University of Minnesota Health is a leader in successful living-donor transplants. We began our program in 1997 to address the growing shortage of livers available from deceased donors. Since then, our surgeons have performed 160 adult-to-adult living-donor liver transplants, using partial livers from the donors. The use of living donors increases the chance of finding a donor, shortening the wait time for patients.
As researchers develop new surgical techniques and better immunosuppressant drugs, more patients with liver disease have become eligible for a transplant. Yet, in the United States alone, roughly 18,000 children and adults are on the waiting list for a new liver. The number of deceased donors cannot keep up with that need, and every year, 1,400 people die before livers from deceased donors become available.
With a living donation, surgery can be scheduled at the convenience of the donor and recipient, often before the liver disease has progressed to a severe stage. More importantly, living donation prevents risk of mortality while on the waiting list and can result in faster recovery and equivalent long-term success for patients.
Using organs from living donors is just one of the many innovations we have pioneered through the years. In 1997, we began performing adult-to-child, living-related-donor partial liver transplants, which later expanded to include adult-to-adult living-donor liver transplants.
The role of the liver
The liver is a very important organ in the body. It performs three major tasks. First, from digested food, it makes proteins that are needed to nourish the body, fight infections, and stop bleeding. Second, it helps the body to rid of wastes, including ammonia, bilirubin, other waste products of natural liver function, and many drugs. Third, the liver excretes bile, which helps digest dietary fats.
When liver function deteriorates it may not adequately perform these tasks and a transplant is necessary. A liver transplant is a major surgical operation in which the diseased liver is taken out of the recipient's body and replaced with a healthy one from either a deceased or living donor.
History of living donor liver transplant
The first living donor liver transplant (LDLT) in the United States was performed in 1989 when a child received a segment of his mother's liver. Since that time, over 1,500 LDLTs have been performed for adults across the nation, with excellent success rates.
Surgeons in Japan were the first to demonstrate that an even larger piece of the liver (one of the two lobes) could safely be removed from a living adult donor and transplanted into another adult. This operation, while more technically difficult than living liver donation for pediatric recipients, also proved to be successful. Only a handful of centers in the United States currently perform adult-to-adult LDLTs. As of 2015, about 1,200 of these transplants have been performed in the United States. The early and long-term results are excellent.
Our University of Minnesota Health transplant team has been performing LDLTs since 1997. The first adult-to-child LDLT and the first adult-to-adult LDLT in Minnesota were both performed here. We now offer LDLT as an option to the majority of children and adults referred to us for a liver transplant. As of November 2015, we have performed 171 living donor liver transplants.
Who can receive a living donor liver transplant?
Most patients who have severe liver disease (MELD scores >15) and who are candidates for a deceased donor transplant can be considered for LDLT. People with very high MELD scores (>25) and certain hereditary liver diseases or unusual blood vessel variations may not be candidates.
What is the general process for finding a living donor?
Once we know a liver transplant is necessary and the recipient has been placed on the deceased donor wait list, potential donors can be identified. We simply ask that you make friends and family aware that live donation may be possible. It may be helpful to discuss this option with your doctor at the time of recipient evaluation. Encourage potential donors to contact the transplant office to ask questions about donation. Potential donor candidates can be referred to our website or the donor coordinator at the transplant office for an initial screening. If the donor passes the initial screening, he or she will be scheduled for a donor evaluation.
About 50 percent of potential donors who come forward for testing do not turn out to be suitable. Some of the most common reasons include age, incompatible blood type, anatomical variation of the blood supply in the liver making it too difficult to hook up to the recipient, abnormal lab tests and obesity. This does not mean that they are not in excellent health. They just don't meet the strict criteria required for such extensive surgery. Even if no suitable living donor is found, the potential recipient will remain on the deceased donor waiting list. If a deceased donor liver becomes available, even during the evaluation of a potential donor, we would proceed with a deceased donor liver transplant. The evaluation of a live donor does not jeopardize or delay the possibility of a deceased donor transplant.
What are the advantages of a living donor liver transplant?
