Innovations in Living Donor Liver Transplantation

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.

Hi, everybody. Welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio.

I am extremely pleased to welcome Dr. Koji Hashimoto, who is the Director of Living Donor Transplantation here at Cleveland Clinic's Transplant Center. We're going to touch a little bit about innovations in living donor liver transplantation. Dr. Hashimoto, thanks for joining us on Butts & Guts.

Dr. Koji Hashimoto: Thank you for having me today.

Dr. Scott Steele: I always like to start out a little bit about yourself, your background, where you're from, where you're trained and how did it come to the point that here at the Cleveland Clinic?

Dr. Koji Hashimoto: I'm a transplant surgeon at the Cleveland Clinic main campus. I’m originally from Japan, so I finished my training residency in Japan, and then I came here 16 years ago.

I did a fellowship training for liver transplant. I'm lucky I stayed in beautiful Cleveland and then I'm here. I'm specialized to do a liver transplant including a living donor.

Dr. Scott Steele: Well, that's fantastic. And we're glad to have you here. So let's start with a little bit of a broad overview of this. So liver transplant, what are some of the diseases or the indications why liver transplant would be required for a patient?

Dr. Koji Hashimoto: The most common indication for liver transplantation is alcoholic cirrhosis nowadays. It used to be a hepatitis C cirrhosis, but since we have a good medication for Hep C so that we don't see the hepatitis C cirrhosis anymore. Very few. The second indication is that non-alcoholic steatohepatitis. We call a NASH. So generally we call it fatty liver disease. So these two indications are main and otherwise we have other many reasons that cause liver cirrhosis and also acute liver failure is a good indication for live transplantation.

Dr. Scott Steele: So morbid obesity is an epidemic in the US and many of the Western societies. And you mentioned NASH as being something for that. Do they go hand in hand? Does morbid obesity go hand in hand with development of NASH or is that just something that your body processes things and all of a sudden you get a fatty liver?

Dr. Koji Hashimoto: I think that this metabolic disorder affects the entire body. Just the liver is a part of the disease.

Dr. Scott Steele: So give us an overview a little bit about what is the scale that we're talking about. How many liver transplants are typically needed here. And then do we have enough donors that are available to meet that demand?

Dr. Koji Hashimoto: Yeah, that's a very important question. So in the United States, there are more than 14,000 people waiting for liver transplantation, but unfortunately we have only 8,000 liver transplantation done in this country. So approximately 6,000 people are not having liver donors.

Dr. Scott Steele: Wow. That's unbelievable. Those are some numbers that we need to change around. So as I was sitting, preparing for this, I kept on thinking to myself, man, living donor liver transplant surgery. So walk us through this living donor liver transplant surgery.

Dr. Koji Hashimoto: Yes. So as we talk about this... So we don't have enough organ donors to transplant all patients with liver failure. So the idea came up with a living donor liver transplantation. So when we don't have enough transplant organs, so approximately I would say 20% of the patients in Cleveland become sick or die before liver transplantation. So to save those people, we can ask someone healthy mentally, physically. So these people can become a living donor. So just donating a piece of the liver to save someone else's life.

Dr. Scott Steele: When sitting there and walking through a perspective, living donor. I'm sure they got to ask you a bunch of questions. But is it safe. How much liver are you going to leave behind? How much liver of mine are you taking? What are the benefits of a living donor transplant versus the traditional deceased donor transplant?

Dr. Koji Hashimoto: So in traditional deceased donor liver transplantation, generally the waiting time for transplant is very long because we don't have enough organs. In the deceased donor liver transplantation, the priority on the transplant waiting determined by MELD score, which is calculated by your blood test. This MELD score goes between six and 40. And the higher the score goes, the more priority you have. So for example, if you have a MELD score of 40, that you can get the liver transplantation within days, but your MELD score is let's say 15, your waiting time will be expected to be like month or years. But if you have a serious complications with liver cirrhosis, sometimes you cannot wait. But in the living donor liver transplantation, if you identify a good living donor, you have no waiting time. Just you can set up the surgery date. And as long as donor and the recipient is available and the surgical team is available, we can go ahead and do a liver transplantation to save your life. So that's the best benefit doing the living donor liver transplantation.

Dr. Scott Steele: Do the patients that are transplanted, a living donor, do they do better or worse than a deceased donor?

Dr. Koji Hashimoto: Generally speaking, a living donor liver transplantation outcome is usually better than the deceased donor transplantation. Because you can receive the transplantation in a timely fashion.

Dr. Scott Steele: So you mentioned a little bit about kind of the waiting list and the MELD score and some of these other ones. So what type of factors go into that? That can impact the patient's qualifications, either get on the transplant or where they live on that transplant.

Dr. Koji Hashimoto: For the recipient qualification, any patient who has a liver failure, or liver cirrhosis, liver disease. So they should be qualified for transplantation unless they have any serious disease except for liver. So let's say someone has heart failure with a liver disease. So those people are not qualified transplantation. To make them qualified, we can also do combine the heart and the liver transplantation. So it depends on other organ systems function. But as long as you have liver failure, you'll be qualified for transplantation.

Dr. Scott Steele: So let's go into Truth or Myth. Truth or Myth: the age that a living donor needs to be is different based on if the liver is going into a child or an adult. Truth or myth?

Dr. Koji Hashimoto: So it's myth. So the truth is... Let's talk about the living donor. So the age of living donor has to be between 18 and 60. The reason we set the age limit at 18 is that the living donor has to make a decision to donate the piece of the liver independently. So we believe if you are age 18 or younger, you may not be able to make a decision independently.

Dr. Scott Steele: Walk me through a little bit about the evaluation process to become a living donor. How does one go about that? Is it oftentimes the person who needs a liver is reaching out and finding these people or do people volunteer? Is it brothers and sisters and uncles and aunts, how does this process work?

