Conversation with Dr AS Soin
Padma Shri Dr. AS Soin
MBBS(AIIMS), MS (AIIMS), FRCS (Edin), FRCS (Glas), FRCS (Transplant Surgery)-Cambridge, UK.
Transplant Care team caught up with Dr Soin and asked him a few questions that are on the minds of most patients.
TransplantCare team : Dr Soin, most patients even after completing the pre-transplant work up are reluctant to undergo the transplant. There is the apprehension about the risk to life and about the financial impact. There is a wishful thinking that maintenance medication will somehow do the magic. Please tell us when is the right time for a transplant?
Dr Soin : The patient should have a transplant when it is clear that there is advanced, irreversible damage to the liver, and the maximum life expectancy of the patient is a year or two even with the best medical treatment. Usually, such patients have had liver disease for several years (chronic liver disease, or cirrhosis – which is the medical term for permanent scarring of the liver). Often, they realize that they are sick only over the previous 6-12 months, or when they develop liver cancer. Patients must have a liver transplant before they become too ill, and before the disease starts affecting other organs such as the kidneys and lungs. Based on evidence from hundreds of thousands of such patients, liver experts have formulated disease scores (CTP, MELD) that are calculated on the basis of the severity of abnormalities seen in advanced liver disease: blood tests such as serum bilirubin, serum albumin prothrombin time, serum creatinine, and the degree of water logging in the body, and the effect of the disease on the brain. Liver specialists use these scores and their own subjective assessment to suggest the right time for transplant.
There are some patients who suffer from sudden (acute) liver failure over a few days that keeps worsening. Such patients need an immediate transplant, often within 1-2 days.
Transplant Care team : Please could you advise the patients on the signs/symptoms they should look for so that they do NOT delay the transplant decision any further?
Dr Soin : Patients who have any decompensation (symptoms and signs indicating advanced liver damage) such as blood vomiting or bleeding with stool, water in the abdomen (ascites) or around the lungs (effusion), kidney derangement (elevated serum creatinine), drowsiness or confusion (liver disease affecting the brain), or breathlessness and low oxygen levels due to shunting of blood away from lungs (hepato-pulmonary syndrome), must immediately seek an opinion from a liver specialist and prepare for an early transplant.
Transplant Care team: In the patient community we often hear that patients stop being diligent about the follow-up. Even well educated patients tend to think they understand their parameters and can now manage their own dose of tacrolimus. Please can you guide the patients about the need for follow up and the perils of self-regulated medication?
Dr Soin : Adherence to medicines and regular testing routine advised by the transplant specialist is vitally importance after transplant to ensure good long-term function of the liver. Patients who slacken on follow up or indulge in self-monitoring and alteration of medication are likely to suffer side effects of medicines and transplant rejection. While patients feel absolutely normal within 2-3 months after transplant, and will remain so in through out their life, they can quickly become ill and develop transplant liver failure if they default on regular tests and medicines.
Transplant Care team: Almost all patients start gaining weight 5-6 months after the transplant. Is this directly related to immunosuppression? What would you advise to the patients?
Dr Soin : Weight gain after transplant is common. While it may due in part to the effect of medicines (steroids, tacrolimus), it is largely due to lack of activity and improved appetite. The effect of steroids is temporary, lasting only for 3-6 months. The tacrolimus effect is easily controlled by dose adjustments by transplant specialists. Patients must refrain from over-eating, and excessive consumption of foods high in fat and carbohydrate content. In addition, they must exercise regularly.
Transplant Care team : Living donation is a real option to at least half the patients, have there been advances in living donation over last three decades, please tell us something that will reduce the anxiety in the minds of potential living donors?
Living liver donation is now very safe in experienced centers. In most high-volume centers, transplant surgeons have developed rigid donor safety protocols entailing a meticulous and detailed assessment of donor age, BMI, fat content of the liver, liver tests, liver anatomy, amount of liver being left behind, and condition of the other systems such as the heart, lungs and kidneys – all of which are important in determining the safety of donation. In addition, several operative steps are undertaken to ensure donor safety. In advanced centers like ours, maximum donor comfort, minimal postoperative pain, good scar cosmesis, and safety is ensured by a combined laparoscopic and open bloodless surgery approach.
Dr AS Soin at present is the Chief Hepatobiliary and Liver Transplant Surgeon Chairman, Medanta Institute of Liver Transplantation and Regenerative Medicine Medanta-The Medicity, Gurgaon (Delhi-NCR),India.
Dr Soin’s team is the first in India and the second in the world to complete 2500 living donor liver transplants. Dr Soin is recognized the world over for pioneering and establishing Liver Transplantation in India from 1998, when he did the country’s first successful transplant to now, when he leads the country’s largest, and one of the world’s largest and most successful liver transplant programs at Medanta.