The Recanati/Miller Transplantation Institute
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Programs Liver Transplantation Living Donor All You Need to Know about Adult Living Donor Liver TransplantationUsually, organs for transplantation are obtained from cadaver donors, after their families give permission. But there are not enough cadaver donor organs available for everyone who needs one, and as a result, increasing numbers of patients are being added to the transplant waiting list. Because of the organ shortage, many patients waiting for livers die on the waiting list or become too sick to undergo transplant. But if a patient can receive a piece of liver from a relative or friend, he or she need not wait for a cadaver organ. Thus, living donor liver transplantation can be an important alternative for many patients. In living donor liver transplantation, a piece of liver is surgically removed from a living person and transplanted into a recipient, immediately after the recipient’s diseased liver has been entirely removed. Living donor liver transplantation is possible because the liver — unlike any other organ in the body — has the ability to regenerate, or grow. Regeneration of the liver happens over a very short period – possibly days to weeks, and certainly within 6-8 weeks. So when surgeons remove a piece of the donor’s liver, the part that remains in the donor grows back quickly to its original size. More than a decade ago, surgeons around the world began to perform these procedures using adult donors for children who needed transplants. In addition, surgeons gained experience in splitting a single cadaver liver into two pieces, for transplantation into two recipients. Mount Sinai surgeons have been at the forefront of these surgical advances. They have also pioneered the use of living donor liver transplants in adult recipients, safely removing the larger right lobe of the donor’s liver.
Frequently Asked Questions
Q. What are the advantages to living donor liver transplant? A. The main advantage is that when the recipient needs the transplant, he or she can receive it without having to wait on the regular transplant waiting list. Patients who must wait on the regular UNOS waiting list usually get much sicker while they wait, and they are much weaker going into the surgery. Patients may become too sick while they wait and may then no longer be eligible for a transplant. Some die before an organ becomes available. In addition, when patients get sicker and weaker on the waiting list, they are more likely to have more complications during the early post-transplant period and have a higher risk of not doing well after transplant. If there were enough cadaveric donor organs available, we would not need to consider living donor liver transplant. It is only because of the shortage of organs that this option has developed. There may be some additional collateral benefits. The transplant can be scheduled electively. It is also possible that the quality of the liver may be better, as living donors are usually young, healthy adults who have undergone a thorough medical evaluation over several days or weeks. Preservation time (when the liver is without blood) is minimal -- minutes, not hours. Q. How much of the donor's liver is removed? A. Usually, about 40-60 percent of the donor's liver is removed. The liver is divided into a right lobe and a left lobe. The anatomical division between the lobes permits surgeons to divide the liver into two distinct parts, which can function independently of each other. The right lobe comprises approximately 60 percent of the total liver volume, and the left lobe comprises approximately 40 percent. During the surgery, the donor's gallbladder is also removed. When the recipient is a small child, a piece of the donor's left lobe, called the left lateral segment, is removed.
