Jan. 19, 2000 George Aponte bought his first Harley-Davidson motorcycle just over a year ago. In the process of filling out the paperwork, he met "an angel" who in late December saved his life by donating half of her healthy liver to replace his diseased one.
Two days before Christmas, doctors at Cedars-Sinai Medical Center performed the transplant -- one of the first completely non-related, living donor, adult-to-adult liver transplants to be accomplished in the western United States.
George found out in 1989 that he had hepatitis C, a potentially deadly and easily transmitted form of liver disease. By undergoing periodic testing and adopting a healthful lifestyle, George was able for several years to maintain relatively good health. But the 41-year-old former building coordinator at a machinery distribution company in Arizona said he eventually became extremely lethargic and his alertness deteriorated sharply.
"I could have a good night's rest, wake up, take my morning shower and drive to work, but in five minutes on the road, I'd be falling asleep," said George, who is married but has been separated for several years. "There were things I was not able to do any more without huffing and puffing. We knew things were getting bad when parts of my job I was very, very good at were slipping away. People would have to explain to me two or three times what was going on."
In 1997, an enlarged spleen, failing liver and other complications required a two-month hospital stay. At that time, he learned that he would not be able to work again until he received a healthy liver. But because of the shortage of cadaver livers, waiting lists are long and his chances were slim.
Fortunately, he decided about a year ago to buy a Harley, and he went to a shop that had a new employee named Karen Carrion. Although Karen doesn't ride motorcycles herself, she once owned a bike shop in California and she handled the paperwork for George's purchase. She learned of George's liver problems through a coworker, and she and George discussed the situation a couple of times when they saw each other at bike events.
Unbeknownst to George, Karen also bought a book about hepatitis C to learn more about the disease and any options that might be open to him. She read about partial liver living donor transplantation and decided to find out if she might be a compatible donor. She even called Cedars-Sinai and asked a transplant coordinator for details about the testing process and the steps she could take to donate half of her liver. Then she went to a bloodmobile and donated blood to discover her blood type.
"She called me up one day and said, 'George, I'd like to talk to you.' We'd never really talked that much before," said George, noting that the two had met face to face only three times.
Karen said George half-jokingly asked her if she had found him a liver donor. "Actually, yes," she replied.
"Who?" he asked.
"Me," she said, informing him that she had already found out that she could be a compatible donor but she needed his permission to go to Cedars-Sinai for additional testing.
"What this woman did out of the goodness of her heart... She's a heck of a person," said George, who refers to Karen as "an angel" who likes to help people.
Before the surgery was scheduled, George escorted Karen on two trips to Cedars-Sinai for preparation and evaluations. She met with seven doctors and underwent countless blood tests, a liver biopsy, chest X-rays, a complete physical exam and a psychological assessment. She also had an MRI performed in October that indicated she had a large, perfectly healthy liver.
The operations were scheduled for late December. By combining her vacation time and the company's planned closing for the final week of the year, she would be able to recuperate before returning to work.
"Even at the very last minute on the operating table, I could have changed my mind and backed out," said Karen. She was assigned a physician who was not a member of the transplant team - ensuring that she would have an advocate to support any decision she made. But she said she never second-guessed her initial wish. "I was not scared at all," she said. "Even when I went into the ICU before the surgery, I felt so much peace."
"One good thing we had on our side," said George," is that we were both positive during the whole thing. We knew that it would work. We never got anxious or scared."
In fact, over the years, George has learned the value of a positive outlook. "From the day you find out that you have hepatitis C, you have to keep your head up. Something is going to come along and make it better for you," he said. "You have to keep a positive attitude. Without a positive attitude, life is nothing."
Karen's operation began about 11 a.m. The donated half of her liver was ready to be removed by 2 p.m. George's surgery began at 4 p.m. His diseased liver was removed by 6 p.m., and the new liver was transplanted immediately thereafter, according to Christopher R. Shackleton, M.D., who led the operations with his colleagues, Steven D. Colquhoun, M.D., and Walid S. Arnaout, M.D.
"Both patients woke up from the operations quickly and recovered promptly," said Dr. Shackleton, Director of the Centers for Liver and Kidney Diseases and Transplantation at Cedars-Sinai. "Karen did not experience any detriment to her liver function, and George manifested very prompt resumption of normal liver function with the transplant."
