The greatest gift: living organ donations

By Stacey Burling
Knight Ridder Newspapers

APRIL SAUL / PHILADELPHIA INQUIRER Jackie Shirley, left, donated one of her kidneys to her older sister Lynn Rogers last year, after doctors told Lynn she needed a transplant.

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PHILADELPHIA — When Lynn Rogers needed a kidney transplant, she called her family together. She would have the best chance of survival with a living-donor transplant, she told them. Would anybody help?

Her daughter and all seven brothers and sisters volunteered. Her younger sister Jackie Shirley, the one who looks just like her, was a perfect match. There was little question she'd do it. She'd lost her mother and a stepson in the past year, and she wasn't going to lose her sister, too. Last August, Jackie gave Lynn one of her kidneys just four months after Lynn went on dialysis.

Increasingly, that's what transplantation looks like in the U.S.

Living donation is up by more than 150 percent in the past decade. Live donors now outnumber dead ones: 6,210 to 5,923 in the first 11 months of last year.

On the Web • LifeCenter Northwest has information about how to become an organ donor, including registering online: www.lcnw.org • Life on the waiting list: a series of stories by Seattleite Jack Slater, who is waiting for a liver transplant: www.seattletimes.com/jackslater

Most of that increase results from a boom in living-kidney donation, which became more appealing with the advent of a less-invasive surgical technique for removing donor kidneys. It is now considered the best treatment for kidney failure.

Partial-liver donations drop

In the past two years, though, living liver transplants, which were embraced enthusiastically by some surgeons in the late '90s, have fallen off dramatically after the well-publicized death of a donor in New York in 2002 and changes in the allocation system for deceased-donor livers. Doctors say that procedure, far riskier for donors than kidney donation, likely will begin growing again because of the demand for transplants.

The rise in living donation is intensifying ethical questions, including how to protect the interests of potential donors — siblings, spouses, friends, co-workers and church members — as pressure to give organs mounts.

"It changes the whole ethical equation," said Arthur Caplan, director of the University of Pennsylvania's Center for Bioethics. "The moral ante is up the more it becomes the treatment of first choice. It becomes harder to say no."

Caplan says follow-up data should be kept on every living donor (currently that's not required) and many surgeons agree. He also favors independent advocates for donors, standardized medical criteria for donations, standardized consent forms and national oversight of living donation.

Sheldon Zink, another Penn bioethicist who studies transplant issues, thinks surgeons should be conservative about living donation. She worries that complications will increase if thousands more people give up one of their kidneys. And, she thinks hospitals need to do a better job of preparing patients for the surgery's impact.

Some donors become depressed, especially if the transplant doesn't go well, she said. Liver donors have told her the recovery was more painful than expected and kidney donors were surprised by how a transplant changes relationships.

Two organs, two techniques

Surgeons complain that patients often think living-donor kidney and liver transplants are similar, but the procedures carry radically different risks and rewards.

Most of us can live healthily with only one kidney. With surgical techniques using small incisions, it's relatively easy to remove a donor kidney, and most patients recover quickly.

Mark Deierhoi, a University of Alabama transplant surgeon, estimates the risk of donor death at one in 5,000 and serious complications at 2 percent to 4 percent.

Studies show donors aren't at higher risk of developing kidney problems later. And recipients of kidneys from live donors do better than those who get deceased-donor kidneys. The median life for transplanted kidneys is 36 years for a living-donor kidney and 19.5 years for a deceased-donor kidney.

For those reasons, surgeons recommend living-donor transplant as the best treatment for people in kidney failure, ideally before they've started dialysis. "That's the ideal approach that we should do on everybody," said Mikel Prieto, a kidney-transplant surgeon at the Mayo Clinic, where 205 of the 250 kidney transplants last year resulted from living donation. "That's what I would do if I had kidney failure."

Donor's liver will regenerate

Livers are a different story. We all have only one liver, but it has the remarkable ability to regenerate when part of it is removed. For many years, surgeons have given relatively small parts of adult livers to children, at low risk to donors and with good results in recipients. In recent years, though, doctors have tried a riskier operation that involves removing 60 percent of the donor's liver.

Nationally, the number of living liver donors leapt from 92 in 1998 to 506 in 2001, but it's been falling since: In the first 11 months of 2003, there were 284.

That's a typical pattern for new surgical procedures, surgeons said. At first, everyone wants to try. Then something bad happens and the pendulum swings the other way.

Abraham Shaked, a transplant surgeon who heads Hospital of the University of Pennsylvania's transplant program and is president of the American Society of Transplant Surgeons, tells potential liver donors their risk of death is 0.5 percent to 1 percent. That's high for healthy people undergoing surgery. Up to 20 percent can have complications, most minor, afterward.

Burckhardt Ringe, a liver-transplant surgeon at Hahnemann University Hospital in Philadelphia, thinks living donation will play a bigger role. He thinks results are good and likes that the procedure makes it possible to transplant patients before they're deathly ill. Four of the 13 liver transplants at Hahnemann in 2003 were living-donor transplants.

He thinks as many as half of liver transplants could involve living donors within a few years. "I think live donation will play a significant role in the future," he said.

Copyright © 2004 The Seattle Times Company

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