Living Donor Liver Transplantation at Stanford University Medical Center

Transplantation of a solid organ from a living donor was initially limited to kidney transplantation, but is now being increasingly used to transplant portions of the liver and some other organs. The use of a part of a liver from a living donor has evolved in recent years because of the increasing shortage and longer waiting time for cadaver liver organs. In early 2001, there were more than 16,000 patients listed with the United Network for Organ Sharing (UNOS) for a liver transplant, but only approximately 4,500 cadaver organs were available for transplantation. The gap between available cadaver organs and need for liver transplantation continues to widen, resulting in more patients becoming critically ill before receiving a transplant and poorer outcomes after transplantation. These facts have been the impetus to expand adult-to-adult living donor liver transplantation.

Living donor liver transplantation (LDLT) is a procedure in which a healthy, living person donates a portion of his or her liver to another person. The feasibility of LDLT was first demonstrated in the United States in 1989. The recipient was a child, who received a segment of his mother’s liver. Since this initial operation, LDLT for children has been very successful, including at Stanford University Medical Center (SUMC). Many pediatric programs across the country now use the technique of LDLT, in which a portion (typically the left lateral segment, i.e., segments II and III) of the adult donor’s liver is removed. In the pediatric experience, survival of the recipient child and function of the transplanted liver (graft) at 1 year is about 90%. Donors have had very few complications. An increase in the percentage of adult patients awaiting liver transplantation, many of whom cannot survive the waiting time for a cadaver liver, has led to the application of LDLT for adult patients, and the preliminary results have been very encouraging in the United States and worldwide. In adult-to-adult LDLT, the entire right liver lobe (segments V, VI, VII and VIII) or, less often, the full left lobe (segments II, III and IV) is removed from the donor and transplanted into the recipient.

The transplant team at SUMC has been performing LDLT in children at the Lucile Packard Children’s Hospital for the past 5 years with excellent results (93% survival). In the latter part of 2000, the same team performed the first four adult-to-adult LDLT procedures at SUMC without complications in the donors and good success in the recipients, which has led to the expansion of this program.

This fact sheet is designed to provide information about LDLT as performed by team of physicians at the SUMC Liver Transplant Program. It also answers the following questions: 1) Who is a good donor? 2) What is the process for evaluating and selecting a donor? 3) Where does the transplant occur? 4) When does the transplant occur? 5) How is the operation performed? 6) What is the postoperative period like for the donor?

Basic facts for the recipient:

• Patients being considered for adult-to-adult LDLT are candidates who are listed to receive a cadaver liver (liver from a brain-dead, unrelated individual) based on the severity of their liver disease and its complications. These patients are placed on the UNOS liver transplant waiting list, and will not be denied a cadaver donor liver if it becomes available prior to LDLT. Thus, failure to find a suitable donor for LDLT will not jeopardize a recipient’s chances of receiving a cadaver liver, based on priority on the UNOS list.

• Patients considered for LDLT will be followed by the same SUMC liver transplant team, who will manage all complications of liver disease with the view to optimizing the patient’s condition prior to liver transplantation.

Basic facts regarding the donor:

• The donor should be a relative (close or distant) or emotionally related to the recipient.

• The donor must be competent and freely willing to donate.

• The donor should be in good physical and mental health.

• The decision to be a donor should be made after careful consideration and understanding the procedure, and accepting its risks and complications.

• There should be no evidence of financial gain arising out of the donation.

• Potential donors who are believed or known to be coerced must be excluded.

• The blood type of the donor must be the same, or compatible, with the recipient.

• The donor must be relatively close in size (or larger) than the recipient.

• Donors need to have the ability and willingness to comply with follow-up.

• All donors must have a primary care physician.

• All donors must have insurance coverage.

What constitutes a good donor?

