Chronic Liver Failure is when the damage to the liver occurs slowly over time. There are four stages: inflammation, fibrosis/scarring, cirrhosis, and then finally ESLD. Common causes of chronic Liver Failure include cirrhosis, chronic hepatitis B or C infection, alcohol-related liver disease, or nonalcoholic fatty liver disease.
When the liver fails, it can result in a range of serious conditions like jaundice, internal bleeding, muscle wasting, and a build-up of toxins in the body. It can be a life-threatening emergency. A liver transplant can help patients suffering from these conditions regain their health and lead productive and fulfilling lives.
Liver transplantation is now the accepted standard of care for patients with end-stage liver diseases, acute liver failure, and selected cases of hepatocellular carcinoma (primary liver cancer). The development of effective immunosuppressive drugs and the refinement of surgical techniques have led to remarkable improvements in the long-term success of liver transplantation.
With new surgical techniques and effective medications, the success rate of liver transplantation is quite high. About 90% of liver transplant recipients continue to do well one year after transplantation.
Transplanting only a part of the liver is possible because of the liver's unique ability to regenerate itself within a few weeks. When surgeons remove a piece of the donor's liver, the part that remains grows back quickly to its original size.
In an adult-to-child liver transplant, a smaller part of the liver (the left lobe) is typically used. In an adult-to-adult liver transplant, the larger right lobe of the liver from the living donor is used.
In Singapore, a living donor liver donation can be from relatives (e.g., spouses, siblings, parents, uncles, aunties, cousins), friends, or even a stranger (altruistic donation). In deceased donor liver donation, the organ is retrieved from deceased donors under Human Organ Transplant Act (HOTA).
Symptoms of Liver Failure differ according to how far the disease has progressed, and how severe it is.
Symptoms of acute Liver Failure include:
If you experience these symptoms, it is a medical emergency and you should go to the nearest Emergency immediately.
Symptoms of chronic Liver Failure can be broken down into early or advanced symptoms.
Early symptoms include:
Advanced symptoms include:
Early diagnosis of liver disease combined with a well-managed treatment plan can often help to reverse the damage and prevent Liver Failure.
Tips on preventing Liver Failure are as follows:
A liver transplant can take place in three ways, where the donated liver can come from either a deceased or living donor.
It is currently the only cure for Liver Failure.
Treatment includes:
Treatment for Chronic Liver Failure includes both medications and changes to your lifestyle and diet such as:
With the liver's regenerative ability, sometimes it may recover with medication. Your doctor may recommend you to go for a liver transplant if your liver no longer works. You will need to undergo screening and tests at the transplant centre to determine if you are suitable for a liver transplant.
The transplant team will assess your suitability for a liver transplant based on:
A donor liver can come from a deceased donor or a living donor.
Living Donor
A living donor liver donation can be from relatives (e.g. spouses, siblings, parents, uncles, aunties, cousins), friends, or even a stranger (altruistic donation). For an adult recipient, approximately 60% of the right lobe will be grafted from the donor. For a paediatric recipient, approximately 30% of the left lobe will be grafted from the donor. The partial livers in both donor and recipient will grow in size and eventually function as a normal liver after a few weeks.
The living donor will need to undergo tests and screenings to determine if he/she is suitable to donate his/her liver to you.
Deceased Donor
In deceased donor liver donation, the organ is retrieved from deceased donors who are certified brain dead and have not opted out of Human Organ Transplant Act (HOTA) or have opted in to Medical (Therapy, Education and Research) Act (MTERA).
A brain dead patient does not have any brain function and will never regain consciousness again, although the other organs such as the liver may still function normally. It is different from being in a coma, where a person is unarousable but tests confirm that some brain functions are still present. A comatose person may still recover or regain consciousness. Organs are never taken from a person in a coma. To be certified brain dead, two independent doctors will perform thorough clinical tests and they must not have been involved in the care or treatment of the patient being certified, or belong to the transplant team.
Once a patient is diagnosed brain dead, it is recognised both medically and legally as death of the person in Singapore, and organ donation can then proceed. In cases where the patient had not pledged his/her organs before passing away, family members can decide to donate his/her organs under MTERA. Assessments will be done to determine if the organs are suitable for donation.
