The road to recovery: A case study on liver transplant success
Vishnu C1, Megala R2
1Deputy Nursing Superintendent, Kauvery Hospital, Hosur, Tamil Nadu
2Nursing Secretary, Kauvery Hospital, Hosur, Tamil Nadu
Background
Since the first human liver transplant done in 1963, the procedure has become a routine procedure with an excellent outcome in terms both of quality and of length of survival. Tolerance can be reliably achieved in some animal transplants but remains to be achieved in humans. One of the major challenges facing the transplant community is the shortage of donor organs: imaginative approaches to overcome this problem include more effective use of marginal donor livers, splitting livers and development of living related transplants. While advances have been made in the field of xenotransplantation, there remain many hurdles to be overcome before this approach can be introduced into human transplantation. In the meanwhile, there are difficulties in determining the optimal criteria for listing patients for transplantation and for treating some of the complications arising after transplantation such as recurrence of disease and complications of immunosuppression, e.g. renal failure, malignancy and vascular disease.
A Case Presentation
A 59years aged male, was a known case of decompensated chronic liver disease, CHILD – C, MELD-17. Patient was on regular follow-up. S/P OGD + EVL multiple times. He recently developed ascites and was on diuretics, there was no history of hepatic encephalopathy / HRS / SBP. He was registered for DDLT. Complete workup was done. Admitted for liver transplantation.
On 11th January, we received a liver Alert from the Royal Care Hospital, Coimbatore. A 19 years old male had RTA and was brain dead; patient had A+ Blood group. We immediately started the arrangements for transplantation. Our OT staff and Transplant Coordinator went to Coimbatore Royal hospital for the receiving the Liver as per procedure. We informed the recipient to get admitted to the hospital on the same day, on 11th January in the evening, to start the pre op management for the recipient.
Recipient hepatectomy was uneventful. Totally 6 units of cryo,1-gram Inj. fibrinogen, 2 units of FFP were transfused intra operatively.
Liver received around 7 pm, recipient wheeled into OT at 09:48pm, Around 8 hours of smooth Transplantation procedure done. Post perfusion patient had mild hypotension requiring small dose of inotropes at the end of surgery.
Patient shifted to Transplant ICU with NORAD support. NG tube was removed and patient was started on liquid diet on the next day. Patient had complaints of Abdomen pain, Injection Tramadol given. Patient recovered very fast, drain tubes removed. His food intake was very good.
On 3th POD TAC level was very high, immunosuppressant drugs given. Patient had drop in hemoglobin on POD 3, one unit PRBC was transfused. Doppler study of graft showed good flow.
Patient had low platelet and WBC count. Glycemic level monitored regularly and brought under control by insulin. Platelets started improving. There was mild increase in hepatic artery resistance index, CECT done showed pruning of left hepatic artery and portal vein. In view of suspected rejection, one dose steroid given. Methyl prednisolone dosage was tapered from day 6. Abdomen drain cut short and stoma bag applied. Patient was settled on POD-8 and consultant planned to discharge the patient. At the time of discharge TAC level 7.86, HB -10.6, Platelet count -68000, Urea -57.0, Creatinine- 0.7. On 8th POD Patient discharged with the IV fluids.
A Second surgery
Patient came to OPD for review after 2 days of discharge. On review patient had complaints of fever-101 F, abdominal pain since morning, associated with chills. Immediately patient admitted to Transplant ICU. Blood Culture procalcitonin, urine culture has been sent. Antipyretics given for the fever & abdominal pain. Patient had increased frequency of stools in 2- 3 days. Patient shifted to transplant ICU and managed with IV fluids, antibiotics, antifungal, steroids and vitamin supplements. Nebulization and incentive spirometry were given. Abdomen drain output was bile tinged, drain bilirubin was 2mg/dl. Blood culture showed Klebsiella and started on colistin. Fever gradually reduced. On 28th January patient had persistent body pain, abdomen pain was a repeated complaint. Patient shifted USG scan for Abdomen and Doppler done. USG abdomen showed mildly dilated IHBR, collection measuring 6 x 4 cm with hyperechoic areas. Patient developed sudden increase in pain abdomen and abdomen drain output showed blood stained bile. Immediately patient shifted to CECT, CECT abdomen done showed active extravasation of contrast from hepatic artery and increase in size of collection. In scan, patient had increased collection in Abdomen. Patient became hypotensive(80/60mmHg), tachycardia (150/min) and desaturation (95% in 10 liter O2). Patient was intubated and resuscitated with IV fluids, blood and started on inotropes. ABG showed increase in lactate level and drop in hemoglobin.
