The Life-Saving Act of Donating a Liver with Dr. Koji Hashimoto

Podcast Transcript

Nada:   Hi, thank you for joining us. I'm your host Nada Youssef, and you're listening to health essentials podcast by Cleveland Clinic. Today we're broadcasting from Cleveland Clinic main campus here in Cleveland, Ohio and we're here with Dr. Koji Hashimoto. Dr. Hashimoto is the director of the living donor liver transplantation, as well as the director of pediatric liver transplantation here at Cleveland Clinic. And today we're talking about living organ donation specifically the liver right?

Dr. Hashimoto: Yes.

Nada:   Thank you so much for being here today.

Dr. Hashimoto: Thank you for having me.

Nada:   Sure, and please remember this is for informational purposes only and it's not intended to replace your own physician advice. So before we jump into the topic, I'm going to ask you some questions off topic to get to know you on a personal level, if that's okay?

Dr. Hashimoto: Okay, sure.

Nada:   What is your favorite spot to go to on the weekends in Cleveland, Ohio?

Dr. Hashimoto: I usually like to stay with my family.

Nada:   Okay, with your family knowing indoor?

Dr. Hashimoto: Off course, I don't have enough time. Trying to stay around.

Nada:   Yeah. Okay, great. And then what about your best vacation spot?

Dr. Hashimoto: Best vacation spot. It's actually Cancun.

Nada:   Cancun, Mexico. Nice, never been there. And if you weren't a physician today, what would you be doing?

Dr. Hashimoto: I never think about anything else.

Nada:   Nothing else?

Dr. Hashimoto: Nothing else.

Nada:   Never. That's amazing. Well, you went for what you want to do. That's very good. All right. So if you or someone you know are suffering from advanced liver disease, make sure you stay tuned. A liver transplant can restore you to an optimum level of health and help you resume a healthy and productive life. Today we will cover topics ranging from finding a match, how the liver transplant works and everything you need to know in between. I want to talk general, first of all, what is living donation and how is it differ from a deceased donation?

Dr. Hashimoto: The living donation is the donation of the organ to save someone's life. There are two types of donation. One is the living donation and then the second one is as you said, deceased donation. The deceased donation is the organ donation coming from some who died with brain death or cardiac death. Instead of the deceased donation, the living donation is taking the organ from someone who is healthy.

Nada:   Okay, so someone living and healthy?

Dr. Hashimoto: Correct.

Nada:   What organs can be donated by living donors?

Dr. Hashimoto: Surprisingly we can donate kidney and of course liver and pancreas and lung.

Nada:   Pancreas, kidney and lung.

Dr. Hashimoto: Those organs can be donated by living donor.

Nada:   Okay, so what are the advantages of having a living donor versus a deceased?

Dr. Hashimoto: It's very important to know that what the difference is between the living donation and the deceased donation for the transplantation. Most of the organs come from the deceased donors in the United States, for example, in the liver transplantation more than 95% of transplantations were done by deceased donors, including the brain death and the cardiac death. The living donor transplantation is only four to 5%.

Nada:   Wow, four to 5%?

Dr. Hashimoto: Right.

Nada:   Okay, so you're talking about the deceased organ donor, is that what you would put on your driver's license?

Dr. Hashimoto: Right, so if you get the driver's license, you have the statement to be the deceased donor or not.

Nada:   Then what qualifies a living, let's go into liver, since we're talking more liver. What qualifies a living liver donor?

Dr. Hashimoto: To be a living donor, you have to have unselfish desire to save someone's life. Let's say we talk about the liver transplantation, so to be a living liver donor, you have to be healthy mentally, physically and the age has to be between 18 and 55. And if you are donating your lever to child the age can go up to 60.

Nada:   Okay, so you have to be 18 to 55, and then 60 if it's for a child?

Dr. Hashimoto: Correct.

Nada:   Okay, and is this covered by insurance?

Dr. Hashimoto: Yes. The living donor has to have insurance, but all the medical expenses will be paid by the recipient insurance.

Nada:   Okay, so the recipient then is the one taking the bill?

Dr. Hashimoto: Correct.

