So, welcome everyone to the 1st of 2 webinars that are being sponsored by the liver transplantation and surgery SIG of the ASLD this 2 part webinars was actually decided upon by the steering committee of our SIG and focuses on living donor liver transplantation. The 1st today is discussing the sort of nuts and bolts of how to build and expand a program from the perspective of a hepatologist and a surgeon, and the session next week will be focusing on sort of the process of identifying and working up a donor and recipient, following from workup to post transplant, including both the medical perspective and uniquely for the 1st time on a SIG webinar, the patient perspective with a donor recipient. I'm David Goldberg, although we're having some technical difficulties I do look like the picture displayed here, always smiling like that, and I will hand it over to Dr. Pratima Sharma who is the vice chair of our SIG, who will be leading this 1st webinar. Thank you, David, and I look exactly like this, this is my 20 year old picture, but I still look like this so welcome to this 1st part series of our webinar building and expanding the living donor liver transplant program. And as David said, this is a unique two part series where in the 1st part we are going to go over the nuts and bolts of building and expanding the living donor program and then the 2nd webinar which is next week, where we are going to hear, you know, the unique donor perspective, in addition to the medical evaluation and surgical evaluation of living donor evaluation. So our 1st, we have two very accomplished speakers here. Our 1st speaker is going to be Dr. Kiran Bamba. She is an associate professor of medicine at University of Washington, Seattle. She's also the medical director of living donor liver transplant program and director of clinical liver clinical trials unit. Dr. Bamba started the program, and she will talk about how building of a living donor liver transplant program. Our 2nd speaker is going to be Dr. Abhinav Kumar. He's a clinical director of Thomas E. Starzell transplant institution, and he's also the chief of division of transplant at University of Pittsburgh. Dr. Kumar will talk about how to expand the living donor liver transplant. As you know, Pittsburgh is number one living donor liver transplant program where two thirds of their volume of liver transplant comes from living donor. So without further ado, I will hand over the mic to Dr. Bamba. Great, thank you. Thanks Pradama and thanks to Dr. Goldberg and Dr. Sharma and Laura too. Thanks for putting on this important webinar and promoting living liver donation and, and I'm really appreciative of being invited to speak. I do look like a more human form of the letters that are that are on the screen. So I'm going to share my slides with you. So, as Pradama said I'm medical director of living donor liver transplant at the University of Washington. I'm really privileged to work with Mark Sturdivant, who's our surgical director of live donor liver transplant, without whom, you know, we could not have built our program. So I'm not going to belabor this, the why of living donor liver transplant, I think, I think we all know this and I think everybody who's attending this webinar has an interest in building it out but just for the sake of completeness, as we all know, the liver transplant waiting list is hands down the most dangerous place for our patients to be. And living donor liver transplant offers many opportunities and several advantages over deceased donor, not the least of which is eliminating that extensive waiting time and the uncertainty of surviving to get a transplant, and the survival after live donor liver transplant is as good as if not better than with deceased donor liver transplant. And I make sure that all of our transplant candidates know this information. So we really did build a program from the ground up, and I just wanted to touch on a few key components. The bare essentials include having a transplant surgeon with training and expertise and living donor liver transplant. I know that may seem obvious or even a little silly to say, but it is so critical, like, I wouldn't be able to do my job. If it weren't for the transplant surgeons and I have enormous respect for all the transplant surgeons I've worked with in the past and work with currently, they're all very skilled, dedicated and then live donor liver transplant is an extra layer of expertise and commitment, and it really is my privilege and it's humbling to work with these individuals. It's really critical that the institution, academic medical center, the hospital has to be fully invested in the living donor liver transplant program that can't be overstated. Transplant hepatologists, all of them need to be invested in live donor liver transplant. In fact, every team member has to be fully vested in living donor liver transplant that's in the inpatient setting, the outpatient setting. Our staff infrastructure and availability are critical. I know some programs may not have to think too much about that, but it turns out that some programs do. And figure out how to navigate that. Obviously, the surgeons need their instruments and specialized equipment to do this technically challenging surgery. You need expertise in body radiology, interventional radiology, imaging software for volumetrics for surgical planning and skilled therapeutic endoscopists are key members of the team as well. At UW, our living donor transplant team consists of our transplant surgeons with the live donor surgical side being led by Mark Sturdivant, who joined our program in 2020. Transplant hepatologists, transplant anesthesiologists, we have a dedicated living donor liver transplant nurse practitioner who's really the heart and soul of the program. She's a real doer. We've recently, thankfully, added a living donor nurse coordinator. Turns out I'm not the best coordinator. I can do some of it, but she's way better at doing it than I am. We have a fantastic independent donor advocate. We have social workers. We have an awesome patient care coordinator. Then, of course, our transplant dieticians, infectious diseases pharmacy, and as needed psychiatry are all involved in the donor evaluation. It really is a team effort. This is just on the donor side. This doesn't take into account the bigger liver transplant team, as you all know, on the recipient side because it's all melded together. In embarking on this, we sought to learn the best practices from other