Live-donor liver transplantation is a lifesaving option for many suffering from end-stage liver disease but also a controversial procedure that raises questions about when it's appropriate to put a healthy person at risk to save another.
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The procedure, in which a segment of the liver is taken from a healthy donor and transplanted into the ailing recipient, is possible because of the liver's ability to regenerate. In weeks, both the old liver and the transplanted liver begin to grow back to a normal size, providing long-term function for both donor and patient.
The first such successful transplantations, beginning in 1989, involved taking liver grafts from adult donors for transplantation into sick children, a procedure with fewer risks to the donor because only about 25 percent of the liver is needed. As pediatric living-donor liver transplantation grew more widely accepted, the technique was modified for use in adult patients, with up to 60 percent of the donor's liver taken.
Through 1996, just six adult-to-adult live-donor liver transplants had been performed in the United States, according to the United Network for Organ Sharing (UNOS), which manages the nation's organ transplant system. Five years later, that number had grown to 412. Today, more than 2,800 adult-to-adult procedures have been performed in the United States.
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In all of those, UNOS reports, four donors have died due to complications of the surgery or immediately following surgery. Though rare, these deaths raise the most serious question surrounding live-donor liver transplants: When is it OK to operate on an otherwise healthy person?
The death of donor Mike Hurewitz at New York's Mount Sinai Hospital in 2002 brought widespread scrutiny of adult live-donor liver transplants, resulting in risk-benefit studies and an examination of screening procedures for donors. Hurewitz developed a bacterial stomach infection and died three days after donating part of his liver to his brother. Reviews blamed poor post-surgical care, and the state temporarily halted the hospital's live donation program until corrective measures were put in place.Story: Brother's transplant gift carries unbearable cost Story: Transplant recipient struggles to go on after brother's death
The other donor deaths were: in 1999 at the University of North Carolina at Chapel Hill hospital, where the donor suffered a series of complications, including kidney failure, pancreatitis, a bile leak and infection; this past May at the Lahey Clinic in Massachusetts, where the donor died during surgery after a vein was detached from the vena cava, causing an uncontrollable hemorrhage; and in August at the University of Colorado hospital, where the donor suffered cardiac arrest, possibly due to a combination of surgical stress and other factors.
UNOS provides transplant centers with guidelines to ensure donors are appropriately evaluated. Potential donors undergo a thorough medical and mental examination prior to signing a written consent agreement, and they must have an independent advocate to represent their interests alone.
Still, there are no standardized procedures, and actual tests to ensure the donor's mental and physical health may vary among transplant centers, said Dr. Connie Davis, chair of the living donor committee for UNOS who stressed that, ultimately, "Every donor, heaven forbid, they have the right to say no. They don't have to do this."
Katrina Bramstedt, a transplant ethicist who also serves as a donor advocate, said that while the ethical questions surrounding living donation are valid, risk-benefit analyses show that the procedure should continue. "Yes, occasionally something goes wrong, but that's going to happen in any surgical procedure," she said. "Generally, the donors are well-informed and very well-screened and they're healthy and ready to go."
After Hurewitz's death, the National Institutes of Health implemented a seven-year study of adult living-donor liver transplants to weigh risks to donors and benefits to recipients. Study results found a 20-25 percent chance of donors experiencing some type of complication, the most common being bile leaks, collection of fluid around the lung and infections. Most were considered minor, said Dr. Carl Berg, the director of hepatology at the University of Virginia, who served as a co-chair of the federal research team. The research found a 50 percent reduction in deaths among the sick patients receiving the live-donor livers, Berg said. Without the live-donor livers, those patients most likely would have remained on the cadaver transplant list — some growing more ill as they awaited a transplant, some dying before a transplant ever happened.
The back-to-back deaths in Colorado and Massachusetts this year shook the transplant community and prompted centers to re-examine their programs, Berg said. However, he added that so long as the benefits of the surgery outweigh the risks of death or complication — and until more Americans decide to become organ donors at death — adult living-donor liver transplants will continue.
"Is it safe?" he asked. "I would give half my liver to my brother in an instant, and I know as much as could be known about the risks. I would still gladly do that as opposed to having him wait for a deceased donor because I know the benefit is there, and I believe (for donors) that the quantified risk is small."
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