Living Liver Donation Faq

Common Questions

• Why is it necessary to use a living person as a liver donor?
• What is the track record for this type of liver transplantation?
• What types of patients have a particular need for this option?
• What are the advantages and disadvantages of living donor transplantation?
• How are living donors identified?
• How are living donors evaluated?

Why is it necessary to use a living person as a liver donor?

The number of patients awaiting liver transplantation in the United States greatly exceeds the supply of cadaver donor organs. More than 15,000 patients are currently registered on the liver transplant waiting list of the United Network for Organ Sharing (UNOS), while only about 4,500 cadaver donor livers become available for transplantation each year. Cadaver donor organ availability appears to have reached a plateau despite many initiatives intended to increase organ donation.

The waiting time for liver transplantation has increased steadily each year, rising from approximately one month in 1988 to more than a year in 1999. Currently, more than one-third of patients in the United States wait longer than two years for a liver transplant, and more patients die each year while awaiting transplantation. There is a critical shortage of donor organs, and this problem will continue to worsen in the foreseeable future.

What is the track record for this type of liver transplantation?

The results of adult-to-adult living donor liver transplantation throughout the world are excellent. At least 275 adult-to-adult living donor liver transplants had been performed in the United States by the end early 2000, and several hundred more in other parts of the world. The living liver donors are hospitalized about a week after the operation and have only occasionally required blood transfusion. Nevertheless, the donor operative procedure is a major operation and not without risk. Mayo Clinic's transplant team estimates a risk to the liver donor's life of 0.5 to 1 percent. The donor is also at risk for temporary problems related to the surgical incision and the possibility of blood clots. The great majority of donors, however, have enjoyed a complete recovery within a few months of their operations, and tremendous satisfaction from giving a loved one their "gift of life."

Adult-to-adult living donor liver transplantation using the right portion of the liver evolved from successful experiences with transplantation of children and cadaver donor split-liver transplantation. The latter procedure involves splitting a whole cadaver liver into two parts, allowing transplantation of two recipients. This technique has been performed at Mayo Clinic Rochester since 1994. Use of the larger right liver for adult recipients is necessary in order to provide the patient with enough liver tissue. With living donor liver transplantation, the healthy donor's liver regenerates to full size within a few weeks of operation, and there is no long-term impairment of liver function. The transplanted liver portion also regenerates, increasing in size to an appropriate match for the recipient.

What types of patients have a particular need for this option?

There are many patients with specific diseases and special circumstances that make it important to proceed with liver transplantation sooner than is possible with a cadaver donor organ. Mayo Clinic Rochester is a leading center for patients with liver and bile duct tumors; such tumors may grow or spread if transplantation is delayed. Mayo Clinic Rochester also has many patients with progressive diseases such as primary hyperoxaluria, familial amyloidosis, pulmonary hypertension, and hepatopulmonary syndrome. These patients all greatly benefit from timely transplantation that becomes possible with a living donor organ.

The shortage of cadaver donor livers has also made it increasingly difficult for foreign national patients to receive a liver transplant in the United States. Since the early 1990s, UNOS has had limited cadaver organ allocation to foreign national patients. This limit was made more restrictive in 1995. Living donor liver transplantation will allow foreign patients a new opportunity to undergo liver transplantation.

Living donor liver transplantation is a popular option for liver transplantation in children. Adult-to-child living donor liver transplantation using the left lateral portion of the liver is safe and effective. The procedure helped reduce the number of children who died awaiting liver transplant. It also helped to avoid family disruption caused by having a child and at least one parent away from home, staying near the transplant center while awaiting a chance for cadaver donor organ transplantation.

What are the advantages and disadvantages of living donor liver transplantation?

