Recipient Turns Donor

By Prof (Dr.) Subhash Gupta in Liver Transplant and Biliary Sciences

Mar 29 , 2022 | 2 min read

1. Complications involved in using a liver than has been used before

A liver that has been transplanted before would have suffered the rejection process. This particular liver which had been transplanted only 3 weeks ago, would not have reached a tolerogenic state as happens normally after transplantation. Therefore if transplanted in another recipient, potentially the rejection process would be more severe. 

2. How did you overcome it? 

  • First, we checked the quality of the liver by looking at the liver function tests. To our surprise, these tests were pristine. 
  • Then, we confirmed that there had been no break in the immunosuppressive therapy after the onset of intracranial bleed whilst the now “recipient turned donor” had been on the ventilator in the ICU. 
  • The coordinators confirmed that no rejection episode had occurred after transplant and the intracranial bleed was unrelated to the transplant process. This information was obtained by carefully studying the post-transplant medical records.
  • Before starting surgery in our new recipient, our team went to the donor hospital and confirmed that the quality of the liver was excellent. This coordination was essential as only then we would be able to keep the cold ischemic time down to a minimum. The liver was out from the body at 1 pm and blood circulation was restored at 5 pm so that it did not undergo damage from ischemia reperfusion injury.

3. Post-transplant, does the recipient have to take extra care.

The initial few days are critical. Luckily, soon after the surgery, the patient came off the ventilator with mental faculties completely intact. The liver enzymes did go very high but with infusion of N-acetyl cysteine, we were able to control it. There is a possibility that a severe rejection episode may happen in the next few days. We are prepared to deal with it as all lines and tubes have been removed so that infection does not flare up, with increased immunosuppressive therapy. 

After the first week, he will be like any other transplant recipient.

We will also be on the lookout for any intracranial bleed as the two previous houses of this liver had undergone major intracranial bleeds. The blood pressure will be kept under control and no antiplatelet agent will be used. 

4. What is the implication of success in transplant in this case for future surgeries? 

Interestingly many recipients now die from post-transplant cardiovascular events and not from failing grafts. Therefore to increase the success of transplant, these events must be prevented and should such an event happen, these organs could be used again. 

5. Any other point you may want to highlight. Because we cannot connect to the family of donor or recipient, is it possible to share how exactly the donor insisted and the reaction of recipient. We will not name any of them

This was an unique situation. Ordinarily, it would not have been possible for a recipient to turn into a donor as the coordinators are too devastated to even approach the family for donation. The family came forward on their own and only because of this, it could happen. 

As this was happening for the first time in India, we needed to explain to the new recipient of the circumstances of the donation and the additional risks involved in transplantation.