Caitlin Whyte (Host): This is Community Connect presented by Tampa General Hospital. I'm Caitlyn Whyte. Joining me is Dr. Ashish Singhal, a Liver Transplant Surgeon and Director of Living Donor Liver Transplantation at Tampa General Hospital. Dr. Singhal, welcome. Doctor, to start us off today, can you tell us what are the key criteria for becoming a live liver donor and how does the evaluation process work?

Ashish Singhal, MD: This is the I think the most important questions for living donor liver transplantation.So the medical requirements for being a donor are like one of the first of this age. The donor should be between 18 to 50 years of age. They should be in excellent physical health with no major illnesses like heart disease, cancer, uncontrolled diabetes.

Their liver function tests should be good. They should not be overweight. We prefer a BMI with less than 30, and the blood type should be compatible with the recipient. And they should have a liver side, which has enough liver volumes for which they can donate safely, and the recipient must be able to receive the required portion.

Apart from that, there are other psychological and social criteria. They should be in good mental health. This should be voluntary decision without any coercion and they should have a good support system. When you talk about the evaluation process, it's a multi-step process, with the initial screening, which is a online or phone based questionnaire, where we go over the basic health and history skinning of the donor, and they can do some basic testing locally. Once that is clear, then they are brought in as in-person medical evaluation. They go through blood tests, infectious disease workup, imaging in CT or MRI to assess the liver volume and anatomy, and also go through the physical exam and meeting with other team members including transplant surgeon, transplant hepatologists, psychologists, social worker and independent donor advocate. And what it does is they ensure that donor understand the process and, and is donating voluntarily, and it protects the donor interest throughout the process. And finally, once everything is done, we review all the testing in a multidisciplinary transplant team meeting and make a decision of based on the total safety and suitability. So this is how the process works for being a living donor.

Host: Great. Well, could you briefly explain the anatomy and physiology that makes a live liver donation possible, particularly the liver's regenerative capabilities.

Ashish Singhal, MD: Liver is a unique organ and, and the most crucial feature is liver is the only solid organ in the human body that can regenerate. And what happens after donation is the donor liver, starts regenerating and it comes to near normal size within 6 to 12 weeks after donation. And the same happens on the recipient side too.

 And this is possible also because of the segmental anatomy of the liver. So the liver has two lobes, right and left lobe which has its own blood supply, own bile duct. So the donor who are fit to donate can donate, a right lobe or left lobe of the liver safely. And also the liver has a, a high functional reserve, which is making a sufficient tube for to maintain the normal metabolic synthetic and detoxifying functions.

There's a need for the careful donor evaluation to ensure the liver volume and function are adequate for safe donation.

Host: What are the risks and benefits associated with live liver donation for both the donor and the recipient?

Ashish Singhal, MD: Firstly the donors, so benefit wise, this surgery is the donor is doing for somebody else. So there's this benefit of a psychological satisfaction. It is an emotional reward for them. And most of the donor, they do it like motivated by the opportunity to save somebody's loved one or somebody in need for liver transplantation.

And it also decreases the waiting time for the recipient. From the risk wise, for the donor, it's a big surgery they had to undergo to anesthesia. So there are risk of potential surgical complication like bleeding, infection, blood clots, pneumonia like with any other abdominal surgery. But they also some additional risk like liver failure and bile leak. If you talk about long-term health effect, some donors may develop chronic liver issues or complication. There's a problem with the scarring. There may be pain for postoperatively and visible scars, and usually the recovery time is between four to eight weeks from the healing standpoint. Some donors may also see some anxiety, depression, especially if the transplant is unsuccessful.

For the recipient's perspective, there are a lot of benefits for the recipient. There's shorter wait time. There's a long waiting list for liver transplantation. So the living donor allows them to reduce time on the transplant waiting list.They have a better outcomes because living donor liver transplant organs are better organs, better match, and we can plan these surgery as elective procedure so that we can do this surgeries when the recipient are there in the best of their health. Risk-wise, they have all the risk like any other disease donor liver transplantation, and like surgical complication, bleeding, infection, rejection, bile duct problem, and inside side effects of the immunosuppression medications.

Host: Well, doctor, how has recent research advanced the safety and success rates of live liver donation procedures?

Ashish Singhal, MD: Recent research has significantly advanced the safety and success rates. And the several key areas I would highlight about. The first one is improved donor and recipient selection. So there are better imaging and diagnostic testing are available now, including 3D CT scan, MRIs and CT volumetry, which gives us a map of the, the vasculature of the liver and give the liver volume, which helps in safer surgical planning.

