Gifts of life: Living Donor Liver Transplant

Living donor liver transplants could save more dying patients but not enough of these are being done here

By Ng Wan Ching, The Straits Times, 30 Aug 2012

Every year, about seven people in Singapore die while waiting for a liver transplant from a cadaver.

Some of these deaths could be prevented, according to a leading liver specialist here, if there are more living donor liver transplants.

Dr K.C. Tan, who did the first such transplant here in 1996, said far fewer of these are being done in Singapore than in other parts of East Asia.

Of the 19 liver transplants done in all hospitals here last year on Singaporeans and permanent residents, three were live and 16 cadaveric.

Living donors could provide a viable solution for the increasing number of people who need a liver transplant, said Dr Tan, who is the director of the Asian Centre for Liver Diseases & Transplantation at Gleneagles Medical Centre.

This has become the case for places such as Taiwan, Hong Kong and South Korea, because of the shortage of cadaveric livers. The people on the waiting lists in these regions run into the hundreds.

Living donor liver transplants are outstripping cadaveric transplants there.

In 2000, Hong Kong reported nine cadaveric liver transplants and 32 living donor liver transplants.

In 2007, South Korea reported 34 cadaveric liver transplants and 286 living donor liver transplants.

In Singapore, there were 30 people on the waiting list for a liver at the end of May, up from nine in 2007.

Doctors said the growing waiting list in Singapore is probably due to more people suffering from the diseases that develop into liver cancer, The Straits Times reported in June.

Greater awareness among doctors of the effectiveness of liver transplants was also cited as a possible reason, the report added.

Living donor transplants are carried out at Gleneagles Hospital, Mount Elizabeth Hospital, Singapore General Hospital (SGH) and National University Hospital (NUH).

The private centres carry out far more living donor liver transplants than the restructured hospitals.

Gleneagles Hospital alone does about 20 to 25 cases a year. But most of its patients are foreigners.

The life-saving surgery involves removing part of the organ from a healthy donor and transplanting it into the patient who has acute liver failure or liver cancer.

This is possible because the liver, the second-largest and one of the most vital organs in the body, is the only organ that can regenerate or rebuild itself.

The livers in both donor and recipient will eventually grow to their original sizes in about two months.

The main causes of liver failure are viral liver infection hepatitis B; fatty liver, which is caused by a build-up of fats in the liver; and liver cancer, whose main risk factors are hepatitis B and C.

Dr Tan said the survival and complication rates of a patient getting part of a liver from a living donor are similar to one receiving a cadaveric whole liver.

What is more important is the reason why the patient needs the transplant.

For a patient with liver cancer or acute liver failure, the survival rate will be poorer than that of the patient who has chronic liver failure.

"Those with chronic liver failure tend to be younger. The paediatric cases also have higher survival rates," he said.

BARRIERS TO TRANSPLANT

Doctors say both related and unrelated living donor transplants may not be common in Singapore for two reasons: Patients may not be able to find a suitable donor or they may be afraid that the procedure is too expensive.

At restructured hospitals, liver transplant surgery from either a cadaveric or living donor costs about $35,000, said a spokesman for the Ministry of Health.

In a private hospital, the surgery for both donor and recipient costs $300,000 in total.

Dr Tan estimates the number of people needing liver transplants in Asia varies from 12to 15 cases per million.

But the reason the number of people waiting for a liver transplant here is lower compared with places such as Hong Kong, Taiwan and South Korea, could be that the disease burden here is lower.

The prevalence of chronic hepatitis B is not as high in Singapore as in Hong Kong and Taiwan, said Associate Professor Tan Chee Kiat, director of the liver transplant service at SGH.

At any one time, about 4 per cent of the population here has hepatitis B, compared with 15 to 20 per cent in Taiwan and about 9per cent in Hong Kong.

Although the prevalence of chronic hepatitis B infection in South Korea is about the same as that in Singapore, the incidence (the rate of occurrence of new cases) of chronic hepatitis C infection, another important cause of chronic liver disease and liver cancer, there is more than twice that of Singapore.

"In other words, the burden of chronic liver disease and liver cancer is lower in Singapore compared with these countries," Prof Tan noted.

There is also very effective medication for the treatment of chronic hepatitis B, which is the main cause of chronic liver disease here.

