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Non-Communicable Diseases WatchNovember 2015

Liver Donors - Anonymous Heroes Who Save Lives

This publication is produced by the Surveillance and Epidemiology Branch, Centre for Health Protection of the Department of Health

18/F Wu Chung House, 213 Queen’s Road East, Wan Chai, Hong Kong http://www.chp.gov.hk All rights reserved

Key Messages

Liver transplantation is a life-saving procedure for adults and children with end-stage liver diseases.

Liver grafts can come either from a deceased donor or living donor.

Globally, there were 25 050 liver transplantations performed in 2013. Among them, 18.3% of livers

were from living donors.

Hong Kong had its first deceased donor liver transplantation, first paediatric living donor liver

transplantation, and first adult living donor liver transplantation in 1991, 1993 and 1994

respectively. Between 1991 and 2014, there were a total of 1 148 liver transplantations performed

at the Queen Mary Hospital (QMH). Among them, 646 used living donor grafts and 502 used

deceased donor grafts.

As the demand for liver grafts continually outstrips supply, it would be hard to reduce the proportion

and number of living donor liver transplantations without an increase in donated livers from

deceased donors.

To support organ donation after death, members of the public may indicate their wish to

donate organs after death by registering in the Centralised Organ Donation Register (CODR) at

https://www.codr.gov.hk/codr/Internet.do and informing family and relatives about this wish.

To have the gift of hope continue to snowball, prospective donors can also encourage family,

relatives and friends to do likewise.

Liver Donors - Anonymous Heroes Who Save Lives

Page 2

Liver transplantation is a surgery to remove a

diseased or injured liver and replace it with a whole

or partial healthy liver from a donor. Liver grafts can

come either from a deceased donor or living

donor (usually a healthy family member). In a living

donor scenario, the operation in the donor involves

taking out the required segments while ensuring

that the remnant liver is sufficient for living donor to

maintain normal body functions. In fact, the

development of living donor liver transplantation is

to compensate the critical shortage of deceased organ

donations for increasing number of patients waiting

for liver transplantation.1, 2

There are many diseases of liver which may need

transplantation eventually. Common indications for

liver transplantation include cirrhosis from chronic

iver diseases, acute liver failure, liver malignancies,

metabolic liver diseases and other irreversible liver

diseases (Figure 1).2, 3 Nevertheless, some patients

ma y not be appropriate candidates for liver

ransplantation, for example, patients with active

alcohol intake or substance abuse, active infection or

uncontrolled sepsis.2

l

t

Non-Communicable Diseases Watch November 2015

Figure 1: Common indications for liver transplantation

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Non-Communicable Diseases Watch November 2015

Global Perspective

From Deceased Donors From Living Donors

Source: International Registry in Organ Donation and Transplantation.

0.3

1.1

1.8

3.7

5.3

7.4

8.2

10.9

12.9

13.66

18.9

19.2

21.9

22.7

23.0

26.5

0 10 20 30

Japan

Russia

Saudi Arabia

Turkey

Hong Kong

South Korea

Netherlands

Australia

Switzerland

United Kingdom

France

United States of America

Portugal

Spain

Belgium

Croatia

Rate per million population

0.04

0.12

0.2

0.23

0.29

0.49

0.53

0.6

0.7

0.8

2.9

3.8

4.0

4.7

12.8

16.1

0 10 20 30

Australia

Netherlands

France

Croatia

Portugal

Spain

United Kingdom

Switzerland

United States of America

Russia

Japan

Belgium

Saudi Arabia

Hong Kong

Turkey

South Korea

Rate per million population

Since the first successful liver transplantation

from deceased donor was performed in 19673,

liver transplantation has evolved and become a

highly successful life-saving procedure for many

adults and children with end-stage liver diseases.

Survival after liver transplantation has also

progressively improved with 1-year and 5-year

survival rates exceeding 85% and 70% respectively.4

Liver is the second most common solid organ to

be transplanted worldwide after kidney. The Inter-

national Registry in Organ Donation and Trans-

plantation of Global Observatory on Donation and

Transplantation (http://www.irodat.org/) estimated

that there were 25 050 liver transplantations

performed globally in 2013. Among them, 18.3% of livers were from living donors.5 While use of liver from deceased donor predominates in the Western countries, use of living donor liver transplantation is more popular in Asian countries. The relatively slow progress of deceased donor liver transplantation in Asia is mainly due to the cultural and religious barriers of organ donation.6, 7 As Figure 2 shows, Croatia had the highest rate of liver transplantation from deceased donors of 26.5 per million population in 2013, whereas South Korea had the highest rate of liver transplanatation from living donors of 16.1 per million population.8

Figure 2: Rate (per million population) of liver transplantation from deceased and living donors

in 2013

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Non-Communicable Diseases Watch November 2015

Source: Department of Surgery, The University of Hong Kong.