Nada:   All right, so Cleveland Clinic has one of the few programs that performs living donor liver transplantation for both adults and children, correct?

Dr. Hashimoto: Yes.

Nada:   It's okay. What do patients need to do to be considered for a transplant?

Dr. Hashimoto: There are two major indication for liver transplantation. One is an acute liver failure and a second is a chronic liver failure. So the most of the patients who come to Cleveland Clinic, they have a chronic liver failure including hepatitis and fatty liver, we call NASH. No alcoholic hepatitis or autoimmune disease or alcoholic liver disease.

Nada:   These are the liver diseases that you to be considered a patient?

Dr. Hashimoto: Correct.

Nada:   For a transplant?

Dr. Hashimoto: Right.

Nada:   And what evaluation process or what phases do they go through to become a donor?

Dr. Hashimoto: To become a donor, first of all, when you decide to be a living donor you have to call in the transplant office at Cleveland Clinic. And the transplant coordinator would take some medical information, do a phone interview and once we know that this potential donor is a good candidate, we are going to bring the living donor in the hospital. In an outpatient clinic and then we do two or three days evaluation including a blood test, X-ray, CT scan, and a MRI.

Nada:   That's how you find out if you have a good candidate?

Dr. Hashimoto: Right.

Nada:   That's what you do? You're checking all their…

Dr. Hashimoto: Right, by doing the blood test, we make sure that people has good liver function, kidney function, and also doing the CT scan. We can see the size of the liver, which is very important and also we can see the anatomy of the liver.

Nada:   Okay, that's basically how you make sure it's a good match?

Dr. Hashimoto: Correct.

Nada:   For the donor or how do you make it?

Dr. Hashimoto: When you say match, we do a special test between the donor and the recipient. We mix the blood from receipt donor together and we can see that how much reaction the recipient have against the donor. So we can say that the risk of the rejection after transplantation, by doing this test. We call cross-match.

Nada:   I see, cross-match. That makes sure it doesn't do an organ failure. You take the patients and the donor's blood and you mix it to make sure it's matching?

Dr. Hashimoto: Right.

Nada:   Great.

Dr. Hashimoto: The other match we have to make sure is a blood type. The blood type that has to be compatible. The compatible mean if we have a blood type A, the living donor has to be blood type A or O.

Nada:   Or?

Dr. Hashimoto: A or blood type O.

Nada:   Oh, A or O.

Dr. Hashimoto: If recipient has blood type O, the donor blood type has to be O.

Nada:   I see, okay.

Dr. Hashimoto: If a recipient has blood type O, lets say, and the living donor has blood type A. So this is the incompatible combination, in this situation you cannot donate.

Nada:   Okay, let's say I found a match. I need a liver transplantation. First of all, besides insurance, you said the recipient is the one paying. But then I saw a lot of questions regarding the donor. Does the donor get paid?

Dr. Hashimoto: Donor never get paid.

Nada:   Donor does not get paid?

Dr. Hashimoto: No it’s illegal by doing the living donation. So you won't be able to get any money or anything else.

Nada:   Okay. It was a question that I saw, so I wanted to ask you.

Dr. Hashimoto: As I said, this is the unselfish desire.

Nada:   Yes, exactly. You have to be very selfless to do something like that.

Dr. Hashimoto: This is a gift of life.

Nada:   Yes. It's a major surgery.

Dr. Hashimoto: Actually priceless.

Nada:   Right, off course, priceless. Let's talk about some of the risks of living donor donation. Are there short-term or long-term risks that that patients should know about?

Dr. Hashimoto: The doing a living donation is a big surgery. It's not a small surgery to take the piece of the liver, so there is a certain risk on a living donation, including from small complication to the large complication. Approximately probably 30% of the living donor have complications after.

Nada:   13%?

Dr. Hashimoto: Right. 30.

Nada:   30%?

Dr. Hashimoto: 30% of living donors have complications.

Nada:   What kind of complications are talking about?

