Acute Liver Failure

Acute Liver Failure (ALF) is a syndrome characterised by deterioration in liver function in previously normal individuals over a period of 16 weeks and manifests as progressively worsening jaundice, liver function and encephalopathy (coma) . In the pre-transplant era, ALF had uniformly poor outcome with a significant number ending in death. However with better intensive care management and timely liver transplantation, many of these patients who are usually younger than those with cirrhosis, can be saved. Transplantation is considered only in patients who develop features of hepatic encephalopathy and severe deterioration in liver function or those who meet recognised criteria (King's College or Clichy). It is therefore prudent, at least in countries where transplantation is not widely accessible, that before the onset of coma and multiorgan failure ensue, patients who continue to have deteriorating liver function be shifted to facilities where transplantation can be offered . Early recognition and risk stratification followed by timely transplantation when indicated is the only way to save patients with ALF.

Liver donation by living donors...........A Necessary Evil but A Gift of Life

Taking organs from a living donor is currently the only reliable way the ever-widening gap between need for organs for transplantation and the organs available from deceased donors can be hoped to be bridged. Until promises of stem cells and other esoteric therapies are practically realised, transplantation from living donors will continue to be in the ever-growing list of 'necessary evils' in modern society. Kidney transplantation from living donors has been around for as long as kidney transplantation itself and hence gained greater acceptability as compared to liver, pancreas or intestine transplantation from living donors. It is believed (and not without some reason) that since donors have two kidneys and one is all that is sufficient, one can be easily donated. However unlike the liver, the kidney does not regain most of (if not all) the lost tissue volume, the other kidney simply adapts and becomes more efficient to take on the additional burden. Similar changes occur in the pancreas and intestine after partial donation. The liver is unique in that the remaining liver (after removal of a lobe for transplantation) is not only usually enough by itself to sustain metabolic activities but it also (demonstrably) grows in size to regain almost all the lost volume. Hence in pure metabolic and tissue mass terms, the living donor is less disadvantaged after partial liver donation than after donation of a part of pancreas, intestine or one kidney. The main concern currently is that removal of a part of one lobe is a much more complex operation than that required for removal of a kidney or a segment of intestine. Hence until a better solution to provide much needed organs for transplantation is found, rather than run down living donation , energies should be concentrated on making the process of donation transparent, simpler, safer and less demanding on the donor.