Written by:
Anoushka Pinto
Donating a part of your liver can save someone’s life. In India, liver transplants are reserved as a treatment option for those battling end-stage chronic liver disease or sudden liver failure. It offers hope when other treatments fall short.
Approximately 85% of liver transplants in India are performed with a living donor. While deceased donor liver transplants are higher in South India compared to North India, efforts to increase awareness and establish protocols for Donation after Circulatory Death (DCD) are underway in order to expand the donor pool nationwide. (Source: ScienceDirect)
The process of organ donation and transplantation is regulated by the Transplantation of Human Organs and Tissues Act of 1994. This legal framework is aimed at safeguarding against organ trafficking and ensuring ethical practices in transplantation. Following these laws is crucial when seeking a liver donor, emphasising the need for coordination with authorised transplant centres and medical experts.
Despite India’s large population, the number of liver donors remains significantly low. And this poses a challenge because there are long waiting lists and a high mortality rate for those waiting for transplants, highlighting the stark difference between demand and supply. In addition, cultural beliefs, religious reservations, and lots of misconceptions about organ donation make it even harder to find donors.
Finding the right liver donor is an important step in the liver transplantation journey, and involves careful matching and thorough compatibility testing to ensure the transplant’s success. Beyond medical procedures, it also upholds ethical standards and legal guidelines governing organ donation. This article explores the intricacies of becoming a liver transplant donor, discussing evaluation protocols, matching criteria, and the crucial role of compatibility testing in this life-saving process.
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Types of donors
Deceased donor
A liver transplant can be performed with a liver from a deceased donor, who has been declared brain-dead (DBD) after suffering irreversible brain stem death. This may be due to non-responsive coma, absence of spontaneous breathing, and lack of brainstem reflexes.
Less commonly, liver from a deceased donor after circulatory death (DCD) is also used. Here, the donor is identified through cardio-respiratory criteria either through a planned withdrawal of life support or unexpected cardiac arrest where resuscitation is not an option. In the case of both DBD and DCD, the donor’s liver can be donated with the consent of their next of kin.
A deceased donor’s liver can be used for an adult, or a part of it can be used for a child. The only requirement is for the donor and recipient to be of approximately the same size and compatible blood type. However, a deceased donor is hard to come by and the waiting list can be long due to its limited supply. It often requires the recipient to be registered with multiple hospitals, and across different states for a higher chance of receiving a liver.
Living donor
Instead of a long wait for a deceased donor, a person can get a transplant quickly with a living donor. Living donation is a voluntary process. Donors must have a compatible liver anatomy and blood type that is suitable for donation.
A living donor does not need to be a close family member. They can be a distant relative, friend, neighbour, or coworker. A living donation is viable due to the liver’s unique ability to regenerate itself. Both the donor and the recipient can end up with a full-sized, functioning liver after the procedure.
Eligibility criteria for a living liver donor
To be eligible as a living liver donor, you must meet the following criteria:
Age: Be a willing adult between 18 and 55 years old.
Health condition: Be in good physical and psychological health.
Blood type: Have a compatible blood type with the recipient (see compatibility table below).
Liver size: Doctors use medical imaging and tests to figure out if the donor’s liver is the right size for both the recipient and the donor.
Liver and kidney function: Have healthy liver and kidney function.
Body weight: Maintain a healthy weight with a Body Mass Index (BMI) of less than 30. Don’t be obese or overweight
Alcohol abstinence: Be willing to abstain from alcohol until fully recovered
You are not eligible to be a liver donor if you:
Are younger than 18 or older than 60
Suffer from heart or lung disease
Have an incompatible blood type
Are infected with HIV or hepatitis
Are an active substance abuser
Have an uncontrolled psychiatric condition
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Evaluation process
1. Living donor
Evaluation of a liver donor is performed in 4 phases, with more expensive and invasive tests scheduled for the later phases. The process typically takes about 7 to 10 days, and is done on an outpatient basis so the donor doesn’t have to stay at the hospital. The main goal is to ensure that the donor is safe and compatible with the recipient, as well as to increase the chances of a successful transplant.
Here’s a breakdown of the four phases of the evaluation:
Phase 1: Liver function tests and liver fat estimation
The first step is to assess the liver’s health through liver function tests and liver fat estimation. These tests ensure the liver is functioning optimally, as an unhealthy liver would leave the transplant ineffective. A noninvasive method called the Liver Attenuation Index is used to determine and quantify fat accumulation in the liver (steatosis).
