Abhi Humar, MD, Chief of Transplant Surgery at UPMC talks about live liver transplant and what it means for donors and those receiving.
Interview conducted by Ivanhoe Broadcast News in February 2019.
Do you have a specific area of expertise within transplantation?
HUMAR: My clinical area of specific interest is live donor liver transplant.
That’s where I want to start. Many of our viewers might have heard of it or might not have heard of it. Tell me, what is a live donor liver transplant?
HUMAR: A live donor liver transplant really just represents another way to do a liver transplant. As you know a liver transplant is the only way we have at the present time to treat someone with end stage liver disease whether it’s cirrhosis from hepatitis C, Hepatitis B, primary sclerosis cholangitis or any congenital disorder in a pediatric patient. Really once the liver fails, the only thing we can do is replace it. So a liver transplant essentially involves replacing someone’s diseased liver with a new liver. The vast majority of livers come from what are called deceased donors. That means someone passes away and donates their organ, and probably 95 percent of the transplants done in this country come from a deceased donor. The problem with deceased donor transplant is really that there are not enough livers for all the people that need them. So if you look at the present time there are fourteen thousand people in this country that are waiting for a liver transplant. We do roughly about 8000 liver transplants a year. So not enough to meet the need. And so really we have to prioritize and only the sickest patients and the patients that we know are going to have the best outcomes qualify for a liver transplant in this country. So people have to wait. The average person waits about one to two years on a waiting list before they can get a transplant. That carries with it the risk of a waitlist mortality meaning that the risk that someone will die before they reach the top of the list, which in this country is somewhere around 20 to 25 percent. So that means a fifth or as high as a quarter of our patients are dying even before they get to a transplant even though we know that a transplant will save them. It also means that not all of the patients that we know we can help with a transplant necessarily would qualify for a transplant because you just don’t have enough livers for all the people. Adding these additional people only makes the witing list longer and does not increase the number of transplants. There’s no sense having that many patients on the list. So that’s the main problem really with deceased organ transplants. A live donor transplant really represents at least one solution to those problems.
A live donor liver transplant just represents another possible option as a way to do a transplant. And essentially what it involves is taking the part of someone’s healthy liver and transplanting it. This is not a new concept. We’ve been doing it with kidneys since the 1950s in fact, where we have two kidneys and we take one kidney and can transplant it. Now we don’t have two livers, but the liver can be divided up into several portions and so it’s possible to take just one of those portions and transplant it into someone. The reason we can do this is you actually only need about 25 30 percent of your liver to do everything that the liver does. The rest is all extra.
The liver also regenerates. Can you talk to me about that?
HUMAR: Sure. The liver is one of the few organs that we have that will actually regenerate. Let’s say we took the right part of the liver away in someone. Well, the left part will increase in size to compensate for that. And that’ll happen in a very quick, very short period of time so usually within eight to 10 weeks that liver will pretty much regenerate back to full size.
How new is the idea of transplanting livers this way – live liver transplant?
HUMAR: It’s a relatively new type of procedure. While transplantation itself is a relatively new field, live donor liver transplants really started to be done onlyin the late 90s So maybe 20 years is about the history of live donor liver transplant in this country, and still they represent as I said a very small proportion of the transplants that are being done. Less than 5 percent.
Is it becoming more of an option for more people?
HUMAR: It has grown a little bit over the last few years. But the growth is nowhere near enough to match the need that’s there. And the growth is really a small growth because if you look around the world at other countries, places like Korea, China, or Japan, India or even middle east, the utilization of live donor liver transplant is significantly higher than what it is here. In fact, there’s some hospitals in India and Korea that probably do as many live donor liver transplants in a year as are done in the entire United States in a year. So that just gives you an idea as to the proportion really of the number of transplants that are being done in that way.
Why does it lag behind in the United States?
HUMAR: There’s several reasons. It does require a degree of technical expertise that you have to build. You have to have a team committed to it. It is a more involved type of procedure. Transplantation is very heavily regulated here in the United States. You’re under the microscope for your results. But I think probably one of the main reasons why it is under utilized in this country is that there’s a lack of awareness about it. A lack of awareness from the part of the patients who need it, from the caregivers who are providing the care for their family members, and even lack of awareness about it from their physicians who are looking after them. The primary care physicians, the gastroenterologists even the liver specialists that are looking after them afterwards don’t really know the real facts about this procedure when it should be applied, who could be a candidate et cetera. It’s really only the people who are at centers that are doing this on any regular basis that that are aware of it.