In view of active bleeding and deterioration of vitals, planned for emergency laparotomy. Patient condition, prognosis and need for emergency laparotomy has been explained to attenders. Patient was immediately shifted to OT. CVC line secured and blood products pushed. He underwent laparotomy suturing of bleeding hepatic artery and stent placement in bile duct done under general anaesthesia on 29/01/2025. At 7. 45pm patient shifted to Transplant ICU, Patient was extubated and started NIV support on POD-1. Patient had drop in hemoglobin and platelet on POD 1, 2 unit LD PRBC, 2unit SDP and 3 unit FFP was transfused. RFT deranged and platelet count decreased. After mobilization patient settled well and complaints of Abdomen pain. Doppler study of graft showed no demonstrable flow in hepatic artery. On POD 2, patient had risen in serum bilirubin levels, liver enzymes and INR. Started RT feed (high protein) in phases. On POD-4, NG tube was removed and patient was started on liquid diet. Patient tolerated normal diet and passed stools. On POD-6 foley’s catheter removed. LFT improved and INR decreased. Patient had low platelet count. Glycemic level monitored regularly and brought control by insulin. Platelet count started improving. Once RFT becomes normal tacrolimus started. MMF started once platelet count increased. On POD-7 patient had abdomen pain, USG abdomen showed collection measuring 9.6 x 8 cm noted in portal hepatic region extending subcapsularly. In view of collection planned for pigtail catheter drainage. After getting informed consent, USG guided pig tail catheter drainage done on POD 11. About 250ml bile stained liquefied hematoma drained. Patient tolerated normal diet and passed stools. Abdomen drain removed, stoma bag applied. At the time of discharge TAC level 3.86, HB -8.3 g/dl, Haemotocrit -26.7 %, TC- 8300/cumm, Platelet count – 113000/cumm, INR-1.30. Patient discharged with Right cut collabag and Pigtail catheter.
On Third Admission
On 14.02.2025, patient had developed cholangitis abscess and fever, referred for ERCP at outside hospital, Bangalore. Patient had darkish of urine and continuous fever. After shifting to ERCP, patient gradually became hypotensive- to 60/40mm/Hg; immediately shifted to ICU care to maintain the blood pressure with the inotropes.
Consultant advised, that once the blood pressure was maintained normal, we should take the patient as ERCP procedure. On same day night, patient blood pressure maintained normal and shifted to procedure. After completion of procedure, one day kept observation on same hospital.
On 15.03.2025 night patient received and admitted for further management in our hospital. While receiving patient had no fever and shifted to Transplant ICU and started ionotropic infusion. Blood reports showed increased bilirubin level and increased procalcitonin. Patient was managed with IV fluids, antibiotics, antifungal, antiviral, steroids and vitamin supplements. Patient had low platelet count and 1 unit SDP was transfused. Glycemic level monitored regularly and brought control by Insulin. Patient tolerated normal diet and passed stools. On 4th day foleys catheter removed, LFT removed. At the time of discharge, patient HB -7.7 g/dl, Haemotocrit -23.8 %, TC- 1910/cumm, Platelet count – 5000/cumm, INR-1.47. On discharge, protein rich diet advice given. Patient came with the review after 3 days, patient didn’t have any symptoms of related to surgery. We are following the post discharge calls follow up for the patient condition.
Conclusion
Liver Transplantation is a life-saving procedure for patients with end-stage liver disease, acute liver failure, and certain liver cancers. Advancements in surgical techniques, immunosuppressive therapies, and post-operative care have significantly improved survival rates and quality of life of rejections, lifelong medication, and complications persist. Continued efforts in public awareness, organ donation outcomes and accessibility. Multidisciplinary care and long-term follow-up play a crucial role in ensuring the success of liver transplantation.