Phase 2: Assessing liver volumes and anatomy of liver blood vessels
The second phase involves calculation the liver volumes through a tri-phasic CT scan. The critical step determines if the donated liver segment meets the recipients volume requirements and ensures the remaining liver portion is sufficient for the donor’s normal liver function.
Phase 3: Tests to evaluate other organ systems
The third phase, also using the tri-phasic CT scan, provides surgeons with a detailed view of the liver and its blood supply, confirming its optimal condition. In some cases, a biopsy may be performed, where a small liver sample is examined under a microscope to check for infections or diseases. Additional tests are done to analyse the donor’s kidney and thyroid function and screen transmittable viruses.
Phase 4: Evaluation by specialists, including psychological assessments
The final phase involves a comprehensive evaluation by specialists to confirm the liver’s suitability for transplant. Though positive outcomes are always the goal, a liver can be deemed unsuitable due to various safety reasons and alternative donors are considered
If the liver is approved, both the donor and recipient undergo a psychological evaluation to ensure they can handle the physical and emotional aspects of the transplants. Finally, Human Leukocyte Antigen (HLA) testing is performed to match patient and donors for bone marrow or cord blood transplants before the authorisation committee meeting.
(Source: Organ India, Fortis Healthcare)
2. Deceased donor
Declaration of brain death
Brain death is the complete and irreversible cessation of all brainstem functions.Though the donor is considered legally dead, i.e their brain has permanently stopped working, their heart is still beating. In India, this is regulated by the Transplantation of Human Organs and Tissue Rules (2014). A team of four medical experts—including a hospital medical administrator, a specialist, a neuro physician or neurosurgeon, and the treating medical officer—must confirm brain death through repeated testing.
Management of deceased donors
Proper management of a deceased donor in the ICU is crucial for preserving organ viability. This involves maintaining homeostasis (a balance among all the body systems) with optimal fluid management, hemodynamic (cardiovascular function) monitoring, and addressing any imbalances.
(Source: ScienceDirect)
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Matching process
The matching process involves several steps to ensure the donor and recipient are compatible:
1. Living donor compatibility tests
Blood type
Blood type compatibility between the donor and recipient is key for a successful liver transplant. In India, a comprehensive blood test is done to ensure compatibility and minimise risk of rejection and other complications. Basically, the blood types of the donor and recipient need to be a match, just like when you’re getting a blood transfusion. There are four main blood groups: A, B, AB, and O.
Type O: As a universal donor, individuals with Type O blood can donate to anyone, but Type O recipients can only receive from Type O donors.
Type A: Donors with Type A blood can donate to recipients with Type A or AB blood.
Type B: Donors with Type B blood can donate to recipients with Type B or AB blood.
Type AB: Donors with Type AB blood can only donate to recipients with Type AB blood.
It’s important to note that the Rh factor (positive or negative) doesn’t affect compatibility for liver transplants.Other blood tests may also be conducted to check the overall health and liver function. These tests can be done at specialised labs or local hospitals.
Tissue matching:
Tissue matching, including Human Leukocyte Antigen (HLA) testing, is performed to evaluate the compatibility between the donor and recipient. This test checks the genetic markers on white blood cells to ensure the donor’s tissue is compatible with the recipient’s immune system. Compatible tissue matching can reduce the risk of organ rejection and improve transplant outcomes.
Chest X-ray
A chest X-ray is performed to evaluate the donor’s lungs and heart. This imaging test checks for any underlying issues that could complicate surgery or anaesthesia, such as infections, tumours, or other abnormalities in the chest cavity. Ensuring the lungs and heart are in good condition is crucial for a safe surgical procedure.
CT-scan
A computed tomography (CT) scan, particularly a tri-phasic CT scan, provides detailed images of the liver. This test helps in assessing liver volumes and the anatomy of liver blood vessels. It determines whether the donor’s liver segment is of adequate size and volume to be transplanted and if the remaining liver will function normally post-donation. It also helps identify any anatomical variations or abnormalities that might affect the transplant’s success.
Electrocardiogram (ECG)
An electrocardiogram (ECG) measures the electrical activity of the donor’s heart. This test is essential to ensure the donor’s heart is healthy enough to undergo major surgery. It helps detect any underlying heart conditions, such as arrhythmias or other cardiac issues, that could pose risks during or after the transplant procedure.
