A. a) Your mother has decompensated liver cirrhosis from hepatitis C and requires a liver transplant. Interferon treatment would not be tolerated in this situation. Medical treatment alone would not be adequate in the long run.

b) Yes - she can undergo the transplant on TB treatment if the TB is not active.

c) The use of anti-TB medication is difficult in patients with liver cirrhosis. Do you have the culture results of the TB? This will help the choice of medication. Second line medication may be needed if the first line medication cannot be tolerated.

d) Hepatitis C is likely to re-infect the new liver but treatment can be given after the liver transplant and is usually quite effective. In a very small group of patients, one can have a rapidly recurring form of hepatitis C but this is unusual.

e) There are currently no effective drugs that will treat cirrhosis specifically. Treatment is usually directed at the underlying cause of the liver disease. At the end of the day, we would need to assess the patient before giving you a final result.

A. It is an extremely difficult decision to decide on the best treatment for a patient with a large HCC and decompensated liver disease. You are quite right in thinking that currently, there is no curative treatment for such a condition except for liver transplantation which would treat her liver cancer together with her decompensating liver cirrhosis. In many centres, due to acute shortage of cadaveric donor livers, patients with liver cancer beyond the Milan criteria are not transplanted. However, there are centres such as ours where living donor liver transplantation (LDLT) is widely practiced and often patients with large tumour, way beyond Milan criteria but with no extra-hepatic metastastes and also no large venous involvement such as the large hepatic veins and the main portal vein, are being transplanted successfully. The majority of patients transplanted in Asia using LDLT are beyond the Milan criteria as there is no other alternative treatment. The 3 year survival rate for this group has ranged from 25-40% and it is well known that for patients who have survived the 3 years are likely to continue living beyond this period as the recurrence rate decreases markedly after the first 12-18 months. The main constraint to LDLT is, of course, the availability of a suitable donor.

A. It is clear your sister certainly needs a liver transplant in the near future for her decompensating liver condition. The development of intractable ascites especially coupled with hepatopulmonary syndrome presents a very grim prognosis without a liver transplant. The success rate of a live donor liver transplant in Singapore is approximately 85% but this will depend very much upon the status of the patient at the time of transplantation. As your sister is young and if her cardio pulmonary status is satisfactory, then I would imagine her potential is very high. Rejection is no longer a major issue in organ transplantation especially concerning the liver nowadays, but it likely she will have treatment for her hepatitis C once she has recovered from her transplantation.

A. The benefit from Nexavar is minimal when the condition is this severe. If he cannot swallow this, one can instead a nasogastric tube to feed him and provide medications but some patients may not tolerate this well. TACE should be considered to try and control the liver cancer. Liver transplant may still be considered if the thrombosis does not extent to the confluence. We will need to review the CT scans to decide. Furthermore, before a transplant can be undertaken, we will need to ensure the cancer has not spread and he is also clinically fit to undergo the operation. The risk is obviously higher in such cases but the alternative will be demise in a short space of time. To really provide a comprehensive answer, we would have to see him in our clinic to assess him properly.

A. A liver biopsy has risks associated with the procedure including death although this is a very small risk. It does provide a better assessment of the liver function when you have hepatitis B. We would not normally do a liver biopsy in this situation. As far as treatment is concerned, there is no proven benefit. If there is a strong family history of liver cancer, one can argue for treatment. One would normally treat only if there is evidence of liver cirrhosis or significant liver enzyme elevation. One's age may help decide on what sort of treatment to consider. Close follow up is essential.

A. These are approximate timings based on an average pt. Assuming there are no major problems with the donor, the pre-op evaluation would take about 2 weeks. The operation will take one day. However, to organise an appropriate time for the surgery is dependent on several factors e.g. blood supply and other surgery. It may thus take one or two weeks from the time the evaluation is complete before surgery is donor. After surgery, the recipient will stay one month in the hospital, and another 6 to 8 weeks in Singapore. The donor will stay one week in hospital and will be able to return to their home country after another one week as an outpatient.