And there are also enhanced risk stratifications and scoring systems available for the donor risk matching. The second is minimal invasive surgical techniques. There are advanced surgical techniques in which the donor surgery can be done via minimal invasive or laparoscopic, and now the robotic assisted surgery is also upcoming.

And there's also the graft selection on the donor side for donor safety, we can use the more donor friendly grafts for the recipients. The next would be the enhanced postoperative care and monitoring. They are very advanced, real time intraoperative monitoring during the surgery to ensure the blood flow and the bile duct intraoperatively and also postoperatively to, to detect anycomplications. And as I said, there's a big role of ethical and psychological in the living donor liver transplant. So there a lot of advancement happened there. They got a donor support through the psychological screening and long-term, health support after the donation.

And there's always a lot of global guidelines and standardization happen to promote standard protocols which ensure donor safety worldwide.

Host: What preoperative preparations are required for a person considering being a live liver donor?

Ashish Singhal, MD: For somebody who's considering to being a donor, preoperative preparation will include a medical evaluation, as I said before, to go through the testing, screening, imaging, including psychological evaluation, counseling, social support assessment, and there's an informed consent process which the donor must fully understand the surgical procedure and risks, the recovery timelines, the potential complications including bile leak, infection, long-term liver function, and also I always talk about mortality risk.

The mortality risk for the being a living liver donor is around one in 750 to one in 1000, which is very low, but it's not zero. There has to be some lifestyle adjustments, like healthy diet, weight management.

Prefer to stop smoking at least several weeks before surgery, alcohol cessation, to improve physical activity. And medication review to make sure they are not taking any supplements which may affect the liver. And the last thing I would say is logistics and planning. They need to have something around 6 to 10 weeks of time off work for recovery.

Home recovery arrangements like transportation, help with daily activities and some financial preparation but the American Society of Transplant Surgeons, runs a program called NLDAC, which supports the donor, for like unpaid wages or travel for going through this process to, support the donors for this time.

Host: And on that note, what is the typical recovery timeline for live liver donors and what postoperative care is involved?

Ashish Singhal, MD: It is a major liver surgery, so it's involved several stages like in hospital and then the first weeks or month after the discharge. So if you talk about the hospital stay after the donation, they stay in an ICU for one or two days. By the time they start eating, walking, pain is better controlled by day three to day four, usually go to the floor. By the time they are eating well, their mobility is increased and usually they get discharged between day five and day seven, if there's no complication. For the first week, they visit the clinic for routine labs, for wound check, for weight check and then review the medication.

Then they come back again in next couple of weeks, which is like four weeks from surgery to make sure the wound is healing okay. By that time they should be done with the pain medication and most likely all the other medications. They should be able towalk nicely but at the time they should be avoid driving. And not lifting any weight more than 10 to 15 pounds. Usually week five to eight, many donors, they return to work like depending what kind of work they do.Normal diet and light exercise, incision must be healing and without any pain. By three months, most of the donor return to their normal daily activities because by the test time, liver has regenerated to near full size.

And they continue to follow up with the proper liver function. So they have another clinic visit at month six and 12 months. By this time, their wound has healed they can go back to their exercise regime or weight lifting if they want to do. The pain should be better controlled, and the activity should be good.

Host: And my final question, Doctor, how does live liver donation impact the donor's long-term liver function and overall health?

Ashish Singhal, MD: As I said, the liver has a enormous regenerative capacity. It has incredible ability to regenerate. After donation, the liver typically regrows to near full size between eight to 12 weeksand most donors return to normal liver function within few months. And long-term liver function remains comparable to pre donation levels in the vast majority of the cases. Over health-wise, if I talk about surgical risks, as with any other major surgery, there are risks including bleeding, infection, but they have, but the serious complication are pretty rare. The long-term complications are like with range of one to 3%, which includes, like abdominal discomfort, fatigue, or digestive problems. The quality of life wise, they have a high quality of life after recovery, many feeling satisfaction from helping another person. Long-term followup suggests no significant increase in liver disease risk compared to the general population. One of the big questions is lifestyle post donation. Donors are usually advised to avoid heavy alcohol use, maintain a healthy weight and avoid medication or substances, which can strain the liver, but they can return to physical activity and work usually at 6 to 12 weeks, depending on the type of job they do.

Host: Great. Well, thank you so much for your work and for your time today. This has been Dr. Ashish Singhal. If you enjoyed this episode, please be sure to like, subscribe, and follow Community Connect presented by TGH on your favorite podcast platform.

I'm Caitlin Whyte, and this is Community Connect presented by TGH. Thanks for listening.