Such medication can improve the patients' conditions to such an extent that patients do not require liver transplants as their liver function recovers, he said.

In SGH, as far as possible, the first option for patients with liver cancer is to have the cancer surgically removed, rather than to have a liver transplant.

"Many patients do well after liver resection and continue living without other medical consequences," he said.

He added that there is an active liver cancer surveillance programme for at-risk patients here and, hence, a significant number of patients have early cancer treatable with surgery when first diagnosed.

"Not everyone with liver cancer needs a liver transplant and this may partly account for the discrepancy in waiting list numbers between Singapore and Hong Kong, Taiwan and South Korea," he said.

But once the patient has a recurrence of liver cancer, liver transplant then usually becomes the treatment of choice, he added.

HEARTENING SURVIVAL RATES

NUH started the liver transplant programme in Singapore in 1990 and performed the first living donor transplant here in 1996, with a team led by Dr K.C. Tan.

Since then, 18 adults and 60 children have received transplants from living donors at NUH.

All the donors recovered well.

At NUH, the 10-year survival rate of recipients, including adults and children, is 80 per cent, said Associate Professor Stephen Chang, a senior consultant at the division of hepatobiliary and pancreatic surgery at NUH and president of the Hepatopancreatobiloary Association of Singapore.

The 10-year survival rate for children undergoing liver transplant is 85 to 90 per cent, said Dr Tan.

NUH does not have separate survival figures for those who received cadaveric and living donor liver transplants.

When Dr Tan moved to Gleneagles Medical Centre in 2002, he started a similar programme at the hospital there.

He and his team expect to do their 200th living donor liver transplant late next month.

Ninety-five per cent of his patients are foreigners who come from places as far away as Mongolia, Russia, Kuwait, Qatar, Bahrain and Ethiopia.

He said they tend to be very ill adults, for whom a transplant is the last resort. The five-year survival rate is 66 per cent.

Of the 199 donors, one died after suffering a heart attack.

Dr Prema Raj, surgical director of liver transplantation at Mount Elizabeth Hospital, said he has carried out 33 adult living donor liver transplants since 2007, including in Egypt and Japan, as well as at private and restructured hospitals in Singapore.

SGH has had a liver transplant programme for adult patients since 2006. It has done 58, both cadaveric and living donor liver transplants. It declined to give more details.

The Ministry of Health said the median wait time for a cadaveric liver as at Dec 31 last year was around six months.

But for those suffering acute liver failure, which means that they could die within days or at most weeks, a transplant is the only way to survive.

It normally takes three to four weeks to prepare a living donor before surgery can be done. But in an emergency, this can be fast-tracked to four to five days.

Dr Tan said: "Living donor liver transplant is the way forward for this group of patients as it is very difficult to get cadaveric organs in time and much faster if there is a suitable donor willing to donate."

Hauled from the brink of death

Mr Jimmy Yeow's face crinkles in delight when he hears his son's voice on the phone.

It is more than the simple joy of a father greeting his child.

His son, Jie Xiang, is also the reason he is alive today.

If he had not received part of Jie Xiang's liver, Mr Yeow, 62, a semi-retired businessman, would have died two years ago.

His three children were then studying in Sydney, Australia, and he had tried to keep them in the dark about his liver, which was failing rapidly from hepatitis B, a viral liver infection.

Fortunately for him, he did not succeed.

First, alerted by her mother, his eldest child flew home to Malaysia to suss out the situation and report it back to her brothers, who were still in Sydney.

What she saw of her father's condition convinced her they had to come home quickly.

Mr Yeow, a Malaysian who lives in Port Dickson, was in a hospital near Kuala Lumpur.

His doctors had told him to gather his family members.

He told Mind Your Body: "I thought to myself, 'I am already 60 years old, why do I need my family members to sign anything for me?'."

Then it hit him that it was not consent for treatment his doctors wanted him to get, they wanted him to settle his affairs.

Mr Yeow knew he was deathly ill. He felt extreme fatigue and nausea and his skin had turned a bilious yellow.

His doctor said he had a few choices. He could go to the United States, Britain, Australia, Japan, China, Hong Kong or Singapore to get treatment. But the Malaysian hospital could no longer help him.

Mr Yeow's brother, a doctor, advised him to see Dr K.C. Tan, director of the Asian Centre for Liver Diseases & Transplantation at Gleneagles Medical Centre.