The deceased donor liver may be transplanted as a whole for one recipient or split into two for two recipients. In a split liver transplant, approximately 60% of the liver on the right will be transplanted onto an adult recipient and 40% of the liver on the left will be transplanted onto a paediatric recipient.
For more information on HOTA and MTERA, visit LiveOn.
You will need to bring:
Think about any question(s) concerning organ transplantation that you would like the doctors to address. If your family member(s) are involved in your decision making and would to find out more, you may ask them to join you for the first consultation.
You must be:
Once you have decided to go ahead with a transplant, you will be placed on the national waiting list, where you wait for a suitable organ from a deceased donor to be available. You will still be eligible for a deceased donor transplant if you have a living donor and the living donor evaluation is ongoing.
For those who are not medically suitable or more than 70 years old, you will only be eligible for a living donor transplant.
Both you and the potential living donor will be required to go through a series of tests to ensure the transplant can proceed, and an operation date will then be scheduled.
Living donor liver transplant
The diseased liver from the recipient is removed and a small portion of the donor's liver will be transplanted into the recipient.
In an adult-to-child liver transplant, a smaller part of the liver (the left lobe) is typically used. In an adult-to-adult liver transplant, the larger right lobe of the liver from the living donor is used.
Deceased donor liver transplant
As of 2020, the average waiting time for a deceased donor liver transplant is 1 year in Singapore1.
The wait time depends on your blood group, Model for End-stage Liver Disease (MELD) score, and other factors. MELD is a scoring system that predicts the risk of death due to chronic liver disease, which ranges from 6 to 40. The higher your MELD score, the higher position you will be on the national waiting list.
The wait can be a difficult and long one. It is normal to feel worried and uncertain. There may be some false alarms, for instance, if the donor organ is not ideal for transplant or if you happen to be ill that day. Our transplant team will be there to offer support in this challenging time.
Be sure to keep your contact details updated so that you can be readily contacted when an organ becomes available.
1Source: NOTU Annual Report 2020
In the time leading up to a transplant, your doctor will ensure that you are in the best of health, both physically and emotionally. You will also need to undergo a range of tests and screenings. These will help them ensure a better match and also identify any risks.
Living Donor Liver Transplant
Step 1
You will need to undergo several tests and screenings such as:
| Recipient blood group | Compatible donor blood group | Incompatible donor blood group |
|---|---|---|
| O | O | A, B, AB |
| A | A, O | B, AB |
| B | B, O | A, AB |
| AB | A, B, AB, O | NIL |
Step 2
The liver transplant doctor will discuss the results with you approximately one week after the tests are done. You will then need to undergo a chest x-ray, electrocardiography (ECG), and more detailed heart scans, as well as other investigations as necessitated by your medical conditions.
Step 3
Appointments will be made for you to see various specialty doctors as required by your medical condition(s). For example, if you have a heart problem, you will need to see a cardiologist. You will also undergo the final step of tests as needed.
You will be seen by:
Step 4
Once all the tests and appointments are cleared, the application will be reviewed by the Transplant Ethics Committee (TEC) to ensure that there is no commercial transaction taking place before and after the transplant. There is a compulsory one-week cooling-off period after the review.
The transplant surgery can go ahead after the TEC has cleared the evaluation. Typically, it will take at least four to six weeks for the surgery to go ahead after your first appointment unless it is an urgent transplant.
Deceased Donor Liver Transplant
You will also undergo the same step 1 to 3 as those going for a living donor liver transplant. Once you have cleared the evaluation, you will be added to the national waiting list.
While you are on the national waiting list, you must turn up for your appointments so that a medical team can help ensure that you are healthy and suitable for a transplant. A match from a deceased donor is likely to be from a person with your blood type.
TEC is a panel of three people, including at least one doctor and one layperson (non-medical), who have been appointed by the Ministry of Health. They will determine whether there has been coercion or financial promises made to the potential live donor.
Both coercion and payment for organs are illegal and punishable under Singapore law.
To ensure that you are fit for a transplant, the liver transplant coordinator will contact you regularly to arrange for health checkups. Some ways to increase your chances of a successful transplant include:
For living donor liver transplantation, you should fast eight hours before your surgery.
