Overview

What is an organ transplant?

An organ transplant replaces a failing organ with a healthy organ. A doctor will remove an organ from another person and place it in your body. This may be done when your organ has stopped working or stopped working well because of disease or injury.

Not all organs can be transplanted. Organs most often transplanted include:

• The kidney, because of diabetes, polycystic kidney disease, lupus, or other problems.
• The liver, because of cirrhosis, which has many causes.
• The heart, because of coronary artery disease, cardiomyopathy, heart failure, and other heart problems.
• The pancreas, because of diabetes.
• The lung, because of cystic fibrosis, COPD, and other problems.
• The small intestine, because of short bowel syndrome caused by necrotizing enterocolitis, Crohn's disease, and other problems. An intestine transplant is sometimes an option if you have problems with total parenteral nutrition (TPN).

More than one organ can be transplanted at one time. For example, a heart and lung transplant is possible.

Not everyone is a good candidate for an organ transplant. Your doctor or a transplant center will do tests to see if you are. You probably are not a good candidate if you have an infection, heart disease that is not under control, a drug or alcohol problem, or another serious health problem.

If your tests show you are a good candidate, you are put on a waiting list. It may be days, months, or years before a transplant takes place.

How successful is an organ transplant?

Organ transplants have been done in the United States since the 1950s. The procedure is always improving, and transplants are more successful today than ever before. Organ transplant success depends on:

• Which organ is transplanted.
• How many organs are transplanted. For example, you could have a heart transplant or a heart and lung transplant.
• The disease that has caused your organ to fail.

How do you prepare for an organ transplant?

First, you'll need to have blood and tissue tests done that will be used to match you with a donor. This is because your immune system may see the new organ as foreign and reject it. The more matches you have with the donor, the more likely your body will accept the donor organ.

You'll need to take care of your health. Continue to take your medicines as prescribed and get regular blood tests. Follow your doctor’s directions for eating and exercising. You also may want to talk with a psychiatrist, psychologist, or licensed mental health counselor about your transplant.

To learn more about what happens, talk to someone who has had a transplant. Your transplant center or doctor can give you the name of someone who is willing to share his or her experience with you.

You may have to wait days, months, or years for your transplant. Be patient, and ask your doctor what you can do while you're waiting.

What can you expect afterward?

After a transplant, many people say they feel better than they have in years. What you can and can't do will depend on the type of transplant you had, other health problems you have, and how your body reacts to the new organ.

You will have to take daily antirejection medicines for the rest of your life to prevent your immune system from rejecting the new organ. You will need less of these medicines as time goes by.

Because these antirejection medicines weaken the immune system, you may have to stay away from large crowds for a while and stay away from people who have infections. Be sure you talk to your doctor before you take any nonprescription medicines, such as cold remedies. These medicines may cause problems with your antirejection medicines.

You will also have regular checkups and blood tests to see how well your new organ is working.

Depression is common after an organ transplant. If you think you may be depressed, get help. The earlier depression is treated, the more quickly you will feel better.

You may need to make some lifestyle changes to keep your new organ healthy and strong. This can include eating healthy foods, getting regular exercise, and getting enough sleep. Your doctor can help you plan any needed changes. Keeping in touch with your transplant coordinator and your local primary doctor, taking your medicines, going to your doctor appointments, and making lifestyle changes are all important.

Who can be an organ donor?

Most people can be organ donors. If you are interested in donating an organ, contact the United Network for Organ Sharing (UNOS) at 1-888-894-6361 or go online at www.unos.org to get more information and to locate the nearest transplant center.

Many people choose to donate an organ upon their death. But a person can donate certain organs while he or she is still living. These people are called "living donors." To be a living donor, you must be in good health and be physically fit, free from long-term diseases such as diabetes or high blood pressure, free from mental health problems, and between the ages of 18 and 60.

Frequently Asked Questions

Preparing for a Transplant

What causes an organ to stop working?

