Expanding The Donor Pool To The Living

Published Monday December 21, 2020

Hayes Atkins, 14, was born with less than functioning kidneys that declined as time went by. He was facing dialysis this fall when a compatible donor stepped forward – his mom, Sara.

Hayes and Sara exemplify one of the seismic shifts in transplantation history – living organ donation. They also hold a significant place in the history of transplantation at UT Health San Antonio, University Health and their collaborative transplant institute, the University Transplant Center.

In November, Hayes became the 5,000th transplant recipient in the program’s 50-year history.

Transplantation science made tremendous technical strides in the 1970s, ’80s and ’90s, but with success came a problem.

“The major frustration of the past 20 years has been that the demand for organs far outweighs the supply of donors,” said Francisco G. Cigarroa, MD, director of the University Transplant Center.

“As Jennifer Milton (the transplant’s center chief administrative officer) always says, 15% to 20% of patients die on the waiting list, which is a number that is far too high, because we know how to save these patients’ lives,” he said.

To encourage donation, transplant programs have mounted education programs about the importance of deceased donations, but at the same time, better education about living donation.

In 1995, Dr. Lloyd Ratner of Johns Hopkins Hospital performed the first laparoscopic donor nephrectomy – image-guided surgical removal of a kidney without making a large incision.

“Believe it or not, I scrubbed in on that first case at Johns Hopkins,” said Dr. Cigarroa, who was a transplant surgery fellow at the time. “And it was a landmark case in which Dr. Ratner was able to convey to the world that this could be done safely by laparoscopy, which meant living donors could recover quite promptly with less pain. I believe that has been a major factor in increasing the number of living donor kidneys for patients.”

Today in some centers, 30% to 40% of all kidney transplants are from living donors.

“Liver transplantation took notice of the new trend, and the last 20 years have been focused on how we can safely do living donor transplants of livers to save recipients,” Dr. Cigarroa said.

The liver, unlike other organs, has the amazing capacity to regenerate itself.  Dr. Henri Bismuth of the Paul Brousse Hospital in Villejuif, France, championed this anatomic understanding and its application in liver transplants.

“The first split-liver transplants, where you were able to divide the liver from a deceased donor and transplant the smaller segment into a child and the larger segment into an adult, came about because of Dr. Bismuth’s work,” Dr. Cigarroa said.

Interest in expanding the donor pool to living persons, coupled with the liver’s ability to regrow, has led to removing the smaller segment of a living donor’s liver to give to a child who needs it, or a larger segment for an adult recipient.

“It’s extremely technically challenging, and for a few years it didn’t really take off,” Dr. Cigarroa said. “But in the last 10 years things have changed, and that has been supplemented by technology.”

In that time, surgeons have mastered intraoperative ultrasound that allows superior views of the liver anatomy in the operating room.  Pre-operatively, surgical teams are using ultra-high-quality CAT scans and magnetic resonance imaging, as well as three-dimensional software. “Today, by the time we take a living liver donor into the operating room, we have a precise road map for treating each patient,” Dr. Cigarroa said.

Small incisions, reduced pain, shorter recovery and incredible precision are the hallmarks of today’s living donor surgeries. The other key factor is altruism, without which no person would give a kidney or part of a liver to another. In 2019, more than 7,300 transplants were made possible by living donors, according to the United Network for Organ Sharing (UNOS). It set an all-time record.

Other efforts to increase the donor pool are ongoing.

Next: Organ Preservation: Turning a Marginal Graft into an Optimal Graft