Living Donor Liver Transplant

What is living donor liver transplant (LDLT)?

Living donor liver transplant (LDLT) is an important life-saving procedure for patients suffering from decompensated liver cirrhosis, acute liver failure and hepatocellular carcinoma (HCC) (liver cancer).

It can be performed on patients with end-stage liver disease regardless of the original cause of the disease. Potential recipients are carefully selected and must meet stringent criteria.

LDLT offers many advantages over cadaveric liver transplantation:

• Surgery can be scheduled when the recipient's condition is optimised.
• The quality of the liver graft is better because it is provided by a healthy donor, with a shorter cold ischaemic time (the time the donated liver has no blood supply).
• Waiting time for LDLT is much shorter than cadaveric liver transplant, which is very important for patients with rapidly progressive liver diseases or deteriorating liver function, or both.

How it works

In LDLT, a healthy donor donates part of their healthy liver to replace the damaged liver of the recipient.

Both the transplanted liver and the portion left behind in the donor are able to regrow rapidly. Even with 70% of its mass removed, the liver will regenerate to 100% functionality within 4 – 6 weeks.

Living donor liver transplant requirements

A suitable living donor would meet the following requirements:

• Aged between 18 – 60
• Be of a healthy weight, in good health and psychologically sound
• Have a compatible blood type with the patient
• Have a healthy functioning liver and kidney
• Willing and prepared to go through the entire living donor liver transplant process including pre-donation evaluation, surgery and recovery

Why do you need an LDLT?

LDLT is usually a treatment for:

• Patients with end-stage liver disease.
• Decompensated liver cirrhosis (liver scarring) in adults. Liver cirrhosis is mainly caused by hepatitis B and C, chronic alcohol consumption, autoimmune liver disease and build-up of fat in the liver.
• Biliary atresia in children, caused by absent or blocked bile ducts, which are tubes that carry bile out of the liver to the gallbladder. The bile backs up and damages liver tissue, and eventually leads to cirrhosis.

Other reasons for LDLT include:

• Liver cancer
• Benign (non-cancerous) liver tumours
• Hereditary liver diseases

Who should not undergo an LDLT?

Liver transplant is recommended only when the risk of demise from the liver disease outweighs the immediate and long-term risks of the transplant. You may not be suitable for liver transplant if you have:

• An active infection
• Cancer outside of the liver
• Alcohol or drug abuse

Your doctor will advise you on your suitability for a living donor liver transplant.

What are the risks of an LDLT?

Liver transplant surgery carries a risk of complications including:

• Bile duct complications, including bile duct leaks or strictures of the bile ducts
• Bleeding
• Blood clots
• Failure of donated liver
• Infection
• Rejection of donated liver

Long-term complications may also include recurrence of liver disease in the transplanted liver.

While the procedure is often life-saving for the recipient, donating a portion of the liver also carries certain risks for the donor. Some mild but uncommon complications that may occur for the donor include:

• Hernia at the incision site
• Prolonged numbness
• Wound infection

Severe complications are rare and the surgeon will discuss them in detail with you prior to the surgery.

How do you prepare for an LDLT?

Transplant surgery is strictly regulated in Singapore.

The process for a living donor liver transplant begins with:

• Finding a compatible and healthy living liver donor, who could be a next of kin, relative or close friend. Matching of donors with recipients is based on blood group, body size, general medical condition and other factors.
• Going through a pre-transplant assessment to determine you and your donor's eligibility. Both you and your donor will have to undergo a rigorous medical examination and psychosocial evaluation. The assessment will be done by an independent team of doctors, including liver transplant surgeons and physicians, cardiologists, psychiatrists, dentists, nephrologists and infectious disease physicians.
• Meeting the donor with your family members for a family conference.
• Preparing and taking any medication to ensure that you are in optimal health for the transplant.
• Seeking approval from the Transplant Ethics Committee, as required under the Singapore Ministry of Health's Human Organ Transplant Act (HOTA).

What can you expect in an LDLT?

If you're receiving a liver transplant from a living donor, your surgery will be scheduled in advance.

Estimated duration

A liver transplant usually takes between 6 – 12 hours.

During the procedure

During the transplant, the surgeon will make an incision over your upper abdomen to remove your liver and replace it with the donor liver graft. The specific part of the liver donated depends on the size of the donor liver and your needs.

Next, the surgeon will connect the blood vessels and bile ducts to the new liver to restore blood flow. The incision will be closed once the vital structures are anastomosed (joined) and working well.

