Evaluation and preparation for a liver transplant (Donor)

Procedures for the Donor – Who is eligible to be a living liver donor?

For a living donor candidate to be eligible for donation, they should meet the following criteria which help in determining if they can safely donate:

• First and foremost, the blood group should be compatible with the recipient. What this basically means is that the blood type of the liver recipient and the donor must be in sync, just as they must be for a blood transfusion. Blood types are essential of four types: A, B, AB, and O.

Note: Rh (the negative or positive element of blood type) has zero effect on compatibility.

• The donor must be an immediate family member (wife, husband, mother, father, brother, sister, son, daughter, grandfather, grandmother, grandson, granddaughter) or should qualify as a close relative of the patient.

• While we appreciate the concern family friends, colleagues, well-wishers, staff or neighbours might have for you and your well-being, unfortunately, they don't qualify as donors.

• Donors must fall between the age group of 18-55 years. The reason behind this stipulation is that older donors usually tend to have more health complications as compared to their younger counterparts. Children below 18 aren’t eligible because they aren’t considered to be mature enough to give their consent.

• Donors should ideally have a body mass index (BMI) that is less than 30 and not be overweight or obese. This is because obese people usually have a fatty liver.

• The donor should be in good physical health and free from any sort of health complications. Similarly, he/she should be mentally fit as well to undergo the procedure. To determine this, a series of thorough medical and psychological tests will be conducted.

• The donor should provide full consent for the surgery and should be doing this of their own free will after fully understanding the risks of surgery.

• Another important point is that as a donor, their decision to donate or not can be changed at any time. This can be during the evaluation, before or after the diagnostic tests are performed or even before the surgery.

Pre-transplant donor evaluation guidelines

As documented above, the donor eligibility criteria are based on factors such as the medical and social history as well as the results of the physical examination and tests. However, in the case of donor evaluation, the assessment process is staged and performed in four different phases. We try to target and finish this process within a week to 10 days. That being said, the duration of the evaluation is subject to the recipient’s diagnosis and current health condition as well as at the discretion of the medical staff in charge. These tests are performed on an outpatient basis and we tend to reserve the invasive and expensive tests to the later stages of the evaluation.

Ideally, the potential donor should be able to tick off all requirements required for each stage of the assessment process before he can carry on to the next stage/phase. We also take care to ensure that all discussions and evaluations pertaining to the tests, results, and identities are kept strictly confidential.

Phase one involves liver fat estimation and liver function tests. Checking the optimal functioning of the liver is important because if the donor’s liver is found unhealthy, then the whole point of transplanting it fails. Thereon, the accumulation of fat in the liver (steatosis) is determined and quantified by a non-invasive method called as Liver Attenuation Index (LAI).

Phase two - The next stage, is where liver volumes are calculated – also known as the second (tri-phasic) CT scan. This test helps in determining if the liver donated meets the volume requirements required by the patients and if the remaining part of the liver is adequate enough for the donor’s liver to resume normal function.

Phase Three also referred to as the tri-phasic CT, gives surgeons a detailed view and insight on the liver and its functioning. Screens are in place to check the anatomy of the liver and its blood supply to ascertain that the liver is in prime condition. In some cases, a biopsy might also be required to investigate further details. In this non-surgical procedure, a tiny part of the liver is removed with the aid of a needle and then examined under a microscope to assess the liver’s quality, check for any bacterial, fungal, parasitic or viral infections, and rule out the presence of any diseases/conditions. Additional tests may also be performed to test for the healthy functioning of the donor's kidneys and thyroid, and to check for exposure to any possible transmittable viruses.

Donors who have managed to successfully clear the first two stages – i.e. ruling out the possibility of having a fatty liver coupled with maintaining adequate volume required for transplant – have a high probability of their liver being accepted for donation. This is the fourth stage where specialists congregate and evaluate whether the kidney is fit enough to be transplanted. While we always hope for positive outcomes, there are times when we have to reject a liver if our team believes that that liver doesn't meet the desired requirements. We understand that rejection can make the patient and the donor feel disheartened and worried. It's a stressful time for everyone involved. But the rejection will always be based after taking into account everyone's best interests and to ensure the safety of both the donor and the recipient. After all, the success of every transplant depends entirely on the quality of the organ being donated. In such a scenario, we usually start exploring the possibility of moving on to an alternative donor.

If the donor’s liver is approved, a psychiatry evaluation will be done by a psychologist to confirm both the patient and the donor will be able to handle the physical and emotional changes associated with the liver donation. Last but not least, Human leukocyte antigen (HLA) testing and matching will be performed to match patients and donors for bone marrow or cord blood transplants; before the authorization committee meeting.

Seeking authorization committee clearance

To conduct a liver transplantation, clearance needs to be approved by the government appointed authorization committee. At Fortis, our team will always be on-hand to explain to the patients and families about the various procedures and legalities involved. This involves filling up, preparing, and understanding the various forms, legal procedures, procuring the affidavits (statements under oath) along with any other supporting documents as required. These documents may include residence proofs for both parties, identity proof such as Passport, Aadhaar card, etc. In addition, establishing the basis of the donor-recipient relationship needs to be done and submitted with the application to the authorization committee to avoid any legal hassles.

In case of donors who don’t qualify as close relatives or are foreign nationals, a no-objection certificate (NOC) needs to be procured from the state of domicile (residence) or embassy. It also needs to be mentioned that the transplant team and the authorization committee are two separate entities. Hence, all decisions made by the authorization committee are at their sole discretion and not influenced by the transplant team in any fashion. The authorization committee may also choose to assess the patient to make sure that there has been no attempt of coercion or bias by any members of the transplant team. Thereafter, any attempt to provide incorrect/invalid/falsified information/data to this authorization committee amounts to a violation of the law and carries with it, a hefty penalty.

Donor candidates may be approved or declined and this decision along with the reasons for the same will be notified by the Clinical Coordinator. The potential recipient will also be made aware of their decision citing that the donor liver can’t be accepted but the reasons behind the same will remain confidential.

Further, cases which have managed to seek approval and authorization for both the recipient and the donor are then evaluated and reviewed by our multi-disciplinary transplant team. It's at this stage where all details relevant to the transplant such as suitability, risks, etc. are discussed in length following which a transplant date is decided upon. However, this transplant date can be scheduled only after seeking approval and clearance from the concerned authorization committee.