One Liver Went to Two Patients 

By Laura Freeman

In an average year, 9,000 American names go on the liver transplant registry list. For 1,500 to 2,000 of those patients, the call they are waiting for will never come, or not before they die or become too ill to qualify for a transplant.

The sad fact is that there simply aren’t enough organs available from deceased donors. To save more lives, transplant teams are using alternative approaches to expand the supply of viable organs. One of those approaches is a split liver transplant.

“Liver tissue is highly regenerative in nature and both sides of the organ have an independent blood supply. When there’s a liver of sufficient size in pristine condition, we may be able to save two lives when the functional capacity of each segment is adequate to keep a recipient of that body size healthy as they recover,” UAB surgeon Saulat Sheikh, MBBS said.

Split transplants from a deceased donor organ tend to be rare because of the multiple factors involved, the need to have a second team ready nearby to transplant a donor of the right size, and because as organs become available, they are offered first to the person at the top of the transplant list. After meeting that person’s needs, that particular liver may not be adequate to share with a second recipient.

Surgeon and Director of Liver Transplant at Children’s of Alabama, Marcos Pozo Jatem, MD said, “In this particular case, the name at the top of the list was one of our pediatric patients. When we received the call offering a full size adult liver, we realized that we had an opportunity to save a second life, so we contacted the UAB transplant program just down the street to see if they had someone waiting who matched the blood type, size and other criteria.”

Sheikh, who is involved in UAB’s living donor liver transplant program which works from similar principles in organ sharing, said, “We quickly identified a patient who could benefit from the split transplant. That launched a massive coordinating effort between teams at Children’s of Alabama, UAB, and the hospital that would be preparing and sending donor organs across the country. Multiple shifts of a number of departments were involved, as well as transportation and support services, and we also called in a machine perfusion team to bring the organ from the donor hospital to Birmingham. Machine perfusion keeps the tissue in better condition even if it has to travel farther. It also gives us detailed data on how well the organ is performing before we transplant it.”

Pozo said, “While the liver was in transit, we were busy at Children’s synchronizing two surgical teams to work in carefully timed sequence. The first team started removing our patient’s diseased liver as soon as the donor organ was on site and we verified it was viable. The other team began splitting the liver, carefully making sure that both segments are in good condition and blood vessels are ready to connect. Meanwhile, a transport team was standing by to rush the second portion of the liver to UAB where their removal and transplant teams are ready to begin.”

This carefully coordinated surgical ballet with a cast of so many was successfully performed a few weeks ago. It has been ten years since the last split liver transplant was performed locally, and it’s uncertain when all the right factors will come together again. When it does, Birmingham is fortunate to have enough depth of transplant capabilities to make it possible.

In the foreseeable future, the shortage of transplantable livers is expected to be addressed through an expansion of the living donor option. “With the liver, tissue matching isn’t quite as complex as it is with some organs. Usually, a compatible blood type is what we’re looking for, if the organ size and quality are adequate,” Sheikh said. “This opens the door for more relatives and other living donors to be evaluated to share a portion of their liver.”

Another advance that is saving lives is an expansion of criteria for acceptable donor livers. Moving to the top of the transplant list is a good news/bad news situation. The good news is that you are first in line if a liver becomes available. The bad news is that the time before you become too ill to qualify for a transplant can be very short.

“The general rule of thumb is that any functioning transplant gives you a better chance for survival than no transplant. Most patients don’t have the time to wait for a perfect ‘Cadillac’ donor liver. Now we are beginning to accept livers from older donors, especially for older patients and those who are running out of options,” Pozo said.

Sheikh said, “We’re also able to accept some livers that we couldn’t in the past. For example, if a donor has hepatitis C, we can transplant the liver and give the recipient medication to eliminate the infection. The hepatitis is gone, but the liver is functioning, helping to keep the patient alive.”