experts in living donor liver transplant. Abhi Kumar and Swetha Ganesh have obviously built an amazing program at Pittsburgh. Some of the things we do, we got ideas from them and we're very appreciative of that. Mark came to Seattle from King Faisal in Saudi, where he almost solely did live donor liver transplant surgeries for about five years. Brought with him just a depth and breadth of expertise and experience that really accelerated our program. We spent a lot of time developing protocols for donor eval, donor surgical management, donor recovery, same thing for the recipient, all written well thought out. Importantly, we engaged our institutional leadership early and often, and that's incredibly critical. Again, the institution needs to be fully on board with live donor liver transplant. Even before Mark physically showed up in Seattle, we already started the conversation with our institutional leadership that this was coming, we were going to build this, and we needed their full support. Importantly, we also needed money to really build out the pieces. I applied for a grant from UW Medicine, and we were very grateful to get funding from this Patients Our First Innovation Pilot Award that really helped us build out key materials to build the program. All of our written materials for donor candidates, our recipient candidates, our donor champion program, which is modeled off of Johns Hopkins and also, of course, Pittsburgh. We had to really rebuild our online presence and work on our digital front door, and that's been really critical, and it's made our program much more accessible. We make sure that our website floats to the top when people search for live donor liver transplant, especially in the Pacific Northwest. We do a lot of outreach to referring providers and to patients, but we reach out often, and we encourage them to send anybody and everybody for consideration of live donor liver transplant. With the help of our transplant outreach manager, Shelby Slagle, we built all of these materials you see here, and we've also been able to effectively engage our institutional marketing team because they are key members as well. Nobody relishes thinking about the harder stuff, but it's really important. If there's one patient in the hospital that can take down a program temporarily, it's a living organ donor if something goes wrong. We always tell our trainees that when we have a living donor recovering in the hospital that all of our patients are important, but don't forget that the living liver donor is also very important. I think the team sometimes looks at these individuals, and they're like, oh, that's a healthy 25-year-old. They're fine, and they are fine until they're not fine. I would encourage anybody considering building a program to really put in writing a well-thought-out crisis plan. The LD COP of AST did a survey that was published in 2020, and it's surprising. It's really the minority of living organ programs, that's liver and kidney, that have an actual crisis plan written out. Then, of course, Charlie Miller at Cleveland Clinic has really been an important voice in advocating for preparedness. I just wanted to highlight a handful of the challenges that we experienced along the way, because I thought it might be informative for other people. Understandably, there was initially just a genuine lack of awareness or genuine misunderstanding about what living donor liver transplant is, what it means, why people would do it. Among our own faculty and staff, and that ranged across disciplines, phlebotomy, radiology, even in the transplant realm. There was some mixed messaging that occurred about live donor liver transplant, kind of provider dependent, varying from sort of lukewarm advocacy all the way up to very enthusiastic advocacy. I think we all already know this. There was a lot of misinformation or just, again, genuine lack of awareness among the general population, including our liver transplant candidates and potential donors about live liver donation, that it's possible, that it's a safe surgery when done in the right hands. Clinics face issues. I don't think that's unique to us. I understand that's occurring at a lot of places. Our availability is something we had to navigate, or I should say, Dr. Sturdivant and our nurse practitioner did a great job of navigating. As the program grew, we had more and more needs, and we had to justify those needs to the institution to get funding, to get support, to get more people, and we needed a very robust means for data tracking and reporting. We tackled all of these head on. We do targeted in-service living donor liver transplant trainings for our faculty and staff, make ourselves readily available to answer any questions or uncertainties that people who work with our team might have. I think we've addressed all that, and we've done enough live donor liver transplants now that that's not so much of an issue anymore. I meet one-on-one with every individual who's going through liver transplant evaluation at our program to talk to them specifically about live donor liver transplant. Again, this is taken from Pittsburgh because it's a very smart idea and effective idea, so we borrowed that. We engage in consistent and repeated messaging about live donor liver transplant. I've had to be pretty flexible and creative in clinic scheduling in order to maximize donor access. I go out of my way to make myself available to accommodate the potential donors' schedule because I know that these are people who are working, and we want to encourage them to go through donor eval without putting up unnecessary obstacles. Just as an example, just trying to work with our clinic because it's stressful for our overflowing clinic anyway. I sometimes see donors before clinic opens, so we let our donors know in advance, if you show up to a dark waiting room, don't worry. I'll see them early, and then we do all the vitals and such on the back end. It actually works out pretty well, and clinic is definitely quiet in the early, early morning. Our team has made a lot of headway in improving OR prioritization for live donor liver transplant, so that's far less of a struggle now. Thankfully, two weeks ago, we just had a living liver donor nurse coordinator start, and that's been just an amazing addition to our team. We've been able to build out Epic to work for us to generate the reports we need. This is what the reboot of our living donor liver transplant program at UW looks like. Prior to Mark's arrival in