VCU news

By Lorraine Cichowski and Mitchell Shiffman

RICHMOND, Va. – A nationwide survey of hospitals that perform liver transplants in adults using liver tissue from live donors reveals a wide variation in the number of surgeries performed and the kinds of donor evaluation and follow-up procedures used at individual centers, as well as high rates of surgical complications for donors.

The results of the broad-based survey – the largest of its kind to date to study the increasingly common use of living donor liver transplants in adults – will be reported in the Feb. 27 issue of the New England Journal of Medicine.  The article appears as a seven-year national project organized by the National Institutes of Health gets underway at nine U.S. transplant centers, including Virginia Commonwealth University, to examine the potential benefits and safety issues of living donor liver transplants.

"Liver transplantation is an important life-saving measure for terminally ill people with liver disease, and donations of liver tissue from live donors have helped many people over the past five years who otherwise would have been denied needed transplants because of the long waiting list for donated organs," says Mitchell L. Shiffman, M.D., professor of medicine, chief of the Hepatology Section, medical director of the Liver Transplant Program at the VCU Health System and co-author of the NEJM article.

"However, as this study and studies before it have shown, there is inconsistency among procedures used at transplant centers, starting with how the centers interview potential donors to how they follow up with those donors after surgery. It's important that we collect more data about liver donors and recipients so that we can develop standardized guidelines and make available to potential donors accurate information on the benefits and short- and long-term risks of surgery. This information will enable us to make living donor liver transplantation a better and more effective procedure for the donor and recipient."

In March 1998, the Hume-Lee Transplant Center at the VCU Health System became one of the pioneering transplant centers in the United States to perform an adult-to-adult living donor liver transplant. Since then, VCU, one of the busiest U.S. centers for living donor liver transplants in adults, has performed more than 75 of the surgeries, transferring a portion of a liver removed from a live adult donor to another adult patient. According to Robert A. Fisher, M.D., surgical director of the Liver Transplant Program, VCU's program has been among the most successful in the country, with excellent results among recipients, no deaths reported among donors and no donors requiring their own listing for transplant. 

Liver transplantation from living donors in children has been common for more than a decade, a response to the shortage of donated organs of the appropriate size from cadavers. The adult-to-adult living donor liver transplant procedure was developed when the shortage of donated livers for adults also began to increase, along with the waiting period for liver transplantation. Currently more than 17,000 Americans with liver disease are waiting to receive a liver transplant. Only 4,500 donated livers were available for transplant last year from the deceased. 

The NEJM article was based on a 24-item survey of 42 U.S. transplant centers for adult-to-adult liver transplantations performed between 1997 and October 2000 and updated data for 2001 and 2002 from national registries and other reports.

The survey found a marked increase in the number of transplantations from living donors performed in adults between 1997 and 2000 � a number that increased in 2001. Although 14 of the centers performed 80 percent of the surgeries, the study found a wide variation in the numbers of transplantations performed at individual centers and different procedures used for evaluating potential donors, following up with donors after surgery and assessing complications associated with liver donations. The survey found a 0.2 percent death rate among donors after surgery and a 14 percent rate of complications, which included bile leak and the need for blood transfusion and another operation.

Partial results from the survey were reported early last year following a workshop sponsored by the NIH and chaired by Dr. Shiffman to review the scientific, medical and ethical issues involved with living donor liver transplantation. That workshop and follow up recommendations led the NIH to announce in October the launch of the Adult-to-Adult Living Donor Liver Transplant Cohort Study.  Researchers at nine transplant centers across the United States, including those at VCU, will compare outcomes of the new procedure with outcomes for patients who receive livers from cadavers.

"Living donor liver transplantation already has gained widespread popularity among patients in need of liver transplants and donors willing to undergo this procedure," Shiffman said. "It will account for an increasing proportion of patients undergoing liver transplantation in the future. However, many questions remain unanswered regarding the overall safety and long-term complications associated with this procedure for both donor and recipient.  These studies will help us answer those questions. Meanwhile, living donor living transplantation should be performed only in accordance with the highest of ethical principles and with the safety of the donor being the No. 1 concern."