Liver Transplantation Breathes New Life in Patient with Decompensated Liver Failure and CKD
PACE Hospitals
PACE Hospitals’ expert Liver Transplant team successfully performed a Living Donor Liver Transplantation (LDLT) on a 49-year-old male patient diagnosed with decompensated chronic liver disease complicated by chronic kidney disease, hepatorenal syndrome, pneumonia, diabetes mellitus, and ascites. The transplantation aimed to replace the failing liver, reverse life-threatening liver failure, improve overall organ function, and enhance the patient's long-term survival and quality of life.
Chief Complaints
A 49-year-old male patient with a body mass index (BMI) of 30 presented to the Liver Transplant Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of abdominal distension due to ascites, reduced urine output, and worsening liver disease. He also had a history of chronic kidney disease and pneumonia.
Past Medical History
The patient was a known case of decompensated chronic liver disease with recurrent ascites and hepatorenal syndrome. He also had chronic kidney disease, diabetes mellitus, anaemia related to chronic liver and renal dysfunction, and a recent history of pneumonia.
On Examination
On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. Abdominal examination revealed distension due to ascites. Clinical findings were consistent with advanced chronic liver disease, with associated renal dysfunction. The remaining systemic examination showed no significant acute abnormalities.
Diagnosis
Upon admission to PACE Hospitals, following a detailed clinical assessment, the Liver Transplant team evaluated the patient for decompensated chronic liver disease with ascites, hepatorenal syndrome, chronic kidney disease, pneumonia, and diabetes mellitus, along with a review of his relevant medical history.
Blood tests, complete blood picture, liver function tests, renal function tests, coagulation profile, and imaging investigations, including liver Doppler, were performed to assess the severity of liver dysfunction, kidney involvement, and overall suitability for transplantation.
The evaluation confirmed decompensated chronic liver failure with ascites, hepatorenal syndrome, chronic kidney disease, pneumonia, diabetes mellitus, and associated anaemia. His Model for End-Stage Liver Disease Sodium (MELD-Na) score was 28, indicating advanced liver disease. A SARS-CoV-2 RT-PCR test was also performed in view of pneumonia and was reported negative.
Based on the confirmed diagnosis, the patient was advised to undergo Decompensated Chronic Liver Failure Treatment in Hyderabad, India, under the expert care of the Liver Transplant Team.
Medical Decision Making (MDM)
After a thorough evaluation by Dr. Govind Verma, (Transplant Hepatologist), Dr. CH Madhusudhan and Dr. Suresh Kumar S, (Liver Transplant Surgeons), along with nephrology consultation from Dr. A Kishore Kumar, 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 advanced chronic liver disease with ascites, hepatorenal syndrome, chronic kidney disease, pneumonia, diabetes mellitus, anaemia, and a MELD-Na score of 28, it was determined that Living Donor Liver Transplantation (LDLT) was the most appropriate life-saving treatment option. This decision was made after careful evaluation of the severity of liver dysfunction, renal status, associated medical conditions, transplant fitness, and the need for definitive restoration of liver function. Nephrology clearance was obtained before proceeding with transplantation.
The patient, donor, and family members were counselled regarding the severity of the condition, the need for liver transplantation, donor evaluation, associated risks and benefits, possible postoperative complications, lifelong immunosuppressive therapy, infection prevention, medication adherence, and the importance of regular follow-up after transplantation.
Surgical Procedure
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 donor and recipient evaluation, obtaining informed consent, and receiving multidisciplinary clearances, both donor and recipient were taken up for surgery under general anaesthesia. Continuous haemodynamic monitoring was maintained throughout the procedure.
- Recipient Hepatectomy: The diseased cirrhotic liver was carefully mobilised and removed while preserving the major blood vessels and biliary structures required for implantation of the donor graft. Adequate haemostasis was maintained throughout this stage.
- Living Donor Graft Implantation: The recipient received a right lobe modified liver graft donated by his son. The graft was positioned appropriately, and hepatic venous, portal venous, hepatic arterial, and biliary reconstructions were performed to establish normal blood flow and bile drainage.
- Graft Revascularisation and Assessment: After completing the vascular anastomoses, blood flow to the transplanted liver was restored. The graft was assessed for satisfactory perfusion, haemostasis, and immediate function before proceeding with closure.
- Completion of Procedure: After confirming adequate graft function and controlling bleeding, surgical drains were placed appropriately, and the abdomen was closed in layers. The Living Donor Liver Transplantation was completed successfully without any intraoperative complications.
Postoperative Care
The patient remained stable after surgery with satisfactory graft function. Bilateral pleural effusion developed during recovery and was successfully managed with intercostal drainage. Treatment was provided to prevent rejection and infection, control pain, fever, nausea, and acidity, and support nutrition. Liver and kidney functions were monitored regularly, and treatment was adjusted when temporary changes in renal function and liver enzyme levels were noted.
Discharge Medications
Upon discharge, the patient was prescribed medications to prevent organ rejection, reduce the risk of infection, relieve pain and fever as needed, protect the stomach, support nutritional recovery, and maintain stable liver and kidney function. He was advised to take all medications exactly as prescribed and continue regular follow-up for monitoring of graft function and overall recovery.
Advice on Discharge
The patient was advised to take all prescribed medications regularly, follow the recommended diet, maintain hygiene, avoid strenuous activity, and attend scheduled follow-ups.