Before offering living donor liver transplantation, Mayo Clinic leaders and the liver transplant team examined the need for the procedure, experience with this approach around the world, potential risks to the donor, advantages and disadvantages compared to cadaver liver transplantation, and ethical issues pertaining to living donation. The Rochester liver transplant program is well suited to perform living donor liver transplantation for several reasons:

• the program's established track record of superb patient and graft survival,
• Mayo Clinic's well recognized multidisciplinary team approach to patient care, and
• the extensive experience of Mayo Clinic surgeons with liver resection, an essential skill in living donor liver transplantation.

Living donor liver transplantation has several advantages over cadaver donor transplantation, including:

• an opportunity for transplantation in a more timely fashion,
• less possibility for complications and death to occur while waiting for a cadaver donor organ, and
• a better opportunity for foreign national patients and those with special circumstances to undergo transplantation.

The disadvantages of this approach include a small risk to the healthy donor and the period of discomfort and recovery for the donor.

How are living donors identified?

All liver transplant candidates undergo a similar evaluation, whether for cadaver donor or living donor liver transplantation. Patients likely to benefit from living donor transplantation are encouraged to consider this option. The patient and family then ask potential donors to contact the living donor nurse coordinator to begin the evaluation process. The coordinator provides the potential donor with specific information about living liver donation and conducts a preliminary survey to determine whether donation may be possible.

Throughout the evaluation process, all possible efforts are made to protect the confidentiality of all potential donors' medical and personal matters, including decisions about whether to proceed with donation. Organ donation is an altruistic gift, and every effort is made to assure that donors who choose to proceed are free from coercion. The transplant team provides recipients, potential donors, and families with counseling and support through every phase of the process, from donor identification through recovery after operation.

How are living donors evaluated?

Potential living donors undergo an extensive evaluation to assure that they are in optimal medical condition to proceed with organ donation. The blood types of donor and recipient must be compatible, but not necessarily identical. The anatomy of the donor's liver must also be favorable for donation. Size requirements vary with individual recipients, whether child or adult. Some normal variations in the distribution of blood vessels or bile ducts may preclude or aid the donor operation. Above all, the donor must be in excellent health.

Are there additional risks to the child associated with LRLT? If so, what are they?

The additional risks are theoretical and include the fact that shorter vessels and bile duct are available from a living donor. Most techniques require using other vessels (like the saphenous vein from the leg) to make up for this deficiency. From the excellent reports of success rates with LRLT, this does not appear to be a MAJOR factor. But one must always worry about looking at medical literature to compare success and complication rates because it could be that only the places with the best success rates write and publish their results. A chief complication with very small children in OLT is clotting of the blood vessels. Technically the LRLT is harder to do, therefore it would not be surprising if it turns out to have a higher rate of clotting blood vessels. On the other hand, many people feel that the major reason blood vessels clot is because of rejection. If there turns out to be less rejection it would also not be surprising to find that there are fewer vessels that clot. The advantages of LRLT are that it can be done "electively" if the child is healthy rather than risking the child getting ill and needing an urgent graft. Urgent transplants always have worse reported success rates. Another advantage is that the donor is often more healthy that the average cadaver donor and more stable at the time the graft is removed.