Q. How much time has to pass between removing the piece of liver from the donor and transplanting it in the recipient? A. The operations on the donor and the recipient take place at the same time. A. Generally, you should be between the ages of 18 and 55 years. We prefer that donors be the same size or bigger than the recipient, but donors can sometimes be smaller than the recipient. You must not be pregnant. You should not be overweight, although if you are overweight, you may still be considered a potential donor if you can lose weight. You should not have any major medical or psychiatric illness. You must also be able to understand the risks of this surgery and be able to comply with our instructions for short- and long-term follow-up medical care. Q. Do I need to be related to the recipient? A. No. Blood relation is not necessary between the donor and recipient. Spouses, friends, even total strangers have donated a part of their liver. Q. If I am related to the recipient, will he or she have less rejection? A. In reported studies, there does not appear to be a lower risk of rejection if the donor is a blood relative. The relationship between donor and recipient also does not appear to affect the amount of immunosuppressive medication the recipient will need. You would probably need to be identical twins for the relationship between the donor and recipient to make a big difference. Q. What is involved in the evaluation process? A. The purpose of the evaluation is to make sure that your liver is normal and of adequate size and that you do not have any medical or psychiatric illness that would make this procedure more risky or difficult for you. We also want to make sure you do not have any medical condition that could be transmitted to the recipient. Finally, we want to make sure that you are becoming a donor voluntarily, and that no one is pressuring you to do this. Q. Will my recipient be removed from the regular transplant waiting list if I am evaluated? A. While a potential donor is being evaluated, no changes are made to the recipient's status on the regular waiting list. As a bonus to recipients of living donor transplants, they are not removed from the waiting list after their transplant but made "inactive" for one year. If they need to be re-listed for a transplant during that time, they retain credit for their previous waiting time. Q. Will my evaluation be covered by medical insurance? A. You should not incur any expenses related to the evaluation, surgery, hospitalization, or immediate post-operative care. Different insurance carriers handle the donor's evaluation in different ways. The majority of Insurance Carriers will approve a Living Donor Evaluation once the recipient has been accepted as a candidate for liver transplantation. When we begin a donor evaluation, we will be in touch with the recipients Insurance Case Manager to determine how we need to proceed. If you (the potential donor) do not have any medical insurance, your evaluation will be submitted directly your recipients insurance carrier. As most recipient insurance carriers will only cover the donors medical expenses up to one to three months after surgery, it is in your best interest to have your own medical insurance coverage before becoming a living donor. If you do have a medical insurance plan, we will need to know your insurance details and will need to provide them to each consultant and department involved in your evaluation and eventual surgery. Some recipient insurance carrier will require us to bill your (the donor) insurance carrier first. Your insurance carrier will most likely deny the claim(s) and will issue an Explanation of Benefits (EOB) form to the donor and to us. We then submit the claim with the EOB to the recipients insurance carrier. While this is a somewhat cumbersome process, as it is dictated by the recipients insurance carrier, we need to follow this direction. However, many recipient insurance carriers have changed their policy and do now allow us to bill the recipients insurance directly without going through this process. This is obviously simpler for us and for you. We instruct physicians and the hospital to insert a specific diagnostic code, V70.8 (liver donor) on all donor bills. You will incur travel expenses and expenses related to prescriptions for pain medication after the surgery; this is usually not a significant amount. Q. May I get my evaluation done by my own doctor? A. Given the extent of the surgery, it is better that our team perform all the tests and examinations. If you live far from our hospital, we can have some portions of the evaluation done locally, but you will still need to be examined by our physicians. For insurance and billing reasons, it is also easier if the evaluation is done at Mount Sinai. Q. What is the first step in the evaluation process? A. The first step is to know your blood type. This is a simple test that your doctor can do, or you can go to any blood donation center and they will check it for free. You must be either the same blood type as your recipient, or blood type "O." Your Rh factor -- positive (+) or negative (-) -- does not affect your suitability to donate. Q. What do I do once I know my blood type? A. Call our Transplant office at (212) 241-8035 and advise the receptionist that you wish to discuss living donor liver transplantation. You will be put in touch with the Transplant Coordinator and the Medical Assistant for the living donor liver transplant program. We will do a brief health screening over the phone, and you will have an chance to