider donation as the final act of love and genorisity toward others.

Myth: If I donate my organs it will cause delays to my funeral arrangements

Fact: Yes there is a possibility. However, given the altruistic nature of the donation, families usually accept this and take it as part of the process of donation.

Myth: I am under age 18. I am too young to make this decision.

Fact: That's true, in a legal sense. But you may express your wish to your parents and they can give their consent and authorize this decision. Children too need organ transplatation & they usually need organs smaller in size then that of an adult.

Myth: I am too old to donate. Nobody want my organs

Fact: There is no defined cut off age for donating organs. Organs have been successfully transplated from donors in their 70s and 80s. The decision to use your organs is based on strict medical criteria and not age.

Myth: When you're waiting for transplant, you're financial or celebrity status is as important as your medical status.

Fact: When you are on the transplant waiting list for an organ, what really counts is the severity of your illness, time spent waiting, blood type and other important medical information. Your income and social status have no bearing when determining how organs are allocated. All patients are equal in an organ waiting list.

Myth: If you agree to donate your organs, your family will be charged for the costs of retrieval.

Fact: There is no cost to the donor's family for organ and tissue retrieval.

Myth: I am an organ recipient I cannot be a donor.

Fact: Organ recepients may not be tissue donors due to the immunosuppressive drugs that are administered. However, the medical team determines whether a healthy organ can be retrieved.

Myth: Organ/tissue removal will disfigure the body and affect cremation/burial arrangements.

Fact: The removal of organs or tissues does not interfere with customary funeral or burial arrangements. The appearance of the body is no altered. A highly skilled surgical transplant team removes the organs and tissues which can be transplanted in other patients. Surgeons suture up the body carefully, hence no outward disfigurement is visible. A scar is present after the organs are removed. In fact in a medico-legal case even a post-mortem would leave behind a similar scar.

Liver Transplant

What is a liver transplant?

A liver transplant is a surgical procedure used to remove a diseased liver and replace it with a healthy one. When the liver is damaged to such an extent that it cannot perform the functions required to let its owner lead a healthy life, a liver transplant may become necessary. Unlike a dialysis machine which can replicate the functions of a kidney, there is no mechanical device to replace the functions of a liver. A transplant is sometimes the only treatment for people with acute or chronic liver disease.

What is liver failure?

Liver failure is the inability of the liver to perform its normal metabolic functions. The liver is a very resilient organ and it can keep going even with much abuse for a good length of time. The liver is also the chemical warehouse of the body and when it is inflammed, it is unable to carry out its functions very well. Signs and symptoms of liver disease then begin to develop.If the problem is very severe, a liver transplantation may be the only answer.

What are the main causes of liver failure?

The causes of liver failure can be many, however the following are the most common:

  • Acute Liver Failure - When the liver is extensively damaged over a short period of time. e.g. -drug overdose can bring on this kind of liver failure.
  • Chronic Liver Failure - When the liver is subjected to damage by infection or abuse over several years. e.g. alcohol liver disease or hepatitis B or C
  • Metabolic Liver Disease - When there are underlying problems with the body's metabolism. e.g. haemachromatosis, wilson's disease
  • Liver Cancer - Cancer in the liver can eventually lead to liver failure
  • Biliary Atresia - This is the most common cause of liver failure in children where the ducts that carry bile out of the liver are damaged or missing.
What are the most common reasons for needing a liver transplant?
  • Cirrhosis from Hepatitis C or Alcohol Liver Disease
  • Primary Sclerosing Cholangistis
  • Auto Immune Hepatitis
  • Primary Biliary Cirrhosis
  • Wilson's Disease
  • Fulminant Liver failure
  • Other cholestatic liver diseases
Is there any special criteria for a person to be on the transplant list?

To be considered for transplantation, a person must have

  • Severe or progressive disease that does not respond to treatment
  • Be physically and emotionally capable of undergoing surgery and follow up medical treatment
  • Irreversible, acute and chronic liver disease
When is a Liver Transplant Necessary?

Liver transplantation is considered when the liver no longer functions adequately and progression towards end stage liver disease is confirmed. A number of factors have to be considered by a team of medical professionals before a patient can be put on the liver transplant waiting list.

What are the general signs and symptoms of liver disease?