2. Deceased donor compatibility tests
When evaluating a deceased donor for liver transplantation, several key tests are conducted to ensure the donor’s organs are suitable for transplant and pose minimal risk to the recipient. Potential donors must be screened thoroughly to exclude any transmissible diseases or conditions that could affect the recipient.
ABO blood typing
ABO blood typing determines the donor’s blood type (A, B, AB, or O) to ensure compatibility with the recipient’s blood type. It is crucial for preventing immune rejection of the transplanted liver. Incompatible transplants can lead to severe complications and transplant failure.
Liver function tests (LFTs)
LFTs are used to assess the liver’s ability to perform its normal functions, including synthesising proteins, producing bile, and detoxifying the blood. They help evaluate the health and viability of the donor liver, ensuring it can function properly in the recipient. Common tests include alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), bilirubin levels, and albumin levels.
Coagulation profiles
The liver produces many of the proteins involved in blood clotting. Abnormal coagulation profiles can indicate liver dysfunction or damage, which might affect the success of the transplant. Tests like prothrombin time (PT) and activated partial thromboplastin time (aPTT) test measure the blood’s ability to clot.
Viral markers
These include screening tests for infections that could be transmitted to the recipient, including hepatitis B (HBsAg, anti-HBc), hepatitis C (anti-HCV), HIV (anti-HIV), and cytomegalovirus (anti-CMV). They identify viral infections to prevent transmitting diseases to the recipient, and help ensure the safety and success of the transplant.
Chest X-rays
Chest X-rays can detect conditions such as infections, tumours, or other abnormalities that might contraindicate organ donation or indicate a systemic infection. They provide images of the donor’s chest, including the lungs, heart, and surrounding structures.
Abdominal ultrasound
Ultrasounds can reveal liver size, structure, and any focal lesions or abnormalities, helping to assess the liver’s overall health and suitability for transplantation. They use sound waves to create images of the abdominal organs, particularly the liver.
Blood and urine cultures
Identifying infections is crucial to prevent transmitting infectious agents to the recipient. Ensuring the donor is infection-free enhances the chances of a successful transplant and reduces the risk of postoperative complications. Blood and urine cultures detect bacterial or fungal infections in the blood or urine, especially if the donor has been hospitalized for more than 72 hours.
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Authorisation committee clearance
In India, conducting a liver transplant with a living donor requires approval from a government-appointed committee that ensures all ethical and legal standards are met before giving the green light for the surgery.
The transplant centre performing the transplantation procedure will guide the recipient and donor through the whole process, including documentation and affidavits, as well as providing proof of identification like Aadhaar card, passport, etc. Establishing and documenting the donor-recipient relationship is crucial to avoid any legal complications.
But if the donor is not a close relative or is a foreign national, they will need to produce a no-objection certificate (NOC) from either their home state or their embassy. It is important to note that the transplant team and the authorization team work separately. The committee’s decisions are made without influence from the transplant team, and they conduct their own assessments to ensure no coercion or bias is involved. Providing the committee with false or misleading information is a serious offence and can carry significant legal repercussions.
Once both the donor and recipient get the go-ahead from the committee, the transplant team reviews the case. They go over all relevant details, including suitability and risks. The transplant date is then scheduled, but only after receiving final clearance from the authorization committee.
How Milaap can help
Milaap plays a crucial role in enabling liver transplant procedures by helping patients raise the necessary funds for their treatment. Many individuals and families facing the high costs of liver transplants have turned to Milaap to create fundraising campaigns, garnering support from friends, family, and the broader community. This support has been vital in covering expenses such as pre-transplant evaluations, surgery, post-operative care, and essential medications.
If you or someone you know needs financial assistance for a liver transplant, consider starting a fundraiser on Milaap.
Liver transplant success stories on Milaap
In times of need, support means everything, and with Milaap, you need not look any further. Milaap enables you to set up a fundraiser for any medical emergency within minutes, and you can easily raise funds for treatment expenses.
Do you know someone who could benefit from fundraising? Simply refer them to us and we’ll be happy to lend a hand.
Visit www.milaap.org or call us on +91 9916174848 to get started now.
For more information, write to us at cx@milaap.org.