For those on the national waiting list, it is important to remain contactable as a deceased donor liver may be available any time. You must come down for the transplant immediately as the surgery must happen within a few hours after the organs are removed from the deceased donor. Do not eat or drink once contacted.
You can prepare a standby bag with necessities for your hospitalisation needs.
Some of the risks include:
Your surgeon will explain the risks in detail to you during your appointment.
The surgeon will make an incision just under your ribs to remove your liver and replace it with the donor’s liver. After the blood vessels are connected, blood flow will be restored and the surgical team will control any bleeding before the incision is closed.
Several tubes need to be inserted into your body during the operation and they will be removed between a few days and a week after your operation:
The surgery will take about six to 12 hours.
After the surgery, you will be monitored in the intensive care unit for several days, where the tubes attached to your body will also be removed once the respective bodily functions return. Once your condition stabilises, you will be transferred to a general ward. You can be discharged within two weeks after the surgery if no complication arises.
Complete recovery may take several weeks. The quality of life usually improves dramatically and most patients lead a healthy, normal life.
You will need to take lifelong medications to ensure that your body does not reject the new liver. Do not self-medicate or consume any traditional medicines. If you miss a dose, inform your transplant coordinator immediately. Do not take a double dose.
You will also need to do lifelong follow-ups with your liver doctor to ensure that you are in good health and to prevent any new complications. The frequency of your appointments depends on your condition. In general, it will be:
If you are experiencing any side effects, inform your liver doctor.
Taking care of your transplanted organ requires utmost care and living a healthy lifestyle. Exercise regularly, eat a balanced diet, manage stress and get adequate sleep.
Physical Health
Take more precautions against falling ill. Your weakened immune system (to prevent rejection) will mean you may be more susceptible to infections. Practice good hygiene at all times and stay away from people who are ill with an infectious disease (cold, flu, fever, etc.).
It is also important to monitor your health. Be aware of how you feel and do self-monitoring if required. This includes checking your weight, temperature, blood pressure and pulse daily.
Mental Health
It is normal to have a mix of emotions as liver transplant is a major life change. There could be several reasons, such as mood changes due to the immunosuppressants, or feeling stressed about your new lifestyle. You are not alone.
Let your transplant team know how you are feeling so that they can help to support you and adjust your medicine if needed. They may also refer you to a psychologist.
Dental Health
Practice good dental hygiene and make regular appointments to see your dentist.
Diet and nutrition
Maintaining a healthy diet and exercising regularly can help to prevent some common post-transplant complications such as heart attacks. It will also help to keep your liver healthy.
Your transplant team will refer you to a dietitian who will work around your nutrition and diet needs and recommend foods for your nutrition plan. Generally, your diet will have to be low in salt, sugar, fat, and cholesterol. It is important to avoid alcohol consumption to protect your liver. You can also discuss with the dietitian if you have any questions.
Exercise
You can explore walking, jogging, cycling, swimming, and other low-impact physical activities. Check-in with your transplant team if you want to start or change your post-transplant exercise routine.
Traveling
It is important to have recovered fully before you travel overseas. Your transplant team may recommend that you wait between two and twelve months after your surgery before you travel. You will need to have enough immunosuppressants for your overseas trip. Let your transplant team know your travel plans as you may need to take vaccines or avoid certain foods depending on your destination.
Driving
It is recommended to wait for at least two weeks after your discharge before you start driving. Some of the medications you need to take right after the surgery may cause tremors and vision changes. It will be safer to have a company in your ride when you start driving again.
Sex Life and Pregnancy Plans
Avoid having sex for four to six weeks after your transplant until your surgery site has healed to prevent the wound from opening again.
The side effects may include:
There are typically no symptoms when your body is rejecting your new liver. You will not feel or notice anything. Some people may experience symptoms such as:
Inform your transplant team immediately if you experience any of these symptoms.
Liver rejection is usually only detected when your laboratory test results show an increase in the blood levels of a liver enzyme. Your doctor will then send you for a liver biopsy to confirm if there is liver rejection. Therefore, it is important to take good care of your body, follow your prescription dutifully and turn up for all your clinic appointments to ensure that the transplanted liver will not be fully rejected.