February of 2020, the UW program had done three live donor liver transplants over at least three or more years. Mark arrived in February. He did his first live donor liver transplant in April, and there was so much angst with the pandemic going on around that. It was a real feat, and it's just been a steady increase over time, but it's not all about the numbers. For us, and for all of us, as you know, it's about keeping families and friends and loved ones together, so this is really our driving force, and it's been an incredibly rewarding experience. My take-home messages are that living donor liver transplant, it's not a diversion, and it's not a hobby. I guess I would say I've had the privilege in hindsight that all of my training, medical school excepted, all of my training, my career, has all occurred at institutions that have living donor liver transplant programs, so it feels very comfortable to me. One of my mentors at UCSF told me, said living donor liver transplant is not for the faint of heart, and I think that is so true, but it is incredibly rewarding, so it's important to have an a priori thoughtful approach to starting a program. It really requires a functional collaborative supportive team approach. Steadfast commitment from your institution is absolutely critical. It really works best when everyone is wholly invested in living donor liver transplant. It really only takes one or two comments that express sort of uncertainty or noncommittal comments about live donor liver transplant to start to plant the seed of doubt in a potential donor or recipient about live donor liver transplant. So really, everybody needs to be on the same page, and the donors and recipients need to feel like they're in the right place and they're going to get the good care they need. Living donor liver transplant education is continuous, it is not a one and done conversation, you have to have it every time you see these individuals back. And my perspective is that you really need to have a fastidious approach to both the donor and recipient conversations that are had and also to the medical and surgical evaluations. So with that, I will stop sharing. and thank you. That was a fantastic presentation, Karen. You know, kudos to you, as well as your team, to expand, to build on your program and with excellent outcomes. So we're gonna keep the questions and answers towards the end. Our next speaker is Dr. Humar. Dr. Humar, you're up next. All right, thanks. Let me just share my screen here. Okay, thanks very much for the invitation. And essentially, I'd like to talk about our philosophy of how we approach living donor transplants and how it's changed over the past several years. Just a warm welcome to everyone from Pittsburgh. And I offer an open invitation for anyone who wants to come and visit and see the program. So this is, before I start talking about our program, a little bit to summarize what the current status of live donor liver transplant is in the United States, as shown on the right-hand curve. We've increased the number of transplants, but it still constitutes only about 6% of the total number of transplants that are done in the United States. And if you contrast that to many places around the world, such as the Middle East, India, the Far East, in those places, it's roughly about 95% of the liver transplants that are done. So why have the number of live donor liver transplants remained so low in the United States? Well, there's many reasons. Obviously, deceased donor transplant is well-established and flourished here, and so there's always that option. A live donor transplant is a complex procedure and it requires some degree of technical expertise, as well as investment of the Institute to build that expertise, as you just heard. And we have a lot of regulations in transplant, you know, CMS, state, et cetera. But really, to me, the main reasons have been that donor complications, especially deaths, when they've occurred, have been highly publicized and they've caused tremendous risk for programs and individual team members. It's led many in the transplant community to believe that a living donor graft is a risky marginal graft that should only be reserved, really, for select patients. And that's really the opposite way of how we should be thinking about it. But what that's led to is that patients and the people who are looking after these patients, and in fact, many healthcare workers, being misinformed about live donor transplants, or even worse, never even being informed about the option of a living donor transplant. And I can guarantee you that, you know, of the 12,000 people that are waiting for a liver transplant in this country, probably the majority have never even heard of the option of a living donor transplant. So this is the number of live donor transplants that are centered over the last 10 years or so, since I came to Pittsburgh. And you can see that, especially over the last five, six years, we've made a real concerted effort to try to grow the program. We're doing roughly about 80 to 100 transplants a year now. It constitutes roughly about 66 or two thirds of all the liver transplants that we do at our center. So if you're going to push a live donor transplant, you better know your results. So we keep a very close eye on our results. This is what our results have been like. So remember, that's in both the donor and recipient, you got to track it very carefully. So donors, we've done 731 since 2009, when I first came here till the end of yesterday. 731 donors that we've done over that period of time. A knock on wood, we've not had any cases of donor deaths or liver failure. Our overall complication rate is about 15.1%. A major complication rate defined as the need for a reoperation or an interventional procedure on an any donor is roughly about 6%. Our mean length of stay is about five days in the donors. All donors, we now do with an ERAS protocol to try to minimize the use of narcotics and early mobilization. And we do them all through an upper midline incision, including big burly men, such as this fellow shown in the figure. We haven't started robotic or laparoscopic, but that's certainly an area in the surgical literature that people are trying to talk about to speed up donor recovery. On the recipient side, this is what our results have been like. This is an analysis we did a few years ago, looking at deceased donor and live donor transplants over a 10 year period of time. And you can see that in terms of patient