Assessment of Potential Donors
Once you agree to be a living liver donor, you will go through an extensive evaluation to determine if you can be a donor to your intended recipient. The transplant team will evaluate whether:
- Your blood type is compatible with the intended recipient.
- You are healthy enough to undergo major surgery and recover completely.
- You have a healthy liver and the portion you would donate is the right size for the recipient and the remaining portion is right for you.
- You are psychologically ready to donate.
Each transplant center has its own procedures and guidelines for evaluating potential donors but here are the typical steps.
1. Blood Type
The first step is to determine your blood type. There are four blood types determined by the presence or absence of two antigens—the A antigen and the B antigen. Blood type A means you have the A antigen. Type B means you have the B antigen. Type AB means you have both antigens. Type O means you have neither antigen.
You must have a blood type compatible with the recipient or you will not be able to donate. Note that the Rh factor (positive or negative) usually is not considered for matching purposes. Here is who can donate to whom:
- Type A can donate to types A and AB.
- Type B can donate to types B and AB.
- Type AB can donate to type AB.
- Type O can donate to types A, B, AB, and O.
The blood type is determined by drawing your blood and testing it.
If you and your potential recipient have blood types that are not compatible, there are three things you can consider:
- Paired exchange. Paired exchange involves finding another donor-recipient pair who have incompatible blood types but where your blood type is compatible with the other recipient, and the other donor’s blood type is compatible with your intended recipient’s blood type. In that situation, you donate to the other recipient, and the other donor donates to your recipient. For example, assume there is a donor/recipient pair where the donor, Jim, is blood type A and the person he’d like to donate to, Lisa, is blood type B. Jim can’t donate to Lisa because they have incompatible blood types. But there is a donor/recipient pair where the donor, Niki, is blood type B and she’d like to donate to Mike, but he’s blood type A. They are incompatible. Paired exchange provides the solution: Jim donates to Mike (both blood type A), and Niki donates to Lisa (both blood type B). This kind of living liver donation arrangement is not common — there were only 24 in 2022 — but the number is increasing every year.
- A different living donor. If you don’t match your intended recipient, maybe there is another friend, relative, or unrelated living donor who can be considered.
- Deceased donation. The recipient could wait for a compatible deceased donor.
2. Your General Health
Living donation may be the only medical procedure allowed where the patient (the donor) purposely leaves the hospital in worse physical health than when he or she walked in. Consequently, the transplant team needs to make sure you are in excellent health — better than the average person — so you can continue to enjoy good health after the donation.
You will go through an extensive physical examination, one that has more tests and evaluations than you have probably ever experienced before. The transplant center will provide you with a schedule for the exams and testing that they require, which often stretches over multiple days. Usually, you can do the exam and testing locally if your recipient lives somewhere else.
- Physical exam including blood testing (cholesterol, blood count, liver function, kidney function, glucose, etc.), blood pressure, height, weight, BMI calculation, personal and family medical history, prescription drug use, substance abuse, smoking history, alcohol intake, history of mental illness and treatment, chest x-ray, electrocardiogram, and testing for viral and bacterial infection (HIV, hepatitis B and C, tuberculosis, etc.).
- A special blood test for hypercoagulability — a long word that means an increased tendency of blood to clot.
- Electrocardiogram and echocardiogram; cardiac stress test if over age 50 or presence of other heart risk factors.
- Pulmonary function test and a chest CT scan for smokers.
- Cancer screening.
- Female donor candidates undergo a gynecological exam, mammography (if over age 40), PAP smear, and pregnancy test.
- Potential donors over age 50 may undergo a colonoscopy.
Most transplant centers also have age restrictions. Typically a donor must be at least age 18 but not older than age 60. Check with your transplant team about their age requirements.
Certain medical conditions will exclude you from being a donor. These conditions, called “contraindications,” vary from one transplant center to another because of the lack of common medical guidelines for evaluating living donors. In the case of liver donation, there are specific health criteria for potential donors. The criteria depend on the transplant center, but here’s a list of common considerations:
- No heart, renal, or liver problems or abnormalities.
- No history of deep vein thrombosis or history of bleeding problems.
- Negative for Hepatitis B and C and for HIV, as well as other infectious diseases.
- No history of diabetes (although Type II diabetes may be allowed if under control).
- Not obese (generally a BMI of 30 or less although the limit is 35 at some transplant centers).
- No prior liver surgery.
- No alcoholism or frequent and heavy alcohol intake.
- No history of cancer (other than skin cancer).
- No drug abuse (cocaine, heroin, opioids, etc. Center policies regarding use of marijuana vary.)
- Your height and weight compared to the recipient is “appropriate.”
If you are overweight but otherwise a good potential donor, you may be given time to lose weight. Several donors who have visited LDO said they were able to lose weight and donate successfully.
3. Health of Your Liver
Following a general assessment of your health, the testing focuses on your liver so the surgical team knows everything about your liver. You will undergo some or all of the following tests:
- Computed tomography (CT) angiography. The test, commonly called a CT scan, is a sophisticated form of X-ray that provides a detailed picture of what your liver looks like–the size, shape, and volume.
- Magnetic resonance imaging (MRI). The MRI looks at the arteries and veins going into and out of your liver, as well as your liver’s bile ducts.
