Hear this interview with Dr. John Roberts, an expert in liver transplant surgery for adults and children. Learn the details of living donor liver transplant surgery including the benefits and risks.
Hello, this is Andrew Schorr of Patient Power to interview a leading medical expert from UCSF Medical Center. One of the areas, and there are many areas, where UCSF Medical Center shines is organ transplant. It certainly is a national if not an international leader, and the chief of Transplant Services is Dr. John Roberts who joins us today. What we'd like to discuss with Dr. John Roberts is one of the more exciting areas in transplantation and that is transplantation from a living donor.
One of the areas where it's certainnly made a difference is with the transplantation of the liver. Dr. Roberts thanks so much for joining us.
I'm glad to be here today.
Dr. Roberts, where does it fit in? Why do we have a need for liver transplants, and where does living donation come in?
Pretty much everybody knows there are not enough organs for all the patients who need transplants. What happens is that organs are directed to those patients who are the sickest. So, the patients who have the greatest chance of dying in the next three months or so are the ones who get priority for the liver transplant.
This works well if you're fairly sick, but one of the problems is that patients who are really sick are frequently in the intensive care unit. They have deteriorated to the point where they have multiple medical problems, other organs aren't working. The operation becomes higher risk. Then, it takes the patients much longer to recover after transplant because when you're relatively well you can walk out of the hospital say within a week after transplant, but if you're really sick and in the intensive care unit, it may take weeks to months before you can get back to a normal life.
Living donor liver transplant is a method of providing patients who have a living donor with a liver before they get really sick. So that's kind of where I see living donor liver transplant. One of the things I tell all my patients is that if we had enough cadaver organs to go around, we wouldn't do living donor liver transplants because we don't want to put a donor at risk and it's a more difficult surgery for the recipient because you're getting a piece of a liver rather than a whole liver. It takes you longer to recover, and it has more complications related to where we sew together the blood vessels and the bile ducts.
Okay, well let's make a couple of points. First of all, you and your team, the whole multidisciplinary team at UCSF, you are really leaders in this. I know you've done about 2,100 liver transplants for adults and children since 1988, so quite a lot, and you're a center of excellence. I believe there are about over 17,000 people on the waiting list for a liver transplant, and maybe 1,700 people die every year as they're waiting. So filling this gap with a living donor can make a difference. You mentioned taking a piece of the liver. Many of us are not familiar with that. Is the liver the one organ that you can actually take a piece from a donor and it will regenerate into a whole liver in the recipient?
When we think about living donor transplant, what we're banking on is the ability of the liver to regenerate itself. Now, it's not the same sort of regeneration we think about with the starfish, where we cut off the arm and it grows a new arm. With the liver, what happens is the remaining liver gets bigger, and your body knows the size of the liver that it needs. When it recognizes that there is not enough liver, it sends nutrients and signals to the liver and says "get bigger."
It's a process that probably happens within normal people every day. Our liver is changing in size slightly, not enough so that you can measure it, but it probably changes a little bit in size every day. If we cut out part of a liver and transplant it into somebody else, the donor, the person who has given up part of their liver, the remaining liver hypertrophies. It gets bigger, and the number of liver cells increases. It gets big enough so that everything goes back to normal in the donor.
In that piece of liver that I put in the recipient, it also gets bigger because the recipient's body is saying "not enough liver" and sends signals to the liver "get bigger and bigger," and it grows,. Both of these processes happen really fast so if I put in a piece of liver that's small, within actually a week or so that liver will have grown a lot. It probably continues to grow over six months to a year, but most of that growth happens within days to weeks after the surgery, and it can happen so fast during the recovery period, particularly for the donor, that we have to give the donor a lot of extra nutrients to allow the liver to grow. So that's one of the things that we do.
Wow. Now Dr. Roberts, help us understand what sort of health conditions cause the need for a liver transplant. I know it relates to end-stage liver disease. What does that mean? What are the situations that the patients find themselves in where they really need a donor?
