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IN CONVERSATION
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), fluid 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.
SCIENCE REPORTER, NOVEMBER 2015
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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
figures 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 figures
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-fifth
to one-third of transplants.
• Fatty liver disease (NAFLD and
steatohepatitis) accounts for another onefifth 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
significant share of liver transplants.
• Primary liver cancer.
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 nonavailability 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 insignificant 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
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opposed it during his lifetime. These
countries have seen the rate of donations
double, averaging between 20-40 PMP.
We understand it is difficult 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 very
complicated procedure (one of the most
SCIENCE REPORTER, NOVEMBER 2015
INCONVERSATION
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
insignificant number compared However,
However, this scenario is going to change
cha
very soon with availability of newer very
v
to the statistics around the
effective drugs for hepatitis C virus. For
world.
other types of liver disease, recurrence
recurren is
difficult procedures developed in the
medical field 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 qualified 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.
SCIENCE REPORTER, NOVEMBER 2015
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 first three months after
transplant are the most risky for getting
such infections as the flu, 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 first 5 to 10 years.
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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
benefits 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
benefits 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 flexibility 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 finding 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
INCONVERSATION
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 fit to be discharged by about 7
to 8 days after surgery. They can usually
resume their normal daily activities by
the end of the first week, moderately
heavy work by the end of the second
week and unrestricted activity by the end
of the first 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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SCIENCE REPORTER, NOVEMBER 2015