ask questions. We will also take detailed demographic and insurance information from you and schedule an appointment for you with one of our physicians. At this appointment, the physician will take your full medical history, review a detailed health questionnaire, and do a physical exam. The physician will then discuss living donor liver transplantation with you, including the potential risks and statistics on the procedure at our hospital, elsewhere in the United States, and worldwide. You will also have extensive blood tests done at this visit. Two or three days later, we will review your test results with you. If everything is normal, we will schedule the second step of the evaluation. Q. What is the second step of the evaluation? A. The next step is to undergo a non-invasive study of your abdomen to measure the volume of your liver and to look at the liver's blood supply and its bile ducts. This study is called an MRI, which stands for "magnetic resonance imaging." The MRI will give us a very detailed picture of your liver, from which we can determine whether or not you can be a donor. You will also have a chest x-ray and you will meet with a social worker, a cardiologist, and one of our transplant surgeons. Other tests or consultations may also be necessary, depending on your individual circumstances. A liver biopsy is required in some cases. This would be scheduled on a different day. Q. Do I need to fast before my appointments? A. You are advised not to eat for 3-4 hours before your MRI study, but in general it is not necessary to fast before an appointment unless we specifically tell you to do so. Q. Should my family come with me to the appointments? A. It is important to have your immediate family or next of kin come with you to at least some of the appointments, so they can participate in the process and understand what is involved before you decide to proceed. All these appointments offer the opportunity for you and your family members to ask questions and learn more about the procedure, so you can make an informed decision. Your designated next-of-kin or your designated health care proxy must participate in the evaluation process or attend the final appointment before the scheduled surgery. Q. How quickly will I know if I can be a donor? A. Generally, within two weeks after you complete every component of the evaluation, we will let you know if you can be a donor. Further medical tests are sometimes needed, however, which would delay your clearance for surgery. It is extremely important that you allow yourself as much time as necessary to digest the information you are reading in this booklet and the additional information you will get in your meetings with us. The decision to donate a piece of your liver is not one you should make lightly. You should consider it very carefully, and discuss it with your family. [back to questions]Q. Who makes the final decision as to whether I can be a donor? A. Once you have completed all required tests, the transplant team meets to review the test results and your recipient's medical condition. The team includes physicians, surgeons, nurse coordinators, medical assistants, radiologists, social workers and any specialist who consulted on your evaluation. No one person makes the decision; the team decides. In our decision-making, we put the well being of the donor ahead of anything else. The donor's safety is paramount. Q. If I am cleared to be a donor, who decides when to do the transplant? A. This decision is made jointly by the transplant team, by you, and by the recipient. The transplant team, particularly the physicians involved directly in your recipient's care, will determine as accurately as possible the best time to do the transplant, based on the recipient's medical condition. Once we know this, we ask for your input as to what suits you best, within our limits. There may be specific weekdays when we can do living donor liver transplants. We need two operating rooms and two teams of surgeons, nurses and anesthesiologists, so the procedure takes a lot of coordination. Q. Should the cause of the recipient's disease affect my decision to donate? A. You are volunteering, with extraordinary generosity, to donate part of your liver in an attempt to save another person's life. Before you make this gift, it is important that you understand the likelihood that your sacrifice will actually save your recipient's life. Some diseases (such as hepatitis C and cancer of the liver) can recur after transplant. We will be discussing the recipient's medical condition with you, what outcome we can expect from transplant, and what possible additional complications, if any, may be associated with the recipient's particular disease. We expect that you will understand and respect the confidential nature of these discussions and will be sensitive to maintaining the recipient's privacy in these circumstances. Your recipient will be aware that we need to have these discussions with you. Q. What are the possible complications of the donor's operation? A. As with any surgery involving general anesthesia, there are possible complications of the anesthesia itself, including heart complications, stroke, and blood clot formation in the legs or lungs. There are also risks of bleeding or of bile leaks after surgery. There is also a risk that the remaining portion of your liver will fail and you will need an urgent liver transplant yourself. There is even a risk that you might die. While these complications are very rare, the risks exist, and we will discuss them with you in more detail