Local Situation

2 1 2 5 9 10 914 12

7

1824

16 18 21 23 24 23

43 41

3040 37 35

12

2 24

4 6

210

2 2

2 34

14

1

9 1532

36

36

34

5639

49 41 43

41

53

44

33

34

27

0

25

50

75

100

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Deceased donor Deceased donor split Living donor

Number

of

liver

trans-

plantations

Year

Hong Kong had its first deceased donor liver

transplantation at QMH in 1991, whereas the first

paediatric living donor liver transplantation and

the first adult living donor liver transplantation was

done in 1993 and 1994 respectively.9 In children, the

most common indication for liver transplantation is

biliary atresia.10 Among adults, the most common

indication for liver transplantation is liver failure

secondary to hepatitis B infection.11 In mid-2003,

QMH became the only liver transplantation centre

in Hong Kong.

A review of a total of 1 148 liver transplantations

(including 134 paediatric recipients) performed at

QMH between 1991 and 2014 revealed that 646

used living donor grafts and 502 used deceased

donor grafts (Figure 3). The overall 1-year, 3-year

and 5-year survival rates were 92.9%, 88.2%

and 85.8% respectively. For paediatric recipients,

the corresponding rates were 93.6%, 91.0% and

91.0%. For adult recipients, they were 92.8%, 87.9%

a nd 85.1% respectively.12

Figure 3: Liver transplantations performed at Queen Mary Hospital, 1991 to 2014

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Non-Communicable Diseases Watch November 2015

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Promotion and Support of Organ Donation

Liver transplantation techniques in Hong Kong

have advanced greatly with a low hospital mortality

(< 2% in 2012) and high long-term survival.9

However, such life-saving practice is hindered

by the shortage of liver grafts.6, 13 Although living

donors can provide certain proportion of organs,

liver transplantation in living donors is technically

more demanding and involves complicated man-

power and logistical issues such as donor selection

and safety.7 Furthermore, there are small but real

risks (such as infection and biliary complication)

for living liver donors. 14 As the demand for liver

g rafts continually outstrips supply, it would be hard

to reduce the proportion and number of living donor

li ver transplantations without an increase in donated

livers from deceased donors.5 While organ donation

is a charitable act, many of us are in fact potential

organ donors after death (Box 1).

Box 1: Criteria for Deceased Organ and Tissue Donation15

General Criteria

There is no age limit in general

Brain death donors can donate both organs and tissue

When cardiac death occurs, the deceased can mostly donate tissue only, such as corneas, skin and bones

The organ has adequate function

Potential donor has no severe or systematic infection, such as HIV

Cancers are contraindicated in organs, skin and bone donation, except primary brain tumours. However,

the deceased cancer patients may donate cornea provided that they do not have lymphoma, leukaemia,

myeloma, malignant tumours of ocular or peri-ocular area

Criteria for Deceased Liver Donor

Deceased liver donor should meet the general criteria for organ donor

There is no age limit for a brain death donor

Deceased liver donor has normal liver function

Deceased liver donor has no history of chronic liver disease

Hepatitis carrier is not suitable for donation

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Non-Communicable Diseases Watch November 2015

To facilitate prospective voluntary donors to

express their wish to donate organs after death,

the Government launched the CODR on 24

November 2008. As at 31 October 2015, there were

over 179 000 registrations.16 To become an organ

donor after death, members of the public can

register in the CODR (Box 2). The CODR provides

multiple channels (including internet, email or fax)

for the public to register their wish to donate organs

after death more conveniently. It also enables

their wish to be readily accessible to Organ

Donation Coordinators of the Hospital Authority

at the critical moment so that the latter can

a pproach the family members as soon as possible

to seek consent to carry out relevant examinations

a nd operations in order to save patients in urgent

need of organ transplantation. In Hong Kong,

expressed consent from relatives of a prospective

donor is required prior to organ and tissue retrieval.

So it is of utmost importance that prospective donors

tell their family and relatives about their wish to

dona te organs and tissues after death. Otherwise,

the family or relatives may prohibit organ and tissue

ha rvesting if they are unaware of their loved ones’

honor able wish.

Box 2:

For those prospective organ donors who wish to register their wish in the CODR, they can:

1. Register online at https://www.codr.gov.hk/codr/Internet.do ; or

2. Download and complete the organ donation registration form, and send it to the CODR System

Administrator by post or fax.