Living Donor Liver Transplantation Just 35 years ago, the first liver transplant in the world was performed at University of Colorado Hospital in Denver. Since then, significant advances have been made with this procedure, and hundreds of lives have been saved here and around the world. Because of the success of liver transplantation, the number of patients who have been listed for this surgery have increased dramatically during the past ten years. Unfortunately, the number of donors has increased very little during this time. Currently, there are approximately 14,000 people waiting for liver transplants in the United States, but only enough livers to perform about 4,700 transplants each year. Because of this organ shortage, more than 1,700 people die each year waiting for a liver transplant. The Liver Transplant Program at the University of Colorado Hospital has undertaken an innovative solution to help reduce the waiting time for our patients on the liver transplant list. Our Liver Transplant Program is one of the first in the United States to offer living donor transplantation for adult recipients. Our own experience includes 56 adult-to-adult living donor liver transplants through Sept. 2001.  We published the first report in this country regarding our experience with this procedure. The paper is located in Transplantation, Vol 66, 1313-1316, No.10, November 27, 1998. What kind of surgery is done? To do living donor surgery, the donor and the recipient are placed in side-by-side operating rooms. The type of surgery performed on the living liver donor involves removal of a part of the liver, usually the right half of the liver. The donated segment of the liver is then immediately placed in the recipient who is in the next operating room. The remaining part of the donor's liver is sufficient to maintain normal body functions.  The recipient receives a large enough segment of the donor liver to maintain body functions as well. During approximately two months, both parts of the donor liver grow to normal size, providing normal long-term liver function for the recipient and donor.   Is anyone eligible for living donor liver transplantation? Because this is a new surgical procedure, recipient patients must be considered individually to make sure that living donor transplantation is appropriate based on their specific medical situation. Some patients may have specific medical problems that would prevent them from having a successful living donor transplant. Who can be a living donor? Living donors must be over the age of 18 and under the age of 60. Potential donors must be in excellent medical and psychological health. Most donors are family members (spouse, parent, sibling, son, daughter, nephew, niece) of the recipient or a close personal friend. I want to be a donor, what's next? Once you've made the decision that you want to be a living liver donor then a series of psychological and medical testing follows to determine if you are in fact an eligible candidate. The first phase of testing includes: Medical history and physical examination Blood tests (The blood type must be compatible with the donor, but it does not have to be an exact match.) Chest X-ray and EKG These tests usually require two-to-three outpatient clinic visits. It is preferable that this testing is done at the University of Colorado Hospital in Denver by members of our liver transplant team. However, potential donors from outside of Colorado may undergo this initial phase of testing in their local community, provided their physician is in consult with our transplant team. If these initial tests suggest that you would be a suitable donor, then another series of tests will be done. These include: Evaluation and discussion of the liver surgery with a transplant surgeon Psychological evaluation MRI scan of the liver (which is similar to a CAT scan) If all of these tests show that you are a suitable donor, then the donor surgery and the liver transplant may be performed at the earliest appropriate time for you and the recipient. This can be as short as a few hours or as long as several weeks after you complete the evaluation. How long will I be in the hospital and out of work? Usually, the donor is admitted to the hospital the same day the surgery is performed. The hospital stay after donor surgery is on average five-to-eight days. If the donor resides out of the Denver metropolitan area, then he/she may be asked to stay in the Denver area for up to two weeks after the donor surgery. Most people are able to return to work after eight weeks, depending on how the surgery goes and the type of job they have. If the donor has a desk job, he/she may be able to return to work sooner than patients with a more physically demanding job. How will liver donation affect my life after surgery? The liver is the only major organ in the body that is able to regenerate itself. Thousands of patients have undergone partial removal of their liver for medical problems. In these patients, the liver is able to regenerate itself back to its normal size and function after about two months. The experience with living liver donors is much more limited, but has been identical; patients have had complete regeneration of their liver with return to normal size and function after two months. Therefore, we do not believe that donating a part of your liver will affect your liver function in the long-term. What are the risks of becoming a living donor? Any time major surgery is done there are risks involved. The most common problems encountered with donor surgery include bleeding, infection and pain related to the surgery. The risk of dying from donating a portion of the liver is estimated to be 1 in 500. Am I making the right decision? This is a question only you can answer. Living donation is not for everyone. You may find it helpful to talk with another patient who has been a living liver donor to discuss your feelings and concerns about becoming a donor. If you are interested in meeting another living liver donor, ask a member of the transplant team to help arrange this. What happens if I decide not to become a donor? If you decide not to become a donor, then the recipient will remain active on the conventional transplant list. The recipient may also elect to find another potential living donor. How much will this cost me? The pre-operative evaluation, surgery and hospital stay and out-patient visits, as well as any medical treatment related to the donor surgery within the first three months, will not cost you anything. The costs are paid by the recipient or the recipient's insurance company. Your only direct costs related to the donation may be medications such as pain pills and antibiotics that you may require after you are discharged from the hospital. You will also be responsible for transportation and non-hospital lodging costs related to the evaluation and surgery.   "Living Donor" Transplants: http://www.livingdonorsonline.org/liverabout.htm http://www-med.stanford.edu/shs/txp/livertxp/livingdonation.html http://www.unos.org/Newsroom/Frame_news.asp?SubCat=donors