during the evaluation. The most common complications of this surgery are small bile leaks from the remaining portion of your liver, minor wound infections, and gastrointestinal upsets (such as constipation, indigestion, occasional nausea or diarrhea). These usually resolve after a couple of weeks. Q. Will I require a blood transfusion during my surgery? A. Blood transfusion during this surgery is very unusual, although it may be necessary. As a precaution, we will ask you to "donate" one unit of your own blood 2-4 weeks before the surgery. If you do need a transfusion, we can then use your own blood, so you will not be exposed to the risks of a transfusion from someone else. Q. Should I stop smoking before my surgery? A. We strongly advise you to stop smoking, even if you are a light smoker. Heavy smokers will be ineligible to donate because of their increased risks. Q. Should I not drink alcohol? A. If you are going to be a liver donor, it is best that you stop drinking. If you have a history of alcohol use, it is very important that you tell our physicians. Alcohol use may not preclude you from being a donor, but you may need to undergo a liver biopsy to be sure your liver has not sustained any damage. Q. Should I stop taking my medication before the evaluation or the surgery? A. You should not stop any prescription medication unless advised to do so by a physician. You should avoid aspirin or non-steroidal medications such as Advil or Motrin for seven days before a liver biopsy or surgery. These medications affect the ability of the blood to clot and put you at higher risk of bleeding complications. Instead, you may take Tylenol if needed. Women who take birth control pills or pills for hormone replacement therapy will be advised to stop taking them because of the increased risk of blood clots during recovery from surgery. Q. How long will I be off work? A. The minimum amount of time you need to allow yourself to recover is 4-6 weeks. Because people recover differently, with varying degrees of fatigue and pain, you may need as long as 8-12 weeks. We prefer that you be in a position - both financially and from a job security perspective - to be able to take twelve weeks, if you need that much time. Q. Will I be entitled to disability pay? A. If your job provides disability coverage, then you will most likely be covered. Because living donor liver transplantation is still relatively new, however, it is best that you discuss this with your benefits department before you decide to proceed. A. The incision is a large one and is the same for the donor and recipient. It is called the "mercedes" incision. See illustration C for an idea of what it looks like.
Q. Will I have a scar after the incision heals? A. In most cases, the incision heals quickly, leaving a fine scar that fades over time but will most likely always be visible. If a wound infection develops, you may be left with a wider scar that will be more obvious. Occasionally, people develop what is called granulation tissue. This is over-growing or over-healing of the skin, and it results in a raised scar. This can be corrected by plastic surgery if it bothers you, but it is unlikely that your recipient's insurance would cover cosmetic surgery. Q. Will I have much pain after the surgery? A. Unfortunately, you will have significant pain after this surgery. We will give you pain medication, but you will still be very uncomfortable for at least the first week or so. You will have less pain as each day goes by, but most donors tell us that they still have a significant amount of discomfort for 2-4 weeks after the surgery. Most pain medication is broken down (metabolized) by the liver. Because you have a significantly smaller amount of liver volume right after your surgery, we will monitor you very carefully to make sure we are not giving you too much medication, which could have serious side effects; most pain medicines make you drowsy and can affect your breathing and bowel function. We will try to get the right balance of pain medication to make you comfortable but not drowsy, so you can do your deep breathing exercises, coughing, and walking. We commonly use an epidural inserted before surgery to administer pain medication after the surgery. The anesthesiologist will discuss this with you the morning of the surgery. You will get a prescription for pain medication to take at home before you leave the hospital. Q. Will I have a normal life after surgery? A. We expect that you will return to a totally normal life within three months after your surgery, provided you do not experience any complications. We do not expect you to have any long-term complications, but as this procedure is still relatively new, we cannot yet give you any statistics on the long-term follow-up of donors who have undergone this surgery. Q. When can I engage in sexual intercourse? A. You will probably want to refrain from sexual intercourse for a couple of weeks until you have less discomfort and are feeling stronger. This decision will be based for the most part on how you are feeling. Q. If I want to start a family, how long should I wait after surgery to get pregnant? A. There is no definite answer on this, but we recommend that you do not become pregnant for at least 3-6 months after surgery. Q. When can I restart my birth control pills or hormone replacement therapy? A. We advise you to wait for a minimum of three months after surgery. Q. How long before my liver grows back to normal size? A. The liver begins to regenerate almost immediately. Probably, most of the regeneration