Organ transplantation is a more common medical procedure today than in the past. People are living longer, which means that disease has a longer time to damage organs. Many diseases can lead to organ failure, including diabetes, cirrhosis, coronary artery disease, hepatitis C, chronic obstructive pulmonary disease (COPD), cystic fibrosis, and Crohn's disease.

If you have been living with a serious chronic disease that has caused a major organ (such as your heart, kidneys, liver, pancreas, lungs, or intestine) to fail, you may want to ask your doctor whether an organ transplant is an option for you. Decisions about whether you will need a transplant are usually made in consultation with a specialist.

How do I get on the waiting list?

After it is determined that you need an organ transplant, the next step is getting on the organ transplant waiting list:

• Obtain a referral from your doctor.
• Call the transplant center where you choose to have your transplant. To locate a transplant center near you, ask your doctor or contact the United Network for Organ Sharing by going online at www.unos.org or calling 1-888-894-6361.
• Schedule an appointment for an evaluation at the transplant center to find out if you are a good candidate for transplant. Your transplant center can perform all of the required tests, or your doctor can order the tests and send the results to the center.

During your evaluation, it is important to learn as much as you can about the transplant center. You may want to find out whether the center will accept your insurance, what your options are if you don't have insurance, and whether support groups are available. Be ready to ask a lot of questions to make sure the transplant center is a good fit for you.

The transplant center will notify you within 2 weeks of your evaluation to let you know whether you have been placed on the waiting list. If you have questions about your list status, contact the transplant center where you were evaluated.

It may be days, months, or even years before you receive a new organ. Waiting may be the hardest part of your transplant. Your transplant team will consider whether the donor is a good match for you, the status of your current health, and how long you've been on the waiting list. Your team will also consider the location of the donated organ, because it must be transplanted quickly to remain in working order.

What if I am not a good candidate for organ transplant?

If you are told that you are not a good candidate for organ transplant, find out if there are other treatments for your condition. Many people can live for years with serious health conditions. If transplantation is not an option, the goal of your care may shift to maintaining your comfort. Talk to your loved ones about the type of care you would like to receive. Discuss their expectations as well as your wishes, care needs, finances, and the needs of your family. Your choices may change as your illness changes.

What do I need to know before having an organ transplant?

It is natural for your immune system to destroy invading foreign substances in order to fight off infection and disease. Basically, an organ transplant from someone else is foreign to your body. When a new organ is placed into your body, your immune system sees it as foreign and tries to destroy it. The most important weapons to fight this rejection are antirejection medicines that prevent your immune system from attacking the donor organ.

Not everyone is a good candidate for an organ transplant. You probably are not a good candidate if you have an active infection, unstable heart disease, or another serious medical problem. Also, you will not be considered for organ transplant if you have an active substance abuse problem. Ask your doctor for more information about organ transplantation and whether you would be considered a good candidate.

While transplantation can be a long and challenging process, your quality of life may be greatly improved.

Because receiving a donor organ is a big responsibility, you'll have to be committed to taking good care of yourself in order to be approved for a donor organ. The best way to do this is to take medicines as prescribed, get regular blood tests, and make any necessary lifestyle changes to stay healthy. Because there are many emotional issues that may come with a transplant, you may find it helpful to see a psychiatrist, psychologist, or a licensed mental health counselor about your transplant.

Success rates usually state how many people who receive the transplant are living 5 years after the transplant.¹

• Kidney: About 8 or 9 people out of 10 (80% to 90%)
• Liver: About 7 or 8 people out of 10 (74% to 76%)
• Lung: About 5 people out of 10 (53%)
• Pancreas: About 8 or 9 people out of 10 (84% to 88%)
• Heart: About 7 people out of 10 (74%)
• Intestine: About 5 people out of 10 (54%)

How can my loved ones prepare?

There are many ways your loved ones can provide you with support during and after your organ transplant. It may be helpful to have at least one support person stay at the transplant center with you during and after your surgery. Before your transplant, this person can talk with the transplant coordinator to arrange for lodging while you are in the hospital. He or she should have a suitcase packed and be prepared to go to the transplant center with you when you get the call that your organ is available.

