What happens if a patient does not have a suitable living donor?

Sometimes there might be difficulties in getting a suitable living donor. The reasons could be aplenty from not being the right match to the donor or the donor’s kidney not deemed satisfactory enough for transplant. In some cases, there might be complications in obtaining an organ from the deceased donor as well. For instance, the waiting list is too long and the patient might not have enough time to wait for the transplant. In such cases, there are a bunch of alternate and innovative procedures that can help the patient in living fulfilling and long lives.

Alternative in living & liver transplant

Swap transplant : Swap liver transplantation is suggested when the patient’s family members or first relatives aren’t regarded as a good match for the patient. Swap transplantation is a popular alternative available for liver transplantations making it possible to save many people’s life. We are all aware that the patients keep waiting for a liver unaware of each other, and eventually die. In swap transplants, two families with suitable living donors aren’t compatible with their own members but are considered appropriate for each other’s patients.

Most swap transplants are considered in cases where there is a blood group mismatch. For instance, one family might have a blood mismatch with the patient belonging to blood group A while the donor belonging to blood group B. In this case, a transplant is not feasible. However, if there is another family facing a similar predicament, say the patient is of blood group B and the donor is of blood group A, then a swap transplant between the two families can be considered as its best solution for all parties involved. This way, both donors are able to donate their livers just that, they will be swapping their livers for the other family’s member. It’s a win-win situation no matter what way you look at it.

A swap transplant, unlike routine live donor transplants, is a more comprehensive procedure. This is because both transplants need to be performed parallel with each other. In addition, considering the scope of the surgery, a large, experienced, and multi-disciplinary teams of experts are required to ensure the success of this nature of surgery.

Dual lobe liver transplant : Sometimes, a potential living donor’s liver volume is considered to be insufficient for a successful transplant. This is diagnosed through the help of a pre-operative CT scan. In such cases, where the organ is deemed unsuitable in size, a dual lobe transplant is suggested for maintaining donor security. There are times when the livers of two family members might be found inadequate for the recipient as their livers aren’t capable of providing a satisfactory graft function being of an insufficient total graft size.

For instance, a person might be overweight for which he requires a larger liver for it to be a successful transplant. In such cases, both the family members can each give up a part of their liver for the patient which can prove adequate when combined together. These are dual lobe transplants wherein one partial liver/graft from each of two family donors are implanted into one recipient. This alternative thus tends to offer not only a sufficient size for the recipient but also ensures a higher degree of safety for the donor.

Such transplants are usually a complex procedure as it requires three operations (one recipient and two donors) to be performed concurrently. Moreover, they are presently only offered by a few world-class health centers.

ABO-incompatible (ABOi) transplant : Historically, blood incompatibility has always been an absolute hindrance to transplantation. The standard transplant procedure guidelines entail that livers can only be transplanted only between two blood group compatible donors. This is because, when a transplant is initiated against an incompatible ABO (blood group), then there are chances of the organ getting rejected. Because blood contains antibodies, if the blood is incompatible, then the blood releases these antibodies to fight against the new organ thus causing the body to reject the transplant.

Over the years, thanks to advancements in medicine, previous ABO-incompatible liver transplant has now been made possible between some living donors and recipients. Thanks to some special immunosuppressive medicines and measures such as plasmapheresis & intravenous immunoglobulin, the body can protect the new liver from antibodies thus helping prevent organ rejection. Especially in case of small children where the antibody levels are low, the chances of an ABO transplant being termed as success are high. As with all modern techniques, only a few centers across the country has the necessary experience and required expertise needed in order to successfully perform ABO liver transplants.

Deceased donor transplant : When all other viable options have failed, a transplant from a deceased donor is the only option for the patient. Patients in need of such a transplant are put on the waiting list maintained by the respective hospitals and organizations at the state level and national level .This organization is responsible for fairly prioritizing recipients as organs become available for transplant.

To get onto the waiting list, the patient has to register themselves for inclusion through a registered transplant hospital. Based on factors such as the patients’ medical history, current health status, along with other factors, an evaluation will be done which will decide whether the patient meets the criteria and if he/she is eligible for a transplant.  Upon completion of the evaluation process, if the patient is deemed suitable for the transplant, then the patient is required to fill up a set of forms and submit it to the hospital. The hospital then is responsible for submitting the form to the relevant state-wide appropriate authority. Once approved, the patient will be on the waiting list of both organizations.

