New Hope for Those Awaiting Liver Transplants
Doctors use a system called MELD or model for end-stage liver disease to score patients awaiting liver transplantation and assign them a place on this list. Many individuals placed on this list die before receiving a donor's liver. New research is being done to decrease wait times and alternative methods of approaching survival. In the picture above the smaller lobe is the one used for transplanting of a living donor. That is the left side.
Liver transplantations are considered to be the best treatment for both acute and chronic liver failure as well as treatment for hepatocellular cancer (cancer that has the liver as its origin). With these particular groups, the long waiting list for a transplant can spell death for them because as they wait their disease process will continue to progress until they are beyond help from the transplant. This was what has prompted doctors in the transplantation field to find an alternative. Waiting on a deceased donor for many is not an option.
Currently, there is a growing acceptance of a living donor. It has been revealed through research that by taking the left lobe (the liver is split into two lobes; right bigger than the left) of the liver there is still enough left to regenerate in the donor and a new organ in the recipient. The liver is the only organ in the body that can regenerate itself if some of it is removed or damaged. Unfortunately, in this case, this led to a problem of not enough liver tissue from a single donor to provide an adequate hepatic function. In this study, the doctors used a section from two sources for their live donor; a brother and cousin. In this way collectively there was enough liver tissue to help the recipient without causing issues with the two donors. This surgery was done in a Muslim nation, and in most cases organ donation, especially after the donor has died, is prohibited by some of their religious prohibitions. Even in the case of the medical examiner needing to conduct an autopsy, many Islamic groups refuse to have the body cut into as it will mean their loved one cannot enter heaven. The ME is then left to the use of MRI or CT scans to see the structures of the body (Zindan et al, 2019).
Why liver transplants
Liver transplantation has become a life-saving treatment for children who are either born with deformities to the liver structure or a myriad of liver diseases. In Asia and some other European countries live donations were developed to help with the lack of deceased donors available for use. Live liver donation is possible due to the livers' unique ability to regenerate. Once transplantation is done the partial livers of both donor and recipient will be grown and remodel to form complete organs. For most donors-the, doctors remove the left lobe of the donor to decrease the potential of side effects for the donor. It has been only recently that live donors have been used for more than pediatric patients in the US. And although deceased donor liver transplants are still considered the standard of care in the treatment of liver failure, the need far outstrips the available organs. It is this studies opinion that a living donor transplant is a lifesaving option for children and adults by buying them time while awaiting a deceased donor (Kehar et al, 2019).
Hurdles to overcome
This article shows that whether the organ is from a live donor or a deceased one, favorable outcomes depend on many things. Among them include the quality of the actual graft, the recipient and donors ages, their MELD (model for end-stage liver disease) score and other already existing conditions in the recipient. Because of this transplant teams must weigh the risk/benefit ratio. This risk assessment helps them decide who will benefit most from transplant and who has the best chance to survive it. Medicine is doing its part to preserve the donated organ and even repairing them prior transplantation to increase chances of success. As technology improves and donors health overall improves, quality of the live donor liver transplants. In addition, there is an improvement in the real-time assessment of surrogate markers of the quality of the graft. People in this article have really explored how beneficial the use of living donor liver transplant was compared to the deceased donor (Kalisvaart & Perera, 2019).
With the increase in the use of living donor liver transplantation research is being done to determine the best age-groups for donor risk index. This index determines the best-expected outcome of post-transplant graft. This study found that after the age of 30 there is an increased risk of complications for living donor liver transplants. Changes like the decrease of overall liver volume and blood flow can complicate how well the graft functions after transplant. Often this type of surgery is the only hope for individuals who are facing end-stage liver disease from hepatitis C. this article reported that by keeping the age around 30-35 years even individuals with hepatitis C could recover from this with LDLT and not have the hepatitis return. Overall 87% of the whole group survived at least one-year post-surgery. And again the younger the LDLT the better the success and overall survival (Dar et al, 2019).
Ever since liver transplantation has been considered as an option for people who suffer from AAH (acute alcoholic hepatitis) study is in dire need to be done that considers the already scarcity of donated livers prior to this new consideration. The overall concern is that once the alcoholic gets a transplant and are feeling better, relapse to drinking again is great. The article pointed out that at the start of any given year there more than 15,000 people waiting for a donor's liver. Another 10,000 is added to the list by the end of the year. Of those waiting about 6,000 transplantations are done while 1700 patients die while waiting and another 1200 are removed as being too sick to undergo the surgery. Their place on the list is greatly influenced by their MELD scores; higher the score-higher a place on the waiting list. By adding people with AAH to the list it will make them first on the list suffering from a self-induced disease. This is totally unfair to the others on the list. This fact has not been missed by the United Network for Organ Sharing who set ethical principles guiding transplantation including utility, justice, and respect for the individual. Only 21% of AAH suffers who have liver transplant remain sober and live past three years. A study published by NEJM selected 26 patients with severe alcoholic hepatitis to undergo transplantation. Six-month survival in the liver transplant group was 77% and while this was much better than the control group it was lower than the 95% survival rate of those with a liver transplant from other causes. The question remains; are we willing to accept such inferior rates of survival when up to 30% of those on the list die each year while waiting for a liver and they didn’t damage their liver through their own actions? (Alsahhar, Mehta & Lepe, 2019).
A study put forth by the University of Pittsburg has shown there are advantages of using a living donor over a deceased donor. Better survival rates, lower costs and more chances of availability are all reasons for this consideration. The study found that three years post-transplant of a live donor was 86% compared to a deceased donor of 80%. University of Pittsburg Medical Center has noted that LDLT should be a first and best option for most people with liver failure (UP, 2019).
Alsahhar, J., Mehta, A. & Lepe,R. (2019). Con: Liver transplantation should not be performed in patients with acute alcoholic hepatitis. Clinical Liver Disease, 13(5).
Dar, F. et al. (2019). Recipient outcomes with younger donors undergoing living donor liver transplantation. Cureus,11(3).
Iwamura, S. et al. (2019). Risk benefit point of the [MELD] model for end-stage liver disease score in patients waiting for deceased donor liver transplantation: Single center experience. Hepatic Research, 49(6), abstract.
Kalisvaart, M. & Perera, T. (2019). Using marginal grafts for liver transplantation: The balance of risk. Journal of Investigative Surgery.
Kehar, M. et al. (2019). Superior outcomes and reduced wait times in pediatric recipients of living donor liver transplantation. Transplantation Direct, 5(3).
University of Pittsburg (2019). New study highlighted advantages of living donor liver transplants over deceased donor. University of Pittsburg School of Medicine.
Zidan, A. et al. (2019). The first two cases of living donor liver transplant using dual grafts in Saudi Arabia. Annals of Saudi Medicine, 39(2). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6464670/pdf/asm-2-118.pdf