UK docs demand live liver transplants
In a case which is gripping the US, a convicted killer wants to donate half his liver to his dying sister before he is executed next week. It couldn't happen in the UK.
For one thing, the UK doesn't much approve of lethal injections. Fair enough, but neither does it practice regular live liver transplantation - even though the country has the most acute organ shortage in Europe. Why?
In Britain, live liver transplants, where a living donor gives half his liver away to someone with acute liver disease, are almost non-existent.
This contrasts to continental Europe, where a third of the 5,000 liver transplants carried out each year are from live donors. In the US the figure is seven percent.
In the UK just ten live donor operations were carried out last year in the whole country - in one hospital, King's College in south west London. The patients were foreigners who were at the bottom of the national waiting list for cadaverous liver donations.
Yet Britain, if anything, has a greater need for live liver donors than the continent.
There is a desperate shortage of cadaveric donors, around 700 last year. The rate is the lowest in Europe, little over a third the Spanish rate.
The UK has a comparatively low, and falling, rate of fatal traffic accidents, to supply corpses. A presumption of consent principle - where organs are freely taken from a corpse unless the person had specifically requested not to - operates in some continental countries, but not the UK.
The shortfall of donors is seen in the results: with growing cirrhosis rates as drinking hours are liberalised across the UK accelerating, waiting lists for a new liver have grown by 10 per cent in the last twelve months. According to Professor Roger Williams, a hepatologist at UCL, the wait for recipients requiring blood group O cadaver organs in some transplant centres is now around 12 months, which, he said, was "unacceptable".
Around 60 people on the waiting lists die every year from acute liver failure.
Two academics, David Price and James Neuberger, wrote recently in the British Medical Journal that "making living liver donation available in the NHS will have a small but important effect on the number of people able to receive a graft". In other words, reducing that figure of 60 dead.
The NHS shouldn't worry that living liver donations are unpopular.
Three quarters of a sample of the general public surveyed in 2003 supported living liver donation. The fact that the liver, unlike other organs, regenerates its size in the donor (and recipient), within weeks, with complete return of function, is undoubtedly a factor in its popularity.
There is a risk to the donor - about a half per cent mortality rate, from bleeding complications - but half the surveyed population thought this was risk worth taking, especially if the recipient was a family member.
Live kidney transplants, with a mortality rate of little less than that of liver transplants, are offered routinely in the UK.
There is no legal barrier against live liver transplants - the Human Organ Transplant Act 1989 only says organs cannot be sold for cash. So there are no opportunities for a modern day equivalent for Sarimner, the wild boar in Nordic mythology that was eaten by the Gods and grew whole every day, to make money by selling half his liver every few months.
A spokesman for UK transplant, the NHS special authority that deals with organ donations, says the UK lacks expertise in living organ transplants, but academics say it is a chicken and egg situation. Prof Williams has argued that the small number of transplant centres in the UK perpetuates the view the view that liver transplantation is a very difficult procedure, whereas in many countries elective grafting with cadaver organs has become almost routine.
Some experts have questioned the efficacy of live liver transplants.
Back in the US, meanwhile, US medical experts are advising against the killer due to die by lethal injection next week being given a stay of execution because he wants to make a live liver donation to his sister, who is mortally ill. The killer's lawyer said a delay to enable a live transplant was justified as the toxins from the injection would make the killer's organ unusable after his death. But the Indiana School of Medicine's principal advises the sister to wait for a donation from another cadaver with her matching rare blood group because the "results are better than from living donations".
Figures quoted by Professor Williams, who has conducted a small number of operations at the Cromwell hospital in London, would dispute this.
In a letter to the British Journal of Medicine, he says survival rates in his programme, 77 per cent after five years, exceed the national average of 65 cent after five years. Similar results are found in a far larger survey by Vanderbilt university in the USA published this week, which analysed 17 years of data. The reason is that live donors are likelir to give fresher, and therefore healthier livers, and recipients are less likely to have waited as long for the transplant during their acute liver crisis.
Some experts worry that some kind of emotional pressure on family members of an ill person is inevitable, made worse by the sudden nature of a liver crisis and the short time in which a decision to donate must be made. But surely the NHS's clinicians are used to handling the similar dilemmas of live kidney transplants, unless doctors think families of that proportion of liver transplant candidates who are alcoholics need special protection. Few alcoholics who receive grafts relapse.
British hepatologists have consistently urged the NHS to start introducing a larger scale live liver donation programme to cut lists and save lives. But they also say living liver donation should not be introduced without public debate and approval. Nor that money should be diverted from initiatives to expand the cadaverous donor pool and develop alternative treatments for end stage liver disease. If those conditions are taken into account, an expansion of living liver donations in the UK is surely right. ®