Of the 17,000 Americans waiting for a liver transplant each year, about 2,000 will become too sick while waiting and be delisted…or simply die waiting. There just aren’t enough livers from recently deceased donors to go around. But there’s an alternative. These patients may be candidates for a living donor liver transplantation (LDLT)—a procedure that has been proven safe and effective but, unfortunately, is widely underused.
As the name implies, it’s a liver from a living person. Not the whole thing, of course, since everyone needs a liver to…live. But it turns out that when you transplant just part of a liver from a healthy person, it regenerates…both in the donor and the recipient. Voilà, two healthy livers. Donors usually are close relatives or friends.
LDLT was first tried in children in 1989 and in adults about 10 years later. The need keeps growing as the gap between people waiting for liver transplants and available livers from deceased donors widens, but public enthusiasm for it waned after a handful of highly publicized cases in which a donor died…tragic but, as it turns out, very rare. Now a new small study finds that it was not only safe for donors but for recipients it’s at least as safe as a standard liver transplant from a deceased person. Combined with other reassuring data, this is one option that anyone who is a candidate for a liver transplant should seriously consider. Here’s what you need to know about this promising solution to a national crisis.
AS GOOD AS A CONVENTIONAL TRANSPLANT
“No procedure is perfectly safe, but with the skill set of a surgeon who has substantial experience in the area, I give it high marks for safety,” said Robert G. Gish, MD, medical director of the Hepatitis B Foundation in Doylestown, Pennsylvania. “At expert centers, LDLT is a standard-of-care option for patients, and it should be discussed with every patient. Even centers that don’t offer it should be telling patients about it.”
According to the most recent data from the Organ Procurement and Transplantation Network, the five-year survival rate for patients receiving a liver from a dead donor was 65.1%…compared with 65.9% from a live donor. In a study of seven patients in Toronto General Hospital who received an LDLT for acute liver failure had a postoperative complication rate of 31%, compared with a 43% complication rate for conventional liver transplants. The patients had similar risk factors going into the operation.
The major benefit, of course, is that there is—theoretically—an almost limitless supply of partial livers available for transplantation, compared with the very limited supply of livers from recently deceased persons. But there can be distinct medical benefits to partial transplantation as well, including being able to make sure in advance that the donor’s blood type and immunological factors are suited for a successful transplantation and that the part of the liver being removed from the donor is the right size for the recipient. You don’t need to be a relative to have a good chance of being a good donor match.
Bonus: As soon as any patient is matched with a medically suitable and willing donor, the procedure can be scheduled. For conventional transplants, patients often have to wait until they become sicker—dangerously sick, in many cases—to move up in the queue, since donated livers are prioritized to those who are the sickest. (It’s a Catch 22—you need to be sick enough to get a liver from a deceased person, but if you get too sick, you may not be able to go through with the operation. Or you may just die before one is scheduled for you.)
Few patients know about the LDLT option, however, and many centers don’t offer it. In 2018, the last year for which data is available, there were 8,250 liver transplants in the US, but in 2017 only 367 were LDLTs.
RISKS OF LDLT FOR THE PATIENT…AND THE DONOR
LDLT is a more complex procedure than conventional liver transplants, and can lead to blood vessel and bile duct damage for both donor and recipient. “This is much more specific to LDLT than it is to regular transplant,” said Dr. Gish, “because you have these very large vessels that in regular transplants are easier to secure together.” But overall recovery for the recipient is similar for both procedures.
For the donor, about half of the liver is removed (either the right or left lobe). There’s a hospital stay of five to seven days and then recovery at home for about six to eight weeks. After that time, donors can resume normal activities. The liver regenerates substantially in that period and continues to grow to nearly the normal size over the next two to five weeks.
There is a 30% chance of a surgical complication, such as bile leakage, although most of these are minor and short-term. However, there are occasional severe complications, and there is a 0.25% to 0.5% risk that the operation will lead to death for the donor, as can happen with many major surgeries. According to Dr. Gish, Stanford has done more than 50 LDLTs with few complications.
THE RIGHT DONOR
The criteria for qualifying as a donor vary slightly from center to center, but some key characteristics to look for in a good donor, according to Dr. Gish, include the following…
- Correct blood type and immunological match. The donated liver also has to be the right size for the recipient—even part of a liver can be too large. You don’t have to be a family member to be a good match.
- Less than 55 years of age. This is not an absolute requirement, but it is followed by most centers since the liver doesn’t grow back as well in older people.
- No high-risk infections or cancers that could be transmitted to the recipient.
- Can’t be considerably overweight, have a fatty liver, be a smoker or have uncontrolled high blood pressure or diabetes, any of which would decrease the risk for a successful transplant.
- Appropriate psychosocial status. The donor—usually a sibling, parent, spouse, relative or close friend—needs to be willing to take six weeks off from work and be psychologically committed to going through with the procedure when it is scheduled. Because this is such a commitment, a psychological screening test is usually required.
WHY AREN’T LDLTS PERFORMED MORE OFTEN?
Living donor liver transplants offer one way out of the current desperate situation that many people with liver failure face now. That’s why patient support groups and the American Society of Transplantation (AST) are working to get the message out, and medical centers such as the Cleveland Clinic have ramped up their LDLT programs.
Still, there are many obstacles, including too few surgeons trained in these complicated operations and too few medical centers that offer them. For donors, the recipient’s insurance usually covers direct medical costs, but they can face substantial out-of-pocket expenses including travel, lost work time and child-care expenses. (When recipients have Medicare, as most do, more of the donor’s costs may be covered.) Many have trouble getting life insurance coverage afterward, an issue that AST is working to change.
These are solvable problems, and they offer a great hope to patients on the waiting list. If you know someone who needs a liver transplant, the LDLT option could save his or her life.