There are two types of liver rejection that may happen after your surgery:
Acute Rejection
This can happen in up to 50% of transplant patients within the first year of the transplantation. The highest risk period is the first four to six weeks after transplantation.
Your doctor will adjust the amount of immunosuppressants you need to take to combat the rejection and prevent further rejections. Additional treatment may be required but it will not affect the chances of your graft survival.
Chronic Rejection
Chronic rejection of the liver is not a common occurrence and it could be due to repeated episodes of acute rejection. The rejection happens slowly over the years but is often reversible with treatment.
It is extremely important to follow your prescription to prevent liver rejection or any related complications.
With the increased incidence of chronic disease leading to organ failure, there is a gap between organ demand and supply of donor organs.
As of 2020, more than 50 people are on the liver transplant waiting list. The average wait time for a suitable organ donor is one year.
Living liver donation is key in easing the ever-present problem of organ shortage. Compared to deceased donor liver transplantation, living liver transplantation has significantly better graft and patient survival in the long term. Other than improved viability of the donated organ, recipients can undergo the operation earlier in a better state of health.
The success rate for living donor liver transplantation is over 99%, although over 20 years or so, some liver transplants are lost to rejection or other causes.
Living donation is a sacrifice and anyone can be a potential organ donor. It is the noblest gift an individual can give. The criteria to determine if an organ is suitable for donation is based on a set of medical standards and not dependent on age* or gender. All that is required is a willing and suitable donor.
* If you are below the age of 21 and are interested to donate your organ, parental consent will be required.
If you are interested to donate your liver to your family member, friend, or even stranger, there are some criteria you have to fulfill. You must be:
You will need to undergo a range of tests and screenings to ensure that you are a good match with the recipient and also to identify any risks.
Step 1
You will need to undergo several tests and screenings such as:
| Recipient blood group | Compatible donor blood group | Incompatible donor blood group |
|---|---|---|
| O | O | A, B, AB |
| A | A, O | B, AB |
| B | B, O | A, AB |
| AB | A, B, AB, O | NIL |
A blood group-incompatible live donor liver transplant may still be done, but there is a slightly higher risk of rejection.
Step 2
The liver transplant doctor will discuss the results with you approximately one week after the tests are done. You will then need to undergo a chest x-ray, electrocardiography (ECG), and more detailed heart scans, as well as other investigations as necessitated by your medical conditions.
Step 3
Appointments will be made for you to see various specialty doctors as required by your medical condition(s). For example, if you have a heart problem, you will need to see a cardiologist. You will also undergo the final step of tests as needed.
You will be seen by:
Step 4
Once all the tests and appointments are cleared, the application will be reviewed by the Transplant Ethics Committee (TEC) to ensure that there is no commercial transaction taking place before and after the transplant. There is a compulsory one-week cooling-off period after the review.
The transplant surgery can go ahead after the TEC has cleared the evaluation. Typically, it will take at least four to six weeks for the surgery to go ahead after your first appointment unless it is an urgent transplant.
Yes, the decision to donate is 100% voluntary. You can withdraw from organ donation any time, up till the day of surgery. Inform your primary doctor about the withdrawal and your decision will be kept confidential.
You can choose who you want to donate your liver to, as long as the assessments have deemed that you are healthy and a match to the recipient, and you have made a completely voluntary decision. You may also choose to be an altruistic donor.
If your blood group is incompatible with your intended recipient, the transplant team may suggest a paired liver exchange if there is another donor who is also incompatible with his/her recipient but both of you are a good match for the other’s recipient. This results in two new compatible pairs and allows others on the national waiting list to move up.
TEC is a panel of three people, including at least one doctor and one layperson (non-medical), who have been appointed by the Ministry of Health. They will determine whether there has been coercion or financial promises made to the potential live donor.
Both coercion and payment for organs are illegal and punishable under Singapore law.
Donating your liver will not affect your general health, life span, or energy level. Your liver will regenerate, grow back to its normal size, and function normally after a few weeks.
There could be minimal risks such as wound infection at your surgical site. Your surgeon will explain the risks in detail to you during your appointment.