By post: CODR System Administrator,

Department of Health, 21/F,

Wu Chung House,

213 Queen’s Road East,

Wan Chai, Hong Kong

By fax: 2127 4962

For enquiries concerning the CODR, please call 2961 8441 or email to codr@dh.gov.hk.

Page 7

To have the gift of hope continue to snowball,

persons who have registered on CODR can also

help by encouraging family, relatives and friends

to do likewise, learn the facts about organ donation

and debunk the myths or misconceptions on organ

donation (e.g. organ donation will NOT make

medical personnel offer less treatment; organ dona-

tion will NOT result in body disfigurement as the

incisions will be properly stitched up; in most cases

they will be covered by burial clothing). To know

more about organ donation, relevant news and

activities in Hong Kong, please visit the designated

website at http://www.organdonation.gov.hk, or the

Facebook fan page “Organ Donation@HK” at

https://www.facebook.com/organdonationhkeng.

References

1. Shukla A, Vadeyar H, Rela M, Shah S. Liver Transplantation:

East versus West. J Clin Exp Hepatol 2013; 3(3):243-53.

2. Varma V, Mehta N, Kumaran V, Nundy S. Indications and

contraindications for liver transplantation. Int J Hepatol 2011;

2011:121862.

3. Song AT, Avelino-Silva VI, Pecora RA, et al. Liver transplanta-

tion: fifty years of experience. World J Gastroenterol 2014;

20(18):5363-74.

4. Lo CM. Transplantation for liver cancer - more than better results.

Nat Rev Gastroenterol Hepatol 2013; 10:74-6.

5. Organ Donation and Transplantation Activities 2013. Barcelona:

Global Observatory on Donation and Transplantation, 2015.

6. Lo CM. Deceased donation in Asia: challenges and opportunities.

Liver Transpl 2012; 18 Suppl 2:S5-7.

7. Ng KK, Lo CM. Liver transplantation in Asia: past, present and

future. Ann Acad Med Singapore 2009; 38(4):322-10.

8. IRODaT Newsletter. International Registry in Organ Donation

and Transplantation. Final Numbers 2013. Barcelona: Global

Observatory on Donation and Transplantation, December 2014.

9. Chan SC, Cheung TT, Chan AC, et al. New insights after the first

1000 liver transplantations at The University of Hong Kong.

Asian J Surg 2015.

10. Chung PHY, Wong KKY, Tam PKH, et al. Split graft liver trans-

plant for paediatric patients in Hong Kong. HK J Paediatr

(new series) 2009; 14:181-5.

11. Chui AKK. Liver transplantation in Hong Kong. Hong Kong

Med J 2002; 8(4):232-3.

12. Hepatobiliary and Pancreatic Surgery and Liver Transplantation.

Hong Kong SAR: Department of Surgery, The University of

Hong Kong. Available at http://www.surgery.hku.hk/hbp.php

[Accessed on 12 August 2015].

13. Chung HY, Chan SC, Lo CM, Fan ST. Strategies for widening

liver donor pool. Asian J Surg 2010; 33(2):63-9.

14. Middleton PF, Duffield M, Lynch SV, et al. Living donor liver

transplantation--adult donor outcomes: a systematic review.

Liver Transpl 2006; 12(1):24-30.

15. Know More about Organ Donation (What is Liver Transplanta-

tion?). Hong Kong SAR: Department of Health. Available at http://

www.organdonation.gov.hk/eng/introduction_liver.html [Accessed

on 11 August 2015].

16. Statistics on Organ/Tissue Donations. Hong Kong SAR:

Hospital Authority.

Non-Communicable Diseases Watch November 2015

Non-Communicable Diseases (NCD) WATCH is dedicated to

promote public’s awareness of and disseminate health information

about non-communicable diseases and related issues, and the

importance of their prevention and control. It is also an indication of

our commitments in responsive risk communication and to address

the growing non-communicable disease threats to the health of our

community. The Editorial Board welcomes your views and comments.

Please send all comments and/or questions to so_dp3@dh.gov.hk.

Editor-in-Chief

Dr Regina CHING

Members

Dr Thomas CHUNG Dr Ruby LEE

Dr Cecilia FAN Mr YH LEE

Dr Anne FUNG Dr Eddy NG

Ms Janice HO Dr Lilian WAN

Dr Rita HO Dr Monica WONG

Dr Winnie LAU Dr Priscilla WONG

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Non-Communicable Diseases Watch November 2015