A Guide For Living Donors

1 A Guide for Living Donors

The fact that you are even considering donating half of your liver to another is a remarkable thing. Whatever your reasons are, you may ensure that someone else lives when otherwise that person will most likely die. But, it is vital that you embark on this process for your own reasons and that you have not been coerced in any way into making a decision that you are uncomfortable with. This is important for reasons of safety as well as peace of mind for you. However, you must also bear in mind that despite your and the transplant teams best efforts, the recipient may still suffer a complication from surgery and may still die. Alternatively, patients who have hepatitis C or liver cancer can have a recurrence of liver damage after successful transplantation and may then succumb to these conditions.

In most countries, it is illegal for the donor to claim or receive a fee or be financially recompensed in any way other than for travel, accommodation and medical expenses.

Who Can Become a Donor?

This varies from country to country as the rules that apply can be very different. But generally, certain criteria are used in deciding the suitability of a prospective donor. These include;

in some countries, only people genetically related to the patient such as a parent, child or sibling can be considered. In addition, close personal relatives such as a spouse or friends may be considered,

in some countries, strangers will also be considered,

an age limit may apply for some centres. Typically, this means donors are between 18 and 55 years of age. In other countries, no such age limits apply,

donors must not be overweight,

donors must not have any major medical problems themselves,

donors must not have any major psychological or psychiatric problems themselves,

donors must be in a position to fully understand the implications of their decisions and be able to participate in the consenting process,

donors must have a compatible blood group to the recipient,

the reasons for your donation must be altruistic and voluntary. Donors must never feel coerced into making any decisions.

preferably, donors should have the backing and support of their own family.

The Assessment

The initial assessment will try to ensure that most of the criteria listed above are fulfilled. For example, a member of the transplant team will ensure that the you do not have any obvious medical or surgical reason for declining the donation. The same is true for psychological and psychiatric conditions. The initial assessment will also aim to provide you and your family with all the information required to either continue with the assessment phase or pull out from the whole process. It will, in addition, ensure that the transplant team is convinced that the decision to donate is being made voluntarily and freely and that you fully understand the implications of your decisions. At each stage of the assessment phase, you will be asked for your consent again. You can decline to consent and therefore stop the process of donation at any time.

The actual process of assessment varies from centre to centre but most involve the following stages;

1. Stage 1

blood tests for blood grouping,
blood tests for infection screening for hepatitis B, C and HIV amongst others,
the completion of a health questionnaire to identify any factors which may prevent transplantation,
Chest X-ray,
ECG,
lung function tests,
a psychiatric evaluation,
after these tests results have been deemed normal and safe for donation purposes, you will meet other members of the team such as the anaesthetist.

2. Stage 2

This stage usually involves an overnight hospital stay in order to establish the size, shape and condition of your liver. This is done by;

ultrasound scan,
CT or MRI scan,
liver biopsy,
echocardiogram.

This will further decide your suitability as a liver donor for your intended recipient.

3. Stage 3

You and your family will meet the surgeons to confirm that all is well. The transplant team must satisfy themselves that you still freely consent to the process and it is medically safe to continue. The risks to you should once again be highlighted and discussed. At this stage in many countries, the information obtained so far is sent to an independent panel or assessor. It is their duty to ensure that all procedures and protocols have been followed and it is safe to continue with the donation. Once approval is given, a date for the operation can be set.

This whole process may take as long as 3 months. It is encouraged throughout the whole assessment process that your family or next of kin accompany you to these clinic appointments so that they are also fully aware of the risks involved.

The Consenting Process

The key issues in consent have already been discussed above, namely, that you are fully informed and aware at each stage of the assessment and that you have not been forced into taking such measures. The process can be halted at any time by;

you, the donor,
the transplant team,
the recipient,
the independent assessor or panel.

Before the Operation

It is useful for you to know the following before the operation;

1. alcohol intake: you should stop drinking alcohol for 2 weeks before the operation date,

2. smoking: you will be strongly encouraged to quit smoking well before the operation. This will greatly reduce the chances of complications, especially chest infections and delayed wound healing,

3. contraception: female donors who take the oral contraceptive pill will be asked to stop taking this from 1 month before the operation. This will decrease your risk of developing a blood clot such as a DVT following surgery. Therefore, alternative contraceptive methods must be used to prevent pregnancies.

Donors are usually admitted to hospital 1-2 days before the date of transplantation. You will then usually be screened for infections again by blood and urine tests and chest X-ray. A repeat ECG may also be taken to ensure that the heart is still functioning normally. You will have regular checks of your temperature, pulse and blood pressure. If at any time, there is a suggestion of infection, the operation will be cancelled and re-scheduled for another day. The recipient undergoes the same process. These checks are of course repeated again each time the operation is re-scheduled.

Once the donor and recipient have been cleared for the operation to proceed, the following will apply to both donor and recipient;

from midnight before the operation, you will be “nil by mouth”, i.e. you will not be allowed to eat or drink anything,

on the morning of surgery, you will be asked to shower and change into a theatre gown,

you will be given surgical support stockings for your legs to help prevent blood clot formation,

you will be asked to remove all jewellery,

dentures and glasses will be removed in theatre,

you will be given medication through a line in your arm or hand to help you relax,

you may have an epidural inserted into the back. This is a tube through which local anaesthetic is given and used for pain control for approximately 2 days after the operation,

general anaesthetic is then given and you will fall asleep for the duration of the operation,

a tube will be inserted through the mouth and into the windpipe. This intubation tube gives the anaesthetist free access to your airways so that a ventilator can be attached,

a small tube called a nasogastric tube is inserted through the nose and into the stomach. This tube is used to drain the stomach of all fluids and reduces the chances of vomiting,

a catheter is inserted into the urinary bladder to drain urine,

a line is placed into your neck or upper chest to give easy access to your circulation. This is used to administer fluids and medication,

after the operation, you will have approximately 2 drainage tubes in your abdomen. These will drain fluids such as blood and bile from inside the abdomen into bags. These drainage tubes remain in place for 4-5 days before being removed.

after the operation, you will be closely monitored for 2-3 days in an intensive care ward.

