Live donor liver transplants U.Va. helping to standardize ‘novel’ procedure

Photo by Andrew Shurtleff

Doctors Carl Berg (left) and Tim Pruett at the University Hospital’s transplant unit.

By Elizabeth Kiem

For more than 17,000 Americans, survival depends on finding a healthy liver.
Most of those livers will become available when an organ donor is deemed brain-dead, allowing surgeons to remove the organ while the heart is still beating. But only 3,000 such “beating-heart cadavers” contributed to successful liver transplantations in 2002.

Now U.Va. is making a concerted effort to bridge that donor gap by joining a national consortium to study the efficacy of living donor transplantations.

With seven years of funding from the National Institutes of Health, U.Va. and nine other transplant centers will pool data and experience to better understand the risks and benefits of what Carl Berg, U.Va.’s director of hepatology, called “a novel and lifesaving form of liver transplantation that has generated significant national attention.”

The first liver transplant from a living donor was performed in 1989. Since then, more than 1,830 such procedures have taken place, compared with more than 51,000 live kidney donations. Kidney recipients generally have a higher survival rate than do liver recipients, and both fare slightly better with live organs than with cadaveric organs.

Because humans have only one liver, the organ must be bisected to remove a lobe for transplantation. Both portions regenerate to almost the original size within weeks if all goes well, but the risk to the donor gives many practitioners pause.

“The living donor procedure goes against a lot of the things we take oaths to do,” said Tim Pruett, director of U.Va.’s transplantation division. “The first is to do no harm. Well, to cut somebody’s liver in half, who’s perfectly well, who doesn’t need you to do that subjects them to a lot of risk and a lot of potential harm.”

The promise of living donors was tested recently by the death of a liver donor at a New York hospital. The ensuing inquiry over donor safety and informed consent reflects the larger debate about applicability and cost-effectiveness of live donor transplants.

“We’re trying to put this whole thing into a format that can be integrated into our society and how we deal with it from a legal perspective, an ethical perspective and a medical perspective,” said Pruett.

End-stage liver disease, once stigmatized as the curse of alcoholism, can be caused by a number of different renal failures, including immunologic and metabolic diseases, hepatitis, tumors and fatty liver disease. There is no accepted standard among transplantation experts as to which forms of cirrhosis are best suited for live-donor transplants and which are more responsive to cadaveric transplants.

U.Va. has a history of advancing the acceptance of liver transplants. In the 1990s, the transplantation division played a large role in reversing the common wisdom that hepatitis B patients should not receive transplants. In the course of a decade, U.Va.’s work in passive immunization helped slash infection rates in such transplants by 70 percent, and survival rates shot up in response. Even the government responded, approving Medicare coverage for such operations.

But balancing the ethical concerns inherent in live donors is a more delicate task than conquering infection rates.

“It’s hard to ethically serve both sides,” explained social worker Phyllis Yensen. “If I know you as a potential recipient, know that you’re getting sicker, and your sister comes to me and wants to donate, how can I serve you both?”

At U.Va., live donor candidates are deliberately channeled to an independent party, called the Donor Advocacy Team, for initial screening to be certain that there is no coercion on the part of the recipient’s providers. Even after consulting with the team about the medical and financial ramifications of being a donor, as well as the likely toll on family and career, a donor who wishes to proceed must assure the members of the transplantation division as well.

“Philosophically, we don’t want to rush it. If you see a donor and are ready to go through with the operation in a week, you haven’t given it ample time,” said Yensen.

A component of the $18.6 million grant will be set aside for research, in the hope that scientific advances will reduce the medical uncertainties of live donor transplantations. In the meantime, U.Va. specialists will continue to rely on time and information as key resources in a complex decision.