End-stage liver disease refers to a liver that's failing, and a very high percentage of those livers are what we call cirrhotic, or the patient's liver has become cirrhotic. Cirrhosis is the scarring of the liver tissue.
There are many different causes of the scarring. Viruses are common. Hepatitis B, hepatitis C, what we call autoimmune diseases where the body attacks the liver itself such as primary biliary cirrhosis. Sclerosing cholangitis is an autoimmune disease. The liver is scarred by either a virus or an autoimmune disease. It doesn't regenerate because there is ongoing scar tissue that blocks that regeneration.
As the liver scars down, the blood that normally passes through the liver can't get there. The blood backs up around the stomach and esophagus and finds another way back. It's also like putting your finger over the end of a garden hose, when you run water through a garden hose and there's nothing blocking the end it all looks fine. But you put your finger over the end and all of a sudden you see little holes all over the place. That's what happens. The water that's in the blood starts leaking out and fills up the abdomen. Finally the liver is responsible for processing waste and toxins that come from your intestines. They have to be passed through the liver in order be cleansed. When the blood can't get through the liver, those toxins can get around to the brain and cause people to be confused and not themselves. That's called encephalopathy.
So when a liver becomes cirrhotic, those are the common complications. We see that patients have bleeding from their stomach and intestines. They have abdomens that become full of fluid. Their ankles swell with the same type of fluid, and they can become confused and not themselves. Those are the main things we see when people get end-stage liver disease and have cirrhosis.
Let's take a few minutes to understand the benefits and the risks of living donor liver transplants. First of all for the patient, we understand it gives them the chance of life and a higher quality of life. Otherwise, they can be so sick. Are there particular risks for them and having a transplant from a living donor that would be any different than if it were a cadaverous liver?
For the recipient, the patient who is going to get the transplant, there are different risks associated with getting a living donor transplant versus a cadaver transplant. A picture is worth a thousand words, but think of the blood vessels in the bile ducts entering the liver with a trunk. They have kind of a big round part of the blood vessels and bile ducts.
As they come into the liver, they divide in branches very similar to the way a tree branches. When we take out part of the living donor liver, we leave the trunk of the tree and the branch to the part of the liver we leave behind because without it the donor couldn't survive. We can only use a branch to say the right side of the liver. We get the branch of the bile duct and the branch of the blood vessels to that side of the liver, and as with branches in a tree, the size of the branch is always less than the trunk, so you have a small branch versus a large trunk. In surgery, when we sew things together, it's easier to sew things together that are bigger, have a bigger diameter like the trunk of a tree, than things that are smaller in diameter like a branch.
When we sew together the branches of the blood vessels and the bile ducts, there's a greater chance that things can go wrong. Most of those problems that occur are problems with sewing the bile duct together because it's very thin and doesn't have a very good blood supply.
Patients who get a living donor transplant have an advantage in that they don't have to wait until they get really sick. They can get transplanted kind of on an elective basis, but the risk of complications related to where we sew together the bile duct is about twice as high as if you got a cadaver liver. That's the main difference between getting a piece of a liver and a whole liver. The branches we work with are smaller and there are more troubles associated with them.
It doesn't mean that those problems lead to the recipient losing their new piece of liver, but it can mean more time in the hospital, more time with the radiologists as we try and take care of these problems and potentially a return trip to the operating room. But over time, all these things usually heal and it just means more time in the hospital and in the physicians offices until these things heal.
Of course, as patients and families consider this, they should ask is the team at the top tier of experience with this sort of transplant. As surgeons like to say, people can feel that they are in good hands, that you're going to do the very best that's available anywhere.
What about on the donor side? What are things for someone who's considering being a living donor? What do they need to consider so they go in with their eyes open? What evaluation happens to make sure that they're right for this procedure?
Well, the first thing we do with the living donor is to 1) send them what we call a health history questionnaire. It's a questionnaire that asks them about general health issues. We want to make sure that the patient is healthy. They have to be between the ages of 18 and 55, and they have to have a blood type that's compatible with the recipient. That means that if the recipient is type O, they have to be type O. If the recipient is type A, they could be type O or type A. So there are some rules in regard to blood type to make sure that they're compatible.
