Liver Transplantation: A Medical Miracle

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surgery-1049588_640Liver transplantation has become a common, lifesaving operation. Unfortunately, its use remains limited due to a shortage of organs. Donated organs come from two sources. The most common source is a newly deceased person who has previously expressed willingness to donate or whose family has agreed to donation. Even in those who agree, many organ donors are not candidates for donation due to concomitant medical conditions, a death related to infection or a previously unknown fatty liver. The second source of liver donation is called living related donation. In this type, a close friend or relative agrees to donate a portion of their liver. To donate a part of the liver, all that is needed to match is blood type and approximate size.

Many thousands of people are on liver transplantation lists across the country awaiting a new chance at life. The lists in New York are exceptionally long due to the large population of people with advanced liver disease, a result of our large population density and an apparent lack of organ generosity among New Yorkers. Our area has some of the lowest organ donation rates in the country although recently, the number of organ donors in our areas has increased.

Liver transplant recipients will receive the gift of life while many non-recipients on the list will die waiting for a liver that never came. Not surprisingly, the largest single group of people who die of liver disease are those that were never offered the chance of getting a liver transplantation in the first place. There are many reasons why people are not offered a liver transplant evaluation. These range from the medical to the psychosocial to a lack of awareness regarding liver disease and the criteria for liver transplantation to the proximity of the nearest liver transplantation center. Most people with end stage liver disease have a silent course that eventually manifests itself as a dramatic change in a person’s health. Some common presentations of decompensated liver disease are jaundice, the development of ascites or fluid in the abdomen, variceal bleeding, hepatic encephalopathy and liver cancer. Many people with these complications are never sent to liver transplant centers where their lives could be saved.

Do all people with cirrhosis need to be evaluated for liver transplantation? Certainly not and not even the majority of people with cirrhosis should be evaluated for transplantation. We evaluate people when they show signs of decompensation. We also evaluate people when their calculated model for end stage liver disease score (MELD) is more than 16. This is a mathematical formula that looks at three laboratory blood values that predict survival. The three values are: serum total bilirubin, serum creatinine and the international normalization ratio (INR). These tests should be obtained on everyone with cirrhosis, regardless of etiology; their doctor evaluates each time the patient. The MELD score can be easily calculated by using one of the many MELD score calculators available for free on the Internet.

Does someone need to be rich and famous to get a new liver? This is one of the major misnomers of the organ allocation system in the United States. In the U.S., all people are eligible for liver transplantation evaluation, regardless of insurance. After being placed on a list, the criteria for actually getting a new liver are blood type, body size and MELD score. For people of the same blood type, those with a higher MELD score are the ones who will get available livers. This makes the system quite fair and equitable and available to all. The problem once again comes down to organ donation. The single most important factor in determining organ availability is zip code. More organs are available in certain parts of the country, especially those areas without helmet laws or where gun ownership is high. Wait lists in the Northeast and far West are long while wait lists in the lower mid-West and South are much shorter.

Another big stumbling block to getting a liver transplant appears to be the lack of referral to a transplant center. If you do not get to a transplant center, you can never receive a new liver. In many communities, patients and physicians are not aware of the availability and feasibility of liver transplantation in their states or neighboring states. As the number of liver transplant eligible patients grows with improved education to the communities and a rising incidence of cirrhosis in this country related to obesity and diabetes, the current organ shortage is bound to get worse.

The growing number of people with end stage liver disease makes it imperative that community awareness is raised regarding liver transplantation and organ donation. As there is no artificial liver disease and no approved “liver dialysis,” the number of transplants performed can only increase if donation increases. This donation can be either cadaveric or living related. Hopefully, our community will learn more about organ donation so that we can provide our neighbors with a chance at a new life. And hopefully a new liver transplantation center in our area will fulfill a much-needed void in the care of the patients on Long Island.

David_Bernstein_Liver_Specialist

David Bernstein, MD, is chief of gastroenterology, hepatology and nutrition at North Shore University Hospital and Long Island Jewish Medical Center.

 

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