The transplant coordinator can also tell the support person where to wait during your surgery. Your support person can be responsible for writing down and asking the transplant team questions during and after your surgery. Also, he or she can stay with you after the surgery and watch for any rejection symptoms or unusual behaviors (such as being overly agitated) that sometimes occur after a transplant.

The support person should know what counseling services are available at the transplant center and know when to ask for help from an outside resource, such as another family member, community resources, or your place of worship.

What tests will I need before my transplant?

Before you can be considered for an organ transplant, you will need to have medical tests to find out whether you are a good transplant candidate and to find out your tissue type. Knowing your tissue type will make matching with a donor organ easier. Some tests are required for all organ transplant candidates, while others are needed to monitor your chronic disease or the cause of your organ failure. In general, tests that are done for all organ transplant candidates include:

• A cross-match for transplant. This is a blood test that shows whether your body will reject the donor organ immediately. Antibodies are proteins made by your immune system that attack and destroy foreign substances (antigens), such as bacteria and viruses. The cross-match will mix a donor's blood with your blood to see whether your antibodies attack the antigens of the donor. If they do, you are not a good match with the donor.
• Antibody screen. A panel-reactive antibody (PRA) test measures whether you have antibodies against a broad range of people. And if you do, it means you are at higher risk of having rejection, even if the cross-match shows that you and the donor are a good match.
• Blood type. This is a blood test that shows which type of blood you have—type A, B, O, or AB. Your blood type should be compatible with the organ donor's blood type, although it is sometimes possible to transplant an organ from a donor with a different blood type.
• Tissue type. This is a blood test that shows the genetic makeup of your body's cells. Each of us has genetic markers on the surface of our white blood cells. We inherit three different kinds of markers from our mothers and three from our fathers. The more of these six markers you share with the organ donor, the more likely it is that your body will accept the donor organ.
• A mental health assessment. Because many emotional issues are involved in having an organ transplant, you will be required to take a mental health assessment to identify any psychological issues that may prevent you from receiving and properly caring for your new organ. A living donor is also required to have a mental health assessment before donating an organ.

The results of these medical tests will be used to match you with an organ donor. The more matches you have, the more likely your body will accept the new organ.

What other factors increase my chance for a successful organ transplant?

Other factors that affect your chance of having a successful organ transplant include:

• The age of the donor organ. In general, the younger the organ donor, the healthier the tissue. But recent research is challenging this thought. It may be that some older organs work just as well as younger organs.
• The length of time that the donor organ is out of the donor's body. The more quickly an organ is transplanted after it is removed from the donor, the more viable the organ tissue remains. Your team will make every effort to quickly transfer the donor organ.
• How well the organ was preserved just before transplantation. The donor organ must be properly preserved while it is being transferred, especially if it was transferred from a long distance. Your team will make every effort to make sure the donor organ is properly transferred to your location.

What else should I consider?

You may be worried about having an organ transplant, being in a transplant center or hospital, or being around medical equipment or doctors. You may have concerns that you will not survive the surgery. All are normal concerns. Most people who have had an organ transplant say that it was a good decision and that the surgery and lifelong use of medicines and lifestyle changes are worth it.

The quality of your life can greatly improve. You should have more energy soon after your transplant. You may enjoy physical activities or foods that you haven't been able to enjoy in a long time. After having a transplant, you may feel better than you have in years—many people report feeling better immediately after their transplant, even while recovering from the surgery.

It is always wise to have an advance directive on file with the transplant center or hospital where you will receive care. An advance directive provides instructions about your medical choices should you be unable to make those choices for yourself. It is a good idea to appoint a health care agent to make your health decisions if you are unable to communicate your wishes. For more information, see the topics Writing an Advance Directive and Choosing a Health Care Agent.