The greatest advantage of LDLT is that it avoids the waiting time for a deceased donor transplant. Currently, the organ shortage is severe. There are not enough deceased donor livers for all of the patients who need one. In 2012, there were over 16,000 patients on the waiting list for a liver;6,878 were transplanted and 6,999 died while waiting. Roughly 25 percent of patients will die of their liver disease before having the chance to undergo a transplant.
For those who do end up receiving a deceased donor transplant, the average waiting time is one to two years (from the day they are first placed on the waiting list). With a LDLT, this waiting time can be bypassed, allowing the transplant to be performed before the recipient's health deteriorates further, sometimes to the point where he or she is no longer able to undergo a transplant. If the transplant can be performed before the recipient's health deteriorates, it is likely that he or she may better able to tolerate the surgery and recover more quickly.
Another advantage of an LDLT is that the piece of liver from the donor may be placed in the recipient immediately after being removed from the donor. Therefore, the amount of time that the liver is kept on ice before the transplant is minimal. In contrast, a deceased donor transplant may need to be in storage for several hours. Thus, the chance of an LDLT graft functioning immediately is probably higher.
Finally, by performing an LDLT, the number of livers available for transplantation overall is increased. The LDLT recipient no longer requires a deceased donor liver, which can then go to a patient who does not have a suitable living donor.
What are the results of a living donor liver transplants like?
The long-term results of living donor liver transplants are excellent. In a recent study of 963 adult to adult living donor transplants performed in United States, survival probability at 10 years was 70 percent for LDLT and 64% for deceased donor liver transplant. According to data from all centers in the United States, about 85 percent of LDLT recipients are alive one year after their transplant. Both adult and pediatric LDLT recipients have a good chance of leading a long and healthy life.
Who can be a living liver donor?
The transplant team will consider many different people as potential donors. Immediate family, relatives or close friends are preferred since they are most involved in the potential recipient's health. The donor must have a compatible blood type and must also be similar in size to the recipient. Most important, the donor must be in good physical and mental health, with no significant history of major medical problems, liver disease or excessive alcohol use. The transplant team will consider donors between the ages of 20 and 50 if they are in good health.
What is the process for evaluating a donor?
All potential donors are encouraged to complete an online survey or call Transplant Services at 612-625-5115. Once the potential donor is determined to be of similar size and compatible blood type, an evaluation or workup is done to ensure that he or she is medically, surgically and psychologically fit for donation. Donor safety is of utmost importance.
1. Medical evaluation
The medical evaluation involves an intensive interview to obtain the donor's medical history. A complete physical examination is also performed. The donor must not have any medical problems that would increase his or her risk for a major operation and the removal of a portion of the liver. Medical problems that would rule out donation include heart or lung problems that require medication, current liver problems or hepatitis infection, a history of cancer, active alcohol abuse, or any history of very heavy alcohol use, HIV infection, diabetes of several years' duration requiring insulin use, and significant obesity. Besides the medical history and physical examination, many blood tests will be done to rule out any significant abnormalities and to make sure the donor's liver function is normal.
2. Surgical evaluation
The liver is one large solid organ. It is made up of 2 lobes (right and left), which are further divided into a total of 8 smaller segments (1 through 8).
Each portion has its own blood supply (arteries and veins) for bringing the blood to and from the liver as well as its own bile duct draining the bile produced by the liver. An LDLT can be performed because it is possible to remove a portion of the liver with its own blood supply and bile duct intact. This portion can then be reconnected in the recipient. However, not all people's anatomy is suitable to splitting the liver in this fashion. So, the purpose of the surgical evaluation is to determine the anatomy of the donor's liver and make sure that donation is technically possible. Most often we use a right lobe of the liver for donation but in special cases where the recipient is small in size, we can use the left lobe of the liver. Special x-rays of the liver, including a computed tomography (CT) scan and a magnetic resonance imaging (MRI) scan, will be performed. These x-rays provide information about the liver's appearance and blood supply. They may also be used to determine if the liver volume would be adequate for adult-to-child LDLTs. On rare occasions, these x-rays are not sufficient and an additional test called liver biopsy is necessary. In a liver biopsy, under deep sedation a needle is placed directly into the liver and a sample is obtained and evaluated under the microscope.