Who are the best candidates? For whom does this work?
HUMAR: At our center it’s really anyone who needs a liver transplant and if they have a willing and suitable donor. And that’s the key. They have to have a willing and a good donor. And the suitable donor may not be suitable for everyone. It may just be suitable for that particular recipient. But we think if that option is available we offer it to all patients. So that includes the sickest patients as well as the patients that are not as sick. It also includes the patients who don’t necessarily qualify for a deceased donor transplant but who we know will get a survival advantage from having a transplant.
What’s the benefit of having this option?
HUMAR: There are multiple benefits. The biggest is you avoid that waitlist mortality. So as I mentioned before about a quarter of our patients are going to die without getting a transplant. If you have a live donor that waiting list mortality is eliminated. For these patients it’s right away a lifesaving option. Other benefits include the fact that patients don’t need to wait on a waiting list, potentially getting sicker. Finally, we can help patients with liver disease that would not necessarily qualify for a deceased donor transplant. Live donor liver transplants increased in this country until 2001 when there was a heavily publicized case in New York where a donor donated and then subsequently passed away because of complications related to the surgery. And that really set the field back quite a bit because people were reluctant to then move forward with this because of potential risks to the donor. And that is one of the things that you have to emphasize is there are some potential risks to the donor.. But it slowly made a comeback, if you will, over the last few years where the numbers have gone up a bit. But if you look at the national data it still represents a very low proportion of the total number of transplants. Last year it accounted for about 4.8% of the total number of transplants done. Now at our center we are different from that and have made a very concerted effort over the last few years to try to utilize live donor liver transplants for all of our patients and to try to help families identify suitable donors. So last year we did a total of about 67 live donor liver transplants of which the majority were for adult patients and a small number for our pediatric patients. Fifty five percent of our transplants are from a live donor and the remainder are from deceased donors.
So that’s a higher proportion here.
HUMAR: Yes, significantly higher.
And you said last year there were four hundred one total.
HUMAR: In the country.
2018 numbers. And 2017 was …
HUMAR: Three hundred and sixty seven.
2016 just over three hundred.
HUMAR: I can’t remember the number off the top of my head but it was somewhere around there.
I wanted to ask you a little bit about Wayne’s case. What is the condition?
HUMAR: He had something called primary sclerosis cholangitis. It’s an autoimmune type of disorder where essentially the body starts attacking the bile ducts inside the liver causing damage to them and ultimately the liver. The bile ducts are like the plumbing system of the liver and damage results in backup of bile which eventually then causes damage to the liver and then eventually results in cirrhosis and all of the complications secondary to cirrhosis.
There is no long-term treatment other than transplant.
HUMAR: There are some treatments that can help slow down the disease and steroids will help decrease some of the inflammatory process that occurs, but ultimately no. There is no long-term cure for PSC and many patients will progress on to develop cirrhosis and end stage liver disease.
So he was at end stage liver disease about two years ago and needed a transplant. Can you take me through the process? His came from a living donor.
HUMAR: Yes that’s right. So essentially Wayne started developing a lot of the complications that we see with liver disease, being jaundiced, fatigue, fluid retention, all of those complications. And then at that point it was determined that his liver disease had progressed enough to the point where he would need a transplant. And so he was evaluated for a transplant and then placed on a waiting list for a transplant. And as with so many patients, even though he was sick and he needed a transplant, he was nowhere near the top of that list to be able to get the transplant. The priority on the waiting list is determined by essentially severity of liver disease which is calculated by a mathematical formula. The higher the score, the sicker the patient, and the higher they are on the list. But Wayne was not high enough that he would be getting a transplant in that in that way but nonetheless continued to have a lot of the problems associated with his liver disease and continued to have deterioration associated with his liver disease. And that’s why a live donor transplant was such a good option for him because it allowed him to get the transplant really when he needed it. And then have a good recovery as a result of that.
Wayne got his through an altruistic donor, someone he knew but wasn’t a family or relation. How unusual is that, doctor?