Patients are allowed to register themselves in as many authorized hospitals as they wish. Moreover, these hospitals can even be spread across the different parts of the country and need not be restricted to a particular domicile. Once the patient has been registered and listed on the waiting list, he/she is required to undertake regular health check-ups so that the transplant team is able to review the condition of the patient on a periodic basis. This allows them to stay aware of any health updates, the status of the progression of the disease if the patient is affected with one and any major changes in the patient's medical condition.

Once the patient is added to the respective waiting list, he/she may receive an organ on the same day or may have to wait for years for a liver to be available. It all depends on the availability as well as other factors such as how well matched the patient is with the donor. In addition, there are two types of waiting lists which vary as per the case and the circumstances of the patient. If the patient’s medical condition is perceived to be severe, then he’s placed on the urgent waiting list – else he’s placed on the regular waiting list.

It’s always better for the patient and his family to be mentally prepared and be financially ready for an urgent liver transplant. In case a potential donor is available, the patient and his family are immediately notified and are requested to visit the hospital on a priority basis. It's important for the patient to give the correct contact details as well as information on any emergency contacts as the transplant team can notify the patient at any time – be it day or night. At the same time, in case there are any changes in the contact information or if the patient is traveling abroad, the same should be conveyed to the transplant team before-hand so that they're always in the loop.

Similarly, in the case of out-station patients who don't reside in the same city, if a donor is made available, they should be able to make quick arrangements to organize an emergency trip. There's also an increased likelihood of more than one patient being called in for the possible transplant. This is because there might be the possibility that the other person proves to be a better fit than the patient for that particular liver transplant. The key is to be present at the hospital as soon as possible to avoid any possible delays as the transplant is a time-sensitive issue. All arrangements including notifying the employer, designating a person to oversee the house/business in the patient's absence, etc. should, therefore, be made well in advance to avoid last minute rush.  Further, there are no specific timelines on how long a patient needs to wait for the liver that he requires as the waiting period tends to be highly variable – could be days, months, or even years before a suitable donor is available.

Next, two sets of teams are assigned to oversee the liver transplant process. The first team is in charge of prepping and preparing the patient for transplant while the other team retrieves the donor's liver. In case of donors who have had a history of conditions such as Hepatitis B or Hepatitis C infection, HIV infection, or has an active infection or cancer, then the donor’s liver is considered to be high risk. Furthermore, the liver of the deceased donor is tested extensively to make sure that it doesn’t pose any sort of health threat to the recipient. What more, many investigations – such as analyzing for the ABO blood group along with HLA matching – are performed in conjunction to ascertain that the liver is functioning properly.

Once the potential liver has been identified, the onus falls on the patient to discuss all relevant details and clarify any questions or doubts he/she may have about the donated organ. Thereon, the patient should discuss the liver's quality, suitability as well as finding out about any possible risks with the transplant team before arriving at a decision. If for any reason, the transplant team is unsatisfied with the liver or if the donor has a change of mind regarding a donation or for that matter any other reason, the patient will be asked to return home and resume the waiting process until the next liver becomes available.

We understand that these false alarms might raise hopes initially but prove to be a dampener when the liver is found unsuitable, one needs to remember that it's a part of the process. We empathize with the patient for the inconvenience and stress caused but it's all done for the greater good while keeping the patient's best interests at heart. Matching the patient with the best possible liver is the primary objective which, in turn, helps boost chances of a successful transplant while also ensuring the patient's safety.

Preparing for an emergency liver transplant

There are times when a patient may be in need of an urgent or emergency liver transplant. An emergency could arise owing to an acute liver failure, rapidly progressive disease or disorder which is worsening with time, viral or bacterial infections, cancer, etc. These cases tend to be time-sensitive in nature and may be in an immediate need for liver transplantation. While for the most part, preparation is similar to a normal transplant, the key differentiator is that everything needs to be done with no time to lose. In that regard, right from getting the paperwork sorted to getting through the evaluation tests, all procedures are to be finished within a quick time frame so as to avoid delays.

Both donor and recipient evaluations are required to be done promptly to ensure a good match between the recipient and the donor. In some cases, a neurological evaluation, including a CT scan of the recipient’s head may also be needed. In most cases, evaluation tests are required to be finished within 12-24 hours which will be supervised by our team of transplant surgeons, pharmacists, specialists, social workers, transplant nurse coordinators, and nutritionists by providing you with comprehensive care through every step of the emergency transplant process. In addition, a clearance from the emergency legal authorization committee is also needed which will also be fast-tracked with the help of our support team. In case a suitable living donor is unavailable, patients are enrolled on the waiting list, where they are placed at a higher priority on the cadaver list.