Transplant teams at the Penn Transplant Institute are performing living donor liver transplantation to both improve outcomes and address the widening chasm between available organs and individuals on the waiting list for a deceased donor liver.
Closely involved with the Living Donor Liver Transplantation (LDLT) Program at the Penn Transplant Institute, Therese Bittermann, MD, MSCE, is a gastroenterologist with a board certification in transplant hepatology. She is the Medical Director of the Living Donor Program and, in this capacity, not only has an administrative role in the program but also meets with the majority of the potential liver donors evaluated at Penn Medicine. Additionally, Dr. Bittermann is involved in clinical research, has published widely on LDLT, and was recently elected to the executive committee of the Living Donor Community of Practice of the American Society of Transplantation. She speaks often on the many benefits of living donation.
"Living donor liver transplantation is a life-saving measure for people with end-stage liver disease," Dr. Bittermann explained in a recent interview. "We also believe that it's a better alternative for most transplant candidates."
Benefits of Living Donor Liver Transplantation
Figure 2: Post-LDLT survival at the Penn Transplant Institute at 1, 3, and 5 years vs. UNOS region 2, northeast centers and other national transplant centers.
LDLT is possible because the segmented anatomy of the liver and the capacity of the organ to regenerate following tissue loss means the liver can be split, Dr Bittermann says (Figure 1). This allows healthy individuals to donate a portion of the organ to another person. Typically, adult-to-adult LDLT involves removing 40 percent to 60 percent of the liver from a healthy donor. Within months of surgery, the donor and recipient livers grow in size to meet the body's needs.
Performed at the PTI since the 1990s, LDLT is now an important pathway to transplant and a preferred option for patients at Penn Medicine. Although the practice comprises only about 6 percent of the liver transplants performed in the US, LDLT accounts for 10 percent of liver transplant surgeries at the PTI.
"LDLT has recently started growing both here and nationally," says Dr. Bittermann, adding that much of this success can be attributed to increased awareness of the benefits of LDLT to patients, their communities and providers alike. LDLT often leads to better outcomes than waiting for a deceased donor liver transplant. At the PTI, for example, LDLT recipients have excellent post-transplant survival rates and among the lowest complication rates in the nation. (Figure 2).
LDLT Outcomes and the MELD Equation
The superior outcomes of LDLT primarily arise from patients' ability to be transplanted sooner and in a greater state of health, than continuing to wait for a deceased donor transplant. This is because undergoing LDLT does not take into consider consideration patients' Model for End Stage Liver Disease (MELD) score, which is what determines their position on the deceased donor waitlist. LDLT is particularly advantageous for those patients who have low to intermediate MELD scores, yet still would very much benefit from liver transplantation.
In fact, the MELD score for most patients having LDLT at the PTI is <15 (Figure 3). Many patients with lower MELD scores may stay on the waiting list for months or years before having a liver transplant. By considering LDLT, patients can undergo liver transplant before the destructive effects of progressive late-stage liver disease can occur, which leads to improved patient and graft survival after transplant. In addition, all living donors receive a comprehensive health evaluation to ensure they can undergo living donation safely. They are frequently younger and with few or no medical problems. This also means that the liver graft the patient receives is healthy too. All donors are followed after surgery to ensure that a full recovery is achieved, and are not responsible for any medical expenses or hospital expenses directly related to the evaluation and donation process.
For more information about the Penn Living Donor Liver Transplant Program, contact Living Donor Liver Transplantation Coordinator Linda Wood, BSN, RN, at 215-615-0564 or linda.wood@uphs.upenn.edu.