Liver transplants: Liver donations in the UK
The discrepancy between organ supply and demand is the greatest problem facing liver transplantation today. One of the biggest frustrations for the transplant community is the contrast between the general public’s stated enthusiasm for the concept of organ donation and the reality of the low actual organ donation rate in the UK. As part of our series of articles on liver transplantation, Dr Andrew Bathgate looks at the current situation regarding liver donations in the UK.
- The liver donor rate in the UK is low compared with other countries, although donor rates within the UK vary considerably. Forty per cent of families approached in UK intensive care units refuse organ donation.
- The number of patients who could benefit from liver transplantation in the UK is rising and exceeds the number of donor livers available.
- Liver transplantation saves lives and provides a good quality of life. Ninety per cent of recipients are alive one year from transplantation, and 70% are alive after five years.
- Transplantation of livers from heart-beating donors who have suffered brain-stem death gives the best results, and this source will provide most livers in the future. Splitting livers and livers from non-heart-beating donors should make a worthwhile contribution.
- Adult-to-adult living-related liver transplantation may contribute to liver donation, but poses significant risks to donors and is stressful for transplant unit staff.
- New UK laws give individuals the right to decide on the use of their organs after death. Families should discuss organ donation well before any serious illness occurs.
Declaration of interests: None declared.
Liver transplantation is a treatment that transforms as well as saves lives. Donated livers are a scarce commodity, and patients are only listed for liver transplantation in the UK if there is at least a 50% chance of the transplant allowing them to survive for five years.1 The number of liver transplants performed in the UK in 2007–08 was 632, of which only 568 were from heart-beating donors - a drop of 7%. The number of registrations for liver transplantation was more than 800. Accordingly, the median time on the waiting list increased. As there is no equivalent of renal dialysis for a failing liver, patients on the waiting list who do not get a liver do not survive and the number of deaths on the waiting list has significantly increased.
The organ donation rate is the number of donors per million population (pmp). This figure varies greatly between countries, and even within the UK there are major regional variations. For example, Spain has a donor rate of 33 pmp, compared with 13.4 pmp in the UK as a whole and 19.0 pmp in the northeast of England. There are many differences between the healthcare systems in Spain and the UK, such as the number of intensive care beds, but the poor donation rate in the UK requires further investigation.
UK Transplant has published an audit of intensive care records of 46,801 patients who are believed to be all the patients who died in intensive care units in the UK between April 2003 and March 2005.2 The results of this indicate that more than 40% of families approached regarding organ donation do not give consent. Only 16% of these refusals were because the stated wish of the potential donor was known. This highlights the need for individuals to make their own views on organ donation known to their families before the unthinkable happens.
The results of liver transplantation in general are very good, with 90% survival at one year and around 70% at five years. There is no doubt that the transplanted organ itself has some influence on the success of a liver transplant. In the past, livers from young, previously fit donors were the norm, but as donation rates have diminished, liver transplant units have had to accept more marginal donors. The best outcome for any given recipient is with a whole liver graft from a deceased heart-beating donor. Several initiatives have commenced in an attempt to improve the situation, but by necessity this involves using more marginal grafts.
Firstly, livers from controlled non-heart beating donors have been transplanted with some success in several UK centres, although the actual number is small and is unlikely to have a significant impact. This process involves the withdrawal of treatment in a controlled situation with the family present. Shortly after the donor’s heart stops, organ retrieval takes place. The proportion of retrieved livers that is suitable for transplantation is reduced compared with livers from heart-beating donors, because of the increased warm ischaemia time (the time during which the liver remains at body temperature). This appears to be less of a problem for kidneys, and the results of non-heart beating kidney donation are very encouraging.
Another initiative designed to increase the number of liver transplants performed in the UK is the splitting of livers. For many years, the smaller left lateral segment of a liver has been split from the rest of the liver to be transplanted into a child. The larger portion has then been transplanted into an adult. It is possible to split large donor livers into right and left lobes with both lobes being used for small adults. The outcome for split liver grafts is not as good as whole liver grafts, but given the gravity of the present situation it is in the best interests of all of those on the waiting list to pursue this initiative. The criteria for a liver being ‘splittable’ are restrictive and mean that only the minority of donated livers can be used in this way.
The last initiative is that of adult-to-adult living donor liver transplantation. This procedure involves removing at least half of the liver from a healthy donor (a relative of the patient) and transplanting it into the recipient in liver failure. The donor hepatectomy is a major operation with significant morbidity and a small, but significant, mortality of about 0.2%.3 This procedure has now been performed on the NHS in three units, with only around 10 patients being transplanted.
The vast majority of liver transplants in the UK will have to continue to be from donors who die a brain-stem death. The recent change in the law in relation to organ donation is therefore timely. The issues surrounding death and dying are complex. The Human Tissue (Scotland) Act 2006 became law at the same time as the Human Tissue Act 2004 came into force in the rest of the UK. These Acts highlight an individual’s right during life to ‘authorise’ or give consent to how they wish their bodies to be dealt with following their death. For example, the action of an individual placing his/her name on the Organ Donor Register (ODR) indicates ‘authorisation’ to become an organ donor.
At present there are 13 million individuals on the ODR in the UK, which equates to 22% of the population, and it is hoped that the Acts will increase donation rates by indicating to families that their loved ones have a legal right to be donors. The potential donor audit has demonstrated that reducing the number of organs lost through the refusal of relatives to donate the organs of their deceased loved ones could greatly reduce the shortage of livers required for transplantation. This obviously has to be dealt with in a sensitive manner, but increasing public awareness of the new Acts and thereby stimulating discussion in families is important to prevent the need for donation decisions at a very difficult time for the families involved.
- Neuberger J, James O. Guidelines for selection of patients for liver transplantation in the era of donor-organ shortage. Lancet 1999; 354:1636–9.
- Barber K, Falvey S, Hamilton C et al. Potential for organ donation in the United Kingdom: audit of intensive care records. BMJ 2006; 332:1124–7.
- Middleton PF, Duffield M, Lynch SV et al. Living donor liver transplantation – adult donor outcomes: a systematic review. Liver Transpl 2006; 12:24–30.