Mohamed Akoad, MD, FACS Chair, Department of Transplantation Alicia Parrott, RN Living Donor Nurse Coordinator

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1 Mohamed Akoad, MD, FACS Chair, Department of Transplantation Alicia Parrott, RN Living Donor Nurse Coordinator

2 Living Donor Liver Transplantation is a surgical innovation that has been developed to address the severe shortage of deceased donor livers available for transplant In New England, the disparity between the availability of deceased donor livers and candidates awaiting liver transplantation has increased as the need for donor livers has outpaced supply Waiting list mortality can exceed 20%

3 Program initiated in December, 1998 Performed the First Adult to Adult Live Donor Liver Transplant in New England One of the largest Live Donor Adult Liver Transplant Programs in the country Live Donor Liver Transplantation accounts for 20-25% of the Lahey Clinic liver transplant volume More than 275 LDALTs performed to date

4 Because it is an elective procedure, the surgery can be scheduled for a time when the recipient is sick enough to justify transplantation, yet in the best possible clinical condition The transplant team can strive to select the perfect donor By avoiding the use of a deceased donor liver, LDALT allows another patient on the United Network for Organ Sharing (UNOS) waiting list to benefit from a deceased donor liver Priceless : living donors truly give the gift of life

5 Healthy adults between the ages of Family members and those emotionally related Clinical requirements: compatible blood type, normal liver and kidney function, adequate liver volume, and abstention from alcohol Donor candidate is willing and prepared to handle the physical, emotional, and financial challenges of live liver donation

6 The potential LDALT recipient first must be accepted as a suitable transplant candidate As a transplant candidate, he/she undergoes a thorough medical and psychosocial screening The transplant candidate undergoes ongoing assessment to ensure that he/she remains an appropriate candidate for LDALT If the transplant candidate s condition deteriorates, a partial liver graft (i.e. lobe of liver from a live donor) may be an insufficient liver volume to sustain the life of the recipient during the period of liver regeneration

7 Largest organ in the body Located in the right upper quadrant of the abdomen under the rib cage Divided into right (~60%) and left (~40%) lobes Gallbladder is located beneath the liver; stores bile Liver has dual blood supply: portal vein (~80%) and hepatic artery (~20%) Common bile duct branches into right and left hepatic ducts, then multiple smaller ducts

8 3D imaging studies All liver cells can do all liver functions Segmental anatomy of the liver Liver cells regenerate

9 The unique segmental anatomy of the liver and its ability to regenerate allow it to be separated into independent anatomic units that are able to retain normal function

10 Submission of preliminary blood work Appointment with donor nurse coordinator, surgeon and Independent Living Donor Advocate to discuss in detail the evaluation process, surgery, risk of complications, and recovery Complete lab panel CT scan to determine liver volume, blood vessel anatomy, and bile duct anatomy Consultations with medical physician, psychiatry, social work, pharmacist, dietician, & financial coordinator Chest x ray, electrocardiogram Possible liver biopsy Additional appointments dependent on age and health history IF acceptable donor -> Pre-op appointments including: Surgical & anesthesia consent Pre-op testing and teaching

11 Body mass index (BMI) > 28: this is a measure of body fat based on your height and weight Presence of fat in the liver on CT scan or ultrasound Any abnormal liver function test or autoimmune marker First degree relative of a transplant candidate with an autoimmune cause of their liver disease (Primary Sclerosing Cholangitis, Primary Biliary Cirrhosis, or Autoimmune Hepatitis), cryptogenic, or fatty liver disease Remote history of substance abuse

12 Surgical removal of the donor s right lobe of liver (approximately 50-60% of the total liver volume) Gallbladder also removed Remaining left lobe of liver will regenerate rapidly in the first few months after surgery

13 Incisional pain managed with PCA Nausea Catheters and drains central line, bladder catheter, and wound drain Daily lab work Physical recovery ambulation, coughing/deep breathing, diet as tolerated Hospital stay 5-7 days

14 Discharge medications pain medicine, antacid medicine, stool softener, anti-inflammatory medicine Diet high protein Liver function tests normalize in about 4 weeks Fatigue factor Return to work 6-12 weeks after donation, dependent on type of employment Feeling completely normal 3 months after donation

15 1 week after hospital Office appointment, labs discharge 1 month after donation Office appointment, labs, 3 months after donation liver ultrasound 6 months after donation Office appointment, labs 1 year after donation regeneration 2 years after donation Office appointment, labs, CT Scan with liver volume and Office appointment, labs, Living liver donors are requested to avoid alcohol, birth control pills, and pregnancy for 1 year after donation

16 The overall risk of developing a complication is 35-40% Wound infection Urinary tract infection Temporary nerve injury Pneumonia Skin breakdown

17 The risk of developing a serious complication that would require an additional procedure is 10-15% Re-operation (bleeding, injury to remaining left lobe or left bile duct) Bile leak or other abdominal collection Blood clot: deep vein thrombosis (DVT), pulmonary embolus (PE) Incisional hernia Death (0.5%risk)

18 Even with the benefit of LDALT, recipient complications can develop: Small for size syndrome Primary graft non-function Bile duct leak/stricture Clotting of the hepatic artery or portal vein Infection Rejection Recurrent disease

19

20 The role of the Independent Living Donor Advocate (ILDA) during the evaluation process is to: Advocate for the rights of the potential living donor Represent and advise the potential living donor Protect and promote the best interests of the potential living donor Assist the potential living donor to obtain and understand information about the donation process Respect the potential living donor s decision and ensure that it is informed and free from pressure or coercion Maintain confidentiality of the potential living donor s evaluation Provide opportunities for the potential living donor to opt out of the donor evaluation process at any time, without consequence The ILDAs are Jonathan Metcalf, MSW, LICSW; Linda Pinnone, MSW, LICSW; & Kim Holroyd, MSW, LICSW

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