Six-month-old Kerala girl's liver transplant more complicated than those of adults: Doctor recalls surgery day

It's only been about a month since Alin Sherin Abraham, a 10-month-old from Pathanamthitta, became Kerala's youngest organ donor. Alin, who was declared brain-dead following an accident on February 5, left the world after donating her organs to five patients. One of the receivers was six-month-old Dhriya, who was born with a life-threatening liver disease called biliary atresia. Dhriya underwent a high-risk, 12-hour surgery under the leadership of Dr Shiraz Ahmad Rather (consultant and head of multivisceral transplant) and Dr Shabeerali T U (chief coordinator and senior consultant) at KIMSHEALTH Hospital, Thiruvananthapuram. Dr Shabeerali recalls the breakthrough surgery day in a conversation with Onmanorama.

An 'unforgiving operation' 
Dhriya was diagnosed with biliary atresia, a condition characterised by a blockage in the ducts that carry bile from the liver to the gallbladder. The disease occurs when the bile ducts, either inside or outside the liver, fail to develop normally and affects approximately one in 70,000 newborns worldwide. Recounting the operation day, Dr Shabeerali says, "We usually call liver transplant an unforgiving operation, because even a minor deviation can impact the outcome in a huge way. Indeed, each transplant is a promise to the family and patient as they come from a situation where the patient is in a life-threatening liver disease. In Dhriya's case, it was an unusual situation where the donor was also a child." 

Dhriya had earlier undergone Kasai surgery elsewhere, a procedure in which the blocked bile ducts are removed, and a new bile drainage pathway is created using a portion of the small intestine. Despite that, she had developed complications including portal hypertension, refractory ascites and synthetic dysfunction. She was then referred to KIMSHEALTH, where a liver transplant was advised as the only viable option to save her life.

"This was an extraordinarily challenging transplant given the age of the donor and recipient. Yet, as a team, we took on the challenge of restoring hope and joy to Dhriya's parents. The post-operative phase was equally demanding, requiring round-the-clock vigilance and the coordinated expertise of intensivists, anaesthetists, nurses, and the entire multidisciplinary team," said Dr Shiraz Ahmad Rather, who, along with Dr Shabeerali, led the surgery.

What makes the surgery complicated?
According to Dr Shabeerali, requiring a transplant at this age is not uncommon, especially for indications like biliary atresia, as in Dhriya, or some other liver or metabolic diseases presenting immediately after birth. "But doing a liver transplant at a young age, like less than one year, is definitely more complicated than an adult liver transplant," he says. "What makes it so complicated is that their blood vessels will be very small, so they are prone to complications in the post-operative period. The usual mode of paediatric transplant is by using a liver from their immediate relatives, such as father or mother. We need only a small portion of their liver for the transplant," the doctor adds. 

Finding the right match
In the case of Dhriya, the doctors had initially evaluated her mother as a donor but deemed her unfit because of fatty liver. The next option, the baby’s father, was ruled out as he was the only breadwinner and had to run around arranging logistics for the transplant. It was at this stage that the offer from K- SOTTO ( Kerala State Organ and Tissue Transplantation Organisation) was received. Ten-month-old Alin Sherin was admitted to Amrita Hospital with a catastrophic brain injury following a road accident, and after 3 days of strenuous efforts to save her life, doctors declared her brain-dead. The parents with extraordinary social commitment and humanity decided to donate her organs, making her the youngest organ donor in the country. The previous youngest was an 18-month-old child in Delhi a few years back. 

Amrita Hospital informed K-SOTTO of organ allocation as per the rules. Organs from such young donors are usually allocated to recipients who match the donor's age. So, only two recipients were waiting with a similar age. One was a child in Amrita Hospital in Kochi, and the other was Dhriya. The baby admitted to Amritha had a bloodstream infection, so couldn’t proceed with the transplant, thereby allocating the organ to Dhriya, who was next in line. Alin's kidneys were allocated to a child undergoing treatment at the Government Medical College, Thiruvananthapuram. 

"The confusion we had was that since such a very young donor's blood vessels will be very small, it will increase the risk of vascular complications, more than what is usual in a paediatric transplant. We explained this issue to the relatives, but considering their difficulties in accepting the father as a donor, we decided to go ahead with the transplant with the liver offered from Alin Sherin," Dr Shabeeerali says. He adds, "This transplant is the first of its kind in India, in terms of the donor's age. Only fewer than 30 such cases happened all over the world as per the records."

The previous occasion when the medical team encountered a challenging case similar to this was while conducting a transplant on a 5-month-old baby and a 9-month-old child weighing 2.9 kg. However, both with a portion of liver from adult donors. Meanwhile, the youngest donor in Kerala before Alin was a 4-four-year-old from Thiruvananthapuram Medical College in 2016.

Liver transplant advantages
According to Dr Shabeeerali, there is a long-term advantage in liver transplant. "Indeed, we see they are having a better life than their non-transplant counterparts, because they take care of the metabolic syndrome. The children will have a good quality of life in the long term after the transplant," Shabeerali says.

On March 16, Baby Dhriya was discharged from the hospital and reached home in a stable condition. They have to continue immunosuppression at a very low dose over time. This case is a breakthrough in medical history because of the donor age and the fact that it leverages the disease-donor program in that country, kindling hope for the needy.

The medical team
The medical contingent involved in the transplant surgery included, Dr Shiraz Ahmed Rather, Clinical Chair of Organ Transplant in KIMSHEALTH and  Dr Shabeerali T U, Senior Consultant and Chief Coordinator of GI, HPB and Liver Transplantation Department who led the team; surgeons Dr Varghese Yeldhow, Dr Ananthakrishna and Dr Vinay along with 8 Surgical registrars, transplant anaesthesia and Liver Critical Care - Dr Hashir A, Dr Prijith R S, Dr Abhijith Uthaman, Dr Rachana R; Pediatric Hepatology Dr Anu K Vasudev, Pediatric Critical care Dr Shijukumar; Hepatology Dr Madhu Sasidharan; Transplant Radiology Dr Manoj K S, Interventional Radiology Dr Maneesh Yadav, Transplant nursing team lead by Liju Skaria, Manu Varghese.

Frequently Asked Questions
1. What is biliary atresia, the condition Dhriya suffered from?
It is a life-threatening paediatric liver disease. In those suffering from it, the bile ducts get blocked or are missing. This prevents bile drainage, and this will cause rapid liver damage. 

2. What are the symptoms of biliary atresia?
a) They appear within eight weeks of birth
b) Dark urine
c) Pale, clay coloured stools
d) Persistent jaundice
e) Firm liver
f) Swollen abdomen
g) Insufficient weight gain

3. Who is Alin Sherin? What happened to her?
Alin Sherin Abraham is a 10-month-old girl from Kerala, the youngest organ donor in Kerala. She was declared brain dead after a road accident in early February.