Liver transplant: New hope for patients as doctors overcome blood group hurdle

Nearly 10 years ago, Zuana underwent a liver transplant to beat terminal liver failure. At the time, it had been 13 years since the first liver was successfully transplanted in India at Delhi’s Apollo hospital. But Zuana’s case was different. Her donor, her grandmother, did not have the same blood type and it was the first such surgery conducted Dr Arvinder Soin.
“Our team started liver transplantation in India 23 years ago and since then we have done it in about 3,600 cases. Over the years, we have continuously tried to innovate to ensure more liver patients can be saved and more people have access to the treatment,” said Dr Soin, who is now the chairman of the liver transplant department at Gurugram’s Medanta hospital and one of the surgeons who conducted India’s first liver transplant in 1998.

Use of blood group incompatible donors (referred to as ABO-incompatible transplant) is among the ways to increase the donor pool, especially in a country like India that largely depends on relatives to donate organs.
Unlike most western countries, where ‘deceased donor transplantation’ is predominant (which involves transplantation of organs from a brain-dead person), 85 per cent of liver transplant cases in India use living donors.
Around 2.5 to 3 lakh people are diagnosed with liver disease or cancer every year in the country, of whom around 50,000 can be saved with transplantation. There are less than 100 centres for the surgery across the country, all of whom together perform about 1,800 liver transplants a year.
Additionally, a liver transplant regry was set up in 2019 to collect data from these centres on survival rates, complications reported, and immunosuppressants used to help improve care across the country.
ABO-incompatible transplant
When the donor from a family does not have the same blood type as the recipient, the surgeons may try one of two approaches – a swap or an ABO-incompatible transplantation, where the transplant is done using a donor of a mismatched blood type.
A swap is conducted when donors from two different families match the blood group of each other’s recipients. Both sets of donors and recipients are then called to the hospital the same day and two transplantation surgeries are conducted simultaneously. This is possible only at high volume centres, with a big database of patients, several operation theatres, and a huge transplantation team.
“We have done this in nearly 60 pairs with 95 per cent success. This is interesting because there is a medically fit donor in both the families, but they individually cannot donate to their family member for the transplant. A swap helps achieve success in such cases,” said Dr Soin.
The other approach, an ABO-incompatible transplant, is a scientific challenge.
If a person is transfused with the wrong blood type, it may result in a severe reaction of the immune system, where the cells of the donated blood get “shredded”, causing shock, kidney failure and even death. So, how is it that the surgeons are able to transplant an entire organ from a person with a different blood type?
To achieve success in the procedure, the patients have to undergo an immunomodulation protocol three weeks before the transplant, which mainly includes two things. One, a medicine is used to kill the B cells that produce antibodies against the other blood types. Two, plasmapheresis – a process which separates the blood to its components outside the body – is conducted to remove the antibodies that are already present.
“The interesting thing is once the transplant is done, the body adapts to the new liver with a different blood type within six to eight weeks. The immune reaction is just a short-term problem and with the immunomodulation protocol, the success is just about 2 -3% less than in compatible donors. So, it is a very good option for those who do not have a blood type matched donor. This is what Zuana underwent and it was the first such case in the country,” said Dr Soin.
Later, a study found that all the eight children who underwent ABO-incompatible transplant at the centre survived.