In 2017, pop star Selena Gomez took to Instagram to reveal that she had received a kidney transplant from a close friend; the procedure was medically necessary due to complications she has had with lupus. This case was noteworthy because it is rare for a personal friend to be found compatible for an organ transplant.
In more recent news, a new law has passed in Northern Ireland, called “Dáithí’s Law” in honor of 6-year-old Dáithí Mac Gabhann. This law means that most individuals are considered to be organ donor volunteers upon death unless they explicitly request to be exempted; an “opt-out” system, if you will.
The thorny issue of organ transplantation has a way of making it into the headlines now and again, but like many issues of our day, the debate around it is rife with misinformation and prejudice. Some people, for religious reasons, reject organ transplantation for deceased individuals, believing that it is necessary for the deceased to be buried whole. However, in my experience as a medical doctor, many people are uncomfortable about discussions around organ donation because it brings up difficult themes of illness and death.
We are at an important crossroads regarding organ transplantation, particularly living donor organ transplantation. On one hand, the procedure has grown safer and more effective, with fewer side effects. And yet, the list of individuals needing organ transplants continues to grow while the list of organ donors remains relatively stagnant; if nothing is done, we may reach a tipping point upon which the entire organ transplant waiting list system collapses.
In addition, there is an East/West divide on the issue of living donor organ transplantation—whereas most organ donors in the West are deceased, more than 97.5% of pediatric liver transplant procedures in Japan come from living donors.
Creating a culture in which organ transplantation is normalized in the West is an uphill battle; some have pointed out that in Victorian England, talking about death was normal, while discussing sex was not; in today’s world, the opposite is true. But organ transplantation is fundamentally about life, not death—the giving of life, the celebration of life, and the precious wonder of second chances.
Indications for Liver Transplantation
“Living donor liver transplantation (LDLT) is recognised as an alternative treatment modality to reduce waiting list mortality and expand the donor pool,” Kasahara and colleagues wrote in the Journal of Hepatology.
Liver transplantation is applicable for a number of diseases, including Alagille syndrome (ALGS), Wilson disease, and alpha-1 antitrypsin deficiency (AATD). Of course, a comprehensive evaluation of donor compatibility needs to be carried out prior to any procedural considerations.
In ALGS, liver transplantation is indicated in approximately 1 in 5 cases and is typically associated with positive outcomes. However, asymptomatic heterozygous parental donors who have intrahepatic bile duct paucity can lead to a poor prognosis in recipients due to ineffective biliary drainage—hence the need for careful preoperative evaluations. In Wilson disease, liver transplantation is indicated for patients who have been diagnosed with chronic liver failure and the fulminant form of this disorder. LDLT using grafts obtained from heterozygous donors is safe and effective; however, many patients can be managed effectively with early diagnosis and conventional medications alone.
Read more about ALGS etiology
AATD is an autosomal recessive disorder that primarily affects the lung and the liver. If left untreated, patients may develop liver fibrosis, progressing to cirrhosis or even hepatocellular carcinoma. Liver transplantation for AATD has been performed for the last 4 decades, with the survival rate at 20 years being 89.1%. Patients usually achieve normal AAT levels within a few months of receiving a liver transplant.
Convincing the Public to Get Onboard
In the International Journal of Surgery, Hibi and colleagues wrote about attempts to promote LDLT in Asia. They reported that the last 20 years have seen a 10-fold increase in the amount of LDLTs performed annually in Asia.
What are the possible causes for this rise? Hibi et al suggest that the strong sense of “family” in Asian culture makes individuals more open to organ donation, especially when it comes to their own family members. In addition, the acceleration of scientific development in organ transplantation in Asia has largely convinced the public that the procedure is safe, effective, and life-prolonging.
Read more about ALGS treatment
Clinicians have 2 main ways to improve the efficacy of LDLTs: reducing the risk to the donor, as well as expanding the donor pool by dealing with the common reasons why individuals who wish to become organ donors are rejected (such as blood group mismatch and a small graft size for adult LDLTs). At present, scientists are developing techniques to overcome these barriers so that most people who wish to donate their organ(s) can do so safely.
Organ transplantation is often touted as the last-ditch option in therapeutics. Nevertheless, it is important that we understand that many organ transplantations, when indicated and approved, are successful and lead to a substantial increase in the quality of life of the recipient. Granted, the cost of the procedure may be one reason why people are hesitant. However, it is our duty as clinicians to explain to members of the public the role of organ transplantations in saving lives and the scientific advancements that have made the procedure safer and more effective.
Kasahara M, Hong JC, Dhawan A. Evaluation of living donors for hereditary liver disease (siblings, heterozygotes). J Hepatol. 2023;78(6):1147-1156. doi:10.1016/j.jhep.2022.10.013
Hibi T, Wei Chieh AK, Chi-Yan Chan A, Bhangui P. Current status of liver transplantation in Asia. Int J Surg. 2020;82S:4-8. doi:10.1016/j.ijsu.2020.05.071