Dr. Colquhoun, Program Director for Liver Transplantation, said there is no such thing as a "routine" transplant, but the need for meticulous care is especially important when operating on a healthy donor.
"This is a totally healthy person by definition, and we can't accept any kind of complications," said Dr. Colquhoun. "This is true with the kidney donors I've been involved with, as well. Your acceptance rate for any kind of complication - anything - is zero. And compared to the kidney operation, a liver transplant is a couple of orders of magnitude more complex, so the risks are greater."
As is typical in these operations in the United States, the entire right lobe of the donor liver was transplanted. Dr. Arnaout, Associate Director for Liver Transplantation, said each lobe usually comprises about 50 percent of the entire liver, although the right lobe often is slightly larger.
"Generally speaking," he said, "people with a healthy liver will not notice the loss of 50 percent of the liver. They don't feel weak, they can't tell the difference. As long as there is sufficient liver tissue to carry on all the functions, you can't tell whether you have 100 percent of your liver mass or 80 percent or 70 percent." In fact, he said, normal people with healthy livers need only about 30 to 35 percent of their liver mass for survival.
"In a living donor situation, our safety margin is pushed much, much higher," he said. "We're not going to take any chances and see if they will be OK with 30 percent of their liver mass. We know they would but we don't want to get there. Taking 50 to 55 percent, the donor is definitely safe and they will not be affected, but at the same time, we have enough liver tissue to be sufficient for the recipient."
John M. Vierling, M.D., Director of Hepatology and Medical Director of Liver Transplantation at Cedars-Sinai, said Karen is expected to recuperate fully over the next six to eight weeks. "During this time, her liver will regenerate the same amount of tissue that had been removed. Thus, she will again have a normal liver. After the healing of her wound is complete, she will be able to participate in all of her former activities without restriction."
Meanwhile, George's surgical wounds will heal and he will be able to resume most of his activities over the next three months, said Dr. Vierling, who serves as chairman of the board of directors of the American Liver Foundation. "The transplanted liver lobe, which is smaller than his native liver, will also regenerate the mass of tissue that his body requires and then cease growing. From three to six months, we expect to see increased evidence of improved nutrition, weight gain, increased muscular strength and exercise tolerance."
Patients whose transplanted livers are functioning well usually can resume full activities, including work, between six and 12 months after surgery, according to Dr. Vierling, who said that George, like all liver transplant patients, will require life-long immunosuppressive medications to prevent rejection of the transplanted organ.
While splitting and transplanting a healthy liver can be accomplished, the surgical and medical team said it is not the ideal solution to the shortage of donated organs.
"The waiting list for liver transplantation in this country grows exponentially at 30 percent per year while the cadaver donor resource expands only at about two to three percent per year. Those numbers are never going to match," said Dr. Shackleton. "It would be wonderful if we had a sufficient supply of donor organs to meet recipient demands and did not require subjecting healthy people to an operation of this magnitude, but the reality is that we don't and we will not for the foreseeable future. The only practical way to transplant in a timely fashion, and circumvent the development of serious or life-threatening complications in many of these patients, is going to be through the option of living donor transplantation."
Dr. Colquhoun said Karen's decision to share her liver with George is an "enormous gift that I don't know how to quantify exactly. But I think the proper term or analogy is that she is really a pioneer. There probably have been fewer than 100 similar procedures done in the United States, which is a pretty small experience. Here's a woman who is signing up for this operation when there's very little known about what the long-term implications might be."
He said the rapidly growing need for donor livers - the waiting list has doubled from about 7,000 to about 14,000 in the last three years - is requiring surgeons and compassionate friends and family members to go to greater lengths to save lives.
"We've reached a point where we're forced to do living donation liver transplants. It didn't make sense before. If somebody was going to be able to get a liver in a reasonable time frame, it just didn't make sense to put another healthy person at risk. But now we've come to a point where it actually makes sense," Dr. Colquhoun said.
"This is a recurrent theme in our field. People need to think about having their organs donated after death. They need to make a decision and talk about it. It's the family members who will ultimately make the decision. If one person dissents, the organ donation falls through, the patient's body dies after their brain, no one benefits from it, and patients die while waiting. If we could transplant all of the organs of people who are brain dead and candidates to be organ donors, we would not have to do this. We wouldn't have to put people like this donor through this operation."
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