survival and graft survival, we have roughly about a five to 10% survival advantage over in our live donor patients versus our deceased donor patients. Now, people always worry about the technical problems and the complications, the surgical complications associated with a living donor transplant. So this is a detailed outline of the surgical problems that we've seen, again, in that same analysis, looking at living donors and deceased donors. And what we've seen is that over time, your results get better. And at the present time, our outcomes in terms of surgical complications are pretty much similar between our living donors and our deceased donors. Some things are a little bit more common in the living donors. So for example, if you look at the incidence of bile leaks, it's a little bit higher in the living donor patients, and that's to be expected given that you've got a large raw cut surface. But our overall incidence of bile leak complications is at about just a little bit over 13%, not a whole lot difference between our living donors and our deceased donors. And our vascular complications are roughly about the same between the two. So we've seen tremendous benefits to the program in terms of pushing the live donor programs. So these are two metrics that are important for program because they're tracked by UNOS and they mean something. So transplant rate and waitlist mortality, essentially they're important for patients because obviously the transplant rate tells them what's the likelihood that you're gonna get transplanted at that program. And the waitlist mortality tells them what's the likelihood they're gonna die while waiting for a transplant. And you can see that our transplant rate just in the last five years has almost tripled and our waitlist mortality has almost halved in that period of time. And that's since that time in the last five years since we've really pushed live donor transplant. So this is where we are currently with our thinking about live donor transplant. To us, a living donor transplant is really the first and best option for all of our patients. It doesn't matter whether they have acute or chronic liver disease, doesn't matter if they have a low MELD score or a high MELD score, if they're young or they're old, if they're primary transplants or they're redos, if they have a tumor or a non-tumor, pretty much anyone who would benefit from a liver transplant, we feel should get a living donor. In fact, many people will often ask me, are there any recipients that shouldn't get a living donor transplant? And my simple answer to that is no. If they need a transplant, I think that they should get a living donor transplant. In fact, in my mind, there are many recipients out there that should only be offered the option of a living donor transplant and really shouldn't be offered the option of a deceased donor transplant because it's really not a reasonable thing for them for whatever reason, either waiting time or the likelihood of getting through it. And my justification for this statement is really belief based on the statement that to me, a living donor graft is the best graft because if you think about it, what constitutes a good graft, whether it's from a living donor or a deceased donor, what's a good liver to transplant into someone? So obviously that's a liver that comes from a young donor, is not fatty, has normal liver function tests, has minimal ischemia and minimal reperfusion injury. So that by definition is the criteria to be a living donor. You have to meet all of those criteria to qualify to be a suitable living donor. So to me, a living donor graft is really the best graft for those reasons. And the other important thing to remember is that a living donor transplant is an elective transplant. It allows you the ability to optimize your recipient. That's important. And it also allows you to have your best and most experienced surgical and anesthesia teams available for that particular case. On a deceased donor transplant, it's often whoever is on call from the anesthesia side and surgical side in the middle of the night. And that may not be the best person to have for that particular case, especially if it's a complicated case. But with a living donor graft, you can ensure that that's going to be there for every case. So what have we done or what can be done to try to push the limits of living donor transplant and maximize really the potential of this very powerful tool that we have? So if you want to think about it, think about why do patients get turned down for or not offered the option of a living donor transplant? So to me, there are really four main reasons why people get turned down for a living donor transplant. One, they're either not the right male score, either too low or too high. Two, they don't, sorry, they haven't been able to find a suitable donor or they've never looked. So donor availability. Three, the donor that they've found has been felt not to be suitable, either because they're ABO incompatible or there's an anatomical problem with that donor. Or finally, that recipient has felt not to be a suitable candidate because for whatever reason, people have felt that they should only get a deceased donor transplant, not a living donor transplant, either because they're re-transplants or they have a particular type of tumor or whatever. So let's look at each of those individual categories and see. So on the low melt side, so there was a very nice analysis done by the group from Colorado that looked at, what's the lowest melt score where you're gonna get a mortality risk benefit with a living donor transplant versus staying on the waiting list. And you could see that anyone with a melt score over 10 actually, has a lower chance of dying with a living donor transplant versus staying on the waiting list. So that's a pretty low melt score that you can think about. So that's certainly a good justification for thinking about this in our low melt patients. But what about on the high melt side? So that's probably one of the more common reasons your melt is too high, as we were told. And each program or many programs have set sort of artificial lines in the sand. They won't do anyone with a melt over 20 or 25 or 30 or whatever. But we don't really have that. We found that using various techniques, surgical techniques and selection of donors, right lobe grafts exclusively, trying to utilize the middle hepatic vein in the graft, et cetera, that you can transplant high melt patients and they do