Although liver transplantation is the best treatment for people with end-stage liver disease, there are currently only enough organs from brain-dead donors available for approximately one-third of the 17,000 plus people on the national United Network for Organ Sharing (UNOS) liver transplant waiting list. Sadly, about 20 percent of patients die each year while waiting for a suitable liver. This scarcity of donors has imposed the need for medical professionals to explore what would otherwise be considered extreme solutions to terminal cases of liver failure: living donor liver transplantation (LDLT).
LDLT in Children and Adults
LDLT is an outgrowth of a series of surgical innovations in segmental liver transplantation, driven initially by the need for pediatric cadaveric livers. The unique segmental anatomy of the liver allows it to be separated into independent anatomic units that are able to retain normal function. Since 1989, several thousand LDLT operations have been performed globally, most commonly between an adult donor and a pediatric recipient. These procedures have significantly reduced the number of pediatric patients dying on the waiting list.
Similarly, living donor adult liver transplantation (LDALT) poses exciting, new surgical possibilities for adult patients with end-stage liver disease. In fact, it has gained widespread acceptance as a lifesaving surgical innovation.
Lahey's Department of Hepatobiliary Surgery and Liver Transplantation first began offering LDALT in 1999 to select patients on our waiting list, and performed the first such procedure in all of New England. Now, our LDALT program is among the top five largest in the United States, having saved more than 90 lives to date.
Major concerns when performing LDALT include ensuring the donor's safety and having an adequately sized liver graft for the recipient. Advances in surgical techniques, however, have helped improve safety, minimize risks and allow LDALT to be widely offered throughout the United States.
In these highly technical operations, the right lobe of the donor's liver (about 60 percent of the total liver) is implanted into the recipient. Following surgery, there is a rapid regeneration of liver tissue, which allows both the donor and recipient's livers to regenerate to nearly full size. Amazingly, it typically takes the recipient less than one month to regenerate fully. That timeframe is a bit longer for the donor, whose liver will take about a full year to accomplish the same feat.
Who Can Be a Donor?
An individual must first volunteer to donate a portion of his or her liver to a family member or someone with whom he or she shares strong emotional ties. Not all volunteers, however, are deemed suitable. The donor's blood type must be compatible with the recipient's, and his or her liver must be large enough relative to the recipient's body size. In addition, careful screening tests must be performed to evaluate the health and suitability of the donor. Psychiatric evaluations are also conducted to ensure that the donor does not feel unduly pressured by other family members and is truly willing to undergo the procedure, even if it should fail.
The Future of Liver Transplantation
Although LDLT will not replace traditional cadaveric transplantation, it may offer the possibility of liver transplantation to an additional 20 to 40 percent of patients on the UNOS waiting list. The immediate benefit of LDLT is twofold. First, because LDLT is an elective procedure performed when the recipient is in the “best” condition, he or she avoids the continued physical deterioration that inevitably occurs while waiting for a suitable liver replacement. Secondly, by avoiding the use of a cadaveric liver, LDLT helps to shorten the UNOS waiting list and allow another patient on that list to benefit from transplantation.