The signs and symptoms of liver disease are quite generalised and your doctor will diagnose this with the help of some diagnostic tests. These symptoms may include:

  • Jaundice (yellowing of skin and eyes)
  • Itch
  • Dark urine or pale stools
  • Vomiting blood
  • Black or bloody stools
  • Swelling of the abdomen due to accumulation of fluid (ascites)
  • Muscle wasting and tendency to bleed
  • Loss of energy, sleep disturbance or drowsiness
  • Confusion
So who can be eligible for a Liver Transplant?

Broadly speaking, liver transplantation is offered to patients with end-stage liver disease with the intention of allowing them to lead a normal, healthy life post transplant. Protocols have been to ensure that the eligibility criteria is transparent and consistent. A panel of doctors, which include hepatologists, surgeons, radiologists, pathologists, psychiatrists and allied health staff will assess the patient and then make a decision about putting the patient on a wait list for transplant. This wait list is often called the ‘active list' and the patient is referred to as an ‘activated' patient. The assessment stage (also called work up) involves approximately five to seven days of various kinds of testing and can be done as an in patient or as an outpatient. This assessment stage is very important for the patient as both the patient and the transplant team get to know each other and the patient understands the process of transplantation and living and taking care of the new liver. Once listed, patients are regularly reviewed by the transplant unit to ensure that they are fit for transplant. They are asked to stay within driving distance of the hospital as a liver may become available at any time of the day or night.

How long is the wait to get a new liver?

There is no guaranteed time frame for the waiting period to get a new liver. A donor liver has to be a suitable match for height, weight, blood group and other medical criteria in order to be suitable for considered for transplantation. The donor liver will generally come from a cadaveric donor. The waiting period can range anywhere from a week to several months. This is primarily because of a major shortage of organ donors.

Can a patient be taken off the Active/Waiting List?

The transplant team keeps a close watch on the patient and monitors their condition with regular blood tests and scans. If the team feels that the patient's condition has improved considerably or deteriorated, such that they no longer meet the eligibility criteria, the transplant panel can decide to take that patient off the waiting list. Similarly, they can reactivate them again depending on their medical condition.

Types of Liver Transplantation

Around the world there is a major shortage of livers available for transplant. The organ is a very precious resource and all livers are considered for transplantation by the transplant surgeon and his team. A transplant surgery will commence only when all tests indicate that the liver is suitable for the recipient. There are two main types of Liver Transplantation - deceased donor and live donor but below you will find different scenarios under these two types of liver transplants.

Cadaveric or Deceased Liver Transplant

A liver maybe used for transplantation if the organ has been removed from someone who has died as a result of overwhelming and irreversible brain damage. This is called brain stem death. This type of transplant requires a whole healthy donor liver. This is the most common type of liver transplant.

In some instances this may be a a split liver transplant, where the entire diseased liver is removed from the patient and donor liver is then split into two. This allows two people to benefit from one liver. Generally, in such cases a child will share part of a liver with an adult. Following transplantation, each liver lobe will grow to form a complete functioning liver. Split liver transplants are the best possible way to treat a maximum number of patients in a society where organs are so scarce.

Living Donor Liver Transplantation

In this kind of liver transplantation, a portion of a healthy individual's liver is removed and transplanted into the patient. The liver is the only organ in the human body which can regenerate; so the liver grows back to its original size both in the donor and the recipient. Blood matches are required and a battery of tests is required to see if the donor is fit and healthy.

Domino Liver Transplant

This type of transplant is quite rare. A liver from a transplant recipient is used for another person with end stage liver disease. These transplants are done only under specific circumstances.

Life After A Liver Transplant

The liver is the second most commonly transplanted major organ after the kidneys. Today, the world over, the number of people surviving a liver transplant is higher than ever before. Figures indicate that one year survival post transplant is 90% while the five year mark rests at 80%. While a liver transplant is still a supra major operation and remains a treatment rather than a cure, it is not at all unusual to find people living normal healthy lives many years post transplant.

Who can receive a liver transplant?

Only patients with end stage liver disease are activated for a liver transplant. It means that when the liver has degenerated to such a stage where it is no longer able to function properly and management by medications alone are no longer possible, a liver transplant becomes the only option.

What happens when I come out of surgery?

