Tackling Organ Scarcity with Living Donor Liver Transplants

In a recent change in policy, the Stanford Adult Liver Transplant Program is making information on live donor liver transplants available to all patients being evaluated for listing on the national organ transplant list – not as a last resort, but on the front end of the evaluation process, when the surgery's chances of success are much greater.

This change in philosophy is the result of continuing cadaver organ scarcity and fluctuating organ procurement guidelines, which favor patients with higher MELD (Model End Stage Liver Disease) scores and more advanced disease, regardless of their geographic location. Today, almost a third of patients awaiting transplant at Stanford are removed from the transplant list because they become too sick to undergo a transplant or die waiting for a cadaver liver, said Andrew Bonham, MD, associate professor of surgery, multi-organ transplantation.

"We're seeing more and more of our patients waiting longer and longer on the list and getting sicker and sicker," said Bonham. "In an effort to get more of these people transplanted, we're now pushing more aggressively to do live donor liver transplants."

Since October of 2015, every patient being evaluated for listing is given information on living donors as part of a standard educational session, said Liver Transplant Coordinator Melodie Deis, RN, BSN. To ensure that patients already listed have been informed about this option, Deis is mailing out information to patients who still meet the criteria for living donor transplant. As a result of this outreach effort, Stanford now has several patients in the queue to be evaluated as living donor candidates.

"With the increase in wait times for cadaver livers, we're trying to find other options for these patients so they can be transplanted earlier when they're healthier and have a better chance at recovery," said Deis. Recipients of a living donor transplant cannot be too sick because they are only receiving a partial liver, not a full cadaver organ.

First introduced for children in 1989, live donor liver transplants for adults followed 10 years later. Adult-to-adult liver transplants require that a larger section of the liver, usually one third to one half, be resected, making it a riskier, more complex surgery than an adult-to-child liver transplant.

"Five to six years ago, this option was not routinely presented," said Bonham. "But we have learned a lot about performing live donation surgery over the past 15 years. We have better techniques, we have better patient selection and we believe we can achieve good results."

There has been significant innovation in the development of new tools to divide the liver more safely with minimal blood loss, said Bonham. One instrument in particular uses a high-pressure water jet that divides the liver tissue, while sparing the veins and the small blood vessels. Stanford surgeons can also modulate the portal flow to ensure that the liver has adequate outflow, and they use a ligature on the portal vein to decrease hyper-perfusion of the grafts, a factor that once prevented the donor liver from recovering.

"In a live donor operation, you have to leave blood vessels open with blood still flowing into the liver, because you need these vessels when you implant the lobe or the segment into the recipient," said Carlos Esquivel, MD, the Arnold and Barbara Silverman Professor in Pediatric Transplantation. "You're actually transecting liver tissue while there is still a lot of blood flow going through it."

Timing is another factor in safely performing a live donor transplant. According to Deis, patients awaiting a cadaver organ do not begin receiving offers until they are very sick, with MELD scores of 35 or above. For living donor transplants, patients must be transplanted much earlier, when their MELD scores are between 15 and 20. The goal is to transplant the liver when the patient is starting to decline, but before they become too sick for the surgery to be successful.

Roger Douglas knows firsthand about the precision of timing the surgery perfectly. He is part of a small, but growing fraternity of adults who voluntarily undergo this highly complex surgery to save the life of a loved one. In 2014, he became a living donor for his 16-year-old son Parker, who was diagnosed with Alpha-1 Antitrypsin Deficiency, a genetic condition that nearly guaranteed he would need a liver transplant before he reached adulthood.

The Douglas family first learned about living donor donation when their son was just one. At age three, he was listed for the first time. But it wasn't until the spring of his freshman year of high school, when his ammonia levels began to rise, that his medical team, led by Esquivel, confirmed that a transplant was needed within 12 to 18 months. The family knew they would choose living donation since Roger was a blood type match.

"Our attitude all along was we're not going to ask for this surgery until the day the medical team says with certainty that he is going to need a transplant," said Roger. "But the day they said that, our attitude was to get it scheduled as soon as practical."

On July 2, 2014, Roger and his son underwent simultaneous surgeries at Stanford. Because Parker at six-one and 150 pounds was the size of an adult, Bonham had to resect the entire left lobe of Roger's liver. After an eight-hour surgery and six days in the hospital, Roger made a full recovery in two months. His son's recovery took much longer, and included a second surgery to repair his bile duct. Parker is now doing well, and despite those difficulties, his parents believe they made the right call. 

"We had the opportunity to let our son be as healthy as possible going into this surgery," said Roger. "We didn't have to be one of the six or seven people all vying for the same cadaver liver. I'm glad that Stanford is becoming more aggressive in promoting living donation as a viable path. With the skills of this team, I think it’s a path people should seriously consider."