S.A. home to nation’s first paired liver exchange
SAN ANTONIO — Sarah D’Angelo was lying in a bed at University Hospital, having just undergone surgery to receive a new liver from an anonymous donor, when her friend walked through the door.
The 65-year-old was under the impression that Natasha Sanchez had just stopped by the hospital to see her. But then she noticed the bag of fluids Sanchez had in tow and the IV port on her hand.
Shocked, D’Angelo asked: Was it you?
Well, not quite.
When Sanchez, 42, found out that her friend needed a transplant, she quietly underwent testing to see whether she was a good candidate to donate part of
her liver. It turned out that she was, but staff at University Transplant Center proposed an alternative.
A man living in New Braunfels, Mark Blair, was also in need of a new liver, but he wasn’t a match with his daughter, Anna Moreno. However, Sanchez was also a good match for Blair, and Moreno was compatible with D’Angelo. If Sanchez agreed to give part of her liver to Blair instead, the hospital told her, two lives would be saved.
Sanchez figured God had lined things up this way, so it must be the right thing to do.
The exchange, which took place over two consecutive days in late April, marked a milestone for University’s transplant program.
Transplant centers have long promoted kidney exchanges, where those who want to give an organ to a friend or loved one but aren’t a match instead donate to another person, in exchange for a donation from someone close to that recipient. Those more routine swaps can become incredibly elaborate: Methodist Specialty and Transplant in San Antonio boasts the world’s largest paired kidney exchange at a single hospital, a multiway swap that has included 23 recipients and donors.
But as far as program directors at University could tell, the April surgeries were the first time in the U.S. that such an arrangement had been struck for liver transplants. The hospital facilitated another liver exchange a few months later, at the end of July.
Liver transplants are more complicated, and most programs in this country are not experienced in doing them with live donors, said Dr. Tarunjeet Klair, the center’s surgical director of living liver donations.
Kidney transplants from living donors involve the removal of the entire organ, but liver transplants take just a portion of the liver. The section must be big enough to help the recipient and small enough that it does not interfere with the donor’s recovery from the surgery. Because the liver can regenerate, it will grow into a fully functioning organ in both people over a few months.
Such a transplant requires different operating room equipment and specialized skill sets of surgeons and other staff.
“Only a handful of transplant centers in the U.S. are doing living liver donation,” said Jennifer Milton, chief administrative officer of University Transplant Center. “The demands and the requirements to have such surgical expertise and such a different level of care, that’s really kept a lot of programs from even offering living liver donations.”
D’Angelo, who met Sanchez when they trained as doulas together a few years ago, said she was glad that the center has made efforts to facilitate more transplants.
“That’s going to make such a huge difference for these people who can’t find the match. It’s going to be like the kidneys,” said D’Angelo, now 66. “I’m grateful that I’m part of it. But the bigger picture doesn’t have anything to do with me.”
University’s ability to facilitate these exchanges is tied to the dramatic growth of its living liver donation program over the past two years.
For three years in a row, from 2015 to 2017, the transplant center completed liver transplants from just six living donors, compared with dozens of procedures using deceased donors. In 2018, University’s living liver transplants increased fivefold, to 30, accounting for nearly 30 percent of the program’s liver transplants that year. As of mid-December, the center was on pace to exceed that proportion, with 39 of 114 liver transplants using living donors.
Increasing those numbers has required a major shift in mindset at the center, said Claudia Grimmer, assistant director of the live liver program. Previously, the hospital would blood type potential donors and wouldn’t even have them come in for further tests if they were not compatible with their intended recipient.
“We could have the most perfect donor in every way, physically, mentally, but if they were not a match by blood, then they were declined,” she said.
Now, transplant staff conduct all the requisite testing for donors and ask them whether they would be willing to consider donating to a different person than they had in mind, even if they are a match to their intended recipient. Program directors have met with the hospital’s chief medical officer and quality review and ethics boards to ensure that it has the proper protocols in place.
University has also relaxed some of the requirements that previously disqualified some people who wanted to donate, including strict criteria for a body mass index of no more than 28. With the new standards, patients with a BMI of up to 33 can be evaluated and cleared for the surgery if they are otherwise healthy, a change that Klair said has made a significant difference.
Donors can also provide their personal information through online questionnaires, rather than lengthy phone calls, which speeds the process.
With a larger pool of possible donors, Klair said, the program has more flexibility to identify potential opportunities for paired exchanges. While the number of organs available for transplant from deceased donors has not kept up with demand, in Klair’s mind, “there is an unlimited supply of living donors.”
He added that the sentiment behind the arrangements tends to resonate with donors, who already wanted to help another person.
That was the case for Moreno, 36, who was hoping to help her father after his liver began to fail in early 2018.
She was disappointed when she and her brother weren’t good candidates for her father, but she never questioned the idea of giving to another person when the hospital raised the prospect of an exchange.
“I was prepared to do the surgery for my dad, so I was prepared to do it for anybody, really,” she said.
When he learned that his children weren’t good matches for him, Blair, 68, was devastated. His place on the deceased donor waiting list wouldn’t be high because he was not as sick as others in need of a transplant. So he prepared himself for the possibility that he’d die in the next year or two waiting for a new organ, as many do every year.
But then the family got the call about a possible exchange. Blair was blown away by the willingness of his daughter and Sanchez to go ahead with the procedures.
“I was absolutely amazed,” Blair said. “You’ve got to be proud.”