A liver transplant operation can take from anywhere between four to twelve hours of surgery. It is a major operation where the diseased liver is removed and replaced with a healthy one. The first few days post surgery will be spent in the ICU. During this time, a team of doctors and specialists will monitor your condition closely. The main things that they will keep an eye on during this time are signs of rejection of the newly transplanted liver, bleeding and infections.

What is it like in the ICU?

Although the ICU (intensive care unit) with all its machines and tubes may seem like quite a scary place to a non medical person, every bit of equipment there is placed for your quick recovery. A highly specialised team of doctors and nurses are present 24/7 to monitor your condition closely. The ICU, also known as the critical care unit is where you will be kept for the next two to five days after your liver transplant surgery. Here in the ICU you may be put on artificial ventilators to monitor your cardiovascular and respiratory condition because you may need assistance with your breathing immediatelay post surgery. There may be tubes going down your windpipe. You will not be able to talk or drink and will be on intravenous drips. You will be very drowsy during this period but there will always be an experienced ICU nurse and a team of doctors who monitor you very closely during this period. When you are able to breathe properly, the tube will be removed and may be replaced with an oxygen face mask. This face mask too will be removed soon so that you can breathe normally. Gradually, all the machines and tubes that were helping you to function while you were recovering post surgery will be removed so that you can be back on your feet as soon as possible. Once the ICU staff and your liver physician feels that you are past danger you will be taken to the wards for speedy recovery.

Will my family be allowed to visit me when I am in the ICU?

Your immediate family will be allowed to visit you, but visits should be kept down to a minimum to avoid any chance of outside infections.

So what will my road to recovery be like?

The purpose of your liver transplant surgery is to get you on your feet again as soon as possible. There will be good days and bad days. A recovery team consisting of your physiotherapist, dietician and social worker along with the nursing and medical team will help you on your path to recovery.

What potential problems can I expect after a liver transplant?

The most common problem after any organ transplant is rejection. Although you are given anti rejection drugs called immunosuppressants, the body still thinks of your new liver as a foreign body and prepares to attack it. The transplant team will constantly monitor your immunosuppression levels to monitor and be on the look out for any indications of rejection. You will need to have constant blood tests - even twice or thrice a week in the early stages. Infection is also a major concern post surgery. Because the anti rejection drugs inhibit the body's ability to fight foreign agents, it means that you will be prone to infections quite easily. Your renal function may also be compromised because of the anti rejection drug, Tacrolimus. Your doctor may switch you to a different immunosuppression if this is the case. Other complications can include hypertension, tumour formation or primary graft non function.

I want to go home!

Yes, the transplant team are also looking forward to sending you home - fitter and healthier than when you came in. To do this they must ensure that you have received adequate knowledge about how to take care of yourself at home. You should have someone to look after you in the first few weeks post surgery and also be able to drive you to your hospital appointments. Your appointments will initially be one or two follow up each week and will gradually decrease to once and then once every three months depending upon the progress you are making.

So when can I get back to my normal activities?

If all goes well, your doctor and the liver transplant team will give you the go ahead. You will then be given permission to drive or go to the gym or pursue your favourite interests. But this will be only at the discretion of your doctor. Your dietician will give you a diet chart which you must follow and your physiotherapist will guide you about the exercises you can or cannot do. Most people get back to leading a normal healthy life after transplant and feel better than they ever did before. Chennai Liver Foundation wishes you all the best and is beside you throughout your journey.

What should I be careful about after I am discharged to go home?

Remember to

  • Take all your medications on time
  • Report any unusual symptoms to the medical team or your nurse. It does not matter if they seem trivial. It is always better to check than to stay worried. Your nurse coordinator and your doctor are only a phone call away.
  • It is very important that you keep all your follow up appointments and make sure you have regular blood tests each time before you see your doctor. This will help the medical team to see that your new liver is functioning at its optimal capacity. They will be alerted to any changes via these blood tests.M
  • Liver transplantation surgery requires life long follow up. Initially, you may have to come in once or twice a week, but as your condition improves and you continue to get better the appointment times will be more spaced out.
  • If you need to see your local doctor post transplant you MUST let your doctor know that you are a transplant patient. The doctor will then liaise with the liver transplant team at the hospital to ensure you receive the correct treatment.