Selection of a suitable donor
It is important to understand that no one knows exactly when a donor organ will be available for you. In Australia, only around 1% of all deaths occur in such a way that organ donation is possible. Only people who have died as a result of brain death are able to donate organs. Injuries or illnesses that result in brain death may include bleeding into the brain, accidents, infections or tumours. Potential organ donors must be brain dead, on a mechanical ventilator and in hospital (because without a supply of oxygen, organs would not be suitable for transplantation).
Equally important is the decision to donate. If the deceased did wish to donate his/her organs and the family support that decision, then all steps will be taken to ensure those wishes are fulfilled. Over 90% of Australians support organ donation ‘in-principle’. However, actual consents in the hospital setting are lower, at around 50%.
When consent for organ donation is obtained from the next of kin and following rigorous tests to confirm brain death, the donor will be assessed for their suitability to donate. If the donor is suitable to donate organs, they will be taken to the operating theatre for organ retrieval surgery that takes several hours to complete. Donor organs will be allocated by matching the blood group, height and weight of the donor and the recipient.
Increasingly, donor organs that are offered for transplantation have some reason why they are not absolutely optimal. With the poor organ donation rates in Australia, and the increasing number of people that need a transplant, even suboptimal donor organs are considered for transplantation. Thus, donors may be older, have some evidence of excess fat in the liver or have evidence of exposure to hepatitis virus infection.
Many liver transplant units worldwide will offer a hepatitis C-positive donor liver (that does not have evidence of significant liver disease) to a recipient with chronic hepatitis C. In all patients with hepatitis C, the hepatitis C infection comes back after transplant, and there is no evidence that the course of the hepatitis C in the new liver is any different if the donor liver has hepatitis C as well. Such a liver will not be used in a recipient who does not already have hepatitis C.
Some donors have evidence of previous exposure to another hepatitis virus, hepatitis B. In most of these cases the donor does not have evidence of active infection, but on the basis of blood tests, we can tell that there are small quantities of the virus in the liver. Without preventative medication, this virus can reactivate in the new liver and cause long-term problems. Therefore, it is policy of transplant units to transplant such a liver and then to use highly effective preventative medicine (an extra tablet a day, called lamivudine) to prevent reactivation. If it is thought that it is in your best interest to accept such a donor, the issues will be discussed with you prior to proceeding to transplant.
In all cases, the transplant team will consider the quality of the donor organ carefully, and will not proceed to transplantation if it is thought that the risks to the recipient are too high. A decision not to proceed may be made fairly early in the process, just after a recipient has been notified, or if new information comes available, may be made even after the recipient has been transferred to the operating room. While this is obviously disappointing, it is in the patient’s best interest not to proceed to transplantation under such circumstances.
Communication
with the donor family
The donor coordinator (the person who organises the donation) writes to the donor’s family with information regarding which organs and tissues were transplanted and how the recipients are progressing. In accordance with the law, identifying information cannot be revealed to donor families or recipients. However, the donor family and the recipient may send anonymous letters to each other. For the family of an organ donor, receiving a card or letter of thanks from a transplant recipient is very special. If this is something that you would like to do at anytime following your transplant, we have set out some guidelines in order to maintain confidentiality. For information on how to write to the donor family, please contact the Liver Transplant Coordinator.