occurs in the first two weeks after surgery. By three months, your liver is probably back to normal size or near normal size. Q. Would I be able to donate part of my liver again in the future to someone else? A. No. Once you donate a portion of your liver, you cannot do so again in the future. Q. When will I be able to drive after my surgery? A. We advise you not to drive for at least the first 2-3 weeks after the surgery. You must be physically and mentally strong, with normal reflexes, and not experiencing any abdominal pain or discomfort, before you decide to drive. You should also not be taking any narcotic medication such as Percocet or Tylenol with Codeine, as these can affect your mental alertness. Q. When can I begin to exercise? A. As soon as you wake up from the anesthesia, you will begin "exercising." You will need to take deep breaths and cough to make sure you are getting air into all the cells of your lungs. This will help prevent pneumonia. You will also begin to exercise the muscles of your legs by flexing and relaxing them periodically. You will be helped out of bed within 24 to 48 hrs of your surgery and will begin walking. We cannot stress enough how important walking is to your recovery. Each day you should be pushing yourself a little bit more. By walking as soon after your surgery as possible, you will help to prevent such complications a blood clots, pneumonia and muscle wasting. You are encouraged to continue a program of daily walking when you go home. Remember: the goal is to be back to normal health within 2-3 months. Q. When can I lift weights, jog, swim, etc.? A. You will need to avoid any heavy lifting for the first four weeks, until your abdomen has completely healed. You should not lift any weights greater than 15-20 lbs. After four weeks, if you are feeling well and are not having any complications, you may begin to return to your normal activities, such as swimming, jogging, aerobics, cycling etc. Begin slowly and build up gradually. Be very cautious with abdominal exercises. Begin slowly with a few repetitions and build up your strength and stamina. Q. When can I go on vacation or fly? A. You should not plan any vacations or trips outside the U.S. for at least 4 weeks and preferably 8-12 weeks after your surgery. If you wish to return to your home in the U.S., and you have a good physician, you may be able to do so 2-4 weeks after the surgery depending on how you feel and how you are recovering. Remember, if we have any concerns about any possible complications, we will want you to return to Mount Sinai for evaluation and treatment. It should be no problem for you to take trips or vacations after 8-12 weeks. Q. Once the transplant is scheduled, will it definitely happen? A. Unfortunately, very little is written in stone when it comes to liver transplant. A number of things could happen that could change our plans. Your recipient's condition might deteriorate to the point where he or she is too sick for a transplant. Or the recipient might develop an infection or some other condition that would need to be treated before the transplant could be done. Rarely, we may need to postpone the transplant at very short notice (sometimes hours before) if we have a number of cadaver transplants that same day. (Because cadaveric organs must be used within a short time, a cadaveric transplant would take precedence over a living donor transplant.) Also, if your recipient has liver cancer, we will do an "exploratory laparotomy" on the morning of the transplant before we begin the donor's surgery. Your recipient would be brought to the operating room first and we would begin the operation by examining his or her abdomen for any signs of spread of the cancer. If the cancer has spread, we would not proceed with the transplant. Q. How long will I be in the hospital? A. The average hospital stay for donors is 4-6 days after surgery. Q. Will I be in the Intensive Care Unit after my surgery? A. After your surgery, you will be taken to the Recovery Room for close observation by the nursing and medical staff. You will most likely remain in the Recovery Room overnight, until you have completely awakened from the anesthesia. Once we see that everything is stable and that you do not have any bleeding or other complications, you will be transferred to the regular transplant floor. Q. Will I be in the same room as my recipient after the surgery? A. No. The recipient goes to the Intensive Care Unit for one to two days before being transferred to the transplant floor. You might coincidentally be assigned to the same room, but this rarely happens because of bed availability. Q. How soon will I be able to eat and drink after my surgery? A. As soon as your intestine starts to work again after the surgery, you will be able to begin to drink and eat again. We will know it is safe for you to begin taking sips of water when you are passing gas. If you do not have nausea or vomiting with the sips of water, you will be able to progress to clear fluids, a soft diet, and then a regular diet within the next two days. Very occasionally, some individuals do not return to normal eating habits this quickly. The less pain medication used, the faster the bowel returns to normal and the diet resumes. Q. Will I have any tubes or drains in me after the surgery? A. You will have one or two intravenous lines in you during and after the surgery, so we can give you fluids to keep you hydrated and also give you medicines. One of these lines may be used to administer your pain medication after the surgery. You will also