The clinical team at the Center for Liver Disease and Transplantation (CLDT) has pioneered and perfected the use of living-donor transplantation for those with serious liver disease, first in children, and now in adult patients. This guide to the procedure has been prepared for anyone considering becoming a donor.
What is living-donor liver transplantation?
Living-donor transplantation involves the removal of a portion of the donor's healthy liver for transplantation into a recipient in need. A family member or someone emotionally close to the recipient may volunteer to donate a portion of their healthy liver. This procedure is made possible by the liver's unique ability to regenerate. After transplantation, the partial livers of both the donor and recipient will grow and remodel to form complete organs.
Why is living-donor liver transplantation desirable?
Living donor liver transplantation has two major advantages over deceased-donor transplantation. First, there is an improved survival rate for the adult transplant recipients who received living-donor livers over deceased-donor livers. Please see charts below. Secondly, the wait for transplantation can be greatly reduced.
One Year Adult Liver Patient Survival (07/01/2012-12/31/2014)
Patient Survival with Deceased-Donor liver: 90.18%
Patient Survival with Living-Donor liver: 84.21%
Three Year Adult Liver Patient Survival (01/01/2010-06/30/2012)
Patient Survival with Deceased-Donor liver: 78.87%
Patient Survival with Living-Donor liver: 96.67%
One Year Pediatric Liver Patient Survival (07/01/2012-12/31/2014)
Patient Survival with Deceased-Donor liver: 92.68%
Patient Survival with Living-Donor liver: 100%
Three Year Pediatric Liver Patient Survival (01/01/2010-06/30/2012)
Patient Survival with Deceased-Donor liver: 96.97%
Patient Survival with Living-Donor liver: 100%
Improved survival is thought to be related to optimal timing of transplantation. Living donor livers are healthy since they are only taken from donors in good physical condition. A living-donor is carefully evaluated to ensure they have an optimal liver for the recipient. Living donor livers are immediately transplanted after being taken out of the donor. This short cold time is also thought to be important in the excellent outcomes of living donor liver transplantation.
Nationally, nearly 17,000 individuals wait for liver transplantation, while only 6,700 deceased-donor organs, those coming from brain-dead donors, become available each year. With living-donor transplantation the timing of the transplant operation can be planned and the progression of the recipient's liver disease and its life-threatening complications can be avoided.
How did living-donor liver transplantation begin and how has it changed?
Living-donor transplantation was first performed in children as a means to alleviate long waiting times for deceased-donor organs. Dr. Jean C. Emond, Vice Chair for Transplantation, helped pioneer this procedure in children in the 1980s, and has expanded its application to adults. The CLDT is one of only a few programs in the nation now offering living-donor transplantation to post-adolescent patients. Dr. Benjamin Samstein became Surgical Director of the program in 2007. He has introduced laparoscopy to our donor's surgery while increasing the use of left lobe grafts minimizing donor trauma and scarring. Dr. Emond and Dr. Samstein typically perform the donor surgery together.
Today, nearly half of all donors can donate the smaller, left lobe of their liver. This leads to lower risks and faster recovery. Donors to children are routinely offered fully laparoscopic donation with all a 3-inch incision in the pelvis to remove the piece of liver.
Who can be a living donor?
General criteria for liver donation include:
- Being in good general health
- Having a blood type compatible with the recipient
- Having an altruistic motivation for donating
- Being between the ages of 20-60
What are the major risks of donating?
Risks to the donor include, but are not limited to, bleeding, infection, bile leakage, and possible death. Donors in the CLDT's living-donor transplantation program have experienced few complications after surgery and during recuperation. All are currently alive and well.
What is involved in the donor evaluation process?
A living-donor candidate must complete the following evaluation process to determine if they can safely donate:
- A blood test determines if the donor's blood type is compatible with that of the recipient. Additional tests are performed to test for healthy functioning of the donor's liver, kidneys and thyroid, and to screen for exposure to transmittable viruses such as hepatitis and HIV, the virus that causes AIDS.
- If the donor's and recipient's blood types are compatible, a physical examination with a CLDT physician is scheduled to further assess the donor's overall heath.
- Consultations with the CLDT's social worker and psychiatrist are scheduled with the donor and their designated care-partner.
- Magnetic Resonance Imaging (MRI) is performed to create a detailed anatomical "road map" of the donor's internal organs to aid the surgery.
- Sometimes additional testing, such as pulmonary function, echocardiogram, or exercise stress testing, is required.
The standard time required to complete the donor evaluation process is two to four weeks, in rare emergency situations, however, it can be completed in as little as 48 hours.
What happens during donor surgery?
Depending on which part of the donor's liver is removed, the incision is either straight up and down, or a four-inch incision at the bikini line. For a full right lobe and left lobe donation, the gallbladder is removed. The donor's liver is carefully split into two segments and one portion is removed for the recipient. The surgeon then closes the incision with self-absorbing sutures. The liver immediately beings to heal and regenerate itself, generally taking six to eight weeks for full regeneration.
How long does the donor remain hospitalized?
Typically, a donor remains in the hospital for four to seven days after surgery. Donors spend their first night after surgery in the Surgical Intensive Care Unit for close monitoring by specialized nursing staff. The following day, they are usually transferred to the general surgical floor where the nurses are specifically experienced in caring for liver donors.
Donors are encouraged to get out of bed and sit in a chair the day following surgery, and to walk the corridors as soon as they are able. To make the donor's immediate recovery as comfortable as possible, Columbia University Medical Center provides Patient-Controlled Anesthesia (PCA) which enables self-administration of pain medication following surgery.
How long before the liver donor is fully recovered?
Every donor's recovery time is different. Typically, donors spend three weeks recuperating after surgery. In the month following discharge from the hospital, donors return to the Center for Liver Disease and Transplantation for outpatient monitoring. Individual recovery rate and the type of occupation dictate how soon a donor can return to work. It commonly averages three to six weeks. The CLDT's clinical staff helps donors determine when it is safe to resume normal activities.
What healthcare costs does the donor incur?
The donor's medical expenses, including the costs of evaluation if performed by the CLDT doctors' fees, and hospitalization, are covered by the recipient's health insurer.
The Health Resources and Services Administration (HRSA) has established a program providing financial assistance to donors called the National Living Donor Assistance Center (NLDAC). The program covers travel, lodging, meals, and incidental expenses incurred by the donor and/or their accompanying person(s) as part of:
- Donor evaluation, clinic visit or hospitalization,
- Hospitalization for the living donor procedure, and/or
- Medical or surgical follow-up clinic, visit or hospitalization within 90 days following the living donation procedure.
The program will pay for a total of up to five trips, three for the donor and two for accompanying persons. The accompanying persons need not be the same each trip.
To learn more, please visit http://www.livingdonorassistance.org
If you are interested in being evaluated for liver donation and want additional information, please contact the Center for Liver Disease and Transplantation by calling our toll-free number for referrals and consultations, 1.877.LIVER MD (1.877.548.3763).
Can a long term survivor of melanoma donate organs?
Some prior absolute contraindications to organ donation have now been reconsidered and are now weighed against the potential recipient's high risk of dying waiting for an organ. Dr. Guarrera answers this question more fully in a New York Times Science Q&A here.