okay. So if you look, these are high melt patients classified as melt over 25 and the living donor versus deceased donor. And you can see that there's virtually no difference in terms of outcome between our live donors and our deceased donors. In fact, the most critically ill are fulminant hepatic failure patients. We try to almost as a preference offer them a living donor transplant. And if you think about it, why do patients with fulminant hepatic failure do poorly after transplant? It's not because these are technically hard transplants. In fact, these are the easiest technically of the transplants because these patients usually don't have portal hypertension or significant adhesions or anything. But these patients do poorly because it's a race against the clock to essentially get them transplanted. And what better way to beat that clock is if you have a living donor available right away. So we have a protocol in fact for working up donors with fulminant hepatic failure. We'll admit the donor to hospital and have them see and get all of their tests. And we're able to do a complete evaluation on patients, on donors within 24 hours and do that transplant in less than 24 hours if needed, if the situation calls for that. Reason number two is that the donors can't find a suitable donor. And if you think about it, it's very hard for someone to find a donor just to put yourself in that situation. Would you be able to ask someone to be a donor for yourself? It's a very tough ask. And so you have to teach people how to go about doing that. And we use lots of resources, including social media, the Champion Program, as Kieran had mentioned, to really help patients help themselves in how to go about the process of finding donors. I think to tell a donor, well, you better go find yourself a living donor and then leave them at that is really doing them a disservice because the vast majority really will not know where to go and what to do after that point. We also have a tendency, or thinking of using donors that maybe others may not. So for example, the non-directed donors, I think they can constitute at least a part of your program. So you can see that roughly about 10 to 20% of our donors are non-directed and they constitute an important part, especially because we use them often to initiate paired exchanges. So here's a useful tool to try to do transplants when donors are incompatible for whatever reason. So since 2019, we've done 12 pairs, so 24 transplants. So if we see someone who is ABO incompatible, for example, our first choice is to do a living paired exchange, a live donor paired exchange on them. And if we can do a paired exchange within three months of listing them for a transplant, then we'll go ahead and do that. But if we're not able to find them a suitable paired exchange within three months and they're ABO incompatible, then we'll actually go ahead and do an ABO incompatible transplant on them using this protocol. And it's actually much easier to do a liver transplant in an ABO incompatible situation as compared to a kidney transplant. The liver tolerates that much better and we've done several of these now with good results. Okay, reason number three is that there's a donor but the liver is not good enough. And lots of reasons why donors get turned down. If the donor is not healthy enough, if they have medical issues, then they have medical issues and you can't make them suitable. But that's really not the most common reason why donors get turned down. And in fact, what I've shown you in the pie graph is our evaluation in 2018. And you can see that we have roughly about a 70% donor acceptance rate. So if we bring a donor in to be evaluated, the likelihood that we're gonna approve them for donation is about 70%, which is pretty high. And that's because there are very few anatomical and size criteria for us that are exclusion for donors. And that's probably one of the most common reasons why donors get turned down is because of anatomy of the liver or size issues. So let me tackle each of those individually. So anatomy is really just a measure, or most of the time is really just a degree of your comfort level dealing with anatomical variations. And so for example, here's some anatomical variations. This is a situation where you, instead of having one hepatic vein, have three different hepatic veins. And some may not use that, but it's a pretty easy thing to reconstruct on the back table. You just put this vein patch in the middle and you can reconstruct all three hepatic veins and implant that. And that's not a very complicated thing to do. Or if you have two portal veins, for example, that's also a relatively easy thing to deal with. You just put the two of them together on the back table or you take a Y graft from the explanted liver and you can put that on there and re-implant that. So anatomy is really just a matter of your comfort level. And the more of these you get, the more comfortable you are. So if you can do one anastomosis, you can do two or three or four, whatever you need to make that liver work. So the other important thing is size. And if you look at size, people often are told that their liver is not big enough. And size you have to be careful with. So in our population, in North America, especially, many of our patients, recipients are going to be obese. And so if you're just going to use their body weight, many of them are not going to have the right size graft. And so you have to take that into account. But even smallish grafts, and a small graft is defined as a graft, which by measurement is a graft weight to recipient weight ratio less than 0.8. But even those, you can get them to work using modern portal vein, sorry, using modern, what are called modulation techniques, where you optimize the flow into that liver. And small grafts often don't work because there's too much blood flowing into that liver for it to manage. But you can use various techniques. And what we do is actually, we very carefully measure exactly what the portal flow is, what the portal pressure is, and what the hepatic artery flow is during the transplant using special transducers. And we have target ranges as what to the ideal measure should be. And then you can adjust things. So if your portal flow, for example, is too high, you can do measurements such as, you can do interventions, such as I've shown on the top, using either a triotide or splenic artery ligation, or a mesarenal or a porticoval shunt if needed. And if your portal flow is