INCONVERSATION - NISCAIRnopr.niscair.res.in/bitstream/123456789/33136/1/SR 52(11...RAVINDER PAL SINGH: If a patient’s liver disease was caused by autoimmune hepatitis, hepatitis

38SCIENCE REPORTER, NOVEMBER 2015

SCIENCE REPORTER: Dr. Singh, we know that liver is the largest organ inside our body. It helps us digest food, store energy, and remove poisons. But sometimes it malfunctions. What are some of the common symptoms that can alert us to a problem with our liver?DR. RAVINDER PAL SINGH: Well, there are some common signs and symptoms that can signal sick liver (cirrhosis) such as loss of appetite, nausea and vomiting, weight loss, fatigue, dark colored urine, abdominal pain, enlargement of the liver (hepatomegaly) or spleen (splenomegaly), itching, abnormal blood sugar, vomiting of blood, jaundice (yellow discoloration of the whites of the eyes and skin), and increased susceptibility to infection.

But not everyone with sick liver will have all of the above mentioned signs and symptoms. Many patients may not have any symptoms and are found to have cirrhosis only on physical examination and laboratory tests; this is called compensated liver cirrhosis. SCIENCE REPORTER: Can a malfunctioning liver be potentially fatal in the long run if not attended in time? DR. RAVINDER PAL SINGH: It is not possible to live without the liver. Once the liver starts to fail, all of its functions diminish. Nutrition gets compromised, toxins start to build up, and waste products start to accumulate. There is swelling of blood vessels of the esophagus which may rupture and show as vomiting of the blood. Toxins build-up in the blood (liver encephalopathy) resulting in severe jaundice (yellowing of the skin and eyes), fl uid accumulation in the abdomen (ascites), and deterioration of mental function (hepatic encephalopathy). It also affects kidneys functions, increases susceptibility to infection, increases bleeding tendency and blood does not clot. Eventually, death occurs.

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39 SCIENCE REPORTER, NOVEMBER 2015

The remainder of transplants come from various uncommon diseases, and a disease known as fulminant liver failure. Fulminant liver failure most commonly happens during toxic reactions to overdose of some medicines, such as acetaminophen—a medicine commonly used to relieve pain and reduce fever, acute viral hepatitis, and mushroom poisoning by Amanita phalloides.

SCIENCE REPORTER: Organ donation after death has always been a very ticklish issue in India, especially in view of our cultural traditions. What is the situation as far as liver donation is concerned? DR. RAVINDER PAL SINGH: It is surprising, but in India every year nearly • 500,000 people die because of non-availability of organs • 200,000 people die of liver disease• 50,000 people die from heart disease • 150,000 people await a kidney transplant but only 5,000 get one.

Nationally, with a population of 1.2 billion people, the statistic stands at 0.08 persons as organ donors per million population (PMP). This is an incredibly small and insignifi cant number compared to the statistics around the world.

Countries like the USA, UK, Germany, the Netherlands have a ‘family consent’ system for donations where people sign up as donors, and their family’s consent is required. (These countries have seen the donations double Per Million Population averaging between 10-30 PMP). Other countries like Singapore, Belgium, and Spain have a more aggressive approach of ‘presumed consent’, which permits organ donation by default unless the donor has explicitly

opposed it during his lifetime. These countries have seen the rate of donations double, averaging between 20-40 PMP.

We understand it is diffi cult to think about organ donation when you have just lost a loved one; however organ donation is a generous and worthwhile decision that can save many lives. By donating, each person can save the lives of up to seven individuals by way of organ donation and enhance the lives of over 50 people by way of tissue donation. SCIENCE REPORTER: What is “living donor liver transplant” and how has it improved the lot of critical liver patients? DR. RAVINDER PAL SINGH: Living donor liver transplant is advantageous to the patient where the waiting list mortality is high (the risk of the patient dying while waiting to get a cadaveric liver from brain dead person). Avoiding a long wait is possible if a person with liver disease has a living donor who is willing to donate part of his or her liver. This procedure is known as living donor liver transplantation (LDLT) or living related liver transplantation (LRLT).

Living donor transplantation is now an accepted method. The success with living donor kidney transplants has encouraged increased use of such techniques. SCIENCE REPORTER: Dr Singh, you have carried out a number of successful living donor liver transplant surgeries. Can you broadly give us an idea how complicated the surgery is and what are the chances of success?DR. RAVINDER PAL SINGH: Living donor liver transplant is a verycomplicated procedure (one of the most

INCONVERSATION

The liver is the largest internal organ and the largest gland in human body. It has a role to play in many bodily functions from protein production and blood clotting to cholesterol, glucose (sugar), and iron metabolism. But the liver is often beset with disorders that can take a heavy toll on your health.

