Evaluation and preparation for a liver transplant (Recipient)

Procedures for the Recipient – What is the preparation required for transplant?

Liver transplant is a major surgery which is why we follow the highest degree of care, standards, and ethics. As a recipient, it's a time to relax and accept transplantation with a positive attitude. While it's easy to get unnerved during the preparation phase where you need to wait for the donor (especially in case of brain-dead ) and undergo several tests and check-ups – the key is to stay calm and collected knowing that a better quality of life awaits at the end of it all. While there are instances where a patient might be in denial thinking they don't need a transplant, it's at this time you should stay strong. There is no point denying the sickness and subjecting yourself to more pain and agony simply out of guilt or trying to avoid the high costs and numerous procedures associated with the surgery. If you truly want to lead a truly successful life, a healthy body and mind is a vital component. Which is why you should not lose precious time stalling and prepare yourself for the transplant.  

We start by evaluating the person and assessing if the person is deemed suitable for the transplant. Upon gauging the suitability and if found suitable, we then proceed to analyze if the potential donors in your family are compatible and eligible for the transplant. Once we have zeroed in on the appropriate donor, we get a clearance certificate from the authorization committee following which a date is fixed for the transplant.

In the interim, both the donor and the recipient will go through extensive training procedures viz. psychological and social evaluations test, diagnostic tests including blood tests, ECG’s, etc. to ensure they are well prepared. Usually, a date in the region of 2-3 weeks is scheduled for the surgery once all formalities have been completed. This important decision also pivots on the status of your current health, your mental and physical capacity to go through surgery along with your expectations for maintaining a certain quality of life.

However, in case a compatible donor can’t be found within the family although the recipient’s evaluations tests have been acceptable, he/she is put on the waiting list for a deceased donor liver transplant. Eligibility to be approved of a transplant will also be based on factors including blood type, urgency, size, and ability to receive the liver.

It needs to be reiterated that because this is a major surgery, adequate arrangements should be made for getting the finances in order while procuring blood products well in advance prior to the surgery.  As a patient, you should also make it a point to clarify all your doubts and queries you might have about the procedure as well as understanding all the risks associated with the surgery and life ahead post-surgery. You should try and speak to friends, family, & colleagues who have undergone the operation or visit online forums to get a better understanding and insights on how life pans out post-surgery.

Pre-transplant recipient (patient) evaluation

When End-stage Liver Disease (ESLD) is confirmed after diagnostic tests and the need for getting a transplant has been established, the patient has to go through a formal evaluation to assess the suitability. This evaluation involves a round of blood tests, CT scans, MRI scans, along with tests to analyze the functioning of various vital organs including the heart & lungs which is performed by the specialists in their respective fields. Thereon, these evaluation tests are carried out with the following goals in mind:

• To identify the root cause of cirrhosis/ESLD with a goal to establish the diagnosis

• Evaluation tests can help detect the extent of liver damage and/or scarring and evaluate how other organ systems such as the lungs, kidney, etc. are affected. The results of these tests will also help in ascertaining the urgency of the transplant.

• Evaluations tests can help in detecting the presence of any liver tumor(s).

• To check if all other vital organs including the heart, lung, kidney, etc. are performing at optimal levels and whether they will be able to withstand this major surgery.

• To analyze the feasibility, complications, and difficulties of the surgery. Any prior risks such as abdominal infections, surgery, thrombosis of liver blood vessels will also be scrutinized to ascertain if they will pose any problems during surgery.

More often than not, evaluation tests are performed on as an outpatient procedure and take about a week to 10 days to finish. We understand that these tests can be hectic and take its toll on patients which is why it's imperative that you relax and maintain your composure at all times. Further, the instructions relayed to you by the doctor in charge need to be followed carefully to ensure the accuracy of these tests.

During the evaluation, a pre-transplant coordinator will be appointed who will be in charge of scheduling the various tests while also doubling up as your main point of contact. Whenever you have a doubt or query regarding any aspect of the evaluation process, this is the person you should be coordinating with. It also needs to be highlighted that based on your evaluation reports, further tests may be ordered if test results are unclear or if there is a need to dig deeper. To ensure that the whole process goes smoothly, you should ideally pay a visit to the pre-transplant clinic on a regular basis so that you're constantly in the loop and aware of what's going on with your reports.

