Bettering the odds for living donors

Transplants: Doctors aim to make sure people know the risks but face as few as possible.

April 29, 2002|By Jonathan Bor | Jonathan Bor,SUN STAFF

When David Kieffer offered to give up 60 percent of his liver to save his ailing friend's life, doctors launched into what would seem an endless series of warnings.

He was a healthy young man electing to undergo major surgery for no reason but to help someone else. He could suffer serious complications, even die. With that in mind, they said, he could back out at any time, right up to the hour of surgery.

But Kieffer, saying he was motivated by friendship and God, went through with the 12-hour operation two weeks ago at Johns Hopkins Hospital. He emerged healthy, if queasy and fatigued, and free of regret.

"It was a risk, but we didn't feel any pressure to do it," said the 28-year-old Kieffer, explaining that he made the decision with his wife, Marty. "We felt compelled to do it by love."

Over the past decade, the rapid growth of "living donor" transplants has provided hope to people who might otherwise wait years to receive livers and kidneys from accident victims and brain-dead patients. But the case in January of Mike Hurewitz, a 57-year-old journalist who died three days after donating part of his liver to his brother at Mount Sinai Hospital in New York, has raised concerns about their safety.

Although doctors acknowledge the risks that liver and kidney donors face, they say that nobody knows the true complication and death rates because surgeons are not required to report problems.

"There are complications that occur that are not generally known about because there is no forum for making them known," said Dr. Andrew Klein, chief of the transplant program at Hopkins. "There should be a way to honestly collect data - some sort of national registry or oversight."

What distinguishes living-donor transplants from other surgical procedures is that they are performed on patients who are perfectly healthy, placing an even greater burden on doctors to "do no harm."

"These patients are being subjected to risk for no immediate benefit to themselves," said Dr. David C. Cronin II, a transplant surgeon at the University of Chicago. "We have to protect those people we call heroes."

In the 13-year history of living-donor liver transplants, there have been three reported deaths among donors in the United States, a mortality rate of about one-half of 1 percent. Arguing that some deaths probably go unreported, Cronin estimates the actual rate is probably closer to 1 percent.

Living-donor kidney transplants have been performed for about 45 years and are much more common. Of the 14,000 kidney transplants performed last year in the United States, about 5,500 were from live donors. The risk of death is thought to be far lower than it is among liver donors, though the exact rate is similarly hard to discern.

Nobody has died donating an organ at Johns Hopkins or the University of Maryland Medical Center, according to doctors at the two transplant centers. But they acknowledge that the procedures pose significant risks of complications, and each center has seen its share.

Surgeons say they have reduced the risks to kidney donors by employing laparoscopic techniques that enable them to remove the organ through a tiny incision.

Nonetheless, doctors could nick a blood vessel, a problem that would require a surgical repair and blood transfusions. Other possible complications include infections, wound hernias and bowel injuries.

"Statistically, their risk of dying or having something really bad happen to them is about the same as it would be driving a car for a year," said Dr. Robert Montgomery, who performs kidney transplants at Johns Hopkins. "That helps them get their arms around what they're doing in terms of risk."

Montgomery said doctors must remain vigilant about potential complications as the number of people who can donate kidneys expands. At Hopkins, doctors are enabling people to become "altruistic donors" to people they don't know. Also, they have devised methods that allow patients to accept kidneys from people whose blood types don't match their own.

Liver donors face a higher risk of complications, in part because doctors must cut through a large organ that is filled with blood vessels. Klein said he worries about infections, bile duct leaks, wound hernias, nausea and pain. At Maryland, doctors recall a patient who was left with numbness in his arm, possibly because his nerves were unnaturally stretched on the operating table.

Doctors at Hopkins and Maryland say they also recall a patient at each institution who developed a blood clot that passed to the lungs. The clots were successfully treated, but represent serious complications that sometimes cannot be prevented.

Dr. Luis Arrazola, a surgeon who runs Hopkins' living donor liver transplant program, said he began testing prospective donors last July for rare genetic factors that could place them at higher risk for clotting. Since then, he has rejected two people who otherwise would have become donors. Nobody accepted into the program has developed the problem, he said.

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