Hundreds of millions of people have registered to serve as organ donors when they die. But not everyone will get the chance. In fact, only three out of 1,000 people die in a way that allows their organs to be used, meaning that the demand for lifesaving transplants far outpaces the number of viable organs.

Enter living donation. A living donor gives a kidney…part of his/her liver…or another type of tissue to a loved one, acquaintance or even a stranger who needs it. Unlike hearts and lungs, which come only from deceased donors, kidneys and livers lend themselves well to living donation. A person needs only one of his/her two kidneys to live…and the liver regenerates, or grows back, so a donor can give a portion of his liver to a recipient, and both their livers will grow to full size. (Donating a portion of your pancreas, intestines or lung is possible but very rare.)

Addressing a Growing Need

Organs from living donors have several advantages over organs from deceased donors. The recipients often spend less time waiting for an organ because they have actively sought out a live donor. And in many cases, expenses for the donor are picked up by the recipient’s insurance (see page 13 for details). The surgery can be scheduled in advance, giving all parties enough time to prepare. And because the donor organ is working up until mere moments before transplantation, long-term outcomes are improved and recovery times shortened for the recipient. Living donors often are related to the patient, and the increased likelihood of genetic matching (versus an organ from a deceased stranger) may reduce the odds of organ rejection. Additionally, every time a live donation occurs, a different candidate on the organ-transplant waiting list moves up. More than 100,000 Americans currently are on the list, with someone new added every nine minutes.

Most patients needing a kidney are in kidney failure related to diabetes and/or high blood pressure. Common ailments that can be treated with a new liver include nonalcoholic steatohepatitis (NASH, or liver inflammation caused by fat buildup in the liver), liver cancer and autoimmune liver diseases such as primary biliary cholangitis and primary sclerosing cholangitis. Hepatitis C used to be a common cause for liver transplants, but today’s effective antiviral treatments mean that far fewer people with hepatitis C require transplants.

Organ recipients typically take immunosuppressive drugs indefinitely to prevent their bodies from rejecting the new organ.

The donor reaps many rewards as well, not the least of which is the knowledge that he/she has saved another person’s life. As one donor wrote on the National Kidney Foundation blog, “To see a loved one who’s been pale, weak and often listless for many months or years gradually become their old self again is pretty powerful. Seeing [my son’s] smile when he came into my hospital room the day after the transplant was unforgettable.”

Many Ways to Give

There are several ways to donate…

Directed donation. You give your organ to a relative, spouse, friend, colleague or unrelated person in need. You must be a match for the recipient, meaning that your blood type and tissue type are compatible.

Paired donation (organ exchange). This involves two or more pairs of living donor/recipients “swapping” donor organs. Example: Jean wants to donate a kidney to her friend Jerry but isn’t a match. Another pair—Lisa and her mother, Judy—are incompatible with each other as well, preventing Judy from receiving Lisa’s kidney. But Jean and Judy are a match, and Lisa and Jerry are a match. Transplant centers connect incompatible pairs, ensuring that each recipient receives a compatible organ.

Nondirected donation. Some individuals (called altruistic donors or Good Samaritan donors) donate to a medically compatible stranger.

Never-Ending Altruistic Donor (NEAD) kidney chain. A person gives an organ to a stranger who already has an incompatible donor. In exchange for that kidney, the recipient’s incompatible donor donates to another stranger in need of a kidney, and the cycle continues. The nation’s longest NEAD kidney chain, still happening at the University of Alabama at Birmingham, has seen 114 people receive kidneys from strangers.

How Living Donation Works

Innovations in transplant surgery have made donating easier and more effective.

Kidneys. Laparoscopic surgery allows kidney removal via several tiny incisions during a three-to-five-hour surgery, reducing the average hospital stay to a day or two. This shortens overall recovery time, reduces post-op pain and lowers the risk for complications. Donors usually are able to return to work in two to four weeks and are back to normal in four to six weeks.

Livers. Liver donation is a bigger endeavor. Anywhere from 25% to 65% of the liver is removed via incision in a four-to-six-hour surgery. Pain following donation is significant, but improvements in post-op pain control have shortened the average hospital stay from seven to five days, and donors often are back to work in four to six weeks and resume normal activities in 10 to 12 weeks.

Both surgeries require general anesthesia. Besides pain, risks include surgical complications such as infection…blood loss or blood clots…and injury to surrounding tissue.

Potential long-term risks of kidney donation may include high blood pressure, reduced kidney function or hernia, but these risks are rare. The risk of dying from the surgery is extremely low, about one in 5,000 cases (0.02%).

Possible risks for liver donors include future bile duct problems, hernia and organ failure. Again, these complications are relatively uncommon. The risk of dying from this surgery is higher than that for kidney donation—about one in 500 cases (0.2%)—but is still quite low.

Some donors experience psychological difficulties afterward, including worrying about their future health or symptoms of anxiety or depression. But most donors report a profound sense of fulfillment and a strong bond with the recipient (if they know each other). According to the American Society of Transplantation, nearly 98% of live donors say that they’d donate again if they could.

Starting the Process

Living donors must be at least 18 years old and usually no older than 60 to 65 (kidney) or 55 to 60 (liver). Race and ethnicity don’t matter—matches frequently occur between people of different backgrounds. Donors undergo extensive physical and mental health evaluations to rule out underlying medical issues such as heart disease, diabetes and depression. Certain well-controlled conditions, such as mild high blood pressure, may be permitted. Many transplant centers require donors and recipients to be vaccinated for COVID-19.

During an informed-consent process, doctors ensure that you fully understand the risks and benefits…are not being coerced into volunteering…and understand how your personal, work, emotional and social life may be impacted in the months following donation.

Ready for the Next Step

For a directed donation, contact the transplant center your friend or family member is working with. For a ­nondirected donation, contact any center you want. The US Department of Health & Human Services’ Organ Procurement and Transplantation Network (OPTN.transplant.hrsa.gov/about/search-membership) lists programs nationwide.

The recipient’s insurance usually will cover the donor’s medical expenses, including evaluation, surgery and ­follow-up testing. (Medicare covers the cost of care for donors.) That said, complications related to donation may not be covered, and some donors experience difficulty obtaining or keeping insurance coverage. Check with your insurance provider or ask your transplant center if it offers medical and disability insurance for donors. Recently introduced legislation, the Living Donor Protection Act, would protect living donors from excessive insurance premiums and help guarantee time off from work to recover. The National Living Donor Assistance Center ­(LivingDonorAssistance.org) may be able to help cover nonmedical expenses such as travel and housing.

The Future of Organ Donation

Researchers in the field of regenerative medicine are actively exploring the possibility of growing human-compatible organs in pigs, as well as using specialized 3-D printers filled with a patient’s own stem cells instead of ink to create human tissues and organs. Both would address—and perhaps end—the donor-organ shortage while avoiding organ rejection. (In the case of pig organs, the animal’s genes would be edited to avoid attack by the human immune system.) Exciting progress has been made—skin, ­urethras and other tissues have been built by hand using patients’ cells and successfully implanted into people—but engineering or growing solid organs such as kidneys and livers has proven more challenging. In October, surgeons at NYU Langone Health in New York City connected a gene-edited pig kidney to a brain-dead patient with malfunctioning kidneys, resulting in swift improvements in kidney function. (The patient’s family consented to the experiment.) Widespread use of these procedures isn’t in the near future, but they could be game changers if they come to pass.

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