Dr. Hashimoto: Starting from the small complication, including wound infection.  It's a small infection on the incision and also sometimes patient feel nauseous and sometime throw up. Including the major complications, bile leak. The bile is the juice that the liver makes. They usually that bile goes down to the intestine, but when you cut liver, there's a small bile duct in the liver. We have to cut and tie, sometimes leaks after surgery. If the living donor leaks the bile, it's going to accumulate in the body and sometime it gets infected.

Nada:   I see. These are the short and long-term risks?

Dr. Hashimoto: Right. So that's a surgical complication. Then also the most important complication is a death or a liver failure. So this should not happen but it has happened in other places. In general, the risk of death or liver failure is a 0.2% of the living donation of the liver.

Nada:   Let's talk about the considerations before donating because it will affect you emotionally, intellectually, physically, financially. You need to know all of it. Can we talk a little bit about that? And if there's actually a great need, because you said there was only, what was the percentage? It was very little.

Dr. Hashimoto: 4 to 5%.

Nada:   4 to 5%. Let's talk a little bit about that.

Dr. Hashimoto: Asking someone to make a donation of the organ is a not the easy thing, so when a patient comes to the clinic, we evaluate the patient for a transplantation and we always ask recipient if you have a living donor, because if you have a living donor, there is no waiting time because if you wait for the deceased donor transplantation, you stay on the waiting list and you're getting sicker and sicker. And then if, once you get to the point you get the liver transplantation from the deceased donor, but this waiting time is totally unpredictable. Sometime it goes weeks and month and even years. And even the organ becomes available. Sometime the recipient is too sick to have a liver transplantation. So we always ask recipient if they have a living donor and if they do, there is no waiting time. They can have liver transplantation before they become too sick. That's why living donor liver transplantation is very important and lifesaving but not all patients have living donors.

Nada:   It's a difficult question to ask someone. How do you ask someone for their liver?

Dr. Hashimoto: I don't have a good answer for it but most of the time family comes to be a living donor but also you can ask your friends. And sometimes some of who you never met. Those people can be a living donor.

Nada:   Let's talk about the liver that you are you taking, how much of the liver of the donor? Are you taking a piece of it? A half of it?

Dr. Hashimoto: If you are donating the liver to a baby, we just need to take 15 to 20% of the liver, which is big enough to save the baby's life. If you donating to the adults we have to take a 30 to 40%, which we call left lobe or if the recipient is big or donor liver size is small, sometimes when you have to take a right lobe, which is the 60 to 70% of the liver.

The decision which lobe we take is the very complex process. Based on the donor liver size or how sick the recipient is, we decide we go for the left lobe or right lobe. So if we take left lobe, which is a smaller lobe, doing the left lobe donation is much safer for the living donor because we taking the smaller lobe but we have to put this risk on the recipient because we transplanting the smaller, but if we take right lobe, which is a bigger side, we have to put the more risks on the donor.

Nada:   Sure, so when you take the small piece from the, you said left lobe, is it?

Dr. Hashimoto: Left lobe is smaller.

Nada:   Okay, so if you take that piece, is it regenerating because the liver is going to regenerate in the donor? Is it going to regenerate in the recipient?

Dr. Hashimoto: The liver is amazing organ so which can regenerate. Usually after we take the liver out and then put it in the recipient, both donor liver and the recipient liver regenerate and back to almost the original size in six to eight weeks.

Nada:   Six to eight weeks for both recipient and donor it regenerates to a full liver?

Dr. Hashimoto: Right, that's why you think it's possible to do a living donation. We call partial liver transplantation.

Nada:   And no wait time, right?

Dr. Hashimoto: Correct.

Nada:   You said no wait time to, if you have a living donor there's no wait time.

Dr. Hashimoto: Just the time for the evaluation.

Nada:   Sure. Okay, and can we talk a little bit about the procedure itself? What to expect. Is it happening at the same time for the recipient and the donor, what does it look like?

Dr. Hashimoto: Once we make sure that the donor and the recipient is a good match, we just do pick the date. Whatever the convenient for the donor and the recipient. So we can have a best team in place and the donor surgery and the recipient surgery happen at the same time.

Nada:   Same time?

Dr. Hashimoto: Right.

Nada:   Same Room?

Dr. Hashimoto: Not in the same room, unfortunately.

Nada:   Okay, same time.

