Times of India
23, February 2010
By Denise Grady

Surgery Offers Patients Chance Of Normal Life That Is Free From Anti-Rejection Drugs
Jonathan Nuñez was 8 months old when a liver transplant saved his life. Three years later, his body rejected the transplant, attacking it so fiercely that it wasted away and vanished, leaving no trace.

That result, seemingly a disaster, was what doctors had hoped for. They deliberately withdrew his antirejection pills as he no longer needed the transplant. His liver had, as planned, regenerated.

Jonathan, a 4–year–old is among a small number of children in the United States who have undergone a highly unusual type of transplant surgery, one that – for the few who are eligible – offers a tremendous advantage: a normal life, free from antirejection drugs, which suppress the immune system and increase the risk of infections, cancer and other problems. Normally, transplant patients must take these powerful drugs for life.

In standard transplants, the diseased organ is completely removed and a new one put in its place. What is different about the operation Jonathan and the other children had is that only part of the recipient’s liver is removed, and it is replaced with part of a donor’s liver. At first, to prevent rejection, the patient takes the usual drugs.

Then, doctors watch and wait. The liver has an extraordinary ability to regenerate, especially in children, and the hope is that while the transplant is doing its job, what remains of the patient’s own liver will regenerate and start working again. The process can take a year or more; in Jonathan’s case, it took three.

If the liver does regenerate and grow large enough, doctors begin to withdraw the antirejection medicines. The patient’s immune system reactivates and, in most cases, gradually destroys the transplant, which is no longer needed. Life goes back to normal, free from a daily schedule of pills and their risks and expense.

“I think we need to promote this idea,” said Dr Tomoaki Kato, Jonathan’s surgeon. He works at NewYork–Presbyterian Hospital/Columbia University Medical Centre. “A lot of the transplant community is focused on how to get patients off immunosuppression, and this is one way,” he added.

But only a tiny fraction of transplant patients are candidates for the operation: certain children with acute liver failure – probably fewer than 100 a year in US, where 525 under 18 had liver transplants last year. The operation is a difficult one. It is longer and more risky than a standard transplant, and surgeons caution that patients have to be selected carefully because not all can withstand the surgery.

The surgery was first tried in Europe in the early 1990s, and later in the United States. But the results were mixed – the liver did not always regenerate – and it never really caught on. Dr Kato said the results may have been poor because the early attempts included adults.

“I think the key is children,” he said. The best candidates are children with acute hepatic failure, a deadly condition in which the liver suddenly stops working, often for unknown reasons. Although the liver might be able to recover, it can’t do so fast enough to prevent brain damage and death from toxins that build up. The only way to save someone’s life is to perform a transplant. Such partial transplants do not work for chronic liver diseases that cause scarring because it prevents the liver from regenerating.

All said and done, Dr Kato has performed the surgery on seven children, ranging in age from 8 months (Jonathan) to 8 years, at Jackson Memorial.