For some patients, a low MELD score doesn’t reflect the severity of liver disease

A 66-year-old woman presented with advanced liver disease caused by alcoholic cirrhosis. She had debilitating encephalopathy and fatigue, which left her unable to work and with a poor quality of life. The patient was originally listed for liver transplantation in Connecticut with a MELD (model for end-stage liver disease) score of 15. She moved to South Carolina in 2018, and after considering all of her options chose the Emory Transplant Center for her ongoing care. The patient was placed on Emory’s liver transplant waiting list in February 2019.

The Emory Liver Transplant Program team agreed that the patient’s MELD score, which continued to hover around 15, did not adequately reflect the severity of her disease. Although her situation was not dire, waiting for a deceased-donor liver placed her at increased risk for further decline, disability and death. A living liver transplant would allow her to undergo liver transplant before any further decline could take place and potentially offer a better outcome. After learning about this option from the Emory transplant team, the patient agreed to move forward.

Donor Evaluation Process

The patient’s 43-year-old son immediately volunteered as a potential donor. After an initial review of his medical records, the Living Donor Liver Transplant Program team requested that he travel from his home in Tacoma, Washington, for a multidisciplinary evaluation. This visit occurred over two days in September 2019. It included an extensive work-up including consults with hepatology, transplant surgery, cardiology, psychology and social work, as well as an independent living donor advocate.

The donor candidate was in overall good health, physically active and eager to donate his liver to his mother. After careful consideration, the care team reached a consensus that he was an excellent candidate and the transplant surgery was scheduled for November 8, 2019.

Imaging Studies to Fully Assess Donor Surgical Options

Adult-to-adult living liver transplants generally pose a slightly higher risk to the donor compared to adult-to-child living liver transplants. This is because the adult recipient needs a larger segment of the donor liver than a pediatric patient would.

The Emory transplant team uses computed tomography and magnetic resonance imaging to carefully determine liver anatomy and calculate liver volumes. In this case, the donor’s left lobe was of insufficient size for the recipient; therefore, the right lobe would be required. This represented about 65% of the donor’s liver volume. The procedure would safely leave sufficient liver in the donor for normal function and provide adequateliver function for the recipient.

The surgeries took place in adjacent operating rooms with two separate surgeon-led teams. After direct assessment of the donor’s liver and bile ducts in the operating room, the decision was finalized to continue with the donor procedure. The right lobe was removed and its vessels reconstructed to facilitate transplantation. Both surgeries were successfully completed, lasting about 12 hours in total.

Recovery and Follow-Up

After surgery both patients were admitted to Emory’s dedicated liver intensive care unit, whose experienced staff cares for patients with all forms of acute and chronic liver disease. Emory’s approach to intensive care of liver patients has become a model for centers across the country.

After liver transplantation, the recipient’s liver function steadily normalized with dramatic improvement in energy and cognition. She returned home 9 days after surgery and continues to do well. The patient has routine follow-up care with the transplant team, utilizing telemedicine during the COVID-19 pandemic. Today, both her liver function and energy level are normal and she is back to resuming her daily activities.

The organ donor spent 5 days in the hospital and remained in the Atlanta area for 2.5 weeks for close follow-up care. After returning to Tacoma, he is feeling back to normal and has resumed his usual activities, including rock climbing and hiking.

Advantages of Living Liver Donor Transplant

Compared to deceased-donor liver transplants, living liver transplants offer:

• Healthier Outcomes for Patients – data suggests that living liver donation may lead to better long-term outcomes and shorter recovery times.
• Organ Lasts Longer – a liver from a living donor typically lasts longer than a liver from a deceased donor.
• Reduced Wait Times and Less Risk – donors and patients who are found to be suitable for living donor liver transplant can schedule surgery at a time that works best for them. This means transplants can occur sooner and reduces the risk of dying while waiting for a liver transplant.

More than 12,000 individuals are waiting for a liver transplant in the United States and many will die before a donor organ becomes available. In 2019, only about 6% of the 8,896 liver transplants performed in the U.S. were from living donors.

Higher prioritization and awareness of living liver transplantation has the potential to benefit thousands of people each year. Clinicians can play an important role in educating patients and referring them for a comprehensive transplant evaluation in the earlier stages of liver failure. Even patients with a low to moderate MELD score could qualify for a transplant, depending on their circumstances.

Emory Transplant Center is committed to the continued health and safety of all patients. During this time, we are taking all necessary precautions to screen for coronavirus (COVID-19) and to prevent its potential spread. We continue to monitor the evolving COVID-19 pandemic and are working with experts throughout Emory Healthcare to keep your patients safe. For the most up-to-date information for our referring partners, click here.