DR. RAVINDER PAL SINGH, Director, Center for Liver Transplant & Gastro-Sciences at the Saroj Super Speciality Hospital, Delhi, has a long experience with liver diseases, liver transplant and liver surgery. He is also an expert in advanced Laparoscopic Surgery & Robotic Surgery. He has earlier been with the Indraprastha Apollo Hospital, Artemis Health Institute, and the Maharaja Agarsen Hospital.

Dr. Singh talks to Science Reporter about the various problems that can occur with your liver, the symptoms to watch out for, and when to approach a liver specialist.

SCIENCE REPORTER: Are there any fi gures pertaining to deaths due to liver complications in India?DR. RAVINDER PAL SINGH: In India, every year nearly 2 lakh people die of liver disease. This may well be an underestimate of the actual fi gures as many do not get access to health care facility and many are undiagnosed.

SCIENCE REPORTER: At what stage does the doctor decide that the complications with the liver warrant drastic action such as going in for a transplant? DR. RAVINDER PAL SINGH: The most frequent reason for transplantation in children is biliary atresia—a disease in which the ducts that carry bile out of the liver, are missing or damaged.

For adults, there are many causes of liver failure that may necessitate transplant surgery, like:• Decompensated Cirrhosis (scarring of the liver) is the most common reason for liver transplants.• Progressive hepatitis, mostly due to virus infection, like hepatitis B or C accounts for more than one-third of all liver transplants.• Alcohol damage accounts for one-fi fth to one-third of transplants.• Fatty liver disease (NAFLD and steatohepatitis) accounts for another one-fi fth to one-third of transplants. This is the fastest growing reason for liver transplant and may surpass all other causes in the near future.• Scarring, or abnormality of the biliary system, accounts for roughly another signifi cant share of liver transplants.• Primary liver cancer.

40SCIENCE REPORTER, NOVEMBER 2015

diffi cult procedures developed in the medical fi eld ever). In this, two operation theatres with two dedicated teams are simultaneously operating on the donor and the recipient. The two teams coordinate various steps so that the time of taking out part of a liver from the donor coincides with the time of taking out whole of liver from the recipient and preparing the recipient for putting donor liver back into him.

The donor procedure is very precise where the liver is cut very meticulously into respective halves. This requires enormous training and many years of hard work and dedicated practice. At the end of donor surgery the part of the liver is taken out with 2 or 3 hepatic veins, 1 or 2 portal vein branches, 1 or 2 hepatic artery branches and 1 or 2 bile duct branches. These are then joined back in the recipient body very meticulously, again by the team of highly qualifi ed and dedicated surgeons.

The anaesthesia team for both donor and recipient liver surgery is also highly specialized and trained for this purpose and is also one of the most essential components of the transplant surgery.

The operation usually takes between 12-14 hours; another 2-4 hours is spent preparing the patient for surgery and for other parts of the surgery. Therefore, a patient will likely be in the operating room for 14 to 20 hours.

A donor is expected to spend about 7 to 10 days in the hospital, whereas a recipient should expect to spend about 21 days in the hospital, although some stays may be shorter or longer.

The donor can usually resume light physical activity in 1-2 weeks and normal activity in about 3 weeks after surgery.

Before leaving the hospital, a recipient is advised to look for signs of infection or rejection, how to take medications and change dressings, and how to understand general health problems. Infection can be a real danger, because the medications taken compromise the body’s defense systems. The doctors will conduct blood tests, ultrasounds, and x-rays to ensure that the patient is doing well.

SCIENCE REPORTER: Can individuals engage in physical activity after receiving a new liver? Are there any precautions that patients need to take after the surgery?DR. RAVINDER PAL SINGH: For the recipient, the fi rst three months after transplant are the most risky for getting such infections as the fl u, so patients should follow these precautions:• Avoid people who are ill.• Wash hands frequently.• Tell the doctor if a cold sore, rash, or water blister appears on the body or spots appear in the throat or on the tongue.• Stay out of crowds and rooms with poor circulation.• Do not swim in lakes or community pools during the three months following transplant.• Eat meats that are well-cooked.• Stay away from soil, including those in which house-plants are grown, and gardens, during the three months following transplant. SCIENCE REPORTER: Can there be a recurrence of the original disease in the transplanted liver?DR. RAVINDER PAL SINGH: If a patient’s liver disease was caused by autoimmune hepatitis, hepatitis B or C viruses, then recurrence is possible. Hepatitis B right now only reoccurs in 5% or less of patients since we have mastered controlling this disease with an immune globulin medicine and an oral medication. Hepatitis C occurs in almost all patients and is progressive in maybe a quarter to half of patients in the fi rst 5 to 10 years.