Posted on Mon, Apr. 12, 2004

Increase in living organ donations raises medical, ethical questions BY STACEY BURLING Knight Ridder Newspapers   PHILADELPHIA - (KRT) - When Lynn Rogers needed a kidney transplant, she called her large family together and asked for help. She would have the best chance of survival with a living donor transplant, she told them. Would anybody help? Her daughter and all seven brothers and sisters volunteered. Her younger sister Jackie Shirley, the one who looks just like her, was a perfect match. There was little question she'd do it. She'd lost her mother and a stepson in the past year, and she wasn't going to lose her sister, too. Last August, Jackie gave Lynn one of her kidneys at Albert Einstein Medical Center in Philadelphia just four months after Lynn went on dialysis. Increasingly, that's what transplantation looks like in this country. Living donation is up by more than 150 percent in the last decade. Live donors now outnumber dead ones: 6,210 to 5,923 in the first 11 months of last year. Most of that increase is due to a boom in living kidney donation, which became more appealing with the advent of a less-invasive surgical technique for removing donor kidneys. It is now considered the best treatment for kidney failure. In the last two years, though, living liver transplants, which were embraced enthusiastically by some surgeons in the late '90s, have fallen off dramatically after the well-publicized death of a donor in New York in 2002 and changes in the allocation system for deceased donor livers. Doctors say that procedure, far riskier for donors than kidney donation, likely will begin growing again because of the demand for transplants. Currently, 84,000 people are waiting for organ transplants. Only about 24,900 got transplants in 2002, the last year for which data is available. The rise in living donation is intensifying ethical questions, including how to protect the interests of potential donors - siblings, spouses, friends, co-workers and church members - as pressure to give organs mounts. "It changes the whole ethical equation," said Arthur Caplan, director of the University of Pennsylvania's Center for Bioethics. "The moral ante is up the more it becomes the treatment of first choice. It becomes harder to say no." Caplan says follow-up data should be kept on every living donor (currently that's not required) and many surgeons agree. He also favors independent advocates for donors, standardized medical criteria for donations, standardized consent forms and national oversight of living donation. Sheldon Zink, another Penn bioethicist who studies transplant issues, thinks it's good that surgeons in this area are conservative about living donation. She worries that complications will increase if thousands more people give up one of their kidneys. And, she thinks hospitals need to do a better job of preparing patients for the surgery's impact. Some donors become depressed, especially if the transplant doesn't go well, she said. Liver donors have told her the recovery was more painful than expected and kidney donors were surprised by how a transplant changes relationships. Surgeons complain that patients often think living donor kidney and liver transplants are similar, but the procedures carry radically different risks and rewards. Most of us can live healthily with only one kidney. With surgical techniques using small incisions, it's relatively easy to remove a donor kidney, and most patients recover quickly. Mark Deierhoi, a University of Alabama transplant surgeon, estimates the risk of donor death at 1 in 5,000 and serious complications at 2 to 4 percent. Studies show donors aren't at higher risk of developing kidney problems later. And recipients of kidneys from live donors do better than those who get deceased donor kidneys. The median life for transplanted kidneys is 36 years for a living-donor kidney and 19.5 years for a deceased-donor kidney. For those reasons, surgeons now recommend living-donor transplant as the best treatment for people in kidney failure, ideally before they've started dialysis. "That's the ideal approach that we should do on everybody," said Mikel Prieto, a kidney transplant surgeon at the Mayo Clinic, where 205 of the 250 kidney transplants last year resulted from living donation. "That's what I would do if I had kidney failure." Livers are a different story. We all have only one liver, but it has the remarkable ability to regenerate when part of it is removed. For many years, surgeons have given relatively small parts of adult livers to children, at low risk to donors and with good results in recipients. In recent years, though, doctors have tried a riskier operation that involves removing 60 percent of the donor's liver. Nationally, the number of living liver donors leapt from 92 in 1998 to 506 in 2001, but it's been falling since: In the first 11 months of 2003, there were 284. That's a typical pattern for new surgical procedures, surgeons said. At first, everyone wants to try. Then something bad happens and the pendulum swings the other way. Abraham Shaked, a transplant surgeon who heads Hospital of the University of Pennsylvania's transplant program and is president of the American Society of Transplant Surgeons, tells potential liver donors their risk of death is 0.5 to 1 percent. That's high for healthy people undergoing surgery. Up to 20 percent can have complications, most minor, afterward. Like many liver surgeons, Shaked has stepped back from the procedure, because of two donor deaths at other hospitals and because he has concerns about results. His research team recently found the survival rate for patients who received living donor livers was about the same as for deceased donor livers. It should have been better; the living donors were younger and their recipients were healthier. At the same time, the system for allocating deceased donor transplants changed. People with liver cancer - the group that initially most wanted living donors because they needed transplants before their cancer spread - now get enough priority on the deceased donor waiting list that they're not clamoring for living donors. Taken together, these factors are making surgeons and people who need transplants more conservative. "We ... have to be exceptionally, exceptionally careful," Shaked said. The trick now will be figuring out which patients do best with living donor livers so success rates will rise. He expects living donation to account for 10 to 15 percent of HUP's liver transplants within five years because the rise in hepatitis C infection is driving up demand for liver transplants. (Only three of 115 transplants last year involved living liver donors.) Burckhardt Ringe, a Hahnemann University Hospital liver transplant surgeon, thinks living donation will play a bigger role. He thinks results are good and likes that the procedure makes it possible to transplant patients before they're deathly ill. Four of the 13 liver transplants at Hahnemann in 2003 were living donor transplants. He thinks as many as half of liver transplants could involve living donors within a few years. "I think live donation will play a significant role in the future," he said. --- © 2004, The Philadelphia Inquirer. Visit Philadelphia Online, the Inquirer's World Wide Web site, at http://www.philly.com Distributed by Knight Ridder/Tribune Information Services