3. Psychosocial evaluation
The potential donor also will be interviewed by an independent living donor advocate (ILDA)/clinical social worker who will obtain psychosocial information. This may include information about mental health, chemical use/abuse, donor occupation, employment status, living arrangements, social support network, potential financial implications of donation and so on. The ILDA will review the potential donor’s understanding of the medical and psychosocial risks. The ILDA also ensures that the decision to donate is free of coercion and is made entirely by the potential donor after careful consideration.
Once the donor's evaluation is complete, all of the information will be carefully reviewed by the Living Liver Donor Committee team in order to make a final decision regarding that donor's suitability. Once the decision is made to accept a donor, a tentative transplant date can be chosen. The donor will be seen by an anesthesiologist in the PAC clinic.
The donor will be asked to come to the hospital the day before surgery. He or she will NOT be admitted at that time, but may need some additional testing done. All donors will be given a bottle of antibacterial soap. The abdomen should be scrubbed from nipples to knees the evening before the surgery, and twice in the morning on the day of surgery, before the donor comes to the hospital. This soap helps to reduce the chance of getting an infection in the incision after surgery. If any donor is allergic to antibacterial soap products, please notify the transplant coordinator.
After noon on the day before surgery, the donor should only have clear liquids. After midnight the day of surgery, the donor should have absolutely no food or drinks. This fasting will decrease the possibility of nausea or vomiting during and after surgery and will help clear the bowel before surgery.
Smoking is not permitted and the donors are encouraged to stop smoking four to six weeks before donation. Smoking increases the risk of heart and lung problems (such as pneumonia) after surgery.
Where can the donor’s family members stay overnight?
An additional bed or cot can be moved into the donor’s hospital room if it is a private room. One family member can stay overnight with the donor during the hospital stay. Additionally, long- and short-term lodging options, at a reduced hospital rate, are available.[AJ1] You also may contact the Accommodations Department at University of Minnesota Health (612-273-6895 or 1-800-328-5576).
The donor is admitted the day of surgery to the Same Day Admission Unit (3C) of University of Minnesota Medical Center at about 5:30 a.m.
The donor will be given a pair of TEDs (which stands for thromboembolic disease): these are special elastic stockings that increase the circulation in the legs. Only a hospital gown may be worn to surgery. All dentures and glasses, nail polish, lipstick, makeup, jewelry, and hairpins must be removed. Valuables should be left in the hospital room, they will be sent to Protection Services or with relatives for safekeeping.
A nursing assistant will bring a cart to the hospital room to transport the donor to the Pre-Induction Room (PIR) outside of the Operating Room. Families may come into this area. They will then be directed to the Surgery Waiting Area on the third floor. After the surgery is done, the doctors will meet with the family there.
In the PIR, an intravenous line will be inserted so that anesthesia medications can be administered. The doctor in charge of anesthesia (the anesthesiologist) will come to see the donor. The donor will meet the anesthesiologist who will perform a para vertebral block and place a small catheter for pain relief during and after surgery. The donor will then be transferred to the operating room.
An endotracheal (ET) tube will be inserted in the donor's throat during surgery to help with breathing. The ET tube is placed after the donor is asleep from the anesthesia. If it is still in place when the donor first wakes up, he or she will not be able to talk. As soon as the donor is fully awake, the ET tube is removed.
A Foley catheter will be inserted in the donor's bladder in the Operating Room to drain urine. A nasogastric (NG) tube will also be inserted through the nose and throat to the stomach. It drains the stomach contents to prevent nausea and vomiting and will remain in place for a couple of days after surgery, or until the bowels start to function.
A small plastic drain with a bulb is left in the donor's abdomen to collect blood and bile, which may accumulate in the area where the piece of liver is removed. This drain is usually removed 4 to 5 days after surgery
The donor operation is done through an incision in the upper abdomen.