A. The donor has a 0.5% risk of mortality assuming that they do not have any major medical issues. The recipient's risk would be better appreciated after the evaluation. Overall, the immediate preoperative risk in a routine patient is 10%. The long term survival is dependent on the underlying liver condition, the age, and the recovery. The overall median 5 year survival is 75%.

A. There is NO long term risk to the donor and they do NOT need to be on life long medications. He cannot donate the liver again even though the size has increased because the artery has only one branch.

A. Yes - the recipient will need immunosuppressant for the rest of their lives to prevent rejection. No medication is free from side-effects. There may be increased risk of hypertension, diabetes, and renal impairment. However, this is part of the overall risk following a transplant and cannot be avoided unless you take an organ from an identical twin.

A. Usually 60% of the right lobe of the liver is removed from the donor through an operation.

A. Yes - the donated liver will also grow to a bigger size.

A. Your report suggests your husband decompensated while on peginterferon treatment. I would recommend you stop all treatment including thrombomax and peginterferon and ribavirin, and your husband come over for further assessment. I am concerned about the rapid rise in bilirubin over at relatively short duration of time, and I am concerned about complications such as portal vein thrombosis, spontaneous bacterial peritonitis, or variceal bleeding. We will also counsel you and your family about live donor liver transplant at the same time

In response to your specific queries:

1. Cost for liver donor transplant here is S$300,000 and above with GST, depending on patients approximate condition. But this does not include pretransplant assessment or management. In view of the rapid rise of bilirubin, I think your husband should come to us sooner rather than later.


2. If fatty liver is >30% then they are not suitable as potential liver donor. Please ask them to start losing weight and we can do the biopsy in Singapore.


3. We accept both genetically related, or emotionally related donor. But the donor must be emotionally related, like being a friend or colleague.


4. It is difficult for me to decide on management through email without assessing the patient clinically. I will strongly advise your husband come over early for treatment.

Many studies have showed among patients with decompensated cirrhosis, half died within 2 years. But the actual survival depends on the individual patient's condition. Again, it is not possible to comment without assessing the patient clinically.

A. Usual symptoms of liver disease are jaundice (yellow discoloration of the eyes), dark coloured urine, itching, vomiting of blood, ascites (accumulation of fluid in the abdomen), easy bruisability or tendency to bleed, and mental confusion. Many people with liver disease have non-specific symptoms only (loss of desire to eat, nausea, weight loss, lethargy, and general feeling of not being well).

A. Types of viral hepatitis are Hepatitis A, B, C, D & E. Of these, Hepatitis D can occur only in conjunction with Hepatitis B.
Hepatitis A and E spread through the feco-oral route i.e by contaminated water and uncooked fruits & vegetables. Hepatitis B and C spread through contact with body fluids i.e by blood transfusion, unprotected sexual contact, use of shared/contaminated needles/razors etc, and transmission from an infected mother to her baby (during pregnancy/childbirth/breast-feeding).

A. Hepatitis A and E are generally self-limiting. After the resolution of an acute infection, they rarely go on to chronic hepatitis or carrier state. Occasionally, however, they may lead to fulminant hepatitis. After the resolution of acute hepatitis B or C, some of the patients may become carriers or may have chronic hepatitis. It is this group of patients who may develop complications, e.g. liver cirrhosis or liver cancer.

A. Chronic hepatitis leads to an ongoing damage to the liver cells and as a response; there is regeneration and scarring of the damaged tissue. This may result in cirrhosis with its attendant problems of liver failure, and/or liver cancer.

A. Cirrhosis of liver may lead to portal hypertension (increased pressure of the blood in portal circulation). This may result in vomiting of blood, black coloured stools, accumulation of fluid in the abdomen (ascites). There may be an alteration in levels of consciousness with tremors, forgetfulness (hepatic encephalopathy) because of the toxins which are not being cleared by the liver. As the liver is unable to synthesize proteins necessary for clotting, there may be increased bleeding tendency. In addition, liver cancer can develop on the background of cirrhosis.