Dr. Hashimoto: Just the same time and in the next room each other.

Nada:   And how many surgeons does it takes to perform the surgery?

Dr. Hashimoto: We usually have a two staff surgeons for each donor and a recipient surgery.

Nada:   And then how long is the surgery?

Dr. Hashimoto: For living donor surgery usually takes five to six hours.

Nada:   Five to six hours, wow.

Dr. Hashimoto: And for a recipient surgery usually takes eight to 12 hours.

Nada:   Wow, that's a long surgery.

Dr. Hashimoto: It's a whole day surgery.

Nada:   No wonder you don't have any time. What does recovery look like and recovery both on the recipient side and the donor because you mentioned it could be much longer?

Dr. Hashimoto: Right, so lets talk about the recovery of the recipient. If no complication happens that recovery is really smooth. The average, the hospital stay after a liver transplantation is seven to 10 days.

Nada:   Seven to 10 days, okay.

Dr. Hashimoto: And then just they're going out of hospital and go home and come back to clinic. That's the best scenario but if something happened, like complication happens, they have to stay longer.

Nada:   Now you did mention some of the short term risks like infection or anything like that. Is that something that happens usually immediately during recovery or is it something that happens later?

Dr. Hashimoto: That's a liver donor. The recovery of the living donor is also depends on what happened after living donation but usually after living donation, the living donor stay in the intensive care overnight just to monitor the vital sign and liver function. And then most of the living donors stay in a hospital for five to six days.

Nada:   Oh, okay. So the donor stays longer?

Dr. Hashimoto: Living donor stays shorter than the recipient.

Nada:   Okay, all right, which makes sense.

Dr. Hashimoto: And then once they go out of the hospital, they stay around in Cleveland in a week or two and they go back home and within the four to five weeks, they can go back to the normal activity. And within two to three months, they can go back to the work.

Nada:   Normal life, yes. Great. So let's talk about for the recipient, let's talk about the benefits of living organ donation. I know you talked about basically shorter waiting time, if any. Can we talk about the quality of life? Is the liver functioning immediately. What are we benefiting for the recipient?

Dr. Hashimoto: Once everything goes well, the quality of life is excellent. You can have a normal life back and enjoy your life and usually the liver transplantation last more than 20, 30 years.

Nada:   Wow, 20, 30 years.

Dr. Hashimoto:  So as long as you take anti-immunosuppression drug to suppress the immune system to prevent rejection, this liver transplantation goes as long as you want.

Nada:   Let's talk about for the living donor, because again, we talked about this as a really big surgery. It's not just a small procedure that they're also going through. Would you say this is a positive emotional experience for someone that maybe it's a relative or a close friend?

Dr. Hashimoto:  Yes.

Nada:   Because if most donations are deceased, why is there a need for living donors? Why is it so important for a living donor?

Dr. Hashimoto:  That's a very good question. Originally we started the living donor transplantation because we don't have enough deceased organs to transplant all patients. That's why approximately 20% of patients waiting for transplantation they die or become too sick before they get liver transplantation. To save those people we started a living donor liver transplantation. Also when you are listed for liver transplantation, you are assigned a score we call marital score. So this marital score is calculated based on the blood test, including the bilirubin, INR and the creatinine. But most of the patients with liver failure, they significant complications including ascites.

Ascites is the fluid in your abdomen, build up in your abdomen, confusion, this we call hepatic encephalopathy. So once you have liver failure, you have ammonia circulating in the blood. The liver supposed to clear the ammonia, but when the liver fail, you cannot clear the ammonia, that's going to affect the brain. That cause confusion and also the patient have a varices.

The varices is an enlarged vein in esophagus and the stomach, sometime it ruptures and it cause catastrophic bleeding. And also when you have a liver failure, you may have a sarcopenia.  Sarcopenia is a muscle loss. So when you have a cirrhosis of the liver, you lose muscle and you get weak. So this complications happen very often but they never increase the marital score by having these complications. Marital score is just calculated by the blood test so even the patient become really sick with those complications. Sometimes the marital score under estimate the severity of the liver disease and those patients won't get the priority on the transplant waiting list.

Nada:   I see.