However, this scenario is going to change very soon with availability of newer very effective drugs for hepatitis C virus. For other types of liver disease, recurrence is less likely, but is still a possibility unless it was a genetic disease that was cured by the liver transplantation. SCIENCE REPORTER: What are the benefi ts and the risks of living donor liver transplants? Are there any particular risks for patients having a transplant from a living donor that would be any different than if it were a cadaveric liver?DR. RAVINDER PAL SINGH: The benefi ts of living donor liver transplant are:• The decrease in the waiting time period is the most important of all risk factors. Many patients die while they are still waiting for getting liver from cadaveric donation. For these people, living donation is a realistic possibility to get transplant and resume their activity.• Few patients are too sick to wait long enough to get cadaveric donation. For them also living donor liver transplant is a reasonable option.• The live donor procedure also allows greater fl exibility for the patient because the procedure may be done for people who are in the lower stages of liver disease. • With a living donor, patients healthy enough to live at home may still receive a liver transplant. • The living donor transplantation may also be more widely used because of the importance of quickly fi nding donors for people who have liver cancer as there is a risk that their disease may progress and spread while he is waiting for liver transplant.

Most of the risks of living donor liver transplant are the same as for cadaveric liver transplant. However, since in living donor liver transplant, the donor is also a healthy living person, therefore, there is some risk to the donor.

SCIENCE REPORTER: What are the criteria for someone to be considered as a living donor? DR. RAVINDER PAL SINGH: The transplant team is in the best position to

HHowever, this scenario is going to chavery soon with availability of newer veffective drugs for hepatitis C virus.other types of liver disease, recurren

Nationally, with a population of 1.2 billion people, the statistic stands at 0.08 persons as organ donors per million population (PMP). This is an incredibly small and insignifi cant number compared to the statistics around the world.

INCONVERSATION

41 SCIENCE REPORTER, NOVEMBER 2015

It is not possible to live without the liver. Once the liver starts to fail, all of its functions diminish. There is swelling of blood vessels of the esophagus which may rupture and show as vomiting of the blood.decide upon this. However, few basics things which are to be kept in mind are:• The donor’s liver must be healthy. • The living donors must have compatible blood type as the recipient. • They must be aged 18-55 years and be able to tolerate the surgery. • The donor cannot receive any money or other form of payment for the donation. • The donor must have a good social support system to aid in emotional aspects of going through the procedure.

SCIENCE REPORTER: Are the donors in any sort of risk due to this surgery? What are the complications, if any, that donors need to be aware about before they go in for giving away a part of their liver? DR. RAVINDER PAL SINGH: There is some risk to the donor as after every surgery like some cough, mild discharge from stitch line, and mild pain. There are also other problems which are rare but

can still occur, like bile leak, bleeding in the drain, infection, and very rarely mortality (0.1 to 1%).

SCIENCE REPORTER: How much time does the donor take to get back on his or her feet?

DR. RAVINDER PAL SINGH: The donor is usually encouraged to walk by about two days after surgery. They are usually fi t to be discharged by about 7 to 8 days after surgery. They can usually resume their normal daily activities by the end of the fi rst week, moderately heavy work by the end of the second week and unrestricted activity by the end of the fi rst month.

SCIENCE REPORTER: What is the difference between a living liver donor and a living kidney donor?DR. RAVINDER PAL SINGH: In living kidney donation, we take one kidney

from the donor and put it in the recipient. The donor is left with one kidney which usually takes over function of both kidneys. However, in living liver donation, only a part of the liver from the donor is taken, while the rest of the liver is left in place. The part which is taken usually grows back to 85% of its volume by three weeks and the rest of it grows slowly over the span of next few months.

SCIENCE REPORTER: Does the surgery require special skills? What is the status of living donor liver transplant surgeries in the country?

DR. RAVINDER PAL SINGH: Yes, liver transplant surgery is one of the most sophisticated surgeries in medical science. The surgery lasts 18-20 hours. It requires intense dedication, training, and very precise surgical skill sets. At present India is doing good work in living donor liver transplant. The kind of surgery and the results are at par with the world, or even better, if I may say so. However, still there are only a handful of liver transplant centers in India and there is a lot of gap between demand and supply.

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INCONVERSATION