If the LDLT recipient is an adult, a larger portion of the liver needs to be removed from the donor, usually the right portion of the liver: about 65% of the donor's total liver.
If the LDLT recipient is a child, only a portion of the left part of the liver is removed from the donor: about 25% of the donor's total liver.
Portion of liver to be used for child transplant
All donors wake up in the Post-Anesthesia Care Unit (PACU). Nurses check the pulse and blood pressure frequently. Oxygen is received through an oxygen face mask. This air will feel cool and moist. The mask will be changed to nasal prongs to deliver the oxygen, which will be discontinued 24 hours later.
Once fully awake, the donor will be transferred to the Transplant Unit (7A) to complete the immediate recovery process.
The incision is located in the upper abdomen just under the rib cage.
Because the incision is large, it may be painful. The pain can be very significant in the first 3 days after surgery. The ribs are also pulled up (retracted) during the surgery in order to give the surgeons access to the liver. Breathing and coughing use some of the same muscles that have been cut, so pain for the donor may be significant. However, the pain can usually be well controlled with the pain medications that are given after the operation. The pain will lessen once the donor is up and around and has some experience getting in and out of bed.
All donors have a patient-controlled anesthesia (PCA) pump. This pump provides a continuous intravenous (IV) infusion of pain medication (usually morphine or hydromorphone). By pushing a button on the PCA pump, the donor can obtain as much pain medication as needed. More can be given during activities that may cause more discomfort, such as walking and coughing. The PCA pump is set so that not too much medication at any one time can be given. Most patients use the PCA pump for 2 to 3 days. Once the IV line comes out and liquids are tolerated, pain medication can be given by mouth instead.
A dry mouth and sore throat from the ET tube are frequent complaints. Rinsing the mouth is allowed, but no food or drinks are permitted until the bowels are passing gas and the NG tube is removed. Ice chips may be allowed once the donor is fully awake after surgery.
Nausea is also common for the first few days. It can be caused by anesthesia medication or by the lack of normal bowel function after the surgery. Medications can help control nausea
A Foley catheter allows urine, as soon as it forms, to flow from the bladder. The nurses watch and measure how much urine output there is. This information helps the doctors determine how much fluid must be given through the IV line.
The Foley catheter will be removed within 48 to 72 hours after surgery. If the donor is unable to urinate within 6 to 8 hours after the Foley catheter is removed, a catheter will be inserted to empty the bladder and then removed. It is not unusual to be unable to urinate the first time after the catheter is removed.
Pneumoboots are sleeves surrounding the lower legs that some donors will wear after surgery. Pressure is applied every so often by inflating and deflating the sleeves with air. Doing so helps to improve circulation and prevents blood clots. The boots are discontinued when the donor is able to be up and walking the halls 4 times a day
To prevent secretions from building up in the lungs after surgery, taking deep breaths, coughing, and turning side to side is essential every 2 hours for the first few days after surgery. Secretions can otherwise collect in the lungs and cause pneumonia. Getting out of bed to walk several times a day is the best way to prevent pneumonia.
All donors will have a breathing machine (called an incentive spirometer) to help expand the lungs and prevent pneumonia. The nurse or the respiratory therapist will provide the instructions how to use it. This machine should be used every 1 to 2 hours while awake
In the evening (on the day of the surgery), the donor may be asked to sit in bed and dangle his or her feet. If dizziness or lightheadedness occurs, the nurse must be informed. Some donors may feel well enough to stand, with some assistance, at the bedside.
The morning after surgery, the donor will get up and walk with a nurse assisting. Administering more pain medication before this first walk will make it easier. Walking will restore normal functioning of the lungs and bowels, enhancing recovery.
A clear liquid diet will be allowed once the NG tube is out of the stomach and the bowels begin to work again. If this is well tolerated, the diet may be advanced. When enough fluids are tolerated by mouth, the IV line may be removed.
