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“It was heart-breaking for me to see what my mom was going through – dialysis was getting to be really painful for her,” says Aliana Deveza, in Santa Cruz, California. “I had to help.”

Deveza’s mother was on the waiting list for a kidney transplant. Like some others in this situation, Deveza wanted to donate one of her own kidneys – but she was turned down because she might develop the same health problems as her mother in later life.

So Deveza came up with a different plan. In 2017 she instigated the world’s first paired exchange of different organs between living donors, swapping half her liver for someone else’s kidney. A case study of the organ swap has now been published, and the surgeons who were involved are calling for more exchanges like this. “You can imagine the enormous impact for mixed organ extended chains,” says John Roberts, a surgeon at University of California, San Francisco.

Most organ transplants come from people who have died, but there are never enough organs for those who need them. As most people can get by with just one of their kidneys, people with kidney failure are increasingly receiving donated organs from relatives or friends.

The search for a swap

If someone wants to donate but their immune system is incompatible, doctors may be able to find pairs of would-be donors who can each give a kidney to the other’s relative. Sometimes there can be long chains of such transfers, usually started by someone happy to donate their kidney to a stranger.

When Deveza was looking into such chains, she came across describing the idea of trading a kidney with the only other organ generally taken from a living donor – the liver. People can donate up to 60 per cent of this organ. The liver is one of the few organs that can regenerate, so the donor eventually regrows a full-sized liver, as does the recipient.

Deveza says she suggested the idea to many hospitals but got nowhere. “They didn’t know what I was talking about. They didn’t know which hospital department to transfer me to. One transferred me to the morgue.”

Finally, she contacted Roberts, who saw the idea’s potential. Deveza was assessed and judged to be in good enough health to donate part of her liver. It then took 18 months to find Annie Simmons, in Boise, Idaho, whose liver was unsuitable to use as a transplant for her sister with severe liver disease.

They drew up a plan: Simmons would donate a kidney to Deveza’s mother, and in return, Deveza would give half her liver to Simmons’ sister.

The proposal was reviewed by the hospital’s head of ethics, and the would-be donors were given the usual health assessments.

An unequal trade

A possible sticking point was whether this was a fair swap. In theory, a liver is worth more than a kidney, because people with kidney failure can survive for many years on dialysis, but there’s no equivalent for liver failure. Liver donation also has a higher rate of complications.

But Deveza had no doubts. “I was losing hope and I really wanted to do something.”

One factor that swayed the ethicists was that people are allowed to altruistically donate part of their liver to a complete stranger. While not an equivalent swap, at least Deveza would be getting some recompense in the form of helping her mother.

The hospital gave the go-ahead and the four operations took place on the same day. In the following weeks, Deveza noticed how tired she felt, which she had been warned would happen as her body put all its energy into regrowing her liver. “It was like bad jet-lag,” she says.

But an ultrasound scan two months later showed her liver was almost back to normal. “Regeneration probably starts within hours,” says Roberts.

The team hope that the ground-breaking case will inspire more people to consider doing the same. Roberts says that direct swaps involving two donors could enable up to thirty extra living-donor liver transplants a year in the US – a ten per cent increase.

For Deveza that would be very welcome. “I set out to do this for my mom and I’m glad that in the process I was able to help other people too. I hope to set a precedent.”