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How Cleveland Clinic works

by Cleveland Clinic
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They are known in the medical literature as extreme living donors. That is, the person who fed the transplant recipient or recipient two solid organs simultaneously or consecutively.

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That's the technical term. Transplant surgeon CH David Kwon, MD, PhD provides a more lyrical explanation.

“I call them people with golden hearts,” says Dr. Kwon, director of minimally invasive liver surgery at the Cleveland Clinic. “They have different attitudes towards life and giving. They help someone and feel really happy. The actions they give will give back to the giver.”

Living donations of dual organs, including the kidney and liver segments, kidneys, kidneys and distal pancreas, can increase the availability of scarce resources, reduce waiting times for transplant recipients (often pediatric patients), and save more lives.

However, dual organ donations remain extremely rare as there are few people who are willing to undergo two demanding procurement procedures and fulfill their porting program duties to minimize the risk of donors.

A 2022 study using national transplant data has identified 146 dual organ living donors in the United States since 1994. This was less than a tenth of all implants involving living donors in 18 years.

A wealth of experience in transplantation and minimally invasive surgery at Cleveland Clinic reduces postoperative pain, promotes recovery and encourages dual organ living donations. Since 2012, 22 dual organ living donors have had one or both of their procurement surgeries at Cleveland Clinic.

“We have one of the biggest series in the United States that I know,” says Dr. Kwon. “We perform minimal invasive surgery, and [smaller] Left lobe of the liver. ”

Left lobe fatectomy is safer for donors as it retains larger functional debris, but requires vigilance of postoperative management of recipients due to smaller graft size.

Cleveland Clinic has arrived Dr. Kwon, one of the world's most experienced laparoscopic living donor liver surgeons since 2019, and offers a complete laparoscopic fluid fat removal procedure for implantation. The biological donor liver transplant program based on MD, MD, and PhD orientation has developed and demonstrated the effectiveness of surgical modifications that lower the threshold for using small grafts, particularly left lobe grafts, without infringement of organ function or transplantation.

“The Cleveland Clinic is pioneering in this field, particularly in its minimally invasive approach for live donor surgery,” says Kadakkar Radakrishnan, MD, pediatric gastroenterologist and liver scientist. “It's an area that requires expertise.”

“We've observed that, in particular, previous altruistic kidney donors want to donate a portion of their liver, after launching their laparoscopic living donor programme,” says Dr. Kwon. “And the previous liver donors want to donate their kidneys. That goes both ways.”

Cleveland Clinic's approach to dual organ donations

Most transplant programs arising from perceived risks of morbidity and mortality, and the ethical obligation to prevent undue harm to healthy volunteers resulting from selection procedures.

Due to the rarity of dual organ living donations, there are few published cases and series reports, and no consensus guidelines exist when procedures are appropriate. Although the incidence and severity of mortality and morbidity appears to be low, case volumes are insufficient to draw statistically meaningful conclusions. Similarly, extended follow-up data on dual organ living donors is limited, and no studies assess the long-term health impact of donating multiple organs.

The Cleveland Clinic's transplant program decided that after extensive medical and psychological evaluations of donors, dual organ living donations would be accepted on a case-by-case basis. To reduce the risk of donors, partial liver donations are restricted to the left lobe, accounting for about 30% of the organs.

“The majority of transplant centers around the world use the right lobes,” says Dr. Kwon. “We have implanted most of our liver, so even though we put more strain on our donors, it's easy to manage our recipients.”

When resecting the liver of a living donor, Dr. Kwon usually shifts the resection surface from its normal position to about 1 centimeter. This shift allows for a search of 3-5% of the viable portion of the caudate condition and liver volume.

“That centimeter is easier to achieve if you actually do it laparoscopically,” says Dr. Kwon. “And by doing what I do, I'm probably adding 10% or more functionality to my left lobe transplant. In addition to that, the technology that Dr. Hashimoto uses allows small grafts to be adapted to the recipient.”

These surgical techniques include modulating the influx of implanted grafts by splenectomy and enhancing its outflow by utilizing all three recipient hepatic veins. This reduces the likelihood of graft dysfunction and small-scale syndromes.

In addition to reducing the risk of living donations for dual organs, left lobe graft utilization increases organ availability in children and small adult recipients. These patients may not be able to accommodate larger donor grafts and may have lower liver disease severity scores than other transplant candidates, resulting in longer wait times.

The left lobe of the dual organ living donor is “a great combination to fill a niche that we haven't looked after in the past,” says Dr. Kwon.