In case of patients who are already battling an ongoing illness or if certain unexpected/incidental problems such as infections, cardiac & thyroid disease, etc. are brought to light during the evaluation, then the patient will be advised to undergo the evaluation in the hospital itself. In addition, these issues will have to be treated before the surgery is scheduled so as to avoid any future complications. Similarly, any patients suffering from conditions such as diabetes, hypertension or untreated cardiac problems will have to stay patient and stand by till the time these issues are corrected. That being said, there have been cases of the liver transplant being carried out even after successful cardiac angioplasty or in conjunction with heart bypass surgery.

Seeking authorization committee clearance

To conduct a liver transplantation, clearance needs to be approved by the government appointed authorization committee. At Fortis, our team will always be on-hand to explain to the patients and families about the various procedures and legalities involved. This involves filling up, preparing, and understanding the various forms, legal procedures, procuring the affidavits (statements under oath) along with any other supporting documents as required. These documents may include residence proofs for both parties, identity proof such as Passport, Aadhaar card, etc. In addition, establishing the basis of the donor-recipient relationship needs to be done and submitted with the application to the authorization committee to avoid any legal hassles.

Further, cases which have managed to seek approval and authorization for both the recipient and the donor are then evaluated and reviewed by our multi-disciplinary transplant team. It's at this stage where all details relevant to the transplant such as suitability, risks, etc. are discussed in length following which a transplant date is decided upon. However, this transplant date can be scheduled only after seeking approval and clearance from the concerned authorization committee.

Making a due arrangement of blood and blood products

Once the transplant decision has been confirmed by all the concerned parties, the next step is making an arrangement for blood and blood products. Around 18 units of blood (in most cases, from any blood group unless the patient falls under a rare blood group) will be required in advance from the patient's family members. Similarly, 3 counts of platelet donations will also be needed but this time it should match the same blood group as the patient. Platelets are usually obtained a day before the surgery as they have a very short shelf-life.

In case of any emergencies or difficulties, there are chances that additional blood might be required before surgery or have it replaced after surgery. In any case, the transplant team will keep the family in the loop of any changes or requirements on this front.

Making Necessary Financial arrangements

At Fortis, we have specially designed liver transplantation packages for our patients. Our packages are all inclusive of the evaluation tests, transplant surgery charges, doctor’s fees, medical supplies, room charges, and includes pre-transplant workup fee and life-long consultation charges for both patients as well as the donor. All the hassles of running around for completing paperwork, medicines, etc. are also taken care of. Our pre-transplant coordinators will be on hand to give you a break-down of the expenses required at the different phases of the process. Our team will also explain the accepted modes of payment while also shedding light on the various inclusions and exclusions of the package.

We have an array of packages which are structured as per the requirements of our patients. For instance, any patient which carries additional risk factors such as kidney or cardio-respiratory problems, or expected to require prolonged ICU care after surgery or in need of a complex surgical procedure owing to their prevailing circumstances may be suggested to opt for the high-risk package. In that regard, patients who are at a lower risk and mostly need a straight-forward liver transplant procedure may be advised to opt for a lower-risk package. In case of patients who are undergoing combined procedures such as a liver-kidney transplant, a dual lobe transplant, or an ABO incompatible transplant, customized packages will be offered to them. Similarly, patients suffering from pre-existing conditions such as hepatitis B or other diseases/conditions that entail the need for additional expensive medicines will also be suggested customized packages. Details about the packages and the accompanying costs are available with our pre-transplant coordinator.

In case of patients who have existing insurance coverage or an employer or embassy sponsored plan and whose expenses for the transplant and post-operative care will be covered by them, the same should be discussed with the TPA helpdesk or patient coordinator well in advance. All required paperwork will be guided by them. In case of certain insurance providers or employer packages, only part of the financial coverage is sponsored by them. Care should be taken to clarify all these doubts before the surgery so as to avoid any unnecessary financial headaches down the line.