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Doubling Up

One liver, two recipients. The operation is new, but UCLA has already had success. For now, the process may be the answer to too few organs for plenty of patients.


On Aug. 9, 1996, a critically ill Judy Burton was wheeled into a surgical suite at UCLA Medical Center and prepped for a liver transplant. Simultaneously, in a surgical room nearby, a baby--a little girl, Burton was later told--was also being readied for the life-saving operation.

Soon, a team of UCLA surgeons would arrive carting a single liver donated by the family of a young man who had been declared brain dead that day.

But was this a case of bad math? One liver. Two recipients?

Not at all. This was brilliant math: a division of one scarce, fragile, donated liver that would benefit two desperately ill people. And it's typical of the way liver transplantations are increasingly being addressed in a pioneering program at UCLA and in a few other transplant centers nationwide.

Since launching the program in July 1996, the UCLA In Situ Split Liver Program has resulted in 43 transplants from 22 donor livers (in one case, only half of a liver was transplanted). Most of the recipients--94%--have survived and are doing well. Only three of the recipients have needed a second transplant, a relatively common complication that occurs when a transplant recipient's body rejects the first organ.

The program essentially doubles the rate of liver transplantation and dramatically reduces the length of time patients spend waiting for a new liver--time in which most grow steadily sicker and weaker.

"This has made an enormous difference in our program," says Dr. Ronald W. Busuttil, director of the Dumont-UCLA Transplant Center. "Basically, every patient is considered a candidate for a split liver."

That such an advance is a godsend is an understatement. Despite years of public education campaigns to increase the number of donor organs, thousands of Americans are in need of transplants, and many die before getting the chance.

Typically, Busuttil says, about 8,000 to 9,000 Americans are registered on the national waiting list for liver transplants. But only about 4,000 livers are donated yearly by the relatives of individuals who have been declared brain dead.

"For every two recipients, there is one donor," Busuttil says. "And as we've improved the technology of liver transplantation and expanded the indications for transplant, the shortage is only going to get worse. It's particularly acute among pediatric patients."

On average, a baby in need of a liver transplant spends about 270 to 290 days on the waiting list, Busuttil says. But under UCLA's split-liver program--in which the liver is typically divided between one adult and one baby--most babies wait less than a month.

While such a technological advance seems logical in hindsight (after all, the liver is the only organ that can regenerate after it has been cut back), the approach was not easy to develop, Busuttil says.

The UCLA team first tried to split a liver in 1992 using a different technique that involved removing the donor liver and then splitting it before transplanting it into two recipients. Only one of four transplants was successful, in part because of the stress of splitting the organ outside the body.

The program was dropped, and the UCLA team moved on to another innovation aimed at babies awaiting transplantation.

Under the Living-Related Donor Program, the parent of a baby in critical need donates a small portion of his or her liver to the child. UCLA has performed more than 30 living-related donor transplants since 1993 with great success. But Busuttil remains uneasy with that solution, which is now used only as a last resort.

"Prior to [the split-liver program], we'd get a baby in and we'd have to tell the parents, 'Unless you do living-related donation, the chance is high that your baby will die.'

"But it carries a risk to the parent. And even one death of a parent would, to me, be absolutely catastrophic. Although that technology has been very successful, we believe it should be a second-line treatment."

Moreover, relatively few families have opted for living-related donation. Sometimes the families who face this choice are headed by a single parent who is the sole wage earner or is responsible for several other children, Busuttil explains. Submitting to surgery is impossible.

Thus, when German surgeons published research on a successful split-liver program in 1996, the UCLA team decided to give it another go. This time, however, they opted to split the liver in the cadaver--or in situ--in the hopes that it would reduce the stress on the organ.

"We had to take a deep breath," Busuttil recalls. "But we had perfected the technology of living-related donor transplants. And we got a vast amount of experience with that. [Split-liver] is kind of the same operation, only it's done in a cadaver."

The team had also learned another crucial lesson: Splitting should be done only on livers from relatively young donors, from the teens to early 40s. Younger livers are likely to be of higher quality and more able to withstand the trauma.

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