There are two types of surgery, traditional open surgery, and laparoscopic surgery. Not everyone is suitable to undergo laparoscopic surgery, especially overweight donors or those with limited space in their upper abdomen. The surgeon will choose the method most suitable for you. You will be administered general anaesthesia before the surgery and will be asleep throughout as this is a major operation.
For traditional open surgery, a 20cm to 25cm J-shaped incision is made on the side of your chest and upper abdomen to remove the liver. The operation is about six to eight hours long.
Laparoscopic surgery, also known as keyhole surgery, is a new, minimally invasive approach for liver transplantation. Laparoscopic surgery involves having two small incisions around 0.5cm to 1cm on the abdomen, where the surgeons will insert a camera and tiny instruments. These are used to separate the part of the liver and its attachments after which the liver is removed through a second incision of around five cm at the lower abdomen. As the second incision does not involve cutting muscle, this method results in faster recovery for the donor than traditional open surgery. The operation is about four to five hours long.
After the surgery, you will be monitored in a High Dependency Unit for about one to two days before moving to the General Ward for another one to two days. You can be discharged within one week after the surgery if no complication arises.
You will not need to consume any long-term medication but will need to come back for follow-up appointments to ensure that you are well:
Your liver doctor will give you specific advice on taking care of yourself to reduce any risk of complications during your recovery.
Exercise
Maintaining a healthy lifestyle is important. You should be able to return to normal daily activities two to four weeks after your discharge. Please seek advice from your doctor if you are looking to resume any contact sports or strenuous activities.
Medicine is an ethical profession. No doctor will risk one life to save another. As a potential organ donor, organ donation will only be considered after every effort to save your life has been exhausted by the medical team. There are seven strict criteria that must be confirmed by two independent doctors, who were not involved in your medical care, before brain death can be certified and organ donation is considered.
In Singapore, Singapore Citizens and Permanent Residents above the age of 21 and above, and are not mentally disordered, are included under the Human Organ Transplant Act (HOTA) unless they have opted out. HOTA allows for organs (kidney, liver, heart and cornea) to be donated in the event of death for the purpose of transplantation.
Over the years, HOTA has been widened in scope so as to grow the organ donor pool. This has meant more people waiting on the transplant list have successfully gotten a life-saving organ. Despite the widening of HOTA, hundreds of people are still waiting for an organ to become available. This is where living organ donation comes in, an area also under the regulation of HOTA. Living organ donation further increases the chance that a suitable liver can be found.
Those who are under HOTA will not only have a chance to help others, but also have a higher priority on the waiting lists should they need an organ transplant. For those who had opted out of HOTA, you will receive a lower priority for receiving an organ on the national waiting list should you require an organ transplant in the future. This will apply specifically to the organs which you have opted out from.
If you have opted out before and would like to opt back in, you will need to complete the Withdrawal of Objection Form and send it to the National Organ Transplant Unit.
For deceased donor organ donation, bodies of those with chronic illnesses or cancer may still be used for education or research purposes under the Medical (Therapy, Education and Research) Act (MTERA).
To find out more about HOTA and MTERA, visit LiveOn.
Yes, anyone above 18 years old can opt into Medical (Therapy, Education and Research) Act (MTERA) to donate their organs and/or tissues for the purposes of transplant, education, or research after they pass on.
Fill in the Organ Donation Pledge Form and send it in to the National Organ Transplant Unit. You are encouraged to discuss your decision to pledge your organs and/or tissues with your family members so that they are aware of your decision and can advocate for your wishes in the event of your death.
MTERA is an opt-in scheme, whereby anyone aged 18 years old and above can pledge your organs or any body parts for the purposes of transplant, education or research, after you pass away. You can choose to donate all your organs and tissues or specify those you wish to donate.
In cases where you have not pledged your organs before passing away, your family members can also decide to donate your tissues and/or organs under MTERA on your behalf, if they wish to do so.
For more details on MTERA, visit LiveOn.
You will not be able to choose who you donate your liver to. Your liver will be matched to the blood group, weight and urgency from the pool of patients on the national liver transplant waiting list.
The hospital bills for any organ removal-related procedures and tests will not be charged to the donor’s family.
All bodies are cared for with utmost respect. Any incisions made during the removal of organs are carefully repaired during the procedure and you will still be able to have an open casket funeral.
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