Living Liver Transplants
A 24-year-old woman’s liver unexpectedly shuts down, sending her to the University of Maryland Medical Center (UMMC) in acute liver failure. No one — including her father and uncle, who are both physicians — knows what caused the young woman’s condition to deteriorate so rapidly, but they do know she will die if she doesn’t receive a new organ quickly. Her boyfriend offered to donate part of his liver, and then they were both on the road to recovery within a few days. Not all living liver donation stories are quite so dramatic, but this one was particularly poignant since it launched UMMC’s re-emergence into living liver transplants after a four-year hiatus. With the addition of John LaMattina, M.D. — an assistant professor of surgery who was trained in living-donor transplant surgery in Istanbul, Turkey — to the liver transplant team, UMMC’s program was recently recertified by the United Network of Organ Sharing (UNOS), which manages the nation’s organ transplant system under contract with the U.S. government. Offered by only a handful of medical centers around the United States, the living liver transplant program first began at UMMC in the late 1990s. LaMattina and Benjamin Philosophe, M.D., Ph.D., head of the section of liver transplantation and hepatobiliary surgery and an associate professor of surgery, are donor surgeons, while Rolf Barth, M.D., an associate professor of surgery, and Sameh Fayek, M.D., an assistant professor of surgery, are recipient surgeons.
“When I first started, the liver transplant program had two surgeons,” Dr. Philosophe says. “Now we have a team of four — two for donors and two for recipients — and all have experience with living donors, which is likely to yield the best possible outcomes.”
A magnet program
In 2009, 218 adult patients nationwide received a living-donor liver transplant according to UNOS, while more than 6,000 get transplants from deceased donors. But more living donations could help save greater numbers of the 17,500 U.S. patients waiting to receive a liver, Dr. Philosophe says — 1,700 of whom die each year while waiting. Indeed, one of the main advantages of living-donor transplants is the availability of an organ to a patient who might not otherwise be classified as “sick enough” for a cadaver liver by their MELD score. Deceased donor livers are allocated to patients with the highest MELD, or Model for End-Stage Liver Disease score within the blood group. MELD is based on blood tests and roughly reflects the severity of liver disease. However, for some patients MELD does not accurately indicate how clinically sick they are. While they are desperately in need of a liver, they are unlikely to receive one because their MELD score is not high enough. Hence, in this context, a living donor liver transplant is truly life saving.
“We want to create a magnet program,” Dr. Philosophe says. “Our strategy is for people to understand that certain patients may not have access to a deceased donor because they’re not high enough on the list. For them, a living donor is their best option, if not their only option.”
Although it may be the ideal option for such patients, the process is still far from simple. Less than half of those who volunteer to give a portion of their liver — typically a relative, friend or co-worker of the patient — are actually eligible to do so after a battery of blood, imaging and other tests weed out those who cannot donate, Dr. Philosophe says. In addition to having a compatible blood type and being otherwise healthy, the donor must also be a similar size to the recipient to ensure that his or her liver is large enough to sustain the recipient. About 60% of the organ is taken, which will grow to full size in both people within a few weeks. “If the donor is a five-foot-one lady and the recipient is a six-foot-two man, her liver may not be big enough,” he says.
Low-risk, but complications can occur
Because liver transplantation involves a large organ and is still accomplished through open surgery — as opposed to kidneys, for example, which can be procured laparoscopically — complications for living liver donors and recipients are more likely. About one-third of both groups suffer some kind of post-operative problem, such as blood clots or infections, which are generally treatable. The mortality rate for donors is exceedingly low though, at less than 0.5%, Dr. Philosophe notes. Still, the ever-present risks are always on physicians’ and recipients’ minds, even if donors are focused solely on saving their loved one’s life.
Fortunately, the vast majority of both donors and recipients go back to their normal lives after weeks of recovery, and those with new livers can expect to live a normal lifespan, Dr. Philosophe says. For the young woman whose transplant kicked off UMMC’s recertification, her operation represented not only a second chance at life, but a very generous gift from her boyfriend.