Doug Thorburn, a transplant hepatologist and clinical director for liver transplantation at the Royal Free Hospital, and liver transplant coordinator Moira Perrin have helped provide answers to some questions patients may have about liver transplantation.
When a donor liver becomes available what factors decide which patient should receive it?
The donor blood group, size of the donor and their history (as this can indicate the quality of the organ) are matched against the recipients’ blood group, size and history. This matching is done by the medical and surgical doctors along with the liver transplant coordinators when details of the donor offer are received.
What happens when a patient is called in because there is a possible liver available for them?
We would telephone the patient to ask them if they are well and if they can come into hospital to be available for the potential donation. All patients are warned that we have not seen the liver at this point and so the procedure could be cancelled once we get more information. Usually they can make their own way in and there is no need to rush. When they arrive on the ward the doctors will review them and carry out tests, which include blood tests and chest x-ray, to check they are fit enough and have no infections.
There is then a period of waiting to establish whether the donor organ is suitable for the patient. If, unfortunately, the liver is not suitable and the operation cannot go ahead, the patient will be informed of this at the earliest possible opportunity.
Where might the liver have come from?
The liver can come from anywhere in the UK, Ireland and, very occasionally, mainland Europe.
Is only one patient called in at a time, or are a few called in on standby?
We call one patient in at a time. Occasionally we call a back-up patient in, if the primary recipient has problems that would make transplantation impossible but which can only be established on the day of transplant or after the operation has started.
Why might the liver be deemed unsuitable for a patient who has been called in to receive it?
When we are offered a liver and select a recipient we do that based on the information we are given by the donor coordinator. Once the retrieval operation on the donor starts the retrieval surgeons assess the quality of the liver. They will be looking at how fatty the liver is, is it smooth, does it have scarring, are there abnormal lumps in the liver and whether we have to biopsy them. The biopsy can help establish if the liver can be safely used. All of these may be factors which would make the donor organ unsuitable for transplantation. They will also inspect the other abdominal organs to ensure there are no other unforeseen conditions in the donor which would make donation unsuitable.
Do we offer patients counselling if it is only established that the liver cannot be used after the patient has been called in?
We want to give our patients the best chance of having a successful liver transplant and if the liver is deemed unsuitable we would not take the risk. Patients are told this as part of the education they receive when they are placed on the transplant list and it is reiterated when they are called in for a possible transplant. We have a clinical psychologist who works closely with the liver transplant team and patients are given the opportunity to meet with them at any point during the transplant process. Understandably, some patients struggle if they are called in and the transplant is cancelled and we offer them the chance to speak to our psychologist in those circumstances.
Have medical techniques improved to the extent that some livers previously thought to be not good enough for transplantation can now be used? And some patients previously thought too ill for a transplant are now being considered for one?
With the shortage of donor organs experienced in the UK we have gradually learned the limits of which donor organs are useable and have expanded the donor pool. The liver is quite a robust organ to transplant but the best outcomes are achieved by matching the donor organ to the right recipient. With advances in our understanding of who benefits from liver transplantation, improvements in surgical technique and in how donor organs are stored while they are being transported to the hospital where the transplant will be performed, coupled with improvements in the care given to patients after transplantation we are able to safely transplant patients who in the past would not have been suitable to receive a liver transplant.
How many people in the UK are currently waiting for a liver transplant?
There are more than 500 patients, including some children, currently waiting for a liver transplant in the UK.
Transplants are only possible thanks to the bravery and generosity of a family who has agreed to their loved one saving lives through organ donation. There currently aren’t enough organs for those who need them, so we would really like to encourage everyone to join the NHS organ donor register and to talk about that decision with their families. If you would like to join the NHS organ donor register you can do so here: www.organdonation.nhs.uk
Can you tell me more about the Royal Free’s liver services?
Because of the shortage of donated livers we offer live donor liver transplantation which is an excellent option for many of the patients on the transplant waiting list. This relies on someone (often a relative or friend) donating part of their liver to a patient who is on the liver transplant waiting list. With suitable patients, this type of donation provides the same excellent outcomes for the patient receiving the liver as a transplant with a deceased donor organ. Following transplantation, the two parts of the liver will quickly regenerate and in most cases, they will regrow to their normal size within two or three months.
The Sheila Sherlock Liver Centre and UCL Institute of Digestive Health at the Royal Free Hospital are constantly striving to improve the treatments we offer and to meet the needs of our patients. In parallel to the transplant services we have a very active research programme for liver transplantation and all other aspects of liver disease which are helping to improve our understanding of liver disease and will mean better outcomes for patients.
A sabbatical with a difference