too low, then that means you generally have a spontaneous splenorenal shunt, and you have to go looking for that and ligate it. So we do all of that in the OR, and we don't leave the OR until we get the numbers right in the range that we want them, because that's really your best, and sometimes the only chance you have to make sure that it's right. And if you don't, then afterwards, it's very difficult to fix it. And this is our experience with what are by definition small for size grafts, that's graft weight ratio less than 0.8. And you can see that our outcomes are really no difference based on that size of the graft in terms of patient survival. And roughly 20% of our grafts are now by definition small for size grafts. And generally as a rule, we follow that, if you have a graft that's over 650, that's gonna work for just about anyone without portal hypertension. And if you have a graft over 750, that'll work for just about anyone even with significant portal hypertension. And finally, reason number four, the recipient is felt to be too high risk for a living donor transplant. As I said before, a living donor graft is really the ideal graft, and therefore that should be the first choice for your high risk recipients, because you can transplant these recipients at a lower meld before they become significantly sick, and before they get significant problems with sarcopenia, because if they're high risk, the chance of them getting through a transplant when they have a meld score of 35 is very tough. But, you know, transplanting them with a meld score of 20 or 15, that's possible. And that you can only do with a living donor at the present time. Also, it allows you to optimize these patients before the transplant. And as I said, having your best surgical team for these complicated high risk patient is really something that can make a difference. So for example, here's our experience with re-transplants. Again, for us, re-transplants is not a contradiction. We've done 17 re-transplants to date using a living donor. And you can see that our patient and graft survival are virtually identical with deceased donor versus a living donor. Lastly, transplant oncology is a new and sort of evolving field. The ability to use transplant to treat either expanded criteria tumors or tumors that we would have previously thought not candidates for treating with a transplant. But unfortunately, many of these patients don't really have many options. And a living donor transplant is really an ideal transplant scenario for these patients who may potentially benefit from a transplant. Why? Because A, it allows for a shorter time to transplant. Many of these patients can't afford to be on the waiting list for a significant length of time because of that risk of progression of disease. It allows you the ability to optimally time the transplant. This can be especially important if you're going to give this in combination with neoadjuvant therapies. Neoadjuvant therapies are very difficult to time if you're going to do a deceased donor transplant because you have no way of knowing exactly when that patient is going to get a transplant. If you're going to use adjuvant therapies afterwards, or the ability to use adjuvant therapies is better in live donor transplant because these patients generally tend to recover quicker, and therefore their ability to tolerate these adjuvant therapies after the transplant is better. And lastly, I think you can be more successful in minimizing immunosuppression in live donor patients. Many of our patients by a year out from transplant are on very minimal immunosuppression. And so I think that's always got to be a plus when it comes to treating patients with tumors. And so we have protocols in place for treating patients with high-learned intrapartic cholangios, metastatic colorectal cancers, tumors beyond Milan, metastatic neuroendocrines. And many of these patients, we only offer the option of a living donor transplant because many of them actually don't qualify for a deceased donor transplant, either because of criteria or because not an approved indication. So in summary, I think it's time to change the paradigm, how we think about liver disease and live donor liver transplant in the U.S. So remember our current rules of allocation, MELD score, all of that, you know, they're all very appropriate, but they were designed for that situation of utilization of a limited resource. You know, that situation where you have 8,000 donors with 14,000 recipients waiting for that. But, you know, that's not the equation that you have for a living donor transplant. The equation that you have for a living donor transplant is really one donor giving to one recipient. And so those rules of allocation really don't need to apply in a living donor transplant situation. Rather, the rule that should be most applicable for is, is that therapy going to provide that patient with a survival advantage over best other treatment that they have available to them at the present time? That's the criteria that we use to decide on any other medical therapy that we offer to a patient, whether it's a surgical therapy or a new drug or whatever. Is it going to give them a survival advantage over anything else that they have available to them? And if it does, then maybe we should offer that to them as an option. So for us, really, live donor transplant is really the first option that we offer to all our patients and not a last resort, because that's really not the way to utilize that. So I'll stop there. And I think we have some time for questions. Wow, that was that was really a great talk. I learned a lot about living donor liver transplant, especially in terms of like the techniques that Pittsburgh is using. So this webinar is open for questions now. And I have a question here for Dr. Bamba. And, Dr. Bamba, you said that you need to have a really nice buy in from your institution to start a living donor program. So, you know, we want to know what are the institutional challenges that you your program has to you have to face in starting the living donor liver transplant program? Thank you. Yeah, that's a great question. From there's many challenges there. I think just basic challenges, just educating people. And that includes the institutional leadership about why living donor liver transplant is, is an important endeavor for them to invest in, and why it could be a high stakes endeavor for the for the institution, and why they should invest money in it, because they