Requirement & Background :
The demand for livers far outweighs the supply of deceased donor organs in our country as well as across the world. 30-40% of patients on the waiting list for a deceased donor transplant either succumb to complications of liver failure or become too sick to undergo a liver transplantation while waiting. Various strategies aimed at increasing the donor pool and reducing waitlist mortality have been explored across the world. One such innovation is domino liver transplantation, appropriately named, as two recipients undergo transplant from one deceased donor. This is possible because in certain rare congenital metabolic disorders such as familial amyloid polyneuropathy, there is a genetic enzymatic defect resulting in the production of an abnormal protein that gets deposited in various tissues of the body causing multisystem organ dysfunction over the first 30 years of the patient’s life. This results in crippling deformities that inexorably progress over time and if untreated by liver transplantation, culminate in death by the fourth decade of life.
The underlying liver is essentially normal in morphology and function apart from the production of the abnormal protein. An older patient in need of an urgent liver transplant either because of sever liver failure or hepatocellular cancer can be saved with such a transplant as the alternative of waiting for another liver on the deceased donor waiting list carries a high risk of death. Further, it would take another 25-30 years for the clinical manifestations of abnormal protein deposition to manifest themselves by which time the second recipient would have exceeded the average life expectancy.
The operation was conducted on 17/11/2011, in 3 operation theaters simultaneously led by4 transplant surgeons.
The deceased donor was a 24-year-old male from Jharkhand, Mr. Mohammed (name changed) working as a chief welder at a construction site in Chennai. He fell from a height and sustained severe head injury and was diagnosed brain dead here. His family (sister and brother) agreed to donate his organs for transplantation.
The first recipient was Mr. Vijay Kumar, a 34-year-old gentleman diagnosed with a genetic metabolic disorder called Familial Amyloid Polyneuropathy (FAP). He suffered from crippling gait and balance disorder, bowel and bladder disturbances among others, which progressed over time. The diagnosis was made in the third decade of life.
The second recipient was a 64-year-old gentleman, suffering from end-stage liver disease with decompensation. He was recently listed for a liver transplant and was not expected to get a liver through the waiting list anytime soon. On being explained the picture, he readily agreed for transplant.
The cadaver donor operation was carried out first and the liver, kidneys, heart valves and cornea were retrieved. The first recipient was subsequently started and the liver was retrieved taking special measures as we would in a living donor operation (preserving native cava and hepatic veins) to allow us to transplant it into the second recipient. The liver was flushed with preservative solution, removed and prepared on the bench with extension grafts from the cadaver donor blood vessels to facilitate implantation in the second recipient. The second recipient was started an hour after the first recipient so that the time outside of blood circulation was kept to a minimum.
The surgeries went on uneventfully and both patients were managed in the liver transplant ICU. They were both discharged 6 and 12 days after transplant and are doing well. No blood or products transfusion were required in Vijaykumar, who is already appreciating the difference in the back pain and urination.
Such measures require a high degree of technical expertise of the operating team, supporting departments and a high maturity level of the program. At the Centre for Liver Disease and Transplantation at Apollo hospitals, Chennai, we have performed around 300 liver transplants including over 200 deceased donor liver transplants, which is the largest number in India. This was the first successful adult domino liver transplant in the country.