It is true that there is a risk of not surviving an organ transplant just as there is with any surgery. There is also a slight risk that your transplanted organ will not function immediately. Some people with kidney transplants from deceased donors require dialysis for a week or more before the kidney functions adequately. Only a few transplanted organs never function. If the donated organ does not work well after your transplant or if it stops working over the years, it may be possible for you to have another organ transplant.

Making the decision to have an organ transplant can be hard. Talking with someone who has had an organ transplant may assure you that you can make the lifestyle changes necessary for a long-lasting, successful transplant.

At the Hospital

How can I prepare for my transplant?

While you are waiting for your organ transplant, you will be given a pager or cell phone so the transplant center can contact you at any time to tell you an organ is available. Always keep your pager with you. You may also wish to give the transplant center several numbers where you can be reached and the name and number of a few people who will always know how to reach you.

Arrange for someone to go with you to the transplant center when you have the organ transplant. This person can support you, listen to your doctor, and can help you remember important instructions from your doctor. This person can also report any change in behaviors or symptoms that you may have either before or shortly after the transplant. It is helpful to have someone who can be there to check in on you during your stay in the hospital and during your recovery at home.

Have your suitcase packed with the things you need to take with you to the transplant center. Your support person should also have a bag packed and ready to go at a moment's notice. You never know when you will receive the call that your organ is available.

What will happen at the hospital?

If you are called to the hospital or transplant center because a donor organ has been found, you will immediately be prepared for surgery while final tests are done to make sure the donor organ is a good match. If it is, you will have transplant surgery right away. If the organ is not a good match, the organ will be given to a person who is a better match, and you will be released to go home and continue to wait for your new organ.

If your current health condition requires that you be hospitalized while you wait for a donor organ, you will receive supportive and lifesaving care (such as blood pressure support for heart failure) until you are matched with a donor organ. During that time, you may be given high doses of a corticosteroid medicine, usually methylprednisolone, to prepare you for the surgery and prevent rejection. High doses of corticosteroids may cause side effects such as high blood pressure, high cholesterol, weight gain, sleep problems, and anxiety. Corticosteroids can also cause more severe side effects such as extreme agitation, paranoia, and psychosis (trouble telling the difference between what is real and what is not real)—some people may feel "out of it" or have hallucinations while taking high doses of steroids. But these side effects are temporary and will go away after you stop taking the corticosteroid medicine.

How long will I be hospitalized after the transplant?

Your recovery time after an organ transplant depends on how healthy you are prior to surgery, which organ was transplanted, and whether your body accepts the donated organ. A longer hospital stay may be needed for a heart or lung transplant than for a kidney transplant. Some people are out of the hospital within a few days after their transplant, while others may need to stay for a few weeks.

After the Transplant

Why does organ rejection occur?

Your body has a natural defense system called the immune system that protects you from infection and disease. The immune system defends your body by producing antibodies and "killer" cells that destroy foreign substances (such as viruses and bacteria). Since the donor organ doesn't match your own tissue exactly, your body tries to destroy the transplanted organ by rejecting it. Rejection is nature's way of protecting your body.

What medicines will I need to take?

After an organ transplant, you will need to take antirejection medicines, or immunosuppressants, for as long as you have the donor organ. Because your immune system will try to destroy the new organ, antirejection medicines are needed to decrease your immune system's response so the new organ stays healthy.

Antirejection medicines weaken your immune system and decrease your body's ability to fight infections, cancer, and other diseases. Over the years since organ transplants were first done, these medicines have greatly improved. Researchers are finding out more all the time about how to better regulate the immune system after a transplant. Current medicines still have the potential to speed up illness or create new disease, such as heart problems, diabetes, cancer, and osteoporosis. But these medicines also will save your life by keeping your body from rejecting the donor organ. It is important to take these medicines daily and exactly as prescribed.

Taking medicines daily for the rest of your life is not as hard as it sounds. It may help to talk to someone who has had a transplant and who can give you some assurance that you will be able to make the medicines a part of your daily routine. Over time, probably, fewer medicines will be needed. Additional medicines may be needed now and then to fight infection or other health problems related to your transplant.

