08/10/02

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University  of Minnesota 

Living Donor Liver Transplant Questions & Answers

Introduction

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 the liver fails and does not adequately perform these tasks, 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 cadaver or living donor.

Liver transplantation has been successfully done since the early 1980s. At first, all donors came from a cadaver, someone who has died and donated his or her organs. Better surgical techniques and advancements in immunosuppression improved success rates and allowed more patients with liver disease to be potentially treated with a liver transplant. Unfortunately, this expansion has led to a marked shortage in cadaver donor organs and greatly lengthened the time that recipients must wait for a liver transplant. Consequently, as the waiting list has grown, so has the number of people dying while waiting for a transplant.

In an attempt to expand the donor pool, physicians are now exploring the use of living organ donors. Living donations are most common for kidney transplants , but are also now an option for liver transplants. Pieces of the liver (one of the two lobes, or even a smaller segment) can be successfully removed from a living donor and transplanted into a recipient.

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 children 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 March 2000, about 200 such transplants have been performed in the United States. Preliminary results have been good.

Since 1996, our transplant team at the University of Minnesota has been performing LDLTs at Fairview-University Medical Center in Minneapolis, Minnesota. 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.

Who can receive a Living Donor Liver Transplant?

Most patients who have severe liver disease and who are candidates for a cadaver transplant can be considered for an Living Donor Liver Transplant (LDLT). Individuals with certain hereditary liver diseases or unusual blood vessel variations may not be candidates.

What is the general process for finding a donor?

Once the decision has been made that a liver transplant is necessary, the potential recipient will have a workup done. Assuming that no unusual problems are found during this workup, the patient can then be placed on the waiting list for a transplant from a cadaver donor. Then an evaluation can proceed to determine if a suitable living donor is available. About 50% of potential donors who come forward for testing do not turn out to be suitable. For example, they may not have a compatible blood type, they may have unusual vessel formation in their livers, or they may have something slightly abnormal with their blood. 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 has still been on the cadaver waiting list the whole time. If a cadaver liver would become available, even during the evaluation of a potential donor, we would proceed with a cadaver liver transplant. Therefore, the evaluation process for an LDLT would not jeopardize or delay the possibility of a cadaver transplant.

What are the advantages of an living donor liver transplant?

The greatest advantage of an Living Donor Liver Transplant (LDLT) is that it avoids the waiting time for a cadaver transplant. Currently, the organ shortage is severe. There are not enough cadaver livers for all of the patients who need one. Over 15,000 people are now waiting for liver transplants in the United States, but only 4,500 transplants are performed every year. Roughly 20% of patients will die of their liver disease before having the chance to undergo a transplant. For those who do end up receiving a cadaver transplant, the average waiting time is 1½ to 2 years (from the day they are first placed on the waiting list). With an 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 is performed before the recipient's health deteriorates, he or she is better able to tolerate the surgery and recovers 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 cadaver liver 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 cadaver liver, which can then go to a patient who does not have a suitable living donor.

What are living donor liver transplant results like?

Since this is a relatively new procedure, long-term results are not available, especially for adult-to-adult Living Donor Liver Transplants. However, short-term results are promising. According to data from all centers in the United States, about 85% of LDLT recipients are alive 1 year after their transplant. Both adult and pediatric LDLT recipients have a good chance of leading a long and healthy life.

Who can be considered for a donor?

The transplant team will consider many different individuals as potential donors. Usually, relatives are preferred, since they are most involved in the potential recipient's health. However, nonrelatives such as good friends or spouses may also be considered. 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 18 and 55 if they are in good health.

What is the process for evaluating a donor?

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.

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.

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. 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 an angiogram is necessary. In an angiogram, a needle is placed directly into a blood vessel, dye is injected, and then an x-ray is obtained to more closely look at the liver's blood vessels.

3) Psychological evaluation

The potential donor will also be interviewed by a social worker from the transplant team to make sure that the donation is entirely voluntary. The decision to donate should be made entirely by the potential donor after careful consideration of the risks and potential complications of the procedure, with no coercion from anyone.

What happens after the donor evaluation?

Once the donor's evaluation is complete, all of the information will be carefully reviewed by the transplant 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. We will then arrange for the donor to donate 2 units of blood before the surgery. Thus, if the donor requires a transfusion during the surgery, his or her own blood can be used. This process of "banking" one's own blood generally takes 2 to 3 weeks.

What happens the day before surgery?

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 12 noon on the day before surgery, the donor should only have clear liquids. After 12 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 in the hospital after the donor is admitted. Smoking increases the risk of heart and lung problems (such as pneumonia) after surgery.

What happens the day of surgery?

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.

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 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.

What is the donor operation like?

The donor operation is done through an incision in the upper abdomen. 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. 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 60% of the donor's total liver. The blood vessels supplying the portion of the liver to be removed are separated out, the liver itself is divided, and the portion to be transplanted is removed. This portion is brought into a separate operating room for the recipient, where the transplant is then performed. The donor operation takes 6 to 8 hours.

Where does the donor wake up from surgery?

All donors wake up in the Post-Anesthesia Car 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 (5C) to complete the immediate recovery process.

What does the donor's incision look like?

The incision is located in the upper abdomen just under the rib cage. AKA the "Mercedes" incision.

How much pain will the donor have?

Because the incision is large, it may be painful. 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.

Besides pain, what else should the donor expect the first days after surgery?

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.

Why does the donor need a Foley catheter?

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 24 to 48 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.

What are pneumoboots?

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.

Why is turning, coughing, and deep
breathing every couple of hours important?

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.

When can the donor sit up and walk?

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.

When can the donor resume eating?

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.

How long does the donor stay in the hospital?

Most donors are in the hospital 5 to 7 days.

What about the donor's recovery period at home?

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 awhile to adapt to this numbness as the nerves grow back. As the nerves grow back, tiny shooting pains may be noticed in the incisional area for 6 to 12 months after surgery.

Are the donor's activities restricted?

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 6 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 3 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.

When can the donor return to work?

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. But if it does, the donor should plan on waiting 2 to 3 months after surgery, to allow the abdominal muscles to heal.

Is there further follow-up after
the donor leaves the hospital?

Donors are generally seen a week after discharge. Then, their incision should be checked every 1 to 2 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.

A CT scan is also obtained 3 months after surgery, to check the remaining liver portion's growth. Blood tests to assess liver function will also be at this time.

When will the donor's liver return to its normal size?

The liver will essentially return to its normal size in about 1 month. A new lobe or segment does not regrow; rather, the remaining liver grows to fill the space of the portion that was removed.

What are the possible complications for the donor?

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:

The overall incidence of complications after donation ranges from 5% to 10%. There is also a small risk (< 0.5%) of death. In the United States, over 1,500 LDLTs have been done for children and 200 for adults. To date, 3 donors from other centers have died as a result of the donor operation or complications. While the risk of death is small, it is very real and must be considered.

What are the long-term effects of the donor surgery?

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.