Donor Evaluation and Preparation

Who can be a living liver donor?

A living donor is a close family member defined as a ‘near relative’ in the THO Act. This is defined as spouse, parents, siblings, grandparents, and children of the recipient. Any of these can be a donor as long as they are healthy and pass all their tests and fulfil the requirements of the law.

  • Compatible blood group with the recipient ( refer table below)
  • A family member (wife, husband, mother, father, brother, sister, son, daughter, grandfather, grandmother, grandson, granddaughter) or close relative of the patient
  • Family friends, well-wishers, staff or neighbours are not accepted as donors
  • Age group 18-55 years
  • Not overweight, because people who are overweight may have fatty liver
  • The donor’s liver should be large enough to provide adequate volume for the recipient (patient) as well as for the donor
  • Donor should be in good overall physical and mental health, undergo a thorough medical and psychological evaluation, fully understand the risks of surgery and only then volunteer for donation.

Compatibility of Blood Groups

Donor Blood Group Recipient Blood Group
O O, A, B or AB
A A or AB
B B or AB
AB AB

 

How is donor evaluation performed?

Donor evaluation is performed in four phases, with more expensive and invasive tests reserved for later phases. The tests take about 7 to 10 days, and are performed on an outpatient basis, usually along with the recipient evaluation.

 

Phase 1        Phase II        Phase III         Phase IV
Liver function tests        Liver Volumes        Tests to evaluate other organ systems         Evaluation by specialists
Liver fat estimation        Anatomy of liver blood vessels

 

These tests may result in a potential donor being rejected. This may prove stressful for the family, but it prevents an unsafe or unsuccessful transplant from occurring. An alternative donor should then be identified. Note that both the patient’s and donor’s emotional health and willingness for transplant are important for successful transplantation. If any weaknesses in these aspects are identified, they should be counselled during evaluation.

What is authorization committee clearance?

Authorization committee clearance refers to the consent obtained from a government appointed committee for a living donor transplant to take place. A transplant can only be scheduled once this clearance is obtained. Donors and recipients must submit proofs of identity, residence and donor-recipient relationship to the committee.

Falsification of documents or other efforts to mislead the authorization committee constitutes violation of law, and carries a heavy penalty. Moreover, the transplant team is independent of the authorization committee, and cannot influence its decision.

Additionally, donors who are not near relatives or foreign nationals must obtain a no-objection certificate (NOC) from the state of domicile or embassy. The committee usually avoids giving clearance to non-near relatives, as it is impossible to determine whether there has been a monetary exchange or not.

What blood products must be donated before the transplant?

Once the medical decision to conduct a transplant is made, the patient’s family is advised to donate about 18 units of blood (any group, unless the patient has a rare blood group) well before the date of surgery, 3 members must also donate their platelets (same blood group as patient). Platelets have a short shelf-life and therefore should be donated only one day prior to the surgery.  In case the surgery is anticipated to be difficult, additional blood donations may be required before or after surgery if when notified by the transplant team.

What if a patient does not have a suitable living donor?

Patients who do not have a suitable living donor or are unlikely to get a deceased donor transplant in time, might benefit from one of these innovative procedures:

Swap transplant: When one of patient’s family members is suitable and willing for donation, but is not a good match for the patient, a paired donation or swap transplant may be considered. In this type of transplant, two families with suitable living donors exchange their donors because they are not a good match for their own patient, but are appropriate for each other’s patients. For example, if donors and patients of one family have blood groups A and B and that of the second family have B and A, respectively, these donors are not suitable for their own recipient. If donors are exchanged, however, both patients can undergo transplantation. Both transplants are performed simultaneously and therefore can only be done by a large experienced transplant team after careful planning.

Dual lobe liver transplant: When a potential living donor’s liver volume is found inadequate for the recipient on a pre-operative CT scan, he/she may be rejected and another donor evaluated. It is common that in one family, two or more people, who were otherwise suitable, might have been rejected for donation because of low liver volumes. If partial livers from both are combined, it is often adequate for the patient. In such a transplant, three operations (one recipient and two donors) are performed simultaneously. Dual Lobe transplants are technically complex and offered by few centres only.

ABO incompatible (ABOi) transplant: Generally, liver transplant is performed with blood group compatible donor livers, because ABO (blood group) incompatible transplantation triggers production of antibodies against the transplanted liver causing organ rejection. Some special immunosuppressive medicines and measures can lower antibody level before transplant and hence prevent organ rejection. In small children, the antibody levels are very low and ABOi transplant can be performed with less preparation and better success. It is usually offered only at experienced centres, though.

Deceased donor transplant: Once recipient evaluation is completed, and the patient is found medically fit for transplant, the prescribed forms have to be completed and submitted through the hospital to the state-wide appropriate authority to register the patient’s name on the waiting list for a deceased donor transplant. Patients may register at more than one hospital, even in different states. After listing, patients should undergo periodic testing and review with the transplant team, and inform them of any significant changes in the patient’s medical condition. When a potential deceased donor liver is available, patients are alerted immediately and called to the hospital.

This process however is streamlined only in a few states such as Tamil Nadu, Karnataka, and Maharashtra, and even there the wait could be long.

Related Links

Approaching the Transplant
Post-transplant Care

References:
www.medanta.org
http://www.bhf.org.uk/
www.unos.org