After the procedure

After your liver transplant, you can expect to:

• Stay in the intensive care unit (ICU) for 3 – 5 days. The medical team will closely monitor your condition to watch for signs of complications, and frequently test your liver function.
• Spend 5 – 10 days in the hospital. Once you're stable, you will be taken to a transplant general ward to continue recuperating.
• Have frequent outpatient consultations as you continue recovering at home. You may undergo blood tests a few times each week, which should lessen over time.
• Take immunosuppressant medication for the rest of your life. This is to prevent your immune system from rejecting your new liver.

Care and recovery after a LDLT

After a liver transplant, it is important to care for your new organ, which includes:

• Adopting a healthy lifestyle
• Regular exercise
• Healthy diet
• Taking medication
• Going for follow-up medical appointments regularly

Your transplant coordinators, dietitians and allied healthcare team will educate and guide you on your post-transplant care.

Outpatient check-ups

Organ transplants have the highest risk of organ rejection within the first 60 days after the transplant:

• For the first 2 months, you may need to attend weekly clinical reviews.
• After the first 2 months, the frequency of visits will be adjusted based on your recovery performance.

Immunosuppression (anti-rejection) medicine

After your liver transplant, you will be prescribed immunosuppressants to stop the immune system from rejecting the new liver. You will need to take them daily for the rest of your life.

The daily dosage is carefully calculated by your transplant physician. It is not recommended to make adjustments to your medication before consulting your doctors, as it may lead to organ rejection.

Immunosuppressants will also increase your vulnerability to infections, especially in the first few months after the transplant when higher doses of these medications are typically required.

Your risk decreases slowly as the drug doses are reduced in the months after. However, you need to be mindful at all times to:

• Avoid contact with individuals with infection
• Avoid eating any raw foods
• Get treated immediately if you experience any signs of infection

While you are on anti-rejection medications you should also:

• Avoid certain foods, such as pomelo and grapefruit, as these can affect the effectiveness of the immunosuppressants.
• Inform your doctor before taking any new medications, including over-the-counter medications and supplements, as these may interact with your immunosuppression and alter their effectiveness.
• Inform any healthcare personnel that you are taking anti-rejection medication before undergoing any dental or medical procedure.

Recognising organ rejection and infection

While anti-rejection medication helps prevent organ rejection, it may still occur. This condition can, however, be reversed if the signs are discovered and treated early.

Symptoms and signs of liver rejection include:

• Fever
• Dark, tea-coloured urine
• Jaundice (yellowish skin and eyes)
• Pale or clay–coloured stools
• Chills, aches, unexpected tiredness and abdominal discomfort

Other than the risk of organ rejection, you will also need to be alert about infection, especially since immunosuppressants will reduce your body’s ability to fight infection.

You can minimise your risk of an infection by:

• Practising good personal hygiene.
• Taking precautions to reduce the risk of getting an infection; for example, avoiding crowded places especially during the cold or flu season.
• Washing your hands often.

Contact your transplant coordinator if any of the below signs occur:

• Fever
• Redness or white spots on the tongue or in the mouth
• Redness, swelling or foul-smelling discharge on open wounds
• Persistent cough without shortness of breath
• Flu-like symptoms
• Painful or burning sensation when passing urine
• Diarrhoea

Nutrition after liver transplant

A dietitian will advise you on maintaining a healthy, balanced diet. Depending on your medical condition, you may be placed on a special diet.

It is important for you to maintain a healthy weight, as weight gain and obesity can damage your new liver and increase your risk of chronic diseases, such as high blood pressure and heart disease.

With a weakened immune system caused by anti-rejection medication, it is important to practise safe food handling. The dietitian and nurses will advise you on how to handle food safely and what foods to take note of.

Recovery period for an LDLT

It may take 3 – 6 months to fully recover from your liver transplant surgery.

Most liver transplant recipients are able to resume normal activities or go back to work a few months after surgery, depending on how ill they were before their liver transplant.

Resuming regular activities after your transplant

Before you resume your regular activities, take note of the following:

• Exercise – You may resume exercise to maintain your weight and physical health. However, you should avoid driving for up to 6 weeks after your transplant. For at least 2 months after your surgery, avoid activities that strain your stomach, including heavy lifting and sit-ups.
• Sun exposure – Transplant patients have a chance of developing skin cancer when exposed to the sun. Use sunblock with at least SPF 30, and wear long-sleeved shirts and a hat when outdoors. You should also examine your skin regularly for abnormal growths or patches.
• Travel – Unless you are returning to your own country, you should avoid travelling within the first 6 months after your liver transplant. Your transplant coordinator will also advise you on which areas to avoid, as some countries may pose a higher risk of infection for liver transplant patients.