Emergency Care
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, excessive swelling, or any other concerning symptoms.
Review and Follow-up Notes
The patient was advised to follow up with the Surgical Gastroenterologist in Hyderabad at PACE Hospitals, as scheduled.
Conclusion
This case highlights the successful use of Living Donor Liver Transplantation in managing advanced decompensated liver disease with multiple associated complications. Timely transplantation, multidisciplinary care, and close postoperative monitoring supported stable graft function and recovery.
Managing Pleural Effusion After Liver Transplantation
Pleural effusion can develop after liver transplantation, particularly in patients with advanced liver disease and higher MELD scores. Fluid collects around the lungs and may cause breathing difficulty or reduced oxygen levels. A Liver Transplant doctor/specialist may recommend close monitoring and supportive care for small effusions, while larger collections may require drainage through an intercostal tube. In this case, bilateral pleural effusion was identified early and managed effectively with drainage. Liver and kidney functions were monitored closely throughout recovery. Timely intervention helped control the complication and supported stable graft function.
Frequently Asked Questions (FAQs)
Why was a living donor liver transplant advised for this patient?
The patient had decompensated liver cirrhosis with ascites, hepatorenal syndrome, chronic kidney disease and a MELD-Na score of 28. These findings indicated that the liver was severely damaged and unlikely to recover with medical treatment alone. Liver transplantation was therefore considered the most suitable treatment to replace the failing liver and improve the patient’s chances of survival. A MELD score of 15 or above, particularly when accompanied by complications such as ascites, is an important reason to consider transplant evaluation.
What does a MELD-Na score of 28 indicate in a liver transplant patient?
The MELD-Na score estimates the severity of advanced liver disease and helps doctors assess the urgency of transplantation. A score of 28 indicates serious liver dysfunction and a considerable risk of further deterioration without transplantation. The score is interpreted together with the patient’s kidney function, sodium level, complications, general condition and response to treatment.
Can a patient with chronic kidney disease undergo a living donor liver transplant?
Yes. Chronic kidney disease does not automatically prevent a patient from undergoing liver transplantation. Kidney specialists assess creatinine levels, urine protein, urine output, estimated glomerular filtration rate and the likely cause and duration of kidney damage. Based on these findings, the transplant team decides whether a liver transplant alone is appropriate or whether combined liver–kidney transplantation should be considered.
Can kidney function improve after liver transplantation in a patient with hepatorenal syndrome?
Kidney function may improve when the impairment is mainly caused by hepatorenal syndrome associated with advanced liver failure. After successful transplantation, improved circulation and liver function may allow the kidneys to recover gradually. However, recovery is not guaranteed, particularly when the patient has long-standing chronic kidney disease, diabetes or prolonged kidney dysfunction.
Can liver transplantation be performed when the patient has pneumonia?
Active pneumonia must be evaluated and managed carefully before transplantation because immunosuppressive treatment after surgery can increase the risk of severe infection. Doctors assess the cause and severity of the pneumonia, oxygen levels, chest imaging, laboratory reports and response to treatment. Transplantation is considered only when the multidisciplinary team determines that the infection is adequately controlled and the expected benefits outweigh the risks.
Why was the patient’s son evaluated as a living liver donor?
A close relative may volunteer to donate part of the liver because the liver has the ability to regenerate in both the donor and recipient. The son would have undergone detailed testing to check blood-group compatibility, liver size, liver anatomy, general health and psychological readiness. Donation proceeds only when the transplant team confirms that it can be performed with an acceptable level of safety for the donor.
Why can pleural effusion develop after a liver transplant?
Pleural effusion is a collection of fluid around the lungs and may occur after liver transplantation because of major surgery, fluid shifts, low protein levels, diaphragmatic irritation, infection or reduced movement during recovery. Patients with severe liver disease and higher MELD scores may have an increased risk of postoperative complications. Small effusions may only require monitoring, while larger collections that affect breathing may need drainage.
Does every pleural effusion after liver transplantation require a chest drain?
No. The treatment depends on the amount of fluid, the patient’s breathing, oxygen level, infection risk and overall condition. A small or stable effusion may improve with careful fluid management, respiratory exercises and treatment of the underlying cause. A chest drain or other drainage procedure may be required when the fluid is large, infected, persistent or causing significant breathing difficulty. Drainage decisions must also consider the patient’s platelet count and blood-clotting status.
Why can liver enzymes increase during the early period after transplantation?
Liver enzymes may rise because of surgical stress, temporary changes in blood flow, infection, medication effects, bile-duct problems, blood-vessel complications or immune-mediated rejection. Doctors interpret the enzyme pattern along with bilirubin, INR, liver Doppler findings and the patient’s clinical condition. Treatment may include adjusting immunosuppressive medicines, managing infection or performing further investigations when the abnormality does not settle.
What follow-up is required after a living donor liver transplant in a patient with kidney disease?
Regular follow-up is essential to monitor the transplanted liver, kidney function and the effects of immunosuppressive treatment. Tests may include bilirubin, ALT, AST, INR, creatinine, electrolyte levels, blood counts, medicine levels and liver Doppler imaging when required. The patient should take all prescribed medicines on time and immediately report fever, breathing difficulty, jaundice, reduced urine output, abdominal swelling, persistent vomiting or discharge from the surgical wound.
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