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This is a stage of liver disease when medical management fails to give curative treatment. Medical management at this stage centers round prolonging lifespan (short term survival) by managing complications of liver malfunction and raised liver pressure.
This is the time to embark on pretransplant evaluation and optimization to ensure high survival rates after transplant.
ESLD occur due to long drawn silent liver scaring due to various causes.
Alcohol is the predominant cause followed by lifestyle related fatty liver disease and viral infections. Rare genetic and metabolic defects can also end up in ESLD. ESLD is a clinical situation where the liver scarring is beyond repair and liver pressure has mounted. Increased pressure inside the liver damages other organ systems as well, leading on to complications like water logging, kidney dysfunction, brain dysfunction, muscle depletion, heart and lung malfunction. Replacing the damaged liver by Liver transplant intervention is the only solution. Pre liver transplant evaluation to asses success rate of liver transplant intervention, optimization to ensure high post transplant success are all crucial.
The commonest cause of long drawn (Chronic) liver disease in India is Alcoholic liver disease. Alcoholic liver disease is silent in its initial phases lasting for 1-2 decades. The disease evolves in three patterns – to begin with fat accumulates in liver (Alcoholic fatty liver). Swelling or inflammation of liver cells follows (Alcoholic hepatitis). After many years of ongoing inflammation, scar tissue (Fibrosis) forms inside the liver and when these accumulate silently, ultimately results in cirrhosis of liver.
Cirrhosis generally occurs due to heavy alcohol consumption (20-40 grams of absolute alcohol per day); but this quantification of alcohol needed to develop cirrhosis is highly variable and depends on other factors like genetic makeup of the individual and lifestyle. Those who have lifestyle disorders like Diabetes, raised blood pressure , raised cholesterol levels have more risk of fatty liver and alcoholism in them may accelerate liver damage resulting in cirrhosis at a younger age.
Viral hepatitis- acute and chronic- Various viruses which infect human body can inflict liver injury. Liver specific viruses like Hepatitis A, B, C, Delta, E are common. These can induce acute liver inflammation (Acute Hepatitis), or long drawn inflammation (chronic Hepatitis). With medical management Hepatitis C is completely curable and Hepatitis B can be suppressed to avoid consequences like cirrhosis and liver cancer.
Liver tumors including Hepato cellular cancer (HCC)- benign and malignant tumours occur in the liver. Early detection of liver tumours and their characterization are important in ensuring curative treatment.Both surgical and non surgical methods are available to treat Liver tumours.
Drug induced liver injury- many medicines used in various medical systems .Over the counter medicines , especially of herbal origin induce serious liver damage.
None alcoholic fatty liver disease (NAFLD)
Those who don’t consume alcohol can develop fatty liver disease in the back ground of sedentary lifestyle, unhealthy food habits, a condition known as Non alcoholic fatty liver disease (NAFLD). When you eat more than the level of physical exercise you engage in, excess calories taken in which are not burned out, transforms into fat and gets deposited in the Liver. Over time – Years or decades in some cases NAFLD progresses to a more serious condition called “fatty swelling” or “Non-Alcoholic Steato Hepatitis” (NASH), where the liver becomes inflamed and scarred and ultimately liver structure and function are deranged. Without treatment, the disease worsens to liver cirrhosis.
NAFLD can be prevented and reversed to a large extend by diet and lifestyle modification along with medical management.
A person who leads a normal life, who is not known to have a liver disease previously, abruptly develops yellowing of eyes and urine, vomiting, clouding of thought processes and sinks into coma. This is the dreadful syndrome of Acute liver failure (ALF). Various causes of ALF range from Viruses, Drug induced liver injury-, Herbal therapy induced liver injury (HILI), Poisonings, Alcohol, pregnancy associated Liver disease.
This is life-threatening illness, where a previously normal liver fails within days to weeks. On top of more than 500 vital functions which liver performs, including filtering, cleansing, manufacturing and digestive functions it performs- all of these come to a standstill in acute liver failure. Sudden loss of synthetic and detoxification function of liver results in jaundice, brain dysfunction, bleeding due to blood clotting mechanisms, and multiorgan failure. Literally a LIVER ATTACK , this clinical condition necessitates early referral to a Liver intensive care unit. Emergency Liver transplant intervention is indicated in many cases.
Liver transplant intervention involves medico surgical management. Transplant surgery and 2-3 months there are likelihood of surgical complications. Beyond 3 months lifelong mostly medical management is all what is needed and extent of survival solely depends on how meticulously this post transplant medical management happens. Long term medical management centers around health of new liver, managing infections, complications involving bile ducts and blood vessels. Management of metabolic syndrome ( Diabetes, hypertension and dyslipidemia) and ensuring health of heart and cancer surveillance as well.
Genetic and metabolic liver diseases- relatively rare, these are seen both in adults and children.
Prevention is always better than cure; a big chunk of liver morbidity is contributed by lifestyle issues and many a time the liver damage is silent and protracted before end stage liver disease sets in. Hence, there is a wide time window for preventive liver care strategies to be in place
Crux of the issue is that preventive strategy is possible only in silent phase of liver disease when patient has no reason to reach a liver care facility. Once symptoms of liver disease start, patient is alerted, but it is too late for a preventive strategy and complete cure is mostly not possible in symptomatic phase. Need of the time is to put Liver screening programs in place to identify liver diseases at an earlier (silent)stage- so that we can aim for cure and NOT palliation. Willingness of general public to undergo liver screening programs is the backbone of preventive liver care. Public awareness matters a lot in this perspective ( please see the lay press articles section and FAQ section)
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