- Ultrasound. Although not as common, you might also have an ultrasound of your abdomen. The ultrasound can provide additional information about your liver such as whether you have stones in your gallbladder.
In some cases, the transplant team may order a liver biopsy. A biopsy involves inserting a needle into your liver, extracting a small amount of the liver, and analyzing it. For example, the biopsy might confirm whether you have fatty liver disease (liver steatosis).
Finally, you might have a genetic test if you are a blood relative of the recipient and the recipient’s liver disease is hereditary. The team wants to make sure you are not at risk of having the same disease in the future.
The information from these tests is used by the surgeon to determine the anatomy of your liver and to decide which segments are best for donation.
You might be rejected as a donor if there are abnormalities in your liver (for example, if you have tumors), if you have a complex anatomy (many veins or arteries), or if your liver is too small. You might also find you have health issues that need to be addressed, such as a fatty liver or cirrhosis. The transplant team will take you through the results of your testing and help you understand whether or not you can be a donor. If health issues have been identified, the team will discuss steps to take to address those issues.
Note: You will want to keep copies of all your pre-donation test results. This information is a useful baseline for comparing test results after donation.
4. Psychosocial Assessment
During the medical evaluation you will meet with a social worker, psychologist, or psychiatrist for a psychosocial assessment, the goal of which is to evaluate your state of mind. This evaluation looks at the mental, emotional, social, and spiritual aspects of being healthy.
Usually this assessment is done in a meeting during which the assessor asks you several questions about your level of understanding of the living donation process and risks, whether are you freely choosing to be a donor, and whether you are emotionally and psychologically ready for donation and recovery. There are no standard procedures for this kind of assessment. However, the UNOS Living Donor Committee put together recommendations. The recommendations were not approved, but they indicate the subjects that might be covered in your psychosocial evaluation. Here is what the committee recommended:
- History and current state. Obtain standard background information such as the prospective donor’s education level, living situation, cultural background, religious beliefs and practices, significant relationships, family psychosocial history, employment, lifestyle, community activities, legal offense history, and citizenship.
- Capacity. Ensure that the prospective donor’s cognitive status and capacity to comprehend information are not compromised and do not interfere with judgment; determine risk for exploitation.
- Psychological status. Establish the presence or absence of current and prior psychiatric disorders, including but not limited to mood, anxiety, substance abuse, and personality disorders. Review current or prior therapeutic interventions (counseling, medications); physical, psychological or sexual abuse; current stressors (e.g., relationships, home, work); recent losses; and chronic pain management. Assess repertoire of coping skills to manage previous life or health-related stressors.
- Relationship with the transplant candidate. Review the nature and degree of closeness (if any) to the recipient (i.e., how the relationship developed), and whether the transplant would impose expectations or perceived obligations on the part of either the donor or the recipient.
- Motivation. Explore the rationale and reasoning for volunteering to donate, i.e., the “voluntariness”, including whether donation would be consistent with past behaviors, apparent values, beliefs, moral obligations or lifestyle. Determine whether the donation would be free of coercion, inducements, ambivalence, impulsivity, or ulterior motives (e.g., to atone or gain approval, to stabilize self-image, or to remedy a psychological malady).
- Donor knowledge, understanding, and preparation. Explore the prospective donor’s awareness of the following:
> Any potential short- and long-term risks for surgical complications and health outcomes, both for the donor and the transplant candidate;
> Recovery and recuperation time;
> Availability of alternative treatments for the transplant candidate; and
> Financial ramifications (including possible insurance risk).
Make sure that the donor understands the data on long-term donor health and psychosocial outcomes continue to be sparse. Assess the prospective donor’s understanding, acceptance, and respect for the specific donor protocol, e.g., willingness to accept potential lack of communication from the recipient and the donor’s willingness to undergo future donor follow up.
- Social support. Evaluate support networks available to the prospective donor on an ongoing basis as well as during the donor’s recovery from surgery. Consider significant others, family members, social contacts, and employers.
- Financial suitability. Determine whether the prospective donor is financially stable and free of financial hardship; has resources available to cover financial obligations for expected and unexpected donation-related expenses; is able to take time away from work or established role, including unplanned extended recovery time; and has disability and health insurance.
Keep in mind that policies and procedures vary from transplant team to transplant team. You should confirm the actual psychosocial evaluation process with your transplant team.
A Review and Decision
Once your physical and psychosocial evaluations are complete, the results are reviewed by the transplant team and a transplant review committee at the transplant center. The purpose of the review is to decide whether it is safe for you to donate and whether your being a living donor is the best course of treatment for the recipient. The committee will also determine if you are donating for the right reasons and are able to consent to the donation.
If you are not approved, you will be told why and then you can work with the transplant coordinator on how to communicate the news to the recipient. More importantly, if you are not approved for a health reason, you should be referred to a health professional to address the issue. There have been situations where the health evaluation revealed the potential donor had a serious health issue he or she was previously unaware of. While the potential donor wasn’t able to save the life of their intended recipient, their interest in living donation did save another life — their own.
If you are approved, you will move to the next phase of the living donation process — the actual donation itself. Remember that even if you are approved for donation, you can change your mind at any time.