HUMAR: You’re right. The most common type of donor that we see is generally a family member. They’re the ones that are most emotionally involved and therefore they’re the most likely to donate. But we see all sorts of other combinations. The common things include obviously your spouse or good friend, but co-workers, church members, acquaintances, friends of friends that may have heard about it. And then we see what we call non directed donors. And these are individuals that come in essentially off the street and say, look, I know you have a lot of patients that need a liver transplant. I’m a healthy individual. I’d like to help someone. And they donate part of their liver to someone that they don’t know who is on the waiting list. So there are a fair number of those as well as there are a fair a number like Rena’s situation where she didn’t really know Wayne but had heard about him and wanted to help and stepped forward. People would be surprised at how many we do end up seeing. You would think that that’s a pretty strange or rare occurrence, but we see it on a regular basis. Either it’s a complete stranger or someone who’s just an acquaintance at best and steps forward to donate.
What are the risks for the person who is donating, giving up a piece of liver?
HUMAR: We tell all donors it is a big operation that they have to undergo. That’s why they undergo this very rigorous evaluation to make sure that their liver is healthy, to make sure that they’re overall healthy, and to make sure that the risks of the procedure are minimized as much as possible. But nonetheless it is an operation that carries with it some risk when you’re removing any portion of someone’s liver, but especially if you’re removing let’s say 60 percent or more of someone’s liver. That’s a big operation for them. If you look at the national data, there have been about 7000 of these operations that have been done in the United States over the last 25 years. The worst possible complication obviously in a donor is death. There have been six deaths associated with liver donation in this country. And we generally quote mortality risk to donors of about 0.2-0.5%. It’s not a high number, but it’s definitely not zero. And since these are individuals that don’t need surgery and are not going to benefit from this surgery, we stress that risk to them and make sure that they’re OK with that. We make sure that they have had time to think about it, if possible, to ask questions et cetera.
Without Rena, would Wayne have survived?
HUMAR: There’s no question that without a liver transplant Wayne would not have survived. His liver disease was progressing and given its natural course he would have succumbed from his liver disease. There’s no question about that. Now whether he would have received a liver transplant from a deceased donor if he stayed on the waiting list. There’s a chance that he certainly could have. But there’s a chance that he may not have. And as I said, our wait list mortality is 25 percent. So that means there’s 25 percent of our patients that are on the wait list who are not getting to that transplant. So there’s no question that Rena’s donation was a lifesaving procedure for Wayne.
What is his prognosis?
HUMAR: His prognosis is quite good. Knock on wood he’s done very well after the transplant. He’s essentially back to feeling normal. He’s gained weight. He’s gained muscle back. He’s probably able to get back to doing work. He may have already started getting back to work and should be able to get back to normal life and we’ll continue to follow him for life because the transplant needs regular monitoring. He needs to take anti-rejection medications for life to keep that liver working but over time we will decrease the dose of those medications and that’s one of the advantages of a live donor transplant, we are able to get patients on lower doses of medications generally. And as I said we’ll continue to monitor him. But our hope is that he’ll have a very long and healthy life.
And how much of Rena’s liver has grown back as you guys continue to monitor her progress?
HUMAR: We monitor her progress regularly and I think we saw her just recently for her three month visit and we generally do a scan at that time to measure the liver. And it’s pretty much 80 to 90 percent back to normal size at this point.
Is there anything I didn’t ask you that you would want people to know about this procedure?
HUMAR: I think what we want to be sure of is that people know that this is an option, and it doesn’t necessarily have to be a direct family member. Oftentimes what we find are that people think that this is something that should only be done as a last resort, that this is something experimental or only their brother or sister can be their donor. These are all misconceptions about live donor transplant. The truth is that it can be done for just about anyone who needs a liver transplant. It’s better to be done when the patient is earlier in the disease process. They’re likely to have a better recovery if we can do it early as opposed to saving it as a last resort. And what we feel is that this is something that should be offered as the first resort and not the last resort. I think it’s important to let patients know and I think it’s important for patients to talk to their family. And by family I mean their extended circle of family. Their extended circle means not only their direct family but their friends, their co-workers, and let them know that they are sick and that this is an option. And then if they’re interested in pursuing it we’re happy to see them and explain fully and do rigorous evaluation on them.
HUMAR: We did a total of sixty seven live donor transplants here.
Sixty-seven out of the four hundred one total. So you do a good percentage.
HUMAR: Yes. We’re the largest program in the country that do this. The next biggest program is doing about 30 transplants. We’ve been promoting it anyways. And I certainly feel that it is a good option for patients.
What are some of the other large centers that also do this?
HUMAR: UCSF has a program. San Antonio Northwestern, Mt. Sinai in New York.
END OF INTERVIEW
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