Your hepatologist at the transplant center will discuss the sources of livers that are available.
Most transplanted livers are from deceased donors who have met the criteria for brain death. This is called a DBD liver, for donation after brain death. Sometimes the donated liver is divided and two recipients receive a portion. The split liver regenerates to normal size quickly in each recipient, within weeks of surgery.
Extended criteria organs (ECD) are those from older donors or those with certain health conditions, many unrelated to liver disease. During the early years of transplant, only livers from donors up to a certain age with no other health issues were offered. Recent research has shown that ECD organs perform well and can be used. Another term you may hear is for a DCD liver, or donation after cardiac death, in which the donor’s death is caused by irreversible cardiac arrest, which may have happened suddenly. These livers and the outcomes in their transplantation are fairly recent and are currently being evaluated.
At most centers you have the right to discuss the offered ECD or DCD liver with the surgeon and to refuse it if you wish. You need to make a decision that is right for you, weighing your condition, the length of your wait, and the particular characteristics of the donated liver. Refusal of a specific liver should not jeopardize your position on the waiting list. Discuss these issues with your team.
Directed donation occurs when donor families ask that a certain organ be directed to a family member, close relative, or friend that is in need of an organ, and is listed for transplant. Your medical team can assist you in discussing this topic.
Another source of donated livers is from a living donor in whom a portion of a liver is given to you from a living person, usually a relative or a friend. The donor’s remaining liver regenerates quickly and the portion given to you does also.
Living donation (LDLT) is done in a limited number of transplant centers. If you decide to have a living donation you will need to investigate the transplant center further. Experts in the field recommend that a center should have performed a certain number of surgeries of this type (15-20 living donations) to achieve proficiency. The center should maintain its expertise by continuing to do living donor transplants once it achieves that level of competence. Outcomes for the donor and the recipient improve if a transplant center has reached a sufficient volume of surgeries. Ask about the history of the center’s experience with this surgery.
There are donor-recipient matching criteria and the process can become complicated. The donor needs to be evaluated as thoroughly as you have been, by a different medical team at the center. Discuss with your hepatologist whether living donation is an option for you. The advantages are that you know the complete medical history of the donor and often you can choose the time of the surgery, assuming your MELD score is above a certain level, usually at 14 or 15. Donating to someone with a very low MELD may be problematic for the recipient, according to recent research.
The national organization regulating organ allocation, UNOS, does not permit payment or compensation for organs from a living person. It is unethical and illegal—reputable transplant centers will not take part in this type of transplant situation. Our national system relies on voluntary organ donation only. Similarly, transplant centers do not recommend going overseas for this surgery, because transplant experts believe outcomes are frequently poorer.