Living-Donor Liver Transplantation
Today, more than 15,000 people are listed for a liver transplant in the United States. Each year about 9,000 new cases are added to this list, but only 5,000 livers from deceased donors are available for liver transplantation. About 1,400 people die each year waiting for a new liver.
In the last 10 years or so, living-donor liver transplantation has been developed to help overcome the organ donor shortage and save lives. This procedure involves removing a portion of a healthy living donor’s liver to help someone already on the waiting list for a liver. At first, people who received living-donor livers were almost always children; that was because children don't need as large a liver as adults, and it allowed the surgeons to use the smaller (left) part of the donor's liver. But the increasing number of deaths each year in adults on the liver transplant list, combined with the growing shortage of deceased donors, has led to the use of this surgery in adults as well.
There are two big advantages to living-donor transplantation:
- Once a living donor has been found, the operation can be scheduled at the donor’s and recipient’s convenience.
- The recipient can receive the transplant before his or her liver disease has progressed to a severe stage. Generally, a favorable outcome is more likely when the patient receives a transplant earlier in the disease process.
For the donor, there is the benefit of knowing that he or she has contributed to another person’s life in a very meaningful way.
Additional Living Donation Topics:
Who can be a donor?
Anyone interested in becoming a living donor must first be carefully evaluated. Doctors examine potential donors to help determine whether donation is the best and safest option for the donor and the recipient.
A donor must:
- Be between the ages of 18 and 55
- Have good general health
- Have a blood type compatible with the recipient
The donor’s sole reason for donating must be an unselfish wish to help the recipient.
Only about one in three people evaluated for live donation turns out to be a suitable candidate.
What does the donor evaluation involve?
Doctors make their decision by looking at two main factors:
- The recipient must be able to benefit from the donor liver.
- The donor must be able to tolerate the surgery and remain healthy after the operation, when a portion of his or her liver has been removed.
The following tests will be done as part of the donor evaluation. The tests are usually performed in this order:
- Initial history and physical exam
Potential donors undergo this exam to ensure that they have no identifiable medical problems. Such problems could prevent them from having any of the evaluation tests, and they could also prevent the surgery itself. A specialist in internal medicine (internist) or liver disease (hepatologist) performs the exam and takes the donor's medical history. The specialist is also well versed in living-donor liver transplantation.
- Written informed consent for live donor assessment and living-donor liver transplantation surgery
After clearing the donor to proceed further, the specialist and donor will discuss the next steps. The specialist will thoroughly explain the tests and any potential risks related to them, as well as the surgery itself and its potential risks.
The specialist will also provide the donor with a written informed consent form regarding these issues. Once the donor has had time to read and understand this consent form and all his or her questions have been answered, the donor will be asked to sign the form. The same consent form will again be discussed with a surgeon during the transplant surgery history and physical exam.
- Anesthesia history and physical exam
Anesthesiologists are doctors who administer medications that keep people asleep during surgery or other procedures. Anesthesiologists are responsible for monitoring vital signs (heartbeat, blood pressure, and breathing) during transplant and other operations. They also deal with pain management.
- Social work visit
A social worker conducts an interview with the potential donor. The social worker reviews plans for the donor's care upon discharge from the hospital after the living-donor liver transplant surgery. Key parts of this plan include:
- Housing arrangements
- Discharge medications
- Transportation to and from postoperative appointments
- Support for personal, emotional, and physical needs
- Psychiatry visit
This consists of an interview with a psychiatrist. This professional talks with the potential donor to ensure that he or she is able to handle the physical and emotional changes associated with living donation. The psychiatrist discusses possible stresses that may result from the procedure and assesses the primary reasons for the donor’s decision to donate.
- Extensive blood tests
These will help determine whether the potential donor has any transmissible diseases (such as viral hepatitis), any underlying liver diseases (such as fatty liver), or any serious medical conditions (such as heart disease) that might make living-donor liver transplantation unsafe for the donor or recipient.
This involves the use of pictures created by sound waves bounced off the heart. An echocardiogram is necessary to see how well the donor's heart is working and how well the heart valves are functioning.
Visit the Health Reference to read more about echocardiograms >
- Pulmonary function tests
These consist of certain breathing tests to determine how well the lungs are working.