"I chose Singapore also because it was easier to get there, compared with other parts of the world," he said.

Time was of the essence. His doctor told him that no airline might take him if he delayed it for even a day.

"I was desperately ill. My stomach had bloated up like a pregnant woman's," said Mr Yeow.

He flew to Singapore with his wife and daughter and was admitted immediately to Gleneagles Hospital.

His sons arrived soon after.

The question then was: Who would be his liver donor?

His daughter, who was 27years old then, was so petite that her liver was not big enough to donate to her father.

Usually, for an adult living donor liver transplant, the larger portion of the donor's liver (the right lobe) is removed for transplantation.

His younger son was then not yet 21. Jie Xiang, then 25, stepped up to the plate without hesitation.

His decision was prompted by love, the thought of losing his father and the pain his mother and siblings would suffer as a result.

"Most importantly, we did not have sufficient time to explore any other options then," said the 27-year-old civil engineer, who now lives in Kuala Lumpur, in an e-mail interview with Mind Your Body.

The period before the transplant was extremely challenging for both father and son.

"It was an absolute test of my mental strength," the younger Mr Yeow said.

There were interviews with doctors, the psychologist, hospital consultants and the Transplant Ethics Committee, which are mandatory by Singapore law before any transplant can be carried out.

"It was a lot to bear," said the younger Mr Yeow.

With the August 2010 operation behind them, both father and son are now "doing great".

The younger Mr Yeow said the experience has taught him the concept of "you live only once".

"With this, I try to live my life to the fullest every day," he said.

His father is, too. He feels like he has been brought back from the brink of death.

The elder Mr Yeow said: "I feel like I am 26 years old again. I know I am a very lucky man."

Giving his liver to save his dad

Mr Ng Cheow Poh, 63, and his son Mr Kenny Ng, 33, will never forget the first few months of 2005.

It was a dark period.

In January that year, Mr Ng Cheow Poh's beloved father died.

It prompted the younger Mr Ng to postpone his wedding for about two months till April, which, as Chinese custom had it, was still within the sanctioned 100-day period following the death of an elder.

But before this could take place, the elder Mr Ng, who had the viral liver infection hepatitis B, developed liver cancer and needed a liver transplant to live.

The younger Mr Ng had to be the donor. His elder brother was not a match and his father wanted to keep his two sisters out of the situation.

This time, the wedding had to be brought forward to February, weeks before the transplant surgery.

The younger Mr Ng, who now runs the family business dealing in garment accessories, said: "There were many things to do, such as interviews and tests before I could donate part of my liver to my father. I had to plan my wedding and try and keep everyone's spirits up even though my dad was so ill and my grandfather had just died. It was hectic."

But he was calm about the surgery.

"I knew it was what I wanted to do. I had no reservations at all. I love my father very much. I did tell my wife that I was sorry to have to put her through it," he said.

The wedding could not take place after the operation because he would need months to recover and that would push the wedding date past the 100 days after his grandfather's death.

"According to tradition, we could either get married within the 100-day period after an elder's death or, if we miss that, three years later," he said.

The transplant, performed by Dr K.C. Tan and his team at Gleneagles Hospital, went smoothly.

For a year after the surgery, the family kept the elder Mr Ng at home, afraid he might catch a life-threatening infection outside of the house. "During that time, I travelled only from home to hospital and back," said the elder Mr Ng, now a grandfather of seven.

His condition was detected in 2002 when he had a gallstone removed.

The surgeon who did the operation noticed that his liver had hardened, which was not a good sign. The elder Mr Ng later discovered he had hepatitis B, a common risk factor for liver cancer.

Within two to three years, his liver was failing. Liver cancer followed and he needed chemotherapy.

"But chemotherapy was not working and I had to have a liver transplant," he said.

His skin darkened, he lost weight rapidly and looked haggard.

These were all symptoms of a failing liver.

But with the transplant, his outlook on life has changed.

"All my sickness is gone. I must live my life properly now. I don't worry about anything and I leave it to my children to handle the business. I stay happy and help to look after my grandchildren," he said with a huge smile.

The younger Mr Ng, now a father of two, is an avid cyclist and is training for a triathlon.

"I want people to know that it is no big deal being a donor. I am the perfect example. After the surgery, I am living like any other normal person and I can do everything a normal person does," he said.