Dr. Hashimoto: By doing the living donor liver transplantation, we can save all these people. Even their marital score is low.

Nada:   I see. Even with us with a low match score. So you're helping with quality of life, increased lifespan. Liver functions is very important. Just like you said, it can be from brains to muscle. It could be everything. Can we talk a little bit about pediatric donation and how that could be different for children?

Dr. Hashimoto:  We have many sick children here. Their body size is very small, when we transplant these small babies, we need a very small piece of the liver but we don't have many deceased pediatric donors out there because children usually don't die, right?

Nada:   Yeah shouldn't.

Dr. Hashimoto: But to save these smaller children we have to get the appropriate size of the liver as soon as possible. So the living donor transplantation helps these people because we just take the 15 or 20% that liver. So that is the big enough to save the children’s life.

Nada:   And as you mentioned earlier, to donate to a child, you could be of age 18 up to 60?

Dr. Hashimoto: Correct.

Nada:   It's not like you need a little another pediatric liver. It's an adult liver?

Dr. Hashimoto: Correct. The living donor always comes from that at.

Nada:   How many people are on that donation list? Is this a significant number?

Dr. Hashimoto: Donation? There is no donation list, so the receipt list.

Nada:   Sorry, recipient list, sure.

Dr. Hashimoto: We have a quite a big recipient list, I think more than 200 people waiting for a transplant.

Nada:   200 people.

Dr. Hashimoto: If you look at the entire country, I think more than 14,000 or 15,000 people waiting for liver transplantation.

Nada:   And if someone wants to donate their liver and they don't know someone that needs it, they just, let's say, just heard you right now. And they said, there's a lot of people, maybe kids that need it and I wanted to be able to do it. They can just call our center and be a donor to find if they're a match. Correct? They don't have to be family or friends?

Dr. Hashimoto: Right, that's a great thing to do.

Nada:   Good and Cleveland Clinic built an online Facebook group, correct?

Dr. Hashimoto: Yes.

Nada:   For the community to create awareness of living donor liver transplant, some education information, even some events. So I wanted to make sure to share that with our audience. It's www.facebook.com/groups/clevelandclinicldlt. L-D-L-T, living donor liver transplantation. All right, what about other organs that are needed? Do those also come through the clinic through the transplantation center or do you have to go, let's say we talked about kidney?

Dr. Hashimoto: The living donor kidney?

Nada:   Yes.

Dr. Hashimoto: Yes, we have a living donor kidney program at the Cleveland Clinic.

Nada:   But this is only for liver, correct?

Dr. Hashimoto: Yes.

Nada:   Okay, great.

Dr. Hashimoto:  This account has a lot of information about living donor liver transplantation.

Nada:   Great. If you are watching and you want to learn more about living donor liver transplantation, please call (216) 444-1976. I'll say that again. It's (216) 444-1976 or you can visit clevelandclinic.org/livingdonation. Is there anything else you would like to tell our listeners or viewers about living donation?

Dr. Hashimoto: If you have liver problems, it's a very important to share your story, how sick you are and what you need with your family or friends. That is the start of the living donor liver transplantation. Once you start sharing your story, your friend or family can spread your story to someone else and also you can use a social network like a Facebook or Twitter. That's gonna even spread your story.

Nada:   Yeah, blast out the message.

Dr. Hashimoto: Those are the one with the tools to find a living donor.

Nada:   Hopefully like that Facebook group that will definitely help people find out where to go and who needs help and how to help. So thank you so much for your time.

Dr. Hashimoto: You're welcome.

Nada:   It's been a pleasure. It's been great. Thank you.

Dr. Hashimoto: Thank you.

Nada:   And thanks again to our listeners for joining us today. If you'd like to hear more of our health essentials podcast from our Cleveland Clinic experts, make sure you go to clevelandclinic.org/hepodcast or you can subscribe on iTunes and for more health tips, news, and information, make sure you're following us on Facebook, Twitter, Snapchat, and Instagram at Cleveland Clinic. Just one word. Thank you so much. We'll see you again next time. This concludes this Cleveland Clinic Health Essentials podcast. Thank you for listening. Join us again soon.