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Chirag Desai, MD, FACS, an abdominal organ transplant and hepatobiliary-pancreatic surgeon at UNC Hospitals, and his team at the UNC School of Medicine’s Department of Surgery performed a “domino” liver transplant which helped two patients from a single donor without splitting a liver.

For the first time in two decades, Chirag Desai, MD, FACS, an abdominal organ transplant and hepatobiliary-pancreatic surgeon at UNC Hospitals, and his team at the UNC School of Medicine’s Department of Surgery, have performed a rare domino liver transplant on the UNC Hospitals main campus.

The 12-hour-long, highly technical procedure took place in early November. This is the second milestone for the team, which also performed a successful rare living donor liver transplant on a mother-daughter pair back in May.

“I am extremely satisfied that our team has the ability to execute such complex procedures safely and effectively,” said Desai, who is also the division chief of abdominal transplantation and surgical director of the Liver Transplant Program at UNC. “These surgeries give North Carolina people access to transplants and cutting-edge technologies.”

The Domino Liver Transplant

The liver is responsible for carrying out many vital duties within the body, from disposing toxic substances to producing proteins and making bile to digest food. Metabolic diseases, viral infections, cancer, and excessive alcohol use can wreak havoc on the liver, causing shrinkage and scarring. Slowly, the liver will become too weak to function and the patient’s quality of life will decline drastically.

Patient #1 was born with a rare metabolic disorder known as maple syrup urine disease, or MSUD, which disrupted his body’s ability to break down amino acids, the smallest component of proteins. When diagnosed, the patient was quickly put on a protein-free, high-carbohydrate diet to prevent his body from accumulating dangerous levels of protein in his body and keep his nutritional levels in check, respectively.

However, Patient #1 later developed diabetes, which made it even more difficult for him to manage his two conditions and stay properly nourished. A new liver would allow his body to once again metabolize proteins. With his metabolic disease improving, he would not have to ingest as many carbohydrates for nutritional purposes, which would, in turn, improve his diabetes. It would be a win-win-situation.

During this domino liver transplant, a liver was removed from a cadaveric organ donor and transferred to the patient with the metabolic disease. Because this recipient’s liver was otherwise normal, it was then transplanted into patient #2, who had cirrhosis of the liver. Patient #2 did not have the metabolic disease, and so this patient’s body had the ability to metabolize proteins from the other organs (as against the first who cannot metabolize from any part) and will not have the metabolic problems of the first patient. Because the first cadaveric donor liver went to the first recipient and the first recipient’s liver went to the second, hence the name “domino.”

Innovating for a Changing Paradigm

These types of surgeries are becoming more common after a new national policy, called the Acuity Circles Policy, changed the way in which organs are shipped to hospitals throughout the United States. Now, livers are harder to get than ever before, which leaves many patients waiting in desperation as their conditions worsen.

Patient #2 had severe scarring on their liver and a low model of end-stage liver disease (MELD) score. The score, which is calculated using blood test results meant they were relatively less ill compared to others competing to get a transplant and had little or no chance of receiving a liver within the next three months.

“The patient was waiting for the transplant for a while because their MELD score was so low,” said Desai. “Because of this surgery, we opened an avenue for them to get the transplant done. Innovations like this, in a changing paradigm of the liver allocation, are going to help recipients to get through the process.”

A Technical Challenge with Astounding Results

The procedure itself is very technical. The first part of the procedure is identical to a classic liver transplant. A liver is recovered from a deceased donor and placed into the first recipient. But in a domino transplant, removing a liver from the first recipient requires extra care and precision to preserve the liver for insertion into the next recipient, which makes the process difficult.

The first recipient’s liver is then “flushed” and placed into a special cooler with ice to keep the organ at the proper temperature for preservation. Then, the next recipient’s liver is removed and replaced with the original liver from the first recipient. Astoundingly, the team did not have to provide a single unit of blood to either patient.

Both patients have recovered from their procedures and are looking forward to taking full advantages of their lives with a new liver.

“Both patients were discharged within 12 days of transplant,” said Desai. “I’m happy to report that the first patient has an extremely good quality of life and his diet restrictions have decreased. The second patient, who had a very poor chance of getting a transplant, did, and is doing well.”

Media contact: Kendall Daniels, Communications Specialist, UNC Health | UNC School of Medicine