always want to see. So with the funding that we got from from UW Medicine for a live donor program, part and parcel with that was we were put on a pretty short timeframe to to build out everything we said we were going to build out. And part of that process was meeting with the CEO of the institution on a regular basis to give updates on what we had accomplished. And, you know, each meeting, it was, you know, what have you done for me lately? So, so it's, and showing them that it can be a, you know, in addition to the right thing to do, and the right thing to bring to the Pacific Northwest and lifesaving opportunity for individuals up here who have not had access to this for decades, is also showing the institution that it's a fiscally viable undertaking. And then all the just constantly reiterating and meeting with them to emphasize the the ongoing support we need and additional support we need as the program builds out. So it's a lot of strategizing and deliberate conversations. How about the cost of transplant? Like, you know, insurances need certain number of living donor liver transplant before they credential your program and things like that. So how did you your program dealt with that? So some of the insurance, we haven't, surprisingly, we went encountered this a lot. Some of the insurance programs will seek sort of a designated center of excellence. But, but, actually, we've, we've had good, I guess, good fortune that we haven't run into too many, too many snags with insurance saying, we, we won't allow your program to do a live donor liver transplant. I have a question for Dr. Humar. This is about graft to recipient weight ratio cutoff. You said that you, your center has used less than 0.8 graft to recipient weight ratio. Although there are no significant differences, but, and then you also talked a little bit about small for size. Could you? Yeah, I mean, you, you can certainly use those, but, you know, you can't go into it blind eyed and just put any graft into any patient. So small grafts can be used, but you have to, as I said, as I pointed out, you have to use sort of modern optimization, use sort of modern optimization of flow to be able to utilize them. So, as I said, we measure flow measurements very carefully in all patients and do modulation, whether it's splenic artery ligations, splenectomy, portocaval shunts, et cetera, to make sure that you've got the exact right flow in patients. And then also you want to be sure that, you know, you use the right donor for the right recipient also. So if you have a small graft, for example, you know, if you're, if your recipient is an HCC patient, who is otherwise has very relatively maintained graft function and is just cirrhotic and, but their liver function are not, are not bad. You know, you could get by with a small graft in that, then it would be fine. But if you're, if the patient you're wanting to transplant has a MELD score of 35 or 40, obviously in that situation, you don't want to use a small for size graft. So you have to tailor the graft to the recipient in that situation and not, and not just use the surgical techniques to be able to utilize small grafts. Thank you. Dr. Bhamba, Dr. Umar said that they, 20% of their volume is non-directed liver trans, non, non-directed living donor transplant or paired living donor transplant. Does UW also do a lot of non-directed living donor liver transplant? Yeah, actually we, we have, we have had quite a few non-directed living donors come forward. I think we've done, I should know this number off the top of my head, but probably about 10, 15% of our transplants are non-directed. And in thinking about that, you know, there was a bigger spike in the non-directed donors in the, in the height of the pandemic. And in speaking to these non-directed donors, it sounded like the pandemic in addition to all the pain and suffering it brought, it also had some salutary effects like allowing people a little more time and space in their lives to think about proceeding with, with non-directed donation. So, so yeah, and I think that's been nationally, there's been a, an increase in non-directed. Thank you. And then there was another question about outreach. I know that Pittsburgh has national, national ads, which says like taking a patient out of the waiting list and then going for a living donor liver transplant. What are the other ways of outreach that both of your programs have done to increase the awareness of living donor liver transplant? So, so certainly awareness is a, is an important issue, but what we learned was, so that national campaign we just did for one time. And what we really found is that that's probably not the most effective way that you're much more likely to be effective with a much more targeted type of outreach where you're reaching out to your referring physicians, meeting them one-on-one or meeting to meeting one-on-one with, or in small groups with the audience that you're trying to reach out to. That's more likely to be the effective type of outreach that you have to do, I think. So we've, we've now turned to a strategy of targeting of more targeted outreach that, that I would find reaching out to individual hepatologists or individual GI programs or, or individual patient group centers, et cetera, and, and talk to them about living donors as opposed to just, you know, running a blanketed ad, because that's usually not going to attract good, a large number of good candidates anyways. Dr. Fong? Yeah, I would, I would agree with that. The targeted, targeted education and awareness. And I, I, I like to ask people why, when, when I sense that, that they have hesitancy about living donor liver transplant, what, what the concern is, what the obstacles are, because there is a lot of misunderstanding and misinformation, and that filters through the, our transplant candidates, you know, when you're talking to them in, in clinic, you know, like, like, oh, but that's only, that's only a, a partial liver. And I was told I need a whole liver and yeah, just, just breaking down all those misconceptions and misinformation on a very local level. And that includes in primary care too, because there's, the primary care providers are also weighing in on some of this information early on for these liver patients. There's another question, which is related to, like, how much time does it take for a donor evaluation? You know, that, you know, you want to give donor enough time to think it through and about the operation. So that's one of