Dr. Koji Hashimoto: So the living donor can be usually the family member or friends, or just a stranger. So meaning. So if you have a liver disease, needing a liver transplantation, when you start looking for the living donor, usually the family comes up first. But if there is any reason that the families cannot be a donor, you can start having a conversation with people around you. And it does include your friends or neighbors or someone else. What I have seen is if you go to church, sometime the church friends can donate and some people use a social network. And if you post your story about what you need and how sick you are, sometimes somebody you don't know, becomes a living donor.

Dr. Scott Steele: Truth or Myth: the liver is the only organ that can undergo a living donor process.

Dr. Koji Hashimoto: That is a myth. The truth is the healthy person can donate a liver, kidney, and pancreas and the piece of lung. So the liver is not the only organ that you can donate.

Dr. Scott Steele: So walk me through. What can a patient expect when visiting you or someone on your team at Cleveland Clinic's Liver Transplant program, what's their journey, who they're meeting with, what tests do they got to undergo? And how long is this process to the point where you are in the operating room with both of them.

Dr. Koji Hashimoto: So as a living donor, when you come to Cleveland Clinic, so you meet the entire liver transplant team. And as a living donor to be evaluated, usually it takes a few days to complete. So we guide you to have a blood test or imaging, the studies, including the scan MRI, and also you're going to meet all specialties, who will be determining your candidacy for living donor. And if you come to Cleveland Clinic Liver Transplant Center, as a recipient, you also expect to see all people in our team. Basically we check you from head to toe, to make sure you're good to go for liver transplantation. So that's something you expect to see.

Dr. Scott Steele: Logistically. How do you decide? There's two different... So one's taking the liver out and the other one's putting it back in. How do you decide which one of those you're going to do? Are you the take it out person? Or are you the put it in person? How does that work? Logistically.

Dr. Koji Hashimoto: I am the person who put it in. And then we have a special team who will be taking out the piece of the liver. And then that's the very important part. We used to make a big incision to take the piece of the liver from the living donor. But three years ago, we changed our strategy. And then we start doing minimally invasive living donor surgery. So we are using very small incision on the living donor, put the surgical instrument inside of the abdomen, and then cut the liver out. And then we take the piece of liver out from the bikini line with a 10 centimeter, small incision, so that after living donation, your decisions will be almost invisible. And this minimally invasive procedure makes the post surgery recovery very quick.

Dr. Scott Steele: So what's on the horizon, as far as research and the Living Donor Liver Transplantation, that's going to help provide better outcomes in quality of life for donors and recipients? I'm sure you mentioned just one of them right now, that you're able to do it through small incisions, but anything else that you guys are working on.

Dr. Koji Hashimoto: So one other important thing is, so when you become a living donor, you can donate either left lobe or right lobe. So the left lobe is usually 30 to 35% and the right robe is 65 to 70%. So if you donate left, which is a smaller side, we can leave the bigger side of the liver in the donor, I think, which is safer for living donor. If you donate right side, you donate almost 60% or 70% of the liver to recipient, but you only have 30% to 35% in your body left. So in terms of safety of living donor, the more liver take from the living donor, the higher the risk goes. So our policy is taking the small liver from the living donor to transplant and save someone else. And which is actually not easy to do because we transplant a small piece of liver. Sometimes the recipient doesn't have good liver function after transplantation. So our research is how to make this small piece work. And actually we've been very successful. Approximately 50% of Living Donor Liver Transplantation is done by left lobe graft.

Dr. Scott Steele: That's incredible stuff. So we'd like to wind up with all of our guests, a little bit of what I like to call quick hitters, where we get to know you little bit better. So what's your favorite food?

Dr. Koji Hashimoto: My favorite food is miso soup.

Dr. Scott Steele: Miso soup. Good choice. What's your favorite sport to play or to watch?

Dr. Koji Hashimoto: My favorite sport is basketball, and I used to play basketball.

Dr. Scott Steele: Tell us about one of the favorite places or trips that you've gone. Where is that?

Dr. Koji Hashimoto: My favorite place is my hometown, but unfortunately I'm not able to visit right now. The favorite place to visit. I like Florida, and I like Mexico. And nowadays I like Abu Dhabi to visit.

Dr. Scott Steele: Nice. Nice, nice. And then finally, you've been here for 16 years. You said, tell us what you like about living here in beautiful Northeast Ohio.

Dr. Koji Hashimoto: So Cleveland has a beautiful weather, as you know. Summer is beautiful and the winter is a little bit cold, but you can see a nice sunshine in summer and a beautiful snow. And I love the people living freedom. They are very warm. So that's why I love it.

Dr. Scott Steele: Fantastic. So why don't you give a final take home message for our listeners about this whole process, this whole program.

Dr. Koji Hashimoto: So the living donor liver transplantation, it’s life saving. So the many people die or become too sick before liver transplantation. So the Living Donor Liver Transplantation is a hope to save those people. So we are working on every day, very hard to provide more opportunities to sick people. So if you have sick people around you, please think about finding a living donor or becoming a living donor.

Dr. Scott Steele: That's absolutely incredible stuff. And so for more information on Cleveland Clinics Liver Transplant program, please visit please Clevelandclinic.org/living donation. That's Clevelandclinic.org/living donation. You can also call the program at 216.444.1976. That's 216.444.1976. And again, you always hear me say it. Please remember it's important for you and your family to continue to receive medical care, regular checkups and screenings and rest assured here at the Cleveland Clinic, we're taking all the necessary precautions to sterilize our facilities and protect our patients and caregivers. Koji, thanks so much for joining us on Butts & Guts.

Dr. Koji Hashimoto: Thank you so much, Scott.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic until next time. Thanks for listening to Butts & Guts.