Living Liver Donation

What is technically feasible for a liver resection in a tumour patient may not be for a living donor. What is an acceptable risk in a tumor patient who has no other chance must not be so in a living donor. The trust between the family and the doctor lies in the agreement that no such boundaries will be crossed.” (121)

Two live liver donors deaths in the United States in 2010: Paul Hawkes in May at Lahey in Boston, and 34 year old Ryan Arnold died four days post-donation at the University of  Colorado hospital on August 2nd, leaving behind his wife and young sons.

Understandably, this has given new attention to adult-to-adult live liver transplants and more specifically, the risks faced by the living donors.

Click here for a rather detailed article on liver resection and living liver donor transplants (.pdf)


Liver Donor Selection

The Adult-to-Adult Living Donor Liver Transplantation Cohort (A2ALL), a multi-center project to evaluate outcomes of donors and recipients in the United States, reported 40% of potential donors were accepted for donation. Donors more likely to be accepted were younger (18-40 years), had a lower body mass index, and more likely to be family members (spouse or biologically related)(157). Some of the reasons why potential liver donors might be rejected include obesity, diabetes, elevated liver enzymes, hepatits, or unusual vascular (blood vessel and bile duct) anatomy (260) 

However, the biggest determining factor in liver donor selection was the transplant center itself. It’s important to remember that while OPTN provides guidelines for the evaluation of living donors, there are very few hard and fast rules. Consequently, each transplant center can determine what they feel is an ‘acceptable’ living donor.

Because transplant centers have such great variability in how they evaluate and accept living donors, it’s important for the prospective living liver donor to serve as her/his own advocate.

For example: a small number of liver donors have been taken to the operating room but had the donation aborted mid-procedure when a medical anomaly was revealed. Some of these abnormalities could’ve been identified if a liver biopsy had been required during evaluation. In fact, one liver donor’s death was ascribed to a congenital condition which would’ve been discovered during a biopsy (160).

This is not to say that a liver biopsy is necessarily the best thing for every prospective living donor. Like any other medical procedure, a liver biopsy comes with a risk of complications. Therefore, it’s important for the prospective liver donor to understand her/his diagnostic and evaluation findings and discuss them in-depth with a surgeon or specialist prior to consenting to donation.

The acceptance rate of prospective living liver donors decreased dramatically following the deaths of Danny Boone and Mike Hurewitz in the early 2000s (159), partially due to a drop in the number of people presenting for evaluation, and partly due to increased vigilance on the part of the transplant programs. The implementation of the MELD score (see section below) also facilitated an increased number of deceased donor transplants and may have reduced the number the recipients appropriate for receiving a living donor liver transplant.

The consequences of the two deaths in 2010 remain to be seen.


Choosing a Transplant Center

A survey of 84 transplant programs in the US describing 449 adult-to-adult liver transplantations: Complications in the donor were more frequent in the centers performing the fewest transplantations from living donors in adults (125).

National liver donor mortality and morbidity (death & complication) rates may be available upon request from OPTN, but center-specific nor surgeon-specific data is not released to the public. Very limited center specific data is available at the OPTN website, only in regards to number of transplants performed and demographics related to the recipient*.

A prospective living liver donor could (and should) inquire from the transplant program itself, but there is no guarantee of a full and complete response.

(See Choosing a Transplant Center for more)

*In 2009, OPTN’s own data task force found OPTN’s database to be ‘incomplete’ and useless for analysis or research. So, don’t hesitate to ask the transplant center about their data submission compliance rate. Don’t take their word for it. Ask them to supply you with official OPTN documents. Your life and long-term health could depend on it.

Choosing a Surgeon

A prospective living donor has the right to choose and meet with their surgeon prior to the procedure. Most people wouldn’t hire a contractor to tile their bathroom without researching and interviewing them first, so why trust a stranger to remove the majority of a vital organ? (See Questions

And in the case of a donor hepatectomy, experience matters:

Forty-three out of 91 donors developed 53 complications (morbidity rate of 47.3%). Twenty-two patients (47.8%) suffered a total of 26 complications in the first period [of performing donor liver lobe removal] whereas 21 patients (46.7%) suffered 25 complications in the later period. Most of the complications in both periods were Clavien Grade I/II. There was a decrease in the incidence of ? Grade III complications in the later period as compared to the first period. The incidence of biliary, cardiopulmonary and abdominal complications was similar in the two periods. There was a trend towards decreasing hepatic complications (ascites, liver failure) during the later period. (182)

Ask your surgeon how many living liver donor procedures s/he has performed. Be specific. And compare those numbers with the US transplant program guidelines,national averages, success rates and otherwise. Do not be afraid of being thought of rude or distrustful; this is your life and long-term health at stake. 


