Transplantation

Living donor transplant offers alternative for patients with liver failure

For people in need of a liver transplant, waiting for an organ from a deceased donor can seem endless. Fortunately, living-donor transplantation offers a more immediate solution for some patients.

According to Marwan Kazimi, M.D., a multi-organ transplant, hepatobiliary surgeon and Surgical Director of Liver Transplantation at Piedmont Transplant Institute, living-donor transplantation offers some distinct advantages for those who are good candidates.

“In general, people with a relatively good physical status but who have significant impediments to daily living because of liver disease or those who have liver cancer, but are at risk for growth and spread of that cancer if they have to remain on a waiting list for a deceased donor, are likely candidates for a live donor transplant,” he said. “Additionally, smaller females and teenagers may stay on a waiting list for years for a match from a deceased donor with similar body characteristics. A live donor is easier to match in these cases because only a small piece of the liver is required to do the transplant.”

The piece of liver from a live donor will regenerate to about 95% of its original size in about two-to-three months in the recipient and in only two months in the donor.

In addition to more immediate access to a donor, the benefits of living-donor liver transplantation are, in general, fewer complications than deceased-donor transplants and a longer survival rate of the donor organ. However, there are also risks associated with living-donor transplantation.

“With living-donor liver transplant, you’re taking a healthy person who wouldn’t need any surgery and subjecting them to a major operation that, like all major surgery, has the potential for complications. Unlike kidney donors who keep one functioning organ, you’re partitioning the liver donor’s one organ,” Kazimi said. “It’s a challenging surgery since the liver has a lot of vascular supply. That requires minimizing the risk of bleeding and clotting in donor while also preserving all of the connections necessary to replace in the recipient.”
The criteria for finding a live donor liver match are fairly simple, just blood typing and anatomical characteristics. But finding the matching donor is up to the person in need.

“Physicians cannot seek out living donors. Our patients can ask us about the process, and we tell them the age range and where they fall on the MELD (model for end-stage liver disease) range. If they meet the criteria, we’ll notify them that they could be candidate,” Kazimi explained. “But then it’s up to the patient to talk to their friends, family, etc., about finding a donor.”

The biggest innovations in living-donor liver transplantation in recent years are a move to laparoscopic and robotic surgeries and the use of non-narcotic, non-steroidal analgesia to minimize the recovery phase. The average hospital stay for recipients and donors is about six days and the average recovery time to resume normal activities is about 6-8 weeks.

The success rate for living-donor transplant recipients is the same as that for those who receive a deceased donor organ. Donors have no change in their expected lifespan. And only one in 1,000 donors have any significant complications.

Kazimi is working to increase awareness of living-donor liver transplantation among the physician community and residents of Georgia.

“To date, we haven’t had a strong living donor environment in the Southeast. Our group just started performing living-donor transplants in late 2017. We are currently performing about six per year, but our goal is to perform 12-15 annually,” he said. “Hopefully, as we do more living-donor liver surgeries and people talk about it more, more donors will come forward.”

Leading-edge care for heart and lung patients
For residents of Georgia who are in need of advanced heart or lung therapies or transplants, Emory Healthcare provides comprehensive, state-of-the-art care.

Emory’s heart transplant program completed Georgia’s first heart transplant in 1985, not long after opening. Today, the comprehensive program provides patients with Ventricular Assist Devices or VADs (mechanical pumps to support weakened hearts) and heart transplants. In fact, Emory’s heart transplant program is using advanced, third generation VADs to support the most critically ill patients until they can receive a transplant.

“Ventricular assist therapy has come into its own. We first started using them in the 1980’s — remember Barney Clark’s artificial heart? There have been so many improvements since then,” said Mani Daneshmand, M.D., director of the Emory Heart and Lung Transplantation and Mechanical Circulatory Support programs, as well as Emory’s ECMO (Extracorporeal Membrane Oxygenation) program. “Today’s newest generation devices are smaller and electrically driven. We see fewer strokes occur and are able to keep patients alive for a lot longer with these new devices. Because of that, we’re able to bring more and more people to transplant or at least delay their need for transplants as we search and locate better organs for them.”

In addition to these new devices, Emory’s heart transplant physicians are also using established technology in new ways. Specifically, patients who are critically ill, but do not need the full support of a VAD, are being bridged to heart transplant using an intra-aortic balloon pump (IABP) that is placed in the subclavian artery instead of the femoral artery. For patients who may need to wait weeks for a transplant, the subclavian artery placement allows them to be ambulatory and fully rehabilitated prior to their transplant.

Similarly, Emory’s lung transplant program, which is the only lung transplant program in Georgia, offers a full continuum of care for complex lung diseases. The program uses advanced technologies to support and bridge patients to lung transplantation. Somewhat akin to the heart transplant program’s IABP, ECMO assists in lung recovery, providing a way for patients who are awaiting transplant to be ambulatory and fully participate in physical therapy, helping them to rehabilitate and get stronger prior to surgery.

Both programs are also developing ex-vivo organ perfusion technologies that will allow physicians to obtain organs that are farther away from Georgia and transport them warm and fully perfused as opposed to cold “on ice.” This novel preservation technology opens up access to a larger number of organs around the country, increasing the likelihood of successful transplants for patients in need.

“The ex-vivo organ perfusion technologies will help us to more aggressively optimize and bring in donors for our patients,” Daneshman said.

He went on to say that one of his goals is to work actively to identify people in need of transplants and ensure they receive the needed surgeries as soon as possible.

Both lung and heart transplant programs at Emory focus on a multidisciplinary approach to patient care.

The lung transplant program employs three pulmonologists and five lung transplant surgeons and regularly collaborates with physicians specializing in Cystic Fibrosis, Interstitial Lung Disease and Pulmonary Hypertension. Additional staff includes nurse coordinators, nurse practitioners, administrative staff and specialists from social work, dietary, physical therapy and pharmacy. Also present at weekly multidisciplinary team meetings are a financial coordinator, psychologist and transplant infectious disease expert.

The advanced heart failure therapy and transplant program consists of 12 cardiologists, all of whom are board certified in advanced heart failure and transplantation. The program is supported by four board certified cardiothoracic surgeons, transplant and ventricular assist device nurse coordinators, physicians’ assistants and nurse practitioners. Additional team members come from other specialties including infectious disease, palliative care, social work, psychology, physical therapy, pharmacy, nutrition, spiritual health, financial, nursing and administrative support and biomedical engineering.

The number of patients receiving transplants and advanced therapies through both programs is growing.

“In the last eight weeks alone, our team has performed 14 lung transplants, eight heart transplants and numerous VADS and ECMOs,” Daneshmand said. “Our mission, as we view it, for our heart and lung transplant programs, is to provide exemplary, effective, and timely care to all the people in Georgia and beyond who need it.”