 Hi, I am Dr. Arvind Kidambi Sheshadri, Consultant, HPB, Surgery and Liver Transplant Manipal Hospitals. Hi, today I will be telling you about who needs a transplant or when we advise transplant as a treatment for a patient who has liver disease. So basically somebody who has a compensated liver disease, the risk to life is less than 10% over a period of one year. So when a patient develops decompensation, this is the time when the patient needs to consider liver transplant seriously as a treatment option. So what we look at is whether the transplant is indicated in the patient. So when the risk of dying without transplant is more than the risk of dying with transplant, meaning somebody who is on a medical management if the survival rate is less than 90% then over a period of one year then we advise a liver transplant because the risk to life, perioperative risk to life while undergoing a liver transplant is around 5-10% which is less compared to the risk to life of somebody who is having a decompensated liver disease and is on medical management. So how do we stratify this risk or how do we calculate the risk? There are various scores that are available. You can go through the internet or Google it. There is something called a child turquat-pug score which is a very simple score but it has a good prognostic value. So this has 5 parameters. It looks at bilirubin, looks at albumin, INR, whether the person has acitus and it looks at encephalopathy and it is scored from 1 to 3 depending on the severity. So there are 3 categories which is A, B and C. A is early, B is moderate and C is severe. So in terms of scoring if somebody has a child score of 7 or more then we advise them to consider a liver transplant as a treatment option. There is also another score which is more accurate and is being used quite frequently which is called the meld or the meld sodium. So this is a model for end stage liver disease and it also has 3 to 4 parameters. The meld sodium has 4 parameters. It looks at bilirubin, INR, sodium and creatinine and based on a statistical model a score is generated. The calculator is available freely on the net. So somebody who has got a normal liver function will have a meld score of say 6 and suppose the meld score is 14 or above this is when we advise the patient to consider a liver transplant and get worked up for it. Because a meld score of 14 or above indicates a risk to life of around 10 to 15% over a period of next 3 months and the risk of a liver transplant is only 5 to 10% in the perioperative period. So when the risk of a liver transplant outweighs the risk of not having a liver transplant and being in medical management is when we suggest a transplant. And all these patients who are on medical management and are decompensated the long term survival say 3 years or 5 years is almost 0 and with a liver transplant the 5 year survival rate is in the range of 80 to 85% and this 10 to 15% mortality includes all cause mortality. Not only mortality related to the graft liver or the transplant surgery this includes all other organ system related mortality. So essentially what I am wanting to say is if a patient is looking for a long term survival say 5, 10, 15 or 20 years liver transplant is the only treatment option that will give you this long term survival because as of now there is no medical treatment that can give you a long term survival or reverse the process that is happening in the liver. So once the liver is damaged the patient has decompensation, child score is 7, 8 or above and the meld score when calculated is 14 or above. This is the right time when the patient should consider a liver transplant and go for the same. So in our experience we have transplanted children who have grown up, have entered college, gotten married, they have a children. There are various examples like the child who was transplanted and I mean it's not in India but who was transplanted in the United Kingdom at the age of 5 years is now 50 years old and she has grandchildren. So there are various examples like this. There is even sports persons who have undergone a liver transplant come back after the transplant, recovered and have gone on to play for the country. So what I would like to say is if somebody is looking for a long term survival and good quality of life then liver transplant is the answer. Especially after the person has developed a reasonable decompensation and the meld score is 14 or above. So once the indication for a liver transplant is clear we need to tell the recipient and the family regarding a liver transplant and counsel them. So it is not a very easy decision because of a few reasons. One, it's a major undertaking, a vital organ is being replaced. The risk a liver transplant entails is in the range of 5 to 10 percent whereas a routine cardiac surgery the risk involved is 0.1 to 1 percent. So the next reason for this is the finances that is involved because compared to the other treatments that is available the cost of a liver transplant is a bit more. So the family also needs to look into this and what are the options that are available to undergo a liver transplant. So once the indication becomes clear we tell the patient and the family that the indication is quite clear that you will benefit by undergoing a liver transplant. Because this will give you a good quality of life, a better quality of life and long term survival. So once the indication is clear then we ask the family what type of treatment they want or what option they are looking for. So if they are okay with the transplant the next decision is from the family side. If they are okay for a transplant then there are two options. One is a living donor liver transplant and the other one is a canovaric liver transplant. In a living donor liver transplant a person who is a part of the family voluntarily agrees to donate a part of his or her liver which could be a right lobe or a left lobe. For the recipient to undergo a transplant. In a disease donor transplant the organ is got from a person who is either brain dead and the patient's family decides to donate the organs or it can be also retrieved from a patient who is undergoing a cardiac death. So what are the risks and what are the advantages of both of this? Once the patient and the family decide on undergoing a liver transplant what are the options that they have? They either have to go for a living donor liver transplant or a canovaric liver transplant. So there are advantages and disadvantages of both these options. In a living donor liver transplant they need to have a donor in the family meaning somebody who is related has to come up voluntarily. The blood group should be compatible they should be between the age of 18 to 50. Rarely we have taken donors up to 55 years of age but that is only when they are very fit and on evaluation everything is okay. And blood group compatible. So a part of his or her liver will be taken up for transplant in the potential recipient. So the advantage of this is we have a good quality of liver. The timing can be controlled somebody needs an urgent transplant or somebody who is having an acute liver failure and the transplant needs to be done within the next 12-24 hours then this is the best option. The quality of the liver is quite good because we have already evaluated for it. And the disadvantage of this is the donor has to undergo a major surgical undertaking. Though the person is normal he will be subjected to surgery there will be a cut on the tummy and though the safety measures and all the procedures have been standardized there have been a lot of advancements and developments. There is a small risk that is associated with this procedure which is in the range of 0.1 to 0.5%. And coming to the next option which is a disease donor transplant the advantages are there is no need to identify any donor in the family because the donor who is going to donate his or her organs is already brain dead or could be because of a cardiac death. So the donor risk is completely 0. The disadvantages is the timing we don't know when a donation is going to happen and the third thing is we don't have a control of the quality of liver because whatever liver is being offered is the one that we are going to use if it is suitable. So the third thing that is going to come into the picture is the finances unfortunately compared to all other treatments this is a bit expensive but still it is one fourth or one fifth the price compared to western countries. The living donor liver transplant costs a bit less compared to a disease donor transplant because in a disease donor transplant the consumables that are consumed the perfusion solution are a bit expensive. There is a brief period of time where we need to use some medicines to manage the donor and there is a small fee that we pay to the government organization which facilitates the whole process. The living donor liver transplant is less expensive compared to the disease donor program it includes the cost of both the donor and the recipient and it covers their surgery, the investigations, hospital and the ICU stay one week to ten days for the donor and three to four weeks for the recipient. So this is how we counsel the family briefly we tell them that the indication is quite clear and they will benefit from a transplant good quality of life and long term survival is possible with this treatment and it is quite safe to perform and good experience and expertise is available. Then we allow the family to make the decision once they decide we give them the option of either going for a living donor liver transplant or a disease donor transplant we walk them up for the same and register and if they are able to get an organ while waiting on the list then that is the best thing that could happen to the patient but while waiting if they are deteriorating we tell them to proceed with living donor liver transplantation and like I said before if everything goes well apart from the 5-10% risk long term survival off late is more likely possible than what it was 10-15 years ago.