the questions. And also like, do you evaluate multiple donors at the same time, or do you stagger them so that, you know, if one doesn't work out, the second one would. So if Dr. Bamba and Dr. Omar, if you can elaborate on that. Yeah, go ahead, Karen. You can go first. So I, you know, I, I agree. It's always nice to give donors some time to think, et cetera. But in reality, what I found is that it's really most helpful for the medical team more than anything else, or it makes them feel better. Donors for the most part, and obviously there's exceptions, but for the most part, they don't need all that time. They've already made the decision up before they actually even come to see you the vast majority of times. And certainly by the time you leave the, you know, the evaluation room, they've already made up their mind of what they want to donate or not. And they're usually trying to figure out, you know, how soon can I get this done, if anything. So I, I think that, you know, the question is, you know, should, should the evaluation be rushed and, or should it not be rushed, et cetera. So I think an evaluation should be complete. I don't think that the rush part really matters, whether you do the evaluation in 24 hours or 24 days. You know, that to me is not as big a difference as having a complete evaluation, making sure that everyone that needs to see them sees them, making sure all the testing is done. And especially in situations that call for a rush evaluation. I mean, you can't wait 24 days and someone who's got a, who's got fulminant hepatic failure. And for those people, for those donors, especially knowing that they could have done something, but they weren't able to, especially if the outcome is bad, that can have a tremendous impact on them long-term. So, so I don't think that, that, you know, rushing it, if the situation calls for it to be rushed is necessarily a bad thing. With regards to your other question about multiple donors, we don't usually evaluate multiple donors for several reasons. One, you know, it just inundates your system too much. You don't have the resources to be doing that many CT scans and MRIs and et cetera. So it's not really very effective resource utilization to do that. So we generally tell donors up front that, or recipients up front, when they say, well, I have lots of donors that want to be worked up. We tell them that, well, we'll evaluate your donors, but one at a time. And if one is suitable, then we'll stop there unless they really don't want to do it. Then we'll move to the next one. We won't evaluate all 10 of them and then have 10 of them and then have one of them decide who wants to be the donor. They have to decide up front who wants to be the first donor. And then if they're suitable, then hopefully go at that point. But if they're not, then move on to number two. All right. I'm going to give Dr. Goldberg for the last question. So Pratima said I could ask the last question, which is sort of a controversial one, but so, you know, this talk was fantastic. And, you know, you hear a lot in both the liver and kidney donation about living donation being the best option. We talked to the community and patients about, you know, being non-directed donors, but yet you don't really hear about doctors, our colleagues knocking down the doors to be non-directed donors. So if we as a field think that this is such a good option, why do you think it's rare that we actually see any of our colleagues doing this? And have either of you, and again, not getting into your medical histories, considered being a donor and sort of, you know, we talk about sort of leading by example to our patients? So we've certainly had medical professionals that have been non-directed donors and it doesn't necessarily have to be doctors, you know, other health care professionals, nurses, techs, coordinators, et cetera. Many have that. And many say that they do it because they see the need and the benefit that can come from it. So, yes, I think certainly health care professionals can do it. But, you know, being a donor is certainly not easy and it requires a time commitment and commitment to have time off to be able to do it. I think many physicians, et cetera, will not consider being non-directed donors because of the time off requirement that they need, because they often tend to be, you know, busier individuals. And if you look at non-directed donors, they often are coming from a background that allows them the flexibility of that. So that may be the reason why it hasn't. So specifically, have I considered being a donor, David? I haven't. I think I probably wouldn't qualify based on the restrictions. So, but that's an interesting question. But I haven't. Yeah, we've also had a fair number of medical professionals come forward to be either directed or non-directed donors. And we've, I'm thinking of a recipient we had who's, both her daughters were physicians, one of them, an oncologist. And I can't remember what the other one, her subspecialty was, but the daughter who was an oncologist was really conflicted because she wanted to help her mom. But she was literally like, I cannot take 12 weeks away from my oncology practice. So, I think there are these practicalities that seep in. Yes, but that, you know, with Dr. Humar mentioned about work, you know, for those listening live or on recording, you know, make sure to sort of contact your congressman or senator about the Living Donor Protection Act, because right now, living donors considered an elected procedure and not covered under FMLA. And our donors are actually not given the same protections as other people. So, just something to think about. But with that, we're, we've now reached the time. We want to thank everyone who listened to this live and who will be listening to this in the future. Apologize for some of the technical glitches with the video and all of that. Next week, Zoom permitting, we will be having the second in the two-part series where we will have a donor recipient talking alongside a hepatologist, myself and Dr. Ben Samstein from Cornell. And really building upon what was discussed today, which is really fantastic. And I learned a lot as well. So, we want to thank our speakers and our moderators. Thank you. My pleasure.

webinar

living donor liver transplantation

transplant surgeon

institutional support

multidisciplinary team approach

benefits of living donor liver transplant

challenges and solutions

paradigm shift

healthcare professionals

patients