Feb. 6, 2002 -- Juanita Chavez and her sister Maria Elena were always very close. But until last year, neither could have imagined that one of them would give the other the gift of life by donating part of a major organ.
At age 30, Juanita had been suffering from liver disease -- triggered by chronic hepatitis -- for a decade. Her body's immune system was attacking her liver. By last summer, Juanita's condition had dramatically worsened. Her skin turned yellow. Her belly swelled so much, she joked that she almost looked pregnant. She endured grueling cramps in her legs, arms, and hands. And she had less and less energy, making it harder and harder just to get through the day.
Juanita needed a liver transplant. But with more than 18,000 other Americans on the waiting list, her chances of having the operation anytime soon seemed slim.
That's when Maria Elena made a heroic gesture. She volunteered to have a portion of her own liver surgically removed and transplanted into her older sister. So last November, the two women entered Cedars-Sinai Medical Center in Los Angeles and underwent the delicate, lifesaving procedure.
"Almost immediately after the surgery, even while tubes were still in me, I felt so much better," says Juanita. "When I was discharged 10 days later, I had to keep reminding myself that my surgical wounds still needed to heal. The rest of my body and mind wanted to do so much. I felt like doing cartwheels."
A Shortage of Organs
Living-donor liver transplants were unheard of before 1989, when a mother donated a portion of her liver to her child. Two years later, the first living adult-to-adult liver donation occurred. It was successful, but it didn't exactly start a tidal wave of similar procedures: In 1997, only three adult patients received a liver from a living donor.
By 1999, however, the numbers had begun to climb. In the first nine months of 2001, there were 365 living-donor liver transplants in the U.S. and 293 of those who received them were adults. While most liver transplants continue to use organs from bodies of people who've recently died -- nearly 3,500 of these cadaver transplants were performed between January and September 2001 -- the waiting list for liver transplants is growing at about 30% each year. The increasingly desperate need for organs is prompting many more surgeons to consider living-donor operations.
"If we had a sufficient supply of cadaver organs, we wouldn't want to subject a healthy donor to an operation of this magnitude," says Christopher Shackleton, MD, director of the multi-organ transplant program at Cedars-Sinai and a leader of the transplant team that performed the Chavez surgeries.
The success rate of living-donor procedures is 95% at Cedars-Sinai, and a bit lower nationwide. This is higher than the 85% success rate achieved with cadaver liver transplants at the same hospital.
Weighing the Risks
Despite many successful transplants, there are clear risks associated with the procedure. In January 2002, a 57-year-old donor, Mike Hurewitz, died at New York's Mount Sinai Hospital from surgical complications following his donation of part of his liver to his younger brother. As a result, Mount Sinai temporarily halted its living-donor liver transplantation program until the Hurewitz case could be evaluated and the hospital's procedures reassessed.
Although the death in New York is only the second known fatality of a living donor in an adult-to-adult liver transplant in the U.S. (the other occurred before the United Network for Organ Sharing began formally keeping such statistics in 1999), it is still very troubling to those who perform these operations. Mark Fox, MD, PhD, director of the program in transplant ethics and policy at the University of Rochester (N.Y.) Medical Center, says that surgeons and ethicists continue to debate the level of acceptable risk.
"As I understand it, the mortality risk among donors is thought to be 0.2% in these procedures, so two out of 1,000 living donors will die undergoing this procedure," says Fox. But, he asks, even if the risk were much higher -- say, one out of 100 living donors -- "would that distinction matter to potential donors if they had the opportunity to do something to save the life of someone important to them?"
Because of the risks, transplantation programs put potential donors through a battery of tests to ensure their good physical health. "Every potential donor also undergoes psychosocial assessments to make certain that they fully understand the risks and benefits, and that they're choosing to become a donor for altruistic reasons," says Shackleton. "We also sit down with the potential donor and his family members in the absence of the prospective recipient and make it clear that this is an entirely voluntary process -- that he shouldn't feel compelled to move forward with the procedure, and that he is completely free to withdraw at any time up to the induction of anesthesia."
The success rate of living-donor operations remains high, in part because the donor organs come from healthy individuals rather than someone who may have died many hours earlier. Also, the patients receiving liver transplants may not have spent many months on the waiting list for an organ, and thus may not be as desperately ill.
"With the living-donor procedures, we can intervene in a more timely way based on the recipient's condition," says Shackleton.
New Best Hope
For many patients with liver failure, living-donor transplants may become their best hope for a healthy future. Anne Paschke, spokesperson for the United Network for Organ Sharing, says that in 2000 there were 1,867 people on the liver donation waiting list who died before a liver became available.
Maria Elena Chavez admits she was nervous about having the operation to donate part of her liver. But she was considered a suitable candidate and was determined to take the risk to save her sister's life.
In the procedure, surgeons take about 60% of the donor's liver and transplant it into the recipient to replace the failing organ. Each patient is in the operating room for as little as 3 hours if the procedures go well, although in some cases it takes much longer. After the transplants, the livers in both patients begin growing almost immediately. "It's really quite dramatic," says Shackleton. "In just two to three weeks, the volume of the liver is markedly greater and approaching what each individual needs."
"By mid-January, two months after the transplant, Juanita was feeling well enough to return to her job as a third-grade teacher. At the same time, the sisters are trying to educate others, particularly in the Latino community, about the importance of becoming organ donors. The sisters are nieces of Cesar Chavez, who co-founded the United Farm Workers of America along with their mother, Dolores Huerta.
According to Shackleton, other than needing to take immunosuppression drugs to prevent rejection of their new liver, living-donor organ recipients like Juanita can expect to lead a normal life. "We expect Juanita to go about her life in a very normal fashion with no encumbrances," he says.