Liver Donor Death/MortalityLiver Donor Complications/Risks

FYI:

[Note: The dangers of obesity in a living donor are pointed out for risk-assessment only and not from a place of judgment. It is ultimately the prospective living donor’s choice whether to undergo the procedure and/or to lose weight prior to the surgery, if approved by the transplant program. It’s important to keep in mind that weight gain and/or obesity post-donation is just as dangerous to a living donor’s health.]

– Wound infections were seen more frequently in overweight individuals.(158)

– In a review of 121 living liver donor transplants at UPMC, four donors returned to the ICU because of subacute liver failure, a right subphrenic (beneath the diaphragm) infection after 3 weeks, a deep vein thrombosis (blood clot) with bilateral pulmonary emboli (blockage of blood vessel in the lung), and a pleural effusion (excess fluid in the lung cavity) that ultimately required decortication (removal of an organ’s surface membrane). All 4 of these donors were obese (body mass index ? 30) with 12.5 ± 2.9% hepatic macrovesicular steatosis compared to 5.2 ± 7.2% in the other 117 donors (p = 0.046). There were no obvious differences in any of the other risk factors that were available for review. (141) 

– Most centers will exclude donors who have >10% steatosis (fat; lipids) on liver biopsy; in part, because in deceased donor transplantation, hepatic steatosis is associated with poor post-transplant graft function, but more importantly because hepatic steatosis increases the risk of bleeding and complications in the donor (159)

Also:

– In one study, liver donors over the age of 50 were associated with a higher degree of complications.(161) There is some evidence that older donors display a delayed and decreased capacity for regeneration(163), which also affects recipient regeneration and graft survival.(164)


Recovery

In one study, 24 donors recovered within 3.4 months. In another study, patients reported a mean complete recovery time of 13 weeks (range, 4 to 52 weeks). Both studies relied on donor self-report of recovery time. (124)

29 to 38% of donors felt that recovery was longer than expected, 33 to 53% found the pain worse than expected, and 30 to 40% of donors reported that the surgical scar was worse than expected. (117)

A survey of 27 liver donors reported a “mean hospital stay was 8 days (range, 3 to 14 days). Ninety-two percent of LDs reported that their hospital stay was shorter than expected or as expected.” When asked about their surgical experience, 33% experienced more pain than anticipated, and 37% reported a larger surgical scar than expected. (127)

Donors reported a mean time to complete recovery of 12 weeks (range, 1 to 52 weeks). Compared with what they expected before surgery, 33% of LDs reported that it took more time than expected to completely recover. Of all donors, 80% have returned to their previous level of physical activity, and 80% have returned to their previous level of social activity. A decrease in sexual activity was reported by 15% (127)


Psychological/Emotional

Six studies reported the occurrence of depression in donors following LDLT, with rates between 0.2 and 15%. Two studies reported a significantly higher rate of psychiatric disorders in LDLT donors after transplantation, compared to before transplantation. There was no association between physical complications and the occurrence of psychiatric disorders. (117)

From the A2ALL study: Of the 392 donors, 16 (4.1%) had one or multiple psychiatric complications, including three severe psychiatric complications (suicide, accidental drug overdose, and suicide attempt). (119)

Forty-two percent of donors reported a change in body image, and 17% reported mild persistent symptoms, primarily abdominal discomfort, that they related to the donor surgery. (124)

The psychiatric risks of right lobar donation has been exemplified at our center by a suicide attempt subsequent to the series reported here.(141)

Almost six years post-donation, 5% of liver donors expressed a diminished self-esteem, and 4% experienced severe depression requiring hospitalization (193).


Long-Term

Long term is defined as twenty years or more post-donation.

Presently, no data exist to predict long-term liver function after living donation. (122)

The long-term outcome of liver donation, however, remains unknown, and transplant centers should continue their follow-up of donors.(126)

Be aware that federal law only requires transplant centers to provide follow-up on their living donors for two-years post-donation. Many transplant centers are not complying with this mandate, or only partially complying.(107)

According to a study published in November 2011, almost six years after donation (69 months) 53% of liver donors were reporting (193):

– intolerance to fatty meals and diarrhea (31%)
– gastroesophageal reflux associated with left liver hypertrophy (9%)
– incisional discomfort requiring pain medications (6%)
– diminished self-esteem (5%)
– severe depression requiring hospitalization (4%)
– rib pain affecting lifestyle (2%)
– exacerbation of psoriasis (1%)


Last updated June 6, 2016