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Review casts pall on UPMC's live-donor liver transplants

| Sunday, Nov. 23, 2008

A long-awaited review of live-donor liver transplants at the University of Pittsburgh Medical Center is expected to show recipients experience a potentially serious complication -- either bile duct leakage or blockage -- more often than the national average, the center's interim chief of transplantation told the Tribune-Review.

The review likely will show that 40 percent to 50 percent of recipients experience the problem, which can require a second surgery, said Dr. Wallis Marsh, UPMC's interim chief of transplantation. That's higher than the national average of 32 percent reported last month in the American Journal of Transplantation.

"I can't say it alarms me because I think that's what it is," Marsh said. "The only thing is, I just want to make sure the recipients know what it is."

The findings have not been submitted for publication, but Marsh said he hopes that can happen by year's end. Information about complication rates would shed light on the controversial live-donor liver surgeries that were the specialty of former transplant chief Dr. Amadeo Marcos.

He abruptly resigned in March, citing personal reasons. Marcos dedicated much of his six-year tenure to growing UPMC's live-donor liver transplant program, one of the center's most important and visible specialties.

UPMC's review of live-donor liver transplant complications was initiated by Dr. Thomas Starzl, the now retired surgeon who performed the world's first successful liver transplant, Marsh said. Starzl was out of the country this week and could not be reached.

Starzl submitted his findings to the New England Journal of Medicine, but they were never published. A Journal spokeswoman said internal policy prevents her from confirming the submission of any medical papers. Marsh said he submitted his independent findings to another publication, the American Journal of Transplantation. Its editorial board asked for revisions and then rejected the paper.

Marsh said he had been working on his paper since October 2007, and that Starzl had started work on his own before that.

Marsh said he and Starzl then agreed to collaborate on a joint study. The results could be submitted to the New England Journal of Medicine late next month, Marsh said.

Besides Marsh and Starzl, Dr. Pierre-Alain Clavien, a Swiss transplant surgeon who created a system for classifying the severity of transplant complications, has participated in the review. Clavien and Marsh have been considered finalists for taking over UPMC's transplant program permanently.

Live-donor liver transplantation is an alternative to waiting for an organ from a deceased donor. In the surgery, doctors take half of a living donor's liver and transplant it into a recipient. Because livers regenerate, donor and recipient livers usually grow to normal size within two months.

Nationwide, the number of liver transplants with live donors, however, has dropped by almost half to 267 last year from 522 in 2001.

Doctors and patients have become more aware of complications, and livers from deceased donors have become more readily available, said Dr. James Trotter, an investigator with the Adult-to-Adult Living Donor Liver Transplant Cohort, a federally funded group known as A2ALL that is looking at the transplants nationwide. UPMC is not part of that study group.

"There's a survival advantage for people who undergo live-donor liver transplant versus waiting on the transplant list," Trotter said. "For many patients listed for transplant, the greatest risk is dying on the list."

The A2ALL group in October reported a 31.8 percent rate of bile duct leakage among recipients. That problem can often be fixed with surgery without losing the donor liver.

The rate of all other problems among live-donor liver transplant recipients at UPMC could be higher than 50 percent, Marsh said. The A2ALL study found that 82.8 percent of all recipients experience some complication, a rate higher than those who receive whole livers from deceased donors.

For donors, the federal government last year adopted rules requiring transplant centers to provide explicit information about risks. UPMC warns donors that complications occur in as many as 30 percent of patients.

Bile duct problems happen less frequently among donors than recipients. Two out of more than 200 donors at UPMC's transplant facilities in Pittsburgh and Italy have required a second surgery to fix their bile ducts, Marsh said. Still, that's too high, Marsh said, because the donors didn't have such medical problems before giving up part of their liver.

"It's not dramatically high, but it's something you don't want to happen because the donors are not sick," Marsh said.

Surgeons might never be able to reduce the frequency of complications, but Marsh said the review has highlighted the problem.

"It's going to help us focus on what we should be focusing on if we're going to improve this operation," he said.

UPMC surgeons are studying a new technique to correct the bile duct problems. But even if surgeons can't altogether eliminate those complications, patients need to be aware of their potential. Once the findings of Marsh and Starzl are validated, Marsh said, he wants to have that information added to the hospital's consent forms.

"Everybody needs to know the risks ahead of them," said Trotter, the A2ALL investigator. "For obvious reasons, everyone wants to know what they're signing up for."

The idea of better informed consent is excellent, said Donna Luebke, a registered nurse in Ohio who is a patient advocate for live-donor liver transplants.

"Any patient having surgery has a right to be informed of the risks and benefits," said Luebke, a former board member of the United Network for Organ Sharing, a national nonprofit that tracks organ policies. "The patient needs to factor in this information to be able to say 'Do I want a living donor' or 'Do I want a deceased donor?' "

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