A Wife's Gift of Life: Successful Living Donor Liver Transplant for End-Stage Liver Disease

Chief Complaints

A 55-year-old male patient with a body mass index (BMI) of 17 presented to the Liver Transplant Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of abdominal distension and altered mental status. He was admitted for comprehensive evaluation and further management.

The patient was a known case of diabetes mellitus and chronic liver disease. He had undergone multiple Endoscopic Variceal Ligation (EVL) banding procedures in the past for complications related to portal hypertension.

On examination, the patient was conscious but had altered sensorium. He appeared clinically ill with features of chronic liver disease. Abdominal examination revealed ascites, with clinical signs suggestive of portal hypertension. No focal neurological deficits were noted, and the remaining systemic examination was stable enough to proceed with further liver transplant evaluation.

Upon admission to PACE Hospitals, following the clinical assessment, the Liver Transplant Team conducted a comprehensive evaluation based on the patient's complaints of abdominal distension and altered sensorium in a known case of chronic liver disease with hepatic encephalopathy. A detailed medical history, physical examination, and pre-transplant assessment were performed to determine the severity of liver dysfunction, identify associated complications, and evaluate the patient's suitability for liver transplantation.

Baseline investigations, including complete blood picture, liver function tests, renal function tests, serum electrolytes, coagulation profile (PT/INR, APTT), blood glucose levels, inflammatory markers, viral screening, blood grouping and cross-matching, arterial blood gas analysis, and other routine pre-transplant laboratory investigations, were carried out as part of the transplant workup. The severity of liver disease was further assessed using prognostic scoring systems, which revealed a Model for End-Stage Liver Disease (MELD)-Na score of 32 and a Child-Turcotte-Pugh (CTP) Grade C, indicating advanced liver failure.

Imaging and diagnostic studies, including ultrasonography of the abdomen, liver Doppler examination, CT imaging where indicated, chest X-ray, electrocardiography, and 2D echocardiography, were performed as part of the comprehensive transplant evaluation. These investigations demonstrated features consistent with advanced chronic liver disease, including portal hypertension, ascites, hepatic encephalopathy, and hepatorenal syndrome, confirming decompensated end-stage liver disease.

Based on the confirmed diagnosis, the patient was advised to undergo End-Stage Liver Disease Treatment in Hyderabad, India, under the care of the liver transplant team, with the objective of restoring liver function, preventing further life-threatening complications, and improving long-term survival.

After a thorough evaluation by Dr. Govind Verma, (Transplant Hepatologist), and Dr. CH Madhusudhan, (Liver Transplant Surgeon), a comprehensive assessment was carried out to determine the most appropriate management plan for the patient diagnosed with decompensated chronic liver failure.

Based on the clinical findings of chronic liver disease with abdominal distension, altered sensorium, hepatic encephalopathy, portal hypertension, ascites, hepatorenal syndrome, high MELD-Na score of 32, and Child-Turcotte-Pugh Grade C status, it was determined that Living Donor Liver Transplantation (LDLT) was the most appropriate life-saving treatment approach. This decision was made after careful evaluation of the severity of liver dysfunction, associated complications, transplant fitness, and the need for definitive restoration of liver function.

The patient, donor, and family members were counselled regarding the condition, the need for liver transplantation, associated risks and benefits, donor evaluation, possible complications, lifelong immunosuppressive therapy, infection prevention, medication adherence, and the importance of regular postoperative follow-ups.

Following the decision, the patient was scheduled to undergo Living Donor Liver Transplantation (LDLT) in Hyderabad at PACE Hospitals under the expert care of the liver transplant team.

The procedure involved the following steps:

• Patient Preparation and Anaesthesia: After completion of donor and recipient evaluation, pre-anaesthesia check-up (PAC), and obtaining informed consent, both the donor and recipient were shifted to the operating theatre. Under strict aseptic precautions, general anaesthesia was administered, and appropriate vascular access and invasive monitoring were established to ensure safe intraoperative management.

• Donor Right Lobe Liver Graft Procurement: The patient's wife underwent donor hepatectomy, during which the right lobe of the liver was carefully mobilized and harvested while preserving adequate liver volume for the donor. The graft was inspected, flushed with preservation solution, and prepared for transplantation after confirming satisfactory vascular and biliary anatomy.

• Recipient Hepatectomy and Native Liver Removal: The diseased cirrhotic liver was carefully dissected and removed. Major vascular structures, including the inferior vena cava, portal vein, hepatic artery, and bile duct, were meticulously prepared to facilitate implantation of the donor liver graft while minimizing blood loss.

• Liver Graft Implantation and Vascular Reconstruction: The right lobe modified liver graft was implanted into the recipient. Sequential reconstruction of the hepatic veins, portal vein, hepatic artery, and biliary tract was performed to restore normal blood circulation and bile drainage. Adequate graft perfusion was confirmed after completion of all vascular anastomoses.

• Hemostasis, Graft Assessment, and Surgical Closure: After ensuring satisfactory liver graft function, haemostasis was secured, and the graft was assessed for adequate blood flow using intraoperative Doppler assessment. Surgical drains were placed as required, and the abdominal incision was closed in layers. The patient was then shifted to the intensive care unit (ICU) for close postoperative monitoring and further management.
  

The patient was closely monitored in the intensive care unit, where liver graft function, blood circulation to the transplanted liver, blood sugar levels, and overall vital parameters were regularly assessed. Supportive treatment was provided to prevent organ rejection, control infection, relieve pain, protect the stomach, maintain nutritional status, and manage blood glucose levels. On the ninth postoperative day, a sudden episode of bloody drain output was observed and managed conservatively with close monitoring. Doppler examination confirmed good graft perfusion without any evidence of graft-related complications, and the patient was discharged in a hemodynamically stable condition with advice for regular follow-up.

Upon discharge, the patient was prescribed medications for prevention of organ rejection (immunosuppressive therapy), infection prevention, fungal prophylaxis, gastric protection, pain relief, fever control, nutritional supplementation, and other supportive medications as required following liver transplantation.

The patient was advised to adhere to prescribed medications, including immunosuppressants, maintain a liver-friendly lifestyle, abstain from alcohol, monitor blood sugar regularly, and attend scheduled follow-up visits with routine investigations.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, jaundice, severe abdominal pain, persistent vomiting, excessive wound discharge, breathing difficulty, reduced urine output, altered consciousness, or any other concerning symptoms.

The patient was advised to follow up with the Surgical Gastroenterologist in Hyderabad at PACE Hospitals, after 5 days.

This case highlights the successful management of advanced decompensated chronic liver failure through Living Donor Liver Transplantation (LDLT) using a right lobe modified liver graft. Timely diagnosis, multidisciplinary transplant planning, careful donor selection, and expert surgical management resulted in successful restoration of liver function and an uneventful recovery, demonstrating the effectiveness of living donor liver transplantation in suitable patients with end-stage liver disease.

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