By Chris Motola
URMC transplant chief: Local living-donor liver transplantation program has received referrals from all over the country
Q: Give us an overview of the living-donor liver transplantation program you head.
A: I’ve been here at the University of Rochester since I came here from Canada six years ago. A few years in I established a living-donor liver transplant program. The reason for this was due to the scarcity of organs, of livers, from deceased donors. Unfortunately, there are about 30% of patients on the waiting list who, while they’re waiting, get too sick to receive an organ or die. So living donors are another way to get organs. Of course, we have to be very careful with the donors, because they’re putting their own lives at risk and we want the best outcome for them. And we’ve been very successful. We’re the second largest living-donor living transplant program in the state of New York. I also do liver surgery, resecting, on patients who have metastases from colon cancer. There’s a group of patients who have so many metastases from colon cancer that we can’t resect the liver. For these patients, the best we can do is chemotherapy. That’s the best outcome we could have is to get chemotherapy, and their survival rate is poor. Unfortunately, only around five out of 100 will reach five years of survival or around that. Since my early years of training, I always questioned myself as to why we couldn’t do transplants on these patients. In the ‘90s, a group from France started doing liver transplants for these patients. The outcomes were not good. But this is 30 years ago. So we started a program in Rochester for liver transplantation in patients with unresectable liver metastasis.
Q: What made you want to try that?
A: This was based on data out of Norway. Norway has been doing this almost for the last 10 years, and they’ve been having very good outcomes. The reason that they were able to do this is because they have an excess of donation and they have shorter waiting lists, so they’ve been able to use livers from deceased donors. And we had to figure out how we could replicate that in the U.S. So we went through the ethics process at the University of Rochester. We got approval and so far we’ve done 10 of these cases. Our outcomes have been very similar to what Norway has been reporting. Instead of five out of 100 being alive five years later, close to around 70% to 80% are. Some of them even get cured and we’re talking about patients with very advanced liver metastasis. We’ve developed a protocol that’s very strict. We’ve been getting referrals from all over the country, even from other countries. We assess the patients in person or virtually and see how they’re responding to chemotherapy, if they’ve removed the primary tumor from the colon cancer and communicate with surgeons who have been involved with the patient to decide if the patient is a good candidate. We’ve surpassed 120 referrals. Of those, around 10 have been candidates from transplantations. They’ve had very good outcomes. And of course, they have to bring a living donor.
Q: What are the outcomes like for the donors?
A: Excellent, with complete, 100% survival. They can return back to work in several weeks with minimal complications.
Q: What’s the experience like for the donor?
A: The donors are healthy patients who evaluate with a very thorough assessment. We make sure they’re ready for this, both physically and emotionally. We want to be sure they’re mature adults who understand what this process is. Right now we accept donors who are between 18 and 60. They go through an educational process about what it means to be a donor. We do a lot of imaging just to be sure that the anatomy of the liver is good, that the size of the liver is good, because we want to make sure that the remaining portion of the liver is enough to survive. The good thing about the liver is that it can regenerate and grow back in both the donor and the receiver. We tell them to expect a five- or six-day stay in the hospital. We want them to stay close to Rochester for about three to four weeks to be sure they aren’t having any complications. And we’ll follow the patients for up to two years after they donate. They can have a completely normal life after they’ve recovered, but it’s probably going to take about two to three months to be the same way that they were before.
Q: Are there any long-term concerns for the donor?
A: This doesn’t have consequences so far as developing other diseases like hypertension, diabetes, cardiac diseases. And we try to minimize as much as possible the size of the incision.
Q: What factors determine whether or not a liver can regenerate from damage it receives?
A: The liver is an amazing organ that has more than 400 functions. And one of the most amazing capacities of the liver is the ability to grow back. But it needs to be a healthy liver to grow back the way it needs to. But there are conditions that impede it. For example, a fatty liver or elderly liver won’t regenerate the way a healthy liver will. So that’s why we need to be cautious.
Q: For the recipient, is there any difference in outcomes between getting a partial liver from a living donor and receiving a whole one from a deceased donor?
A: Yeah, that’s a good question. If we have a deceased organ, that’s ideal, but unfortunately there’s not enough, so the only way we can do this is with a live donor. Now, live donations are excellent organs even if they are partial. We know it’s coming from a healthy person. The other advantage is we have more flexibility in scheduling the surgery. We can make sure everything is setup. With deceased organs, one may become available in the middle of the night.
Q: Do you see this potentially becoming a more common practice in the U.S.?
A: I think if we do it cautiously, selecting patients in the appropriate way, and the donors as well, I think we’re going to be able to obtain good outcomes and show these results nationally. We’re in the process of creating a task force to create a consortium with similar institutions that are doing it.
Lifelines
Name: Roberto Hernandez-Alejandro, M.D.
Position: Chief of URMC’s abdominal transplant and liver surgery division; director of Living-donor Liver Transplantation; investigator at the Wilmot Cancer Institute
Hometown: Mexico City, Mexico
Education: Universidad de La Salle
Affiliations: Rochester Regional Health; Western University (Canada)
Organizations: American Surgical Association; International Liver Transplant Society; International HPV Association
Family: Married, two daughters, one son
Hobbies: Biking, exercise, yard work, travel