• Patient suffering from end stage liver disease receives live liver transplant with brother as donor
• Both patient and donor were Jehovah’s Witnesses
• Specialized resources arranged to support the surgery

In yet another commitment to saving lives using the latest technologies in medical treatment, Aster CMI Hospital Bangalore successfully performed India’s first live liver transplant on Jehovah’s Witnesses from Nigeria. The surgery was challenging compared to a normal liver transplant because in order to protect the patient’s religious beliefs, the medical team could not use blood or blood products (Fresh frozen plasma, Cryoprecipitate, Platelets etc). Very few such surgeries have been successfully conducted worldwide.

Jehovah’s Witnesses are followers of a Christian faith that prohibits the use of blood or blood products in the treatment of the followers of the faith.  37-year-old Gehojadak, a Jehovah’s Witness follower had developed decompensated liver disease and visited more than 3 countries seeking treatment over the last 4 years but was turned away by most doctors due to the highly risky nature of surgery.

At Aster CMI Hospital, a team of liver specialists, comprising of Dr. Rajiv Lochan, Dr Sonal Asthana – Consultant Liver Transplant Surgeons, Dr. Mallikarjun Sakpal – Consultant Hepatologist, Dr. Arun V – Consultant Anesthesiologist and Dr. Prakash Doraiswamy – Consultant Intensivist, thoroughly reviewed the patient’s medical history before recommending a bloodless liver transplant and charted out a feasible pathway to make the surgery a success.

“Preparation is key”, says Dr Rajiv Lochan, Consultant Liver Transplant Surgeon. He continued “At Aster CMI, we have reduced blood use by 50% in all our procedures. We follow the WHO recommendation of ‘three pillars of blood management’. This transplant was especially challenging as we did not have the safety net (of using blood) even if the patient’s life was at risk due to their advance directive. We have performed other non-transplant liver surgeries in Jehovah’s Witnesses and this gave us the confidence to take on Gehojadak’s transplant.”

The team spent several counseling sessions with the recipient-donor and family to fully understand the various interventions and supportive measures that could be used during surgery. “Even if their hemoglobin levels dropped to life-threatening levels, the patients were clear that they would not accept a blood transfusion. Keeping the limitations in mind, the most effective treatment path was planned, and we spent close to 2 months preparing the patients for surgery. The hospital arranged customized artificial products like synthetic drug molecules, to conduct a bloodless liver transplant,” said Dr. Arun V, Consultant Anesthesiologist.

Dr. Sonal Asthana, Consultant Liver Transplant Surgeon said “In preparation for the surgery the patient and his brother also had to undergo ‘prehabilitation’ – a process during which the brothers strengthened their haematopoietic system to withstand the surgery without external blood transfusion. The patients were given haematinics – Iron and various vitamins and erythropoietin to improve their haemoglobin levels supported by regular physiotherapy and nutrition to strengthen their muscles.”

Without a liver transplant, Gehojadak’s chances of survival were less than 10% over the next 2 years. “Typically, during a liver surgery, patients tend to lose a large amount of blood which needs to be replaced for the patient’s survival. For a normal liver transplant, doctors keep at least 3-4 units of blood and a similar quantity of plasma/platelets on reserve for the patient. In this case, we had to figure out an alternative,” Dr Mallikarjun Sakpal, Consultant Hepatologist said.

“We instead used a ‘Normo-volemic hemodilution’ technique where we took two units each of both the patient and donor’s blood and kept it connected to their system throughout the surgery using special equipment so that there is no break in the blood circulation loop. This technique was discussed beforehand with the patient and was in line with their beliefs. The patient lost about 2 Units of blood during this surgery, but through this technique we were able to compensate for the loss,” said Dr Prakash Doraiswamy, Consultant Intensivist. He added that the surgeons used a “cell-salvage” technique during surgery to collect and reuse the blood lost during the surgery.

This kind of cell savage technique is rare, and the technical expertise used to perform this is not widely available in India.

The critical surgery took a 12-hour period to complete where two teams of specialists with close to 25 doctors including anesthetists, intensivists worked in absolute sync with each other and Gehojadak finally received a life-saving liver transplant. In a period of two weeks, the patient and his brother were fit enough to go home and were discharged from the hospital.

The kind of surgical technique and technology required in order to successfully pull off this surgery is par excellence and we are extremely proud of our team for being able to give this patient a new lease of life. India is always seen as one of the preferred medical destinations, the reasons being many on the list such as cost effectiveness, focus on advanced medical technology and availability of skilled medical professionals and we believe that the country’s medical tourism sector is expected to become more popular with continuing development in the near future.” said Dr. Nitish Shetty, CEO, Aster Hospitals, Bangalore.