The Operation

This is discussed in detail on the page entitled “Living Donor Liver Transplantation”.

Possible Complications of the Donor Operation

It is vital for you and preferably your family and next of kin to fully understand and appreciate the very real risks that such major surgery inherently brings. Although serious complications are uncommon, they still occur. It is thought that around 20% of all donors will experience some complication of surgery though thankfully, the majority of these problems are minor. However, the following complications can occur;

1. Risks during the operation itself, including;

heart attack,
stroke,
haemorrhage (bleeding)
death – this is estimated to occur in around 0.5-1% of cases.

2. Risks immediately after the operation, including;

haemorrhage: bleeding may occur as the liver has a rich blood supply.

bile leakage: bile may leak from the cut surfaces of the liver although this usually settles by itself.

infection: these can occur at the wound site. Chest infections or pneumonia can also occur.

thrombosis: clots can develop in the deep veins of the leg (DVT’s). These can fragment and travel through the circulation to the lungs where serious complications can occur. This is called a Pulmonary Embolism and is potentially a fatal condition.

liver failure: it is possible that the remainder of the donors liver fails to function properly. In this instance, the donor may also find themselves in a situation where they need a transplant to survive.

The Recovery Period

As donating half your liver is a major undertaking, your recovery will take some time. Most donors will have some pain as would be expected after any type of major operation. Transplant centres have different methods for helping patients control their pain from the use of epidurals (see above) to Patient Controlled Analgesia (PCA). PCA’s are used by some centres as a means of letting the patient control (within pre-set limits, programmed by the anaesthetist) the amount of pain killers that patient gets. This is done by connecting a pump full of pain killers which is controlled by a hand held unit. Every time the patient presses a button, a fixed dose of pain relief is administered through an intravenous line.

It is imperative that the donor starts to mobilise as quickly as possible after the immediate post-operative phase. Physiotherapy can then begin which will help donors to mobilise further and recover quicker from the operation. Early mobilisation alone with physiotherapy, deep breathing exercises and an effective cough are also vital to help prevent a build up of secretions in the lungs. This helps to reduce the chances of developing chest complications such as pneumonia.

It may take 1-2 days for the bowels to start working again. During this time, donors are given fluids intravenously. Thereafter, bowel function begins to return slowly. At this stage, donors start drinking sips of fluids only. Gradually, as bowel function returns further, donors are allowed to eat a light diet. This process continues for a few days after surgery until a normal diet can be resumed.

The incision required to remove a portion of the liver is similar to that used to transplant the liver into the recipient. Therefore, both recipient and donor have the same large wound, located just below the rib cage in the upper abdomen. This is sometimes called a “Mercedes Incision”. Initially after surgery, the wound will have a dressing applied over the top to protect it. How the incision is closed depends on the surgeon. Some will use stitches whereas others will use staples. The wound which will be obvious at first will fade with time.

A total hospital stay of 6-10 days is expected after the operation for most donors. But clearly, this greatly depends on the speed of your recovery and on any complications that may arise. If at this time you have recovered sufficiently, you will be discharged from the hospital.

Follow-up Arrangements

The transplant team will need to ensure that the appropriate follow-up arrangements are in place after the donor has left the hospital. The exact arrangements for follow up differ from centre to centre but a typical schedule of follow-up looks like this;

1. 1-2 weeks following discharge: you will be appointed to return to the hospital clinic. The surgeon will examine the wound and some blood tests will be taken to ensure that the liver and other organs are functioning properly.

2. 3 months following discharge: further blood tests and a scan of your liver are done. The scan is able to determine whether your remaining liver (the left lobe) has grown back and to what degree.

3. 1 year after donation: a general check up is done to assess how you are and how the donation has affected you.

4. Thereafter, many transplant centres will offer an assessment on an annual basis.

For patients and donors traveling abroad, follow up arrangements may be made either with the transplant centre (this will of course entail further journeys to get to the centre) or local specialist clinics if these are possible.

How long you remain off work depends on the nature of your work. Heavy lifting is not advised for at least 6 weeks following surgery. But clearly, this time period may be longer if you suffer from complications. In generally, you will be advised to refrain from work for around 8-12 weeks. This may of course have financial implications. You are therefore asked to take this into account before deciding on liver donation.

Some Other Questions after Liver Donation

When can the contraceptive pill be restarted?

Women are usually advised to restart the oral contraceptive pill after at least 3 months post-surgery. Adequate alternative contraceptive methods must be used during this time.

When can sexual activity restart?

There are no time limits for this. Donors can resume sexual activity whenever they feel comfortable. However, it may take several months before all sexual activities can be comfortably performed.

When can donors drive again?

Driving laws vary in different countries. It is therefore not possible to determine here how these laws will apply to each donor. To some extent, you should enquire about any restrictions that may apply locally. In the UK for examples, driving licenses and restrictions are overseen by the DVLA. Other countries will have their own equivalents. Insurance companies should also be informed.

But in general, donors will probably feel comfortable enough to drive at 6 weeks after surgery.

Can donors drink alcohol?

Donors can drink alcohol after discharge from hospital. Clearly, common sense must be exercised and all patients as well as donors must drink in moderation. There are nationally agreed guidelines on alcohol intake in the UK but not all countries will have such guidance.