Live Organ Donor Dangers Debunked by Unlikely Source

Ingrid Hein

April 09, 2019

VIENNA — More than 1000 living-donor liver transplants are performed each year in Turkey, compared with about 300 in the United States, which makes the country straddling Eastern Europe and Western Asia an unpredictably ideal location for surgeons to learn more about the procedure.

In fact, Nabil Dagher, MD, from NYU Langone Health in New York City, went to Turkey for nearly 3 months to learn about living-donor transplantation.

When he returned, he started the live-donor liver transplantation program at Johns Hopkins University in Baltimore. In 2016, he performed the world's first-ever liver transplant between HIV-positive patients.

And it was at Hopkins that the first kidney transplant between HIV-positive patients took place last month.

With more than 17,000 patients on the wait list for a liver in the United States, but only 5000 deceased-donor livers available each year, an estimated 1700 patients die each year waiting for an organ.

Live-donor liver transplantation in the United States has faced many challenges, Dagher told Medscape Medical News in advance of the upcoming International Liver Congress 2019, where this will be discussed.

"You have to go back and look at the 1990s to really get a sense of what's happened and what changed enthusiasm early on for live donation in the States," he said.

First Successful Transplant

Segmental liver transplantation from a living donor was first proposed by Blanca Smith MD in 1969 (J Pediatr Surg. 1969;4:126-132).

The first successful live-donor transplant was performed by Christoph Broelschm, MD, at the University of Chicago Medical Center in 1989, when a 29-year-old mother donated a portion of her liver to her 2-year-old daughter, Alyssa, who has gone on to have children of her own.

After Alyssa, the practice of parents donating a portion of their liver to their children became more common.

"Parents donating their left lateral section to their kids meant that they no longer had to wait for a deceased liver, so wait-list mortality dropped significantly," Dagher said.

However, when the procedure was performed in adults, "it didn't go well initially with the left lobe; it was too small," he said. After a switch to the right lobe, "it went great."

Throughout the 1990s, the number of liver transplants in the United States increased every year, but in 2002, a donor died (Liver Transpl. 2004;10:1315-1319).

The 57-year-old man volunteered to donate the right lobe of his liver to his brother. The procedure went smoothly, but 3 days after surgery, the man developed tachycardia, profound hypotension, and vomiting. And after a cardiac arrest, the otherwise healthy man died.

Tragedy Strikes

The cause of death was emphysematous gastritis secondary to Clostridium perfringens infection and toxic-mediated shock. Autopsy demonstrated gas gangrene of the stomach as the underlying cause of the hemorrhage and numerous colonies of Gram‐positive bacilli.

This patient's death was devastating to his family and care providers. The medical team reported that the loss was "completely unexpected, probably unpreventable, and the cause was almost inconceivable."

Still, the publicity surrounding this untimely demise prompted professionals to explore the balance between risk to the donor and risk to the recipient because of a longer wait list.

And warranted or not, the procedure developed a bad reputation.

There are other reasons living donation is lower in the United States. For example, the registry of deceased donors is better organized here than it is in Turkey and other Asian countries. About two-thirds of people who need an organ receive one.

In addition, time off work for donation is not always a simple affair. Although the donor's liver grows back quickly — in about than 8 weeks for most donors — it does not happen overnight.

Another setback is the fact that patients who have donated an organ have less-favorable insurance rates. That is changing because new legislation mandates that donation history not affect cost, Dagher reported. However, this is very recent and not an overarching policy yet.

"We absolutely educate donors about the risk that their insurer may not want to insure them," he said.

In the United States, complications are relatively uncommon because of the highly vigilant follow-up of recipients and donors.

Low Complication Rates

A recent single-center study showed that the complication rate in live liver donors is below 10% (J Am Coll Surg. 2018;227:24-36). Another study showed that the risk for early death among live liver donors is 1.7 per 1000 donors, and that the mortality rate for liver donors is no different than that for healthy matched individuals (Gastroenterology. 2012;142:273-280).

However, the risk to a patient needing a liver is high. "The chance that you are going to die waiting for a deceased liver or get too sick to be transplanted is about 25% to 30%," Dagher said.

We are now entering an era in the West in which it is accepted that a very small percentage of donors will have complications, he explained.

Americans are now realizing that living-donor transplants are a very good option.

"In other parts of the world, they came to grips with that earlier than us," but Americans are now realizing that living-donor transplants are a very good option, he said.

In the East, a deceased liver is hard to find because the donation registry is unorganized, so physicians have had to find other strategies to help patients with acute liver failure, said Yaman Tokat, MD, from Florence Nightingale Hospital in Istanbul.

The Florence Nightingale Hospital has become a training hub; its website states that it is "the one and only living-donor liver transplant education center."

In the East, often when someone is sick, "the whole family goes to hospital to care for him or her. It's a whole family disease." And finding a living donor is not as difficult as in other countries, said Dagher. "We find people very willing to donate." In Turkey, fourth-degree relatives can become liver donors.

Regeneration of the liver "starts on operating table," he said. The end point is 6 months, but after 1 week, "about 60% to 70% is grown back, and after 2 months, it's almost 100%."

Donors typically go home 5 days after their surgery, "and in a few weeks, they go back to work," he pointed out.

A team from Turkey recently assessed the medical records of 1140 liver donors and determined that patients treated at centers with more experience were the least likely to have complications (Clin Transplant. 2018;32:e13262).

For the most part, liver donation is safe. Over the past decade in Turkey, about 10,000 liver transplants were performed and only six donors died, Tokat reported. He added that he hopes to help the West increase its live-donor transplantation numbers.

Dagher and Tokat have disclosed no relevant financial relationships.

International Liver Congress (ILC) 2019. To be presented April 13, 2019.

Follow Medscape Gastroenterology on Twitter @MedscapeGastro and Ingrid Hein @ingridhein


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