Other Cleveland Clinic approaches involve modifications to anesthesia regimen and postoperative pain management to protect dual organ living donors.

Historically, low-center venous pressure (CVP) techniques such as preoperative fluid restriction, vasodilators, and diuretics have been used to reduce potential blood loss in patients undergoing liver surgery. “If the amount of fluid is high, cutting the liver will cause more bleeding, so let the patient dry as much as possible,” says Dr. Kwon.

However, because fluid restriction can cause renal stress in previous renal donors, Cleveland clinic anesthesiologists limit the reduction in CVP to protect the remaining kidneys of dual organ living donors.

Similarly, nonsteroidal anti-inflammatory drugs are not used after surgery to ensure renal protection in the living donors of dual organs, says Dr. Kwon. Instead, along with flat abdominal blocks and drugs such as gabapentin and acetaminophen, a minimally invasive approach will allow patients to recover without pain.

The impact of one donor

Dual organ life these days shows the impact of procedures and the generosity of donors.

In 2020, Rev. Nathan Howe, who was then 37 years old and a unified Methodist Church pastor, donated his kidneys to his 74-year-old father, John. Elder Hau suffered from polycystic kidney disease and had been on peritoneal dialysis for two and a half years while awaiting the transplant.

John Howe initially resisted receiving kidneys from a living donor due to the risks the person thought he would face. A seminar on livelihood donations from the Cleveland Clinic, in collaboration with the National Kidney Foundation, changed his mind.

Nathan Howe was rated by donors and turned out to be a match with his father. His kidneys were collected laparoscopically and implanted by the kidney transplant surgery team at Cleveland Clinic. The father and son only spent two nights in the hospital.

That positive experience and recognition that Nathan Howe's second donation of life motivated him to act. “I think it's important that we support each other as much as possible,” he says. “This is how I was able to do that.”

Howe contacted the Cleveland Clinic in 2024 to determine whether a portion of her liver could be safely donated. The assessment confirmed his eligibility. He ultimately coincided with 11-year-old Ahmad Rai, born with a hereditary disorder progressive familial intrahepatic bile congestion (PFIC) type 2. This condition causes bile acids to aggregate within the hepatocytes, causing overloading of the hepatocyte system, causing structural damage, liver damage, liver dysfunction and ultimate damage.

Ahmad had undergone a residential liver transplant at the Cleveland Clinic in 2016 at the age of four. A few years later he developed bile duct complications, causing recurrent hepatitis, fibrosis, portal vein hypertension and splenomegaly. Insertion of the biliary drainage and radioactive ablation in viria did not resolve biliary duct obstruction.

“Ahmad's liver had not improved and he began to fail again. In the end, he was determined to need a second liver transplant,” says Dr. Radhakrishnan.

“Ahmad was very sick, but his Perd [pediatric end-stage liver disease] The score wasn't that high, so he wasn't given much priority on the transplant waiting list,” says Dr. Hashimoto. They have to grow. They have to go to school. Luckily for Ahmad, there was a perfect living donor that was a good match. ”

Dr. Kwon led the laparoscopic search of Nathan Howe's left lobe, and Dr. Hashimoto performed the implant.

Cholecystectomy, cleaving and dissection of liver vessels, and cutting of liver parenchyma were performed through five abdominal ports. A 9cm ultrapubic transverse skin incision via a previous Pfannenstiel incision used in Howe's kidney donation surgery allowed for removal of liver grafts and gallbladder. An incision in the abdominal wall was made horizontally to reduce the chance of a hernia.

Dr. Kwon recovered 31% of Hau's liver. Due to Ahmad's small size – he weighed 70 pounds at the time of surgery – the inclusion of a caudate part in the donor graft also required correction of influx and influx, as small-scale syndromes were not a concern.

Ahmad Rai and his mother, Aya Akkad

Recovery and meetings

Donors and recipients recovered peacefully. Hau was discharged from the hospital five days later. Ahmad's liver is functioning normally. He returns to school and enjoys playing soccer and video games.

“He has a good opportunity to live a normal life,” says Dr. Hashimoto.

Hau's liver donation was made anonymously, but Ahmad and his family were able to meet with Nathan after surgery by working with the transplant coordinator. Ahmad and Hau talked about Ahmad's love for football, the path that led to donations and transplants, and each of them thanked others and talked about their sense of hope.

“I'm very grateful [his first liver donor] And Nathan,” Ahmad says.

“Organ donation is very life-filled for both donors and recipients,” says Howe. “It's important to cultivate these connections.”

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