Twenty-four years after liver transplantation, the recipient becomes a body donor

Abstract

Organ donation and body donation are philanthropic acts based on voluntary altruism with no primary benefit to the donor. Both rely on the same humanistic principles, but they differ in the purpose for donation. Although organ donation is aimed at helping patients improve their medical condition, body donation is mainly done for research and educational purposes. Two recently published studies have demonstrated that the majority of motives for organ donation originate from the wish to save other people's lives,1 whereas the main motivation for body donation is related to the wish to be useful after death.2 Nevertheless, both types of donation represent anatomical gifts that are extremely valuable to society. Moreover, organ donation and body donation face the same problem: the need is significantly greater than the availability.3, 4 Here we report for the first time the case of a long-term survivor of liver transplantation who donated her body for education and research to give something back for the extra years of life that were given to her by transplantation. This report describes the case of a Caucasian female who was a 24-year survivor of liver transplantation and donated her body for education and scientific research. The patient suffered from primary biliary cirrhosis, which was first diagnosed in 1980. Before the onset of the disease, she taught for many years as an elementary school teacher. Her chronic liver disease progressed, and she underwent orthotopic liver transplantation on April 9, 1986 at the age of 50 years. She belonged to the group of the first 100 liver transplant recipients at University of California Los Angeles (UCLA).5 Except for several rejection episodes, she did well over the next 20 years. In July 1997, she signed up to donate her body to the UCLA Donated Body Program for research and educational purposes.6 According to her daughter, her primary motivation for donation was her wish to give something back to the liver transplant team for the extra years of life that were given to her by transplantation. The purpose of her donation was to give the liver transplant team priority to study the allograft anatomy and to provide organs for education and research. More than 20 years after she underwent orthotopic liver transplantation, the patient developed clinical signs of liver dysfunction. Her last hospitalization in December 2009 was due to a urinary tract infection and Pseudomonas bacteremia. She developed multiorgan failure and expired on December 19, 2009 at the age of 73 years. According to her wishes, her body was brought to UCLA, and it was cryopreserved at −10°F (−23°C) until cadaveric dissection. We performed cadaveric abdominal dissection on December 14, 2011. Before dissection, the cadaver was thawed at 40°F (4°C) for 5 days. Abdominal access was achieved through the previous chevron incision. The skin and fascia were well healed, but Prolene suture material was still present. The liver was soft and had no obvious nodularity (Fig. 1A). The suprahepatic vena cava anastomosis was found to be intact with a running Prolene suture line (Fig. 1B). All structures of the porta hepatis, including the common bile duct, portal vein, and hepatic artery, were carefully dissected out (Fig. 1C). We identified Prolene suture material at the arterial anastomotic site. The artery and the portal vein were widely patent without any evidence of thrombosis. A trichrome stain of a liver wedge biopsy sample showed postmortem autolytic changes and patchy bridging fibrosis (Fig. 2). After the abdominal dissection, the body was used by orthopedic residents for training purposes, and the brain was used for a research imaging study. After the completion of all anatomic studies, the residual body was cremated and released to the family for the funeral. (A) Anterior liver surface after laparotomy, (B) suprahepatic vena cava with an intact anastomotic suture line, and (C) dissection of the porta hepatis with encircled bile duct (green) and hepatic artery (red). The portal vein was widely patent and was intubated with a metallic probe. Postmortem liver histology at the time of anatomic dissection. Trichrome stain (×100) shows patchy bridging fibrosis (asterisks) and postmortem autolytic changes (arrows). The uniqueness of this case is not based on new scientific findings; instead, this case is an extraordinarily altruistic example of the essence of organ and body donation. Because the majority of transplant recipients go through a life-threatening period before transplantation, many wish to give something back to the transplant community as an expression of their gratitude. Working as volunteers in support groups or as ambassadors to promote organ donation is one way for recipients to give back. Body donation by a liver transplant recipient for research and education as described herein has never been reported before and is another altruistic way for a transplant recipient to express gratitude. Furthermore, this highlights the importance of first-person consent because donors have the psychological benefit of knowing that their anatomic gift will help future generations. A recently published study investigated the motivations for body donation to science.2 The majority of donors (93%) stated that the desire to be useful after death was the main criterion in their decision to become a body donor, and 49% of donors were motivated to express their gratitude for life and health and to medical professions. The criterion for being useful was mainly related to medical research and education in this study and another study.7 These altruistic motives were also observed in our patient and appeared to be reinforced by the fact that this patient received a lifesaving gift from an organ donor. Furthermore, her profession as an elementary school teacher might also have had a positive impact on her motivation for body donation as a way of contributing to teaching and education. Organ donation and body donation have many things in common. The attitude toward both types of donation is related to the level of the donor's education. A survey study of cadaveric body donor applications revealed that 40.5% of the applicants had completed high school, and 17% had graduated from college, whereas the corresponding figures for the national population were 36.6% and 8.5%.8 In this study, the typical body donor applicant was likely to be a white, female, 70-year-old homemaker with a high school degree. Many of these features were also present in our patient. Similar conclusions also apply to organ donation. A Spanish survey found that a positive disposition toward donation was higher in subjects who achieved secondary or university education levels. These data imply that donor education plays an important role in both organ and body donation and should be considered for donation campaigns. There is also documented evidence that people who know or have contact with someone who has received or needed an organ transplant have a better attitude toward organ donation.1, 9 Similar donor attitudes have been reported for body donation for dissection.7 The decision of a significant proportion of body donors (25%-33%) was influenced by having known somebody who had already donated or intended to donate his or her body for dissection. These observations imply that active disclosure of being an organ or body donor might be another effective strategy for increasing the acceptance of organ and body donation. A Swedish study investigated the public attitude toward autopsy, organ donation, and anatomic dissection in an age-stratified random sample of 1950 individuals.10 The analysis revealed that 85% accepted autopsy for themselves, 62% were willing to donate their own organs, and 15% were positive toward whole body donation for dissection. Interestingly, those individuals who accepted whole body donation also had a positive attitude toward organ donation. Similar findings were reported by a British study in which the proportion of body donors carrying organ donor cards was 63%, which was twice as high as the national average.7 As also illustrated by the present case, these data imply that organ transplant recipients appear to be an important target population for whole body donation. This knowledge, perhaps better disseminated with accessible networking social media and registries, might help make transplant recipients aware of this altruistic opportunity by which the dead can teach the living. Henrik Petrowsky M.D.* , Fady Kaldas M.D.* , Warwick Peacock M.D.*, Dean Fisher , Johnny C. Hong M.D.* , Charles Lassman M.D., Ph.D.§, Ronald W. Busuttil M.D., Ph.D.* , * Department of Surgery, University of California Los Angeles, Los Angeles, CA, Dumont-UCLA Transplant Center, University of California Los Angeles, Los Angeles, CA, UCLA Donated Body Program, University of California Los Angeles, Los Angeles, CA, § Department of Pathology Ronald Reagan UCLA Medical Center David Geffen School of Medicine University of California Los Angeles Los Angeles, CA.