Visit the Health Reference to read more about pulmonary function tests
- CT scan
This computerized x-ray shows detailed pictures of the internal organs. Doctors use the scan to determine the size of the portion of the liver that can be safely donated, and to check the adequacy of the liver's blood supply. Prior to this test, the person performing the CT scan will provide more detailed information about the test and its potential risks to the donor. Visit the Health Reference to read more about CT scans
- Transplant surgery history and physical exam
A transplant surgeon will personally review, in detail, all of the tests performed on the potential donor until that point. This is done to determine if the tests listed below are needed prior to the transplant surgery. The surgeon will also review the results of these additional tests before deciding whether the surgery is safe. At that point, the donor will be informed that he or she is cleared to donate.
- Written informed consent for live donor assessment and living-donor liver transplantation surgery
After the surgeon's confirmation, the surgeon and the donor will then discuss the surgery itself and any potential risks. The postoperative course and routine for follow-up visits will also be discussed in detail. The surgeon will again review with the donor the written informed consent form regarding all these issues. After the donor has had enough time to read and understand the consent form and all questions have been answered, the donor will be asked to sign this form once again.
- Liver biopsy
In this procedure, a needle is used to remove a tiny portion of the donor's liver. The procedure does not require surgery. Specialists examine this sample under the microscope to assess the quality of the liver tissue and exclude the presence of any possible disease. Prior to this test, the person(s) performing the liver biopsy will provide more detailed information about the test and its potential risks.
Visit the Health Reference to read more about liver biopsies
- Arteriogram (also known as angiogram)
In this x-ray study, a dye is injected into arteries going to the liver via a small tube placed through the groin. This dye, called an intravenous contrast dye, makes the arteries show up well in an x-ray scan. The test is performed to determine if it is possible to remove a portion of the liver. Before the test, the person performing the arteriogram will provide more detailed information about the arteriogram and its potential risks.
What happens during the donor surgery?
During living-donor liver transplant surgery, the donor will have a partial hepatectomy, the surgical removal of a part of the liver. This type of surgery is sometimes used to treat patients with liver disease. A partial hepatectomy done on a person with no liver disease has fewer risks than when it is performed on a person with liver disease.
Once the patient is under general anesthesia, the surgeon makes a cut across the abdomen. The surgeon chooses the size and exact location of this cut to safely locate and remove the gallbladder and a portion of the liver. It is necessary to remove the gallbladder, since it is located under the part of the liver that will be removed.
The surgeons remove about 25 to 65 percent of the donor’s liver as well as all of the gallbladder. While the donor is still in the operating room, drains will be placed in the abdominal cavity to allow fluids to be drained during postoperative healing. The entire donor operation takes six to 10 hours.
After the donor surgery is started, a second team of surgeons begins to operate on the liver recipient. The evaluation process does not stop when the surgeries begin, but continues throughout the surgeries. If at any point the surgical team believes that the donor is at risk or that the segment of the liver is not appropriate for transplantation, the surgery will be stopped. This happens about 5 percent of the time.
What are the health risks of the donor surgery?
There are built-in risks for all surgeries, especially those done under general anesthesia. The risk of having some type of complication (either minor or major) from living-donor liver transplant surgery is about 15 to 30 percent (about 2 in 7 cases). Most complications are minor and resolve on their own. In rare cases, the complications are serious enough to require another surgery or medical procedure.
The most common liver-related complication is bile leakage. Bile is a liquid produced by the liver that aids in digestion. Bile leakage happens about 5 to 15 percent of the time. Most bile leaks resolve without the need for surgery. Occasionally, tubes need to be placed through the skin and liver to aid in the healing process. In rare cases, surgery may be needed to correct the bile leak.
Today, the donor's risk of death from donor surgery performed in the United States is about 0.2 percent (one out of 500 donors). Someone from the transplant team will discuss the risks of this procedure with you.
Are there other potential risks related to the donor surgery?
If the recipient has medical insurance, the recipient’s medical insurance may pay for all, some, or none of the donor's surgery or postoperative treatment. It may be necessary to bill the donor's insurance company to see if they will pay any of the medical expenses before submitting a bill to the recipient’s insurance company.
A financial counselor is available to talk to the donor about the costs associated with living-donor liver transplant surgery, and to answer questions about the possible sources of payment for those costs.
After the donor's gallbladder and section of liver have been removed, insurance companies may consider the donor to have had a “pre-existing” liver disease or other related medical problem. Because of this, they may refuse to pay for medical care, treatment, or procedures related to those conditions.
This could also cause health insurance and life insurance premiums to be raised and remain higher. Furthermore, in the future, insurance companies could refuse to insure the donor.