A. Treatment of cirrhosis generally depends on the clinical manifestation and underlying liver function. The patient may require endoscopic banding/sclerotherapy of the esophageal varices if he has had vomiting of blood or black stools. He/she may need diuretics (medicines to increase urine output) for fluid collection in abdomen and swelling of feet. If the patient also has active viral hepatitis, he/she may require specific treatment (antiviral medication for hepatitis B, interferons for hepatitis C). Other than these, for a patient with well compensated cirrhosis, the treatment is supportive. Unfortunately, there is no effective medicine to reverse the process of cirrhosis.

A. The common signs of worsening or decompensation in a cirrhotic patient are increasing fluid accumulation in the abdomen (ascites) which is unresponsive to treatment, and signs of hepatic encephalopathy (altered consciousness, tremors, forgetfulness, etc). Blood tests may reveal low levels of albumin, high levels of bilirubin & ammonia and elevated prothrombin time (reflecting decreased coagulability of blood). An episode of upper GI bleed can precipitate decompensation.

A. The ideal treatment of decompensated cirrhosis is liver transplantation. Other forms of treatment like liver dialysis may serve as temporary supportive measures and as a bridge to transplantation.

A. Liver cancer can be either primary or secondary (spread from cancer elsewhere in the body, eg. colonic cancer). Secondary liver tumors are generally diagnosed concurrently or on follow-up after treatment of the previous cancer elsewhere. Primary liver tumors can be related to hepatitis B or C, can develop on the background of cirrhosis from other causes, or can be idiopathic (unknown cause).

A. Patients with liver cancer may present with pain or a lump in right upper abdomen. They may have non-specific complaints like weakness, inability to eat, loss of weight etc. In addition, they may have symptoms attributable to the pre-existing hepatitis or cirrhosis.  

A. Liver transplantation is a surgery in which the diseased liver is completely removed and replaced with a normal liver or a part of liver from the donor. The donor liver can be from a deceased person (cadaveric donor) or from a living person.

A. You should be between 21-50 years of age and free from any significant medical or psychiatric problems. You cannot be pregnant or overweight. Preferably a body mass index of 30 or less is required. If you smoke, you are advised to stop prior to surgery. If you have any major medical problems, you will be ineligible to be donor. In addition, your blood type needs to be compatible with the recipient's blood group. You must be either the same blood type as your recipient or blood type 'O'. You must be competent and freely willing to donate.  

A. The donor should be either related or emotionally-related to the recipient.

A. The donor undergoes removal of a part of his / her liver; right lobe if the recipient is an adult and a part of left lobe if the recipient in an infant or child. This part of liver is removed along with its attached blood vessels and bile duct. The donor is operated under general anaesthesia. A drain placed in the abdomen at the end of the surgery and will be removed once drainage is minimal post operatively. The remaining liver of the donor is sufficient for his functions and it regenerates within 2 to 4 weeks to almost the normal size. All effort is made to make the donor surgery as safe as possible. The blood loss in this procedure is usually minimal and the donor generally does not require any blood transfusion.  

A. Generally, the donor stays in the hospital for a total of 7 days. After surgery, the donor spends the first two nights in the ICU to be closely monitored and normally transferred to the general ward the following day. Donors are encouraged to get out of bed and sit up in the chair on the following day after surgery and walk short distances as soon as they are able.

A. Recovery time varies from each individual. Typically, donors spend 2-4 weeks to recuperate after surgery. Most of the time, the donor is able to return to work 4-6 weeks post-surgery. They are however, advised not to lift heavy objects or do strenuous exercise for at least 6 months.

A. After discharge, the donor is advised to be monitored weekly for 2 weeks, then once in 3 months, 6 months and a year, depending on the individual's condition.

A. It takes typically 5-6 working days.