Doubling Up

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.

“You have to select the donor very carefully. We know that older organs won’t tolerate being out of the body for longer periods of time,” Busuttil says.

Because a brain-dead donor’s heart is still functioning, the blood supply to the liver is preserved while the surgeons divide the organ. This lowers the rate of complications.

Finally, the split-liver process works because the liver can be divided into a small piece for the pediatric patient and a larger piece for the adult. The adult recipient does not need to have an entire liver, unless the person is exceptionally large. And the small portion transplanted into a baby will grow as the child grows.

“I envision a scenario some day in which livers are routinely split and offered to two recipients,” says Busuttil, adding that if every transplant center that could offer the protocol did so, it would trim the waiting list by 1,000 annually.

But given that an average of 500 Southern Californians are awaiting a liver transplant at any one time, the UCLA program has had an impact on the national waiting list. UCLA’s liver transplant program is the largest in the world, having completed 350 transplants in 1996.

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Patients are asked to consent to receiving a split liver, and virtually all of them have, Busuttil says.

Mary Peters of Yorba Linda didn’t hesitate when doctors informed her that her baby daughter, Stevie, would probably be offered a split liver.

“They told us that if we waited for a whole liver from a baby her size, it would probably never come,” Peters recalls.

Stevie underwent a split-liver transplant at UCLA in May at the age of 10 months. She was born with a potentially fatal defect called biliary atresia.

“She is doing really well,” Peters says. “She’s developing. She’s happy. She looks like a healthy baby.”

Judy Burton, 50, had less than a week to live when she was offered a split liver just more than a year ago. The assistant superintendent for school reform at the Los Angeles Unified School District had become suddenly and acutely ill one month earlier from a disorder called autoimmune hepatitis.

“I was stunned that it was a split liver,” Burton acknowledges. “I had no idea that could be done. But I also felt that it was so fortunate that two people’s lives could be spared by one organ being donated. And when I was told a baby girl had received the other part, I hoped that she would do well.”

Burton was later told that the girl had survived. As for her, she feels “better than I have in 20 years.”

“I feel so fortunate that science afforded me this opportunity to continue to be alive,” she says. “I had been so concerned that, once on the waiting list, there would not even be a donor. I feel so blessed that I had such a short time on the waiting list.”

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Want to Be a Donor?

For information on organ donation, including how to get a donor card, call:

* Southern California Organ Procurement Center, (800) 786-4077.

* Regional Organ Procurement Agency, (800) 933-0440.