If they're compatible and it doesn't look like they have medical problems, we have a number of things that happen. One is that they seek what we call an Independent Donor Advocate. In our institution, this is a social worker whose real responsibility is to make sure that the donor gets through the process with a good understanding of the issues regarding liver donation in general and issues regarding his or her specific case. They see an internist who looks at them for their general health. They see two surgeons — myself and Dr. Asher who does the donor surgery — to discuss their particular case. We do a lot of blood tests, and we do a number of X-rays.
One set of X-rays is to look at the blood vessels to the liver to make sure we can safely cut out the right or left lobe of the liver, and then another set looks at the bile duct so we can make sure that the bile duct has the right anatomy to be able to donate a piece of liver. Not everybody has an anatomy that allows them to donate a piece of liver. That doesn't mean that their liver will ever cause them trouble. It just means that there is no way we can cut that piece of liver and safely give it to somebody else.
There is a risk of death associated with donating a piece of liver. It's about one in 500. The risk of death of donating a kidney is about one in 3,000, so this is a riskier operation than donating a kidney. The stakes are usually higher for the recipient of the transplant because unlike kidney failure, where you have a dialysis machine, in liver failure we don't have that kind of machine that allows a patient to survive until they can get a cadaver organ.
There also is a risk of complications associated with any surgery, and there are complications associated with this surgery.
There's going to be pain related to having an incision, and people need to think that they're going to have to take some time out of their life until they get back to feeling normal. We have surveyed our donors and have asked them how long did it take you to feel 100 percent again? When the donors responded, about half of them said that within six weeks they felt back to 100 percent. Three quarters of the people felt they were back 100 percent by three months, and the last quarter took six months before they felt that they'd recovered back to 100 percent.
When people talk about being 100 percent, that's a psychological feeling of feeling well, I'm doing everything I want to do. People are going to be changed because they now have a scar across their abdomen that they didn't have before. Those are the kinds of things that donors need to understand as they go forward with this surgery.
Dr. Roberts, I know your team has immense experience comparatively in doing this, and since January of 2000, you've done over a hundred of these living donor liver transplants. You must feel that the donors really have given an incredible gift and have been very courageous as they've done this.
Yes, I think we are always in awe of what the donors have done in terms of providing of themselves to the recipients. It really is a heroic act because people take on themselves not only a risk of death but also pain and suffering for their loved one to get the benefit of the liver transplant.
You know, the donors have always impressed us in terms of their selflessness in doing that. We try to make sure that we protect the donor from injury and risk that's outside of the other risks that we know of for this operation. That's why we have an Independent Donor Advocate that really helps to make sure that the donor understands the issues involved with donation and that there are not issues related to their personal life at work or finances that would suffer after they've donated. We really think the donors have done a lot, and we try to help the donors in whatever way we can to make this a positive experience.
Well, Dr. Roberts, I want to congratulate you on the program you have at UCSF Medical Center. I know it's certainly exemplary, and I know you'd agree with me that we all wish there were more donor organs available from people who die who choose to make arrangements so that organs can be donated. Since there is that gap, it's really wonderful what you and the donors are able to do to fill it to give people continued life. Dr. John Roberts, chief of the Transplant Service at UCSF Medical Center, thank you so much for being with us. I really appreciate your time and your devotion to patients.
Well, thank you for having me on, and I have to say that here at UCSF, taking care of both the donor and the recipient is really a team effort. I'm only a part of that, and it's the nurses and the doctors and other health care workers that really allow us to do well with taking care of these patients.
Thank you sir. For information about the physicians and services at UCSF, please call the physician referral service at 1 (888) 689-UCSF or 1 (888) 689-8273.
Recorded May 2008
Photo by Tom Seawell
Reviewed by health care specialists at UCSF Medical Center.
This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.
Liver Transplant Program
400 Parnassus Ave., Sixth Floor
San Francisco, CA 94143
Phone: (415) 353-1888
Fax: (415) 353-8917