A good donor is someone who is in good physical and mental health, older than age 18, and free from:

- HIV infection

- Chronic viral hepatitis

- Active alcoholism or heavy alcohol use

- Psychiatric illness under treatment

- History of malignancy

- Heart and lung disease requiring medications

- Diabetes mellitus of greater than 7 years’ duration

- Free from any other serious chronic medical illness

- BMI (body mass index) of 30 or less

What is the process for evaluating the donor?

• The potential donor will be asked to complete a questionnaire that includes attaching a copy of his or her blood type (to confirm whether the blood type is compatible with the recipient).

• If the ABO blood type is appropriate, the donor's size (height/weight compared to that of the recipient) is acceptable, and the details on the questionnaire indicate donor suitability, the potential donor will have additional laboratory studies (complete blood count, liver panel, blood tests for hepatitis B and C, and tests to incure normal clotting including proteins S, protein C and anti-thrombin III). Other tests include EKG and chest X-ray.

• If the laboratory tests confirm that the donor is suitable, a volumetric CT scan will be arranged at Stanford to calculate the volume of the donor's liver that will permit a successful outcome.

• If the CT scan indicates that LDLT is feasible, the donor will return to Stanford for consultations with a hepatologist (primary contact physician and advocate for the potential donor), liver transplant surgeon, and a social worker. Under some circumstances, a psychiatric evaluation may also be appropriate. Additional laboratory tests, chest x-ray and electrocardiogram will also be performed during the visit to Stanford.

• The potential donor will be asked to sign an informed consent document, which will document understanding of the surgical procedure and recuperative period, knowledge of the approximate risk of potential complications (10%) or death (0.2%), unknown long-term risks of undergoing this procedure, expected outcome of the recipient, alternative available for the potential recipient, and SUMC statistics with LDLT. There will be a "cooling off period" between the initial consent process and scheduled donor operation.

• After the tests and consultations are completed, the medical and social details of the evaluation will be discussed at a committee of the transplant team members. The decision regarding the suitability of the donor will be made at that time. This decision will be communicated to the donor by one of the team members, usually the transplant coordinator. If not selected, the physician team members can be contacted for an explanation. Note that all information concerning the donor will be kept in strict confidence.

Where does the transplant occur?

• All adult liver transplants, both cadaveric and LDLT, are performed at Stanford University Hospital. Pediatric liver transplants are performed at the Lucile Packard Children’s Hospital by the same transplant surgeons.

When does the transplant occur?

• The transplant is scheduled at a mutually convenient time for the donor and recipient. In the case of the latter, the team members will decide the optimal time based on the condition of the recipient and control of complications. For example, if the recipient develops a sudden fever, the procedure will be delayed until the cause is found and potential infection controlled.

• The advantage of LDLT is that the procedure can be timed when both recipient and donor are both in the best possible condition.

How is the operation performed?

• After all of the medical issues have been settled, the donor-recipient match-up is completed and the Patient Selection Committee has approved the transplant pair, a date is selected for the operation. After the surgery date is scheduled, the donor will donate 2 units of autologous blood.

• Two teams perform the donor and recipient operations simultaneously.

• As the diseased liver is removed from the recipient by one team, approximately half of the donor’s liver (either right lobe or left lobe) is removed by the other team.

• Once the donor operation is complete, both surgical teams complete the transplant by attaching the right or left lobe into the recipient.

• The donor operation usually takes 5-7 hours and the recipient operation about 10-12 hours.

• Both half-livers (the remaining half in the donor, and the transplant half in the recipient) grow to almost full size within 6-8 weeks.

What is the postoperative period like for the donor?

• Prior to the transplant procedure, the donor will receive a detailed description of the procedure and will have an opportunity to discuss the potential risks and side effects of the operation with members of the transplant team.

• The donor is usually in the hospital for 5-7 days. Most patients are up and out of bed (with assistance) by the second or third postoperative day. It is usually necessary to stay off work and usual home activities for a month full time and 2-4 weeks part time, depending upon the rapidity of the recovery.