Gas pain and constipation are not uncommon. Walking and drinking plenty of fluids will help with these problems
Most donors are in the hospital 7 to 14 days
When the donor is discharged from the hospital, routine care such as showering, getting dressed, and simple daily activities should not be a problem.
To heal, it is important to eat a good diet with adequate amounts of protein, vegetables, and fruit. Fruits, vegetables, bran, and fluids will also help the bowels to work normally. Constipation can be painful, but can usually be prevented.
The donor's temperature should be checked daily for about a week. A normal temperature is 98.6 degrees Fahrenheit. Temperatures greater than 100 degrees may be a sign of an infection. The transplant coordinator should be notified of any such fevers.
To keep the incision clean, a daily shower should be taken. The incision should also be checked daily for any signs of swelling or tenderness.
Some donors experience numbness along the incision due to the cutting of nerves during the surgery. It may take a while to adapt to this numbness as the nerves grow back. As the nerves grow back, tiny shooting pains may be noticed in the incision area for 6 to 12 months after surgery
After major surgery, it is common to tire easily for a few weeks. Family members and friends should be asked to help with household chores, meals, errands, or child care. The donor may return to general activity as tolerated. However, for at least 12 weeks after surgery, the donor must not participate in any muscular activity and must not lift more than 10 pounds.
The donor should be able to drive by three weeks after surgery. However, he or she should not drive while taking any kind of prescription pain medication. There are no restrictions on resuming sexual activity.
Generally, the donor is the best judge of the right time to return to work. He or she should be able to return to work by 6 to 8 weeks after surgery if the job does not involve heavy physical labor or lifting. If it does, the donor should plan on waiting two to three months after surgery, to allow the abdominal muscles to heal
Donors are generally seen a week after discharge. Then, their incision should be checked every one to two weeks until totally healed. Blood chemistries also need to be checked at first. It is not unusual to note mild liver dysfunction initially, but this quickly returns to normal.
Donors are seen in clinics at 3 months, 6 months, 1 year and 2 years after surgery. Blood tests to assess liver function will also be at this time.
The liver will essentially return to its normal size in about 3 months. A new lobe or segment does not regrow; rather, the remaining liver grows to fill the space of the portion that was removed.
The donor operation is a major procedure, so there are many potential complications. If donating to an adult, the rate of complications may be higher because a larger piece of the liver has to be removed.
Possible complications include the following:
- Bleeding: The liver has a very rich blood supply, so bleeding during the operation may be significant. By donating his or her own blood before the surgery, the donor minimizes any chance of needing an outside transfusion. However, if there is more bleeding than expected, it may be necessary to use blood from the blood bank. A re-operation is rarely required to stop postoperative bleeding.
- Bile duct problems: Bile may leak from the cut surface of the liver or from where the bile duct is divided. The site where the bile duct is divided may become narrowed, making it difficult for bile to pass through. These complications may require a specialized x-ray ERCP and stent placement or, rarely, a re-operation.
- Other complications may include an infection of the incision, Pneumonia, an infection inside the abdomen, a hernia (if the muscles don't heal together properly), bowel obstruction and blood clots in the legs.
The overall incidence of complications after donation ranges from 40% to 50%. There is also a small risk (1:200) of death. In the United States, over 1,200 LDLTs have been done. To date, 2 donors from other centers have died as a result of the donor operation or complications in the last 5 years. While the risk of death is small, it is very real and must be considered. There is also a small chance the donor may need a liver transplant in the event the residual liver does not function well and the risk of that complication is 1:500 or .002%.
When the incision is made, nerves are cut and the scar area may feel numb or tingle for several weeks or months after surgery. After the incision is healed, no difference in energy level, ability on the job, life expectancy, susceptibility to illness, sexual functioning, childbearing, or general feeling of health should be noticed. There is no need for changes in lifestyle or diet, nor will special medications be needed. Studies have shown that self-esteem remains high for years after donation and that donors maintain a positive attitude because of the surgery.
The donor should not receive any bills. But if the donor does, the bills should be sent to:
The Transplant Center
420 Delaware St. S.E.
Mayo Mail Code 482
Minneapolis, MN 55455