Outcome of split-liver transplantation

Last Updated: 2001-04-10 17:03:53 EDT (Reuters Health)

WESTPORT, CT (Reuters Health) - Split-liver transplantation is technically feasible, according to researchers in France, although survival rates are better for recipients of the larger right graft than for recipients of left-liver transplants.

Dr. Daniel M. Azoulay, of Hopital Paul Brousse in Villejuif, and a multicenter team examined the outcomes of 34 adults who received split-liver transplants and 88 who received whole-liver transplants between July 1993 to December 1999.
Thirty livers were split ex situ and four were split by in situ procedures. In all cases, the donor-recipient match was "optimal," the researchers say in the April issue of Annals of Surgery.

Patient and graft survival rates were similar between recipients of whole-liver transplants and recipients of right-liver transplants.

Left-liver transplants were associated with higher levels of graft failure from primary nonfunction, and therefore with lower patient and graft survival rates.

Specifically, the 2-year survival rate among patients with whole-, right- or left-liver transplants was 88%, 74% and 64%, respectively. The corresponding rates of graft survival were 85%, 74% and 43%.

"The principal pretransplantation factors influencing patient survival were graft steatosis and the hospital status of the recipient," the authors say. "The two principal factors affecting graft survival were graft steatosis and a graft-to-recipient body weight ratio of less than 1%."

Dr. Azoulay and his associates believe that "there are no medical or ethical obstacles to more widespread use" of split-liver transplantation. They suggest that outcome could be improved by "rigid selection criteria for donors and recipients, particularly for the smaller left graft, and possibly also...in situ splitting in cadaver donors."

Annals of Surgury 2001;233:565-574.
http://www.stadtlander.com/reuters/transplant/23071131011.html