Brenton Luper, left, living liver donor, with his mother, transplant recipient Karen Luper, following their surgeries.

VCU Health is one of the first in the country to perform a blood type incompatible liver transplant — part of an ongoing effort to increase patient access to lifesaving organs amid a national shortage. 

Responding to a patient’s urgent need for an organ transplant, VCU Health has performed, for the first time in its history, a liver transplant in which the donor’s blood type was incompatible with the recipient’s — a situation that would normally rule out the transplant.

The team at VCU Health Hume-Lee Transplant Center performed the blood type-incompatible liver transplant using a living donor. In this case, a son offered a portion of his liver to his mother to make the transplant possible.

“I’ve never been first in anything,” exclaimed Karen Luper, of Henrico County, who is the liver transplant recipient. “It’s great, and the team was nothing but phenomenal.”

Rallying around Karen and her son, Brenton Luper of Henrico County, was a team of experts with the skills and unique experiences to pull off the complex transplant — all the while making VCU Health Hume-Lee Transplant Center one of just a handful of transplant centers in the country to successfully perform an ABO, or blood type, incompatible liver transplant.

“The multidisciplinary approach and teamwork that realized this very complex and rare transplant is emblematic of the very best VCU Health has to offer our patients,” said Marlon Levy, M.D., chair of the Division of Transplant Surgery and director of the Hume-Lee Transplant Center. “We are so pleased with the outcome for Mrs. Luper and her family, and so grateful to the team for their incredible expertise.”

What is an ABO-incompatible liver transplant?

There are four blood types – A, B, AB and O. Typically, for an organ transplant to occur, the blood types of the donor and recipient need to be compatible or matched to prevent the recipient’s antibodies from attacking the transplanted organ.

For an ABO-incompatible transplant to occur, the recipient’s immune system needs to be prepared for the incompatible organ, starting 7 to 10 days before the transplant. During that time, the prospective organ recipient receives medication to prepare his or her body to accept the organ and undergoes plasmapheresis. Plasmapheresis is a process in which the recipient’s antibodies, which would normally attack the incompatible blood type, are removed from the plasma and replaced with another solution. Then, if needed, the patient receives what are known as immunoglobulins to help fight infection without rejecting the new organ.

VCU Health Hume-Lee Transplant Center has performed ABO-incompatible kidney transplants. It’s ABO incompatible liver transplants that are exceedingly rare in the United States.

VCU Health team offered exceptional skills, experience

Karen Luper knew she would one day need a liver transplant. For 15 years, she managed her decompensated cirrhosis. Though very sick, her condition did not elevate her Model for End-Stage Liver Disease (MELD) score high enough on the transplant waiting list to receive a deceased donor organ. Karen’s VCU Health Hume-Lee Transplant Center care team, which relaunched its living-donor liver transplant program last year, urged her to look into living donation. Her son, Brenton, was a candidate, but his A1 + blood was not a match to his mother’s O+.

That’s when the multidisciplinary team came together to establish the necessary procedures and protocols to make an ABO-incompatible liver transplant possible. Though rare in the U.S., the procedure is more routine internationally. This is where team members drew on their diverse backgrounds and unique experiences to plan and coordinate the surgeries.

The team included Dr. David Bruno, surgical director of adult and pediatric liver transplantation, VCU Health Hume-Lee Transplant Center; Dr. Seung Duk Lee, transplant surgeon; Dr. Kimberly Sanford, medical director of transfusion medicine; Idris Yakubu, PharmD, transplant pharmacist; Erin Schulz, living-donor transplant coordinator; and Dr. Vinay Kumaran, surgical director of living donor liver transplantation, who would be one of Brenton’s surgeons and whose resume includes more than 700 living liver donor cases.

Many others came together to form a group with the experience and expertise to ensure positive outcomes for Karen and Brenton, who also underwent a battery of tests to ensure he was fit for living donation.

It was complex surgery, both from a clinical and a procedural perspective. But “it became a non-decision because you were so comfortable with everyone,” Karen said. “I can’t tell you how good it made you feel to have that personal touch.”

The telehealth appointment that changed everything

After years of managing her condition, Karen took an unexpected turn for the worse. She recalled a conversation she’d had with her long-time VCU Health hepatologist, Dr. R. Todd Stravitz, on a telehealth visit in early April.  “He knew me so well he could tell that something was majorly wrong. We talked for five minutes and he said, ‘How fast can you get here?’”

“Karen is tremendously stoic and positive. I’ve known her for a long time, enough to know that she needed care quickly,” said Stravitz.

Karen was rushed to VCU Health for treatment. It was finally time for the liver transplant she knew she would someday need. But there was a global pandemic raging in Virginia and around the world.

“We didn’t have the luxury of waiting,” said Dr. Bruno. “We were faced with a nearly impossible situation and had to overcome that in order to save Karen’s life.”

The team acted quickly and followed necessary transplant-specific COVID-19 precautions for both Karen and Brenton, including testing, isolation and monitoring.

And on April 21, with the team working in concert and with surgical precision from start to finish, Brenton donated the right lobe of his liver to his mother.

Benefits of living-donor organ transplants

For prospective recipients, living-donor liver transplants reduce the time and stress of being on the national transplant waiting list. The organ from a living donor is often healthier and so are the recipients, since they don’t have to spend as much time waiting for an organ. In addition, live donors add organs to the donor pool, increasing the number of transplants possible each year amid a national organ shortage.

For the donor, the surgery entails removing part of the liver, which is then transplanted into the recipient. The liver grows back to its original size and function in both the donor and recipient in generally four to six weeks.

There are approximately 12,700 people on the national liver transplant waiting list, according to the Organ Procurement & Transplantation Network. Last year, there were 8,243 deceased donor liver transplants and only 524 living donor liver transplants in the U.S. Meanwhile, 1,192 patients died before they could receive a lifesaving transplant, and another 1,186 became too sick to undergo surgery and were taken off the transplant waitlist. What’s more, up to 30 to 40 percent of these patients may have had a suitable living donor despite blood type incompatibility.

“We are doing things that aren’t done in many other transplant centers in the U.S. to give our patients an option they won’t have elsewhere,” Kumaran said.

Moving forward at VCU Health, ABO incompatible transplants will be evaluated on a patient-by-patient basis.

A strong mother-son bond 

For Brenton Luper, the gravity of the selfless act to donate a portion of his liver to his mother occurred the day after surgery.

“It hit me, what this is going to mean for our lives, our family’s lives, our friends’ lives,” Brenton said. “This will have an impact much longer than any of us anticipated.”

On that day, Brenton was recovering in Hume-Lee’s inpatient transplant unit. Because no visitors were allowed due to COVID-19 safety protocols, the team placed mother and son across the hall from one another. The night before their surgeries, staff made accommodations for mother and son to eat dinner together.

 “I said I’d see you on the other side [of the hallway],” Brenton recalls.

They certainly did.

“And every time I think about it, I get teary-eyed,” said Karen Luper.

A son giving a selfless gift to his mother, and a talented team making it possible, will help not only Karen Luper, but many others who, just like Karen, are faced with the stark reality of a national organ shortage.

For more on VCU Health’s living-donor liver transplant program, and the remarkable story of another living donor liver recipient, Edward Foster, visit VCU News.