Successful Living Donor Liver Transplantation for Decompensated Chronic Liver Disease

Chief Complaints

A 41-year-old female patient with a body mass index (BMI) of 18 presented to the Liver Transplant Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of progressive abdominal distension and yellowish discoloration of the eyes for 20 days. She also reported significant weight loss and loss of appetite over the preceding three months.

The patient had a history of Type II Diabetes Mellitus diagnosed eight years earlier, which was managed with insulin therapy for blood glucose control. She was also a known case of triple vessel coronary artery disease, diagnosed on coronary angiography, and was receiving medical therapy for cardiovascular disease prevention and lipid management. She had underlying decompensated chronic liver disease complicated by portal hypertension, jaundice, ascites, and hepatorenal syndrome. There was no prior history of gastrointestinal bleeding, hepatic encephalopathy, pedal edema, large-volume paracentesis, or decreased urine output.

On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. Clinical examination revealed abdominal distension with ascites and icterus consistent with advanced chronic liver disease. There were no signs of active gastrointestinal bleeding, hepatic encephalopathy, or acute abdominal complications. The remaining systemic examination was otherwise normal.

Upon admission to PACE Hospitals, following a detailed clinical evaluation, the Liver Transplant and Surgical Gastroenterology team assessed the patient for progressive abdominal distension, jaundice, significant weight loss, and loss of appetite, along with her relevant medical history.

Based on the clinical findings and comprehensive evaluation, the patient was diagnosed with decompensated chronic liver disease (DCLD) complicated by portal hypertension, jaundice, ascites, and hepatorenal syndrome. Disease severity assessment demonstrated a MELD-Na score of 26 and Child-Turcotte-Pugh (CTP) Class C, indicating advanced liver failure requiring liver transplantation.

Routine laboratory investigations, liver function tests, renal function tests, coagulation profile, imaging studies, and transplant workup were performed to evaluate the severity of liver disease, assess transplant suitability, and optimize the patient before surgery.

Based on the confirmed diagnosis, the patient was advised to undergo Decompensated Chronic Liver Disease (DCLD) Treatment in Hyderabad, India, under the expert care of the Liver Transplant Department.

After a detailed evaluation by Dr. Suresh Kumar S (Consultant Surgical Gastroenterologist and Liver Transplant Surgeon) and the multidisciplinary liver transplant team, comprehensive donor and recipient assessments, pre-anesthetic evaluation, and transplant workup were completed to determine the most appropriate treatment strategy.

Considering the patient's advanced decompensated chronic liver disease with portal hypertension, ascites, jaundice, hepatorenal syndrome, and high MELD-Na score, it was determined that Living Donor Liver Transplantation (LDLT) was the appropriate treatment for long-term survival and restoration of liver function. The patient's brother was evaluated and found to be a suitable living donor.

The patient and her family members were counselled regarding the diagnosis, disease severity, transplant procedure, potential risks, expected postoperative recovery, lifelong immunosuppressive therapy, and the importance of strict follow-up.

Following the decision, the patient was scheduled for Living Donor Liver Transplantation (LDLT) in Hyderabad at PACE Hospitals, under the expert care of the Liver Transplant Department.

The following steps were carried out during the procedure:

• Patient Preparation and Anaesthesia: After completing all preoperative assessments and obtaining informed consent, the patient was taken up for surgery under general anaesthesia with appropriate intraoperative monitoring.

• Recipient Hepatectomy: Exploration revealed a macronodular cirrhotic liver with significant ascites. The native diseased liver was carefully mobilized and removed after meticulous vascular and biliary dissection.

• Donor Graft Preparation: The patient's brother underwent donor hepatectomy, and a modified right lobe liver graft was harvested. A neo-middle hepatic vein was constructed using segment V and VIII veins with a polytetrafluoroethylene (PTFE) vascular graft to optimize venous drainage.

• Liver Transplantation: The recipient portal vein was confirmed to be patent. The donor liver graft was implanted with sequential vascular and biliary reconstruction, ensuring satisfactory inflow, venous outflow, and biliary continuity. No space-occupying liver lesions or peritoneal deposits were identified intraoperatively.

• Completion of Procedure: Following successful reperfusion, satisfactory graft perfusion and hemostasis were confirmed. The procedure was completed successfully without any significant intraoperative complications.
  

The postoperative course was closely monitored with regular clinical assessments and daily Doppler ultrasound examinations to confirm adequate graft perfusion. The patient received supportive care to maintain hydration, prevent infections, control pain, protect the stomach lining, support nutrition, and facilitate recovery. A postoperative right-sided pleural effusion was successfully managed with an intercostal chest drain and serial monitoring until lung expansion improved, after which the patient continued to recover well.

The patient was discharged with medications to prevent organ rejection, prevent infections, manage pain, protect the stomach lining, maintain fluid balance, support liver function, control blood sugar, reduce the risk of blood clots, support bone health, and promote overall recovery following liver transplantation. She was advised to take all medications as prescribed and attend regular follow-up visits for ongoing monitoring and dose adjustments based on clinical and laboratory findings.

The patient was advised to follow a high-protein diet, wear a mask, avoid crowded places, maintain proper wound and drain care, monitor blood sugar as instructed, and gradually resume daily activities as tolerated.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, abdominal pain, vomiting, shortness of breath, yellowing of the eyes, wound or drain-related problems, or any other concerning symptoms.

The patient was advised to return for a follow-up visit with the Surgical Gastroenterologist in Hyderabad at PACE Hospitals after 4 days. She was also advised to return for a follow-up visit with the Endocrinologist after 7 days.

This case highlights the successful management of decompensated chronic liver disease with living donor liver transplantation (LDLT). Timely transplantation, meticulous surgical care, and comprehensive postoperative management resulted in a favorable recovery. This case demonstrates the effectiveness of a multidisciplinary approach in achieving successful transplant outcomes.