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With the increasing success of liver transplantation as a therapy for patients with end-stage liver disease, the demand for this procedure continues to grow. Currently, there are almost 17,000 patients on the waiting list in the United States for liver transplantation. However, there are less than 5,000 livers available for transplantation. The result has been longer waiting times and increasing mortality on the waiting list.
While there are ongoing attempts to increase donation rates and utilize novel techniques such as dividing a liver for transplantation into two recipients, this will still leave a shortage of livers for transplantation.
With the knowledge that the liver has a remarkable capability of regeneration, the concept of living-donation was developed in the early 1990's. The use of adult-to-child living-donor liver transplantation has helped to diminish waiting list mortality.
The majority of liver transplants come from deceased organ donors. Organ donors are adults or children who have become critically ill (often due to an accidental injury) and will not live as a result of their illness or injury. If the donor is an adult, he/she may have agreed to be an organ donor before becoming ill. Parents or spouses can also agree to donate a relative's organs. Donors can come from any part of the United States. This type of transplant is called a cadaveric transplant.
A child receiving a transplant may either get a whole liver, or a segment of one. If an adult liver is available and is an appropriate match for two children on the waiting list, the donor liver can be divided into two segments and each part is transplanted.
Living family members may also be able to donate a section of their liver. This type of transplant is called a living-related liver transplant. Children receiving a partial liver seem to do as well as children who receive a whole liver. Relatives who donate a portion of their liver can live healthy lives with the segment that remains.
The benefits of living liver donation are two-fold. One is that the operation can be done electively, when the recipient is in optimal condition, which enhances the probability of success following transplantation. The other is the psychological benefit to the donor knowing that she/he has helped to contribute to the transplant in a very meaningful way.
The utility, the risks and benefits have been defined in the adult-to-child living liver transplant procedure. However, the critical shortage is in the adult population, and this has drawn the interest of utilizing living adult donors for adult recipients.
Adult-to-adult living liver donation is a relatively new area. While adult-to-child liver donation has been practiced for more than 10 years, the adult-to-adult procedure has only been developed within the past few years. In the case of the pediatric recipient, a much smaller amount of liver can be taken from the donor, with less risk than for an adult donor. However, in the adult recipient, more liver must be removed from the donor since the adult recipients requires a larger piece of liver. While the liver has a great potential for regrowth, if insufficient mass of liver is transplanted, the liver will fail.
Living donor transplant risk for adult-to-adult donation is significantly higher than for adult-to-child donation. The estimated risk of dying (for the donor) is about 0.2 percent (one in 500 cases) for adult-to-child and about one percent (one in 100 cases) for adult-to-adult donation. In addition, there is about a 15 percent risk to the adult-to-adult donor of other complications, such as wound infection, bile duct leaks, etc. In addition, there are long-term risks that have not been assessed, due to the relatively short follow-up period of the limited experience worldwide. Nevertheless, since the shortage of organs is most critical in the adult population, there is rationale to continue to pursue this avenue of donation.
At the Hillman Center for Pediatric Transplantation at Children's Hospital of Pittsburgh of UPMC, we currently perform living-donor liver transplantation. The guidelines for acceptance are identical for those who will get a cadaveric organ. The candidate must be acceptable for both living-donor and cadaveric donor liver transplantation.
Once a patient is evaluated and deemed acceptable for transplantation, the issue of living-donation can be addressed. The initial phase of testing consists of blood type assessment for compatibility, and that the donor liver is perfectly normal. Next, a rigorous assessment by a multidisciplinary team includes:
Finally, the anatomy of the donor liver is evaluated for suitability for donation. The latter requires that certain tests be done, including:
Given the variations in the anatomy within the liver, only about one in four potential donors actually is suitable for such donation. It is possible that a cadaveric liver may become available at any time during the evaluation for living-donation, in which case cadaveric transplantation would be recommended.
NOTE: This video below depicts graphic content of liver transplant surgery.
View this video of pediatric transplant surgeons at Children’s Hospital of Pittsburgh of UPMC performing a living-donor liver transplant. It is narrated by George Mazariegos, MD, director of the Hillman Center for Pediatric Transplantation.
The patient is a 5-month-old infant with progressive liver failure who had undergone a failed Kasai procedure for biliary atresia. The living donor was the child’s maternal aunt.
Learn more about the Liver Transplant procedure.
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