Liver Transplant

Living Donor Liver Transplant in Mayo Clinic in Minnesota and Arizona

The number of patients awaiting liver transplantation in the United States greatly exceeds the supply of cadaver donor organs. More than 15,000 patients are currently registered on the liver transplant waiting list of the United Network for Organ Sharing (UNOS), while only about 4,500 cadaver donor livers become available for transplantation each year. Cadaver donor organ availability appears to have reached a plateau despite many initiatives intended to increase organ donation.

The waiting time for liver transplantation has increased steadily each year, rising from approximately one month in 1988 to more than a year in 1999. Currently, more than one-third of patients in the United States wait longer than two years for a liver transplant, and more patients die each year while awaiting transplantation. There is a critical shortage of donor organs, and this problem will continue to worsen in the foreseeable future.

Living Donor Liver Transplant: A Success Story

The results of adult-to-adult living donor liver transplantation throughout the world are excellent. At least 275 adult-to-adult living donor liver transplants had been performed in the United States by early 2000, and several hundred more in other parts of the world.

The living liver donors are hospitalized about a week after the operation and have only occasionally required blood transfusion. Nevertheless, the donor operative procedure is a major operation and not without risk. Mayo Clinic's transplant team estimates a risk to the liver donor's life of 0.5 to 1 percent.

The donor is also at risk for temporary problems related to the surgical incision and the possibility of blood clots. The great majority of donors, however, have enjoyed a complete recovery within a few months of their operations, and tremendous satisfaction from giving a loved one their "gift of life."

Adult-to-adult living donor liver transplantation using the right portion of the liver evolved from successful experiences with transplantation of children and cadaver donor split-liver transplantation.

The split-liver procedure involves splitting a whole cadaver liver into two parts, allowing transplantation of two recipients. This technique has been performed at Mayo Clinic in Rochester since 1994. Use of the larger right liver for adult recipients is necessary to provide the patient with enough liver tissue.

With living donor liver transplantation, the healthy donor's liver regenerates to full size within a few weeks of operation, and there is no long-term impairment of liver function. The transplanted liver portion also regenerates, increasing in size to an appropriate match for the recipient.

Saving More Lives

There are many patients with specific diseases and special circumstances that make it important to proceed with liver transplantation sooner than is possible with a cadaver donor organ. Mayo Clinic is a leading center for patients with liver and bile duct tumors; such tumors may grow or spread if transplantation is delayed. Mayo Clinic also has many patients with progressive diseases such as primary hyperoxaluria, familial amyloidosis, pulmonary hypertension, and hepatopulmonary syndrome. These patients all greatly benefit from timely transplantation that becomes possible with a living donor organ.

The shortage of cadaver donor livers has also made it increasingly difficult for foreign national patients to receive a liver transplant in the United States. Since the early 1990s, UNOS has had limited cadaver organ allocation to foreign national patients. This limit became more restrictive in 1995. Living donor liver transplantation will allow foreign patients a new opportunity to undergo liver transplantation.

Living Donor Liver Transplant for Children

Living donor liver transplantation is a popular option for liver transplantation in children. Adult-to-child living donor liver transplantation using the left lateral portion of the liver is safe and effective. The procedure has helped reduce the number of children who die awaiting liver transplant. It also helped to avoid family disruption caused by having a child and at least one parent away from home, staying near the transplant center while awaiting a chance for cadaver donor organ transplantation.

The Pros and Cons of Living Donor Liver Transplant

Before offering living donor liver transplantation, Mayo Clinic leaders and the liver transplant teams in Rochester and Arizona examined the need for the procedure, experience with this approach around the world, potential risks to the donor, advantages and disadvantages compared to cadaver liver transplantation, and ethical issues pertaining to living donation.

The Mayo Clinic liver transplant program in Rochester and in Arizona is well suited to perform living donor liver transplantation for several reasons:

• The program's established track record of superb patient and graft survival
• Mayo Clinic's well-recognized multidisciplinary team approach to patient care
• The extensive experience of Mayo Clinic surgeons with liver resection, an essential skill in living donor liver transplantation.
• Living donor liver transplantation has several advantages over cadaver donor transplantation, including:
  • an opportunity for transplantation in a more timely fashion
  • less possibility for complications and death while waiting for a cadaver donor organ
  • a better opportunity for patients from other countries and those with special circumstances to undergo transplantation

The disadvantages of this approach include a small risk to the healthy donor and the period of discomfort and recovery for the donor.

Screening for Recipients and Donors

All liver transplant candidates undergo a similar evaluation, whether for cadaver donor or living donor liver transplantation. Patients likely to benefit from living donor transplantation are encouraged to consider this option. The patient and family then ask potential donors to contact the living donor nurse coordinator to begin the evaluation process. The coordinator provides the potential donor with specific information about living liver donation and conducts a preliminary survey to determine whether donation may be possible.

Throughout the evaluation process, all possible efforts are made to protect the confidentiality of all potential donors' medical and personal matters, including decisions about whether to proceed with donation. Organ donation is an altruistic gift, and every effort is made to assure that donors who choose to proceed are free from coercion. The transplant team provides recipients, potential donors, and families with counseling and support through every phase of the process, from donor identification through recovery after operation.

Potential living donors undergo an extensive evaluation to assure that they are in optimal medical condition to proceed with organ donation. The blood types of donor and recipient must be compatible, but not necessarily identical. The anatomy of the donor's liver must also be favorable for donation. Size requirements vary with individual recipients, whether child or adult. Some normal variations in the distribution of blood vessels or bile ducts may preclude or aid the donor operation. Above all, the donor must be in excellent health.