have a catheter (drainage tube) in your bladder so we can monitor how your kidneys are working during and after the surgery. Having the catheter in your bladder also means that you will not need to get up to the bathroom immediately after your surgery. You may also have one or two small drainage tubes in your abdomen to drain any blood or bile that might ooze after the surgery. All these tubes and intravenous lines will be removed within 2-3 days. Q. Will I get injections of pain medication after the surgery? A. We use a variety of methods to give pain medication. Sometimes, the anesthesiologist inserts an epidural catheter, which permits numbing medication to be administered directly into the spinal cord to prevent pain. You may also have what is called PCA (Patient Controlled Analgesia). With PCA, you have a intravenous line attached to a computer-controlled pump. You press a button whenever you need pain medication, and the medicine is immediately administered directly into your vein. It is important to realize that you cannot "overdose" with this system, as a computer controls the amount of medicine you can give yourself. Once you are eating normally, we will switch you to a pill for pain medication. Q. Will I need to come back to the hospital for check-ups? A. This procedure is major surgery, and we need to monitor you very closely at first to make sure everything is OK. You must come back for a check-up and to have your staples removed 10 days after your surgery. You will probably need another check-up at one month after your surgery, and you will have a final check-up at about three months after your surgery. At that time, you will have a CT scan or MRI done to check your liver size and also some basic blood tests, and a physical exam by one of the hepatologists. You may need other appointments as well, depending on how you are feeling. You should have an annual physical exam with your primary care physcian after being a living liver donor. Q. Must I remain close to the hospital after my surgery? A. You do need to remain close to Mount Sinai for at least 2-3 weeks after your surgery. You also need to be able to return here to Mount Sinai if you experience any problems during your recovery. If you are from out of town or out of state, you may stay at our nearby Transplant Living Center. We recommend that you have a relative or friend stay with you, especially immediately after you leave the hospital. Q. Will I need to take any medications after I donate a part of my liver? A. You will not need any medications except for some pain medication. If you were to develop a wound infection, you might need to take antibiotics. Q. Will I need a nurse to take care of me when I leave the hospital? A. Although this is a very big operation and you will be extremely tired and weak, you most likely will not need any professional nursing care at home. You will need a friend or family member to do your food shopping, perhaps cook your meals for you, and just generally be available should you run into any difficulties. It is also nice to have some company when you first come home from the hospital. You should have someone available to take you to and from the hospital for your check-up. Q. When will my sutures or staples be removed? A. You will need to make an appointment to return to the out-patient office approximately ten days after your surgery to have your staples removed. Q. Do I need to do any special preparation prior to surgery? A. The medical evaluation we perform on potential living donors is extremely thorough. Once you have completed your evaluation and we decide to proceed, there is not much additional testing to be done. We will want you to donate a unit of your blood within 2-4 weeks before your surgery. We may also need to repeat some of your blood tests, if they were done more than 30 days before your surgery date. You will also need to give a sample of your blood to our blood bank within 72 hours of the surgery. We will probably have you and your recipient and your immediate family come in two or three days before the surgery for a final review of everything, for any minor tests that may be needed, and to answer any remaining questions you may have. Q. Do I need any special diet before surgery? A. No. You can eat and drink normally until midnight before the surgery. There is no need to take laxatives or enemas. If you regularly take any medications, we will instruct you about these when you come in for the final appointment before surgery. You should not drink alcohol for the three months preceding surgery. Remember, if you are taking oral contraceptive pills or hormone replacement therapy, you must discontinue them three months before the surgery. Do not take any asprirn, Advil or Motrin (non-steroidal) medication within seven days of your surgery. Q. Will I be admitted the night before surgery? A. No. You and your recipient will be admitted to the hospital on the morning of the surgery. You will probably need to be here at either 6 A.M. or 7 A.M., and the surgery time will be either 8 A.M. or 9 A.M. Q. What should I bring with me on the morning of the surgery? A. Bring only minimal belongings, with no valuables. Because we already have your insurance information, there is no need to bring any documentation with you unless we specifically ask. Leave all jewelry at home or give it to your family for safekeeping. You may want to bring a basic toiletry bag and ask your family to hold it for you. Procedure For Evaluation As A Potential Living Donor
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