In general, the antirejection medicines you will take after an organ transplant include:

Corticosteroids, such as prednisone or methylprednisolone. A high dose of corticosteroid, often methylprednisolone, is given right before your transplant, to decrease your immune system's activity, reduce inflammation, and prevent rejection. High doses of corticosteroids are usually continued for a few days after your surgery and then tapered to the lowest dose that helps prevent rejection. Taking high doses of corticosteroids for just a few days may cause temporary side effects such as high blood pressure, high cholesterol, weight gain, sleep problems, and anxiety. High doses can sometimes cause more severe side effects, such as extreme agitation, paranoia, and psychosis (trouble telling the difference between what is real and what is not real)—some people may feel "out of it" or have hallucinations while taking high doses of steroids. But these side effects are temporary. Prolonged use of corticosteroids can cause glaucoma, steroid-induced diabetes, and increase your risk of getting an opportunistic infection (such as pneumocystis pneumonia), which is a type of infection that occurs in people with weakened immune systems. Some experts are finding that some people may be able to avoid use of steroids or to use them sparingly.

Calcineurin inhibitors, such as tacrolimus and cyclosporine. These block the message that causes rejection. You probably will always need to take calcineurin inhibitors, because they are an important part of your lifelong care after a transplant. These medicines are helpful, but they also have potentially serious side effects such as high blood pressure, too much potassium in the blood (hyperkalemia), and kidney problems. These medicines can also cause nausea, vomiting, diarrhea, high cholesterol, tremors, and seizures. And they can put you at increased risk for infection and cancer. There is a great deal of research on the development of newer calcineurin inhibitors with fewer side effects. Ask your doctor for more information if you are having any of these side effects.

Antiproliferative agents, such as mycophenolate mofetil, azathioprine, and sirolimus. Antiproliferative agents prevent the immune cells from multiplying. These antirejection medicines are also an important part of your lifelong care after a transplant. They prevent your immune system from attacking and destroying the donor organ. Common side effects can include nausea, anemia, reduced number of white blood cells (leukopenia), high triglycerides, and intestinal upset. Antiproliferative agents also increase your risk of getting an opportunistic infection, cancer, and other life-threatening conditions.

Monoclonal antibodies, such as daclizumab, basiliximab, and rituximab. These antibodies block the growth of immune cells that are responsible for rejection. They are used early after transplantation with calcineurin inhibitors and antiproliferative agents.

Polyclonal antibodies, such as antithymocyte globulin-equine and antithymocyte globulin-rabbit. Polyclonal antibodies temporarily deplete the body's immune cells. These medicines are used in the hours and days immediately after your organ transplant to prevent your body from rejecting the donor organ. They may also be used again if your body starts to reject the donor organ. They are often used to reduce early use of calcineurin inhibitors, which can have serious side effects. Side effects of polyclonal antibodies include fever, itching, joint pain, and decreased number of white blood cells (leukopenia). Severe side effects may include an increased risk for cancer and opportunistic infections, serum sickness (a bad reaction to your own tissues), and a condition that prevents your body from making antibodies that fight infection.

You may have to take other medicines to prevent infection or to control other health problems you have (like high blood pressure).

What kind of physical issues will I face after transplant?

Almost immediately after a transplant, many people report feeling better than they have in years. The physical limitations you have will depend on the type of transplant you had, other conditions you may have, and whether your body rejects the donor organ. You will likely not face major physical limitations after you have healed from your transplant.

The daily antirejection medicines can cause some bothersome and sometimes serious side effects in some people. High blood pressure and high cholesterol are common problems after a transplant, although they can be treated with other medicines. You may be at increased risk for getting certain types of cancer and conditions such as diabetes. You will be at higher risk for infections, especially opportunistic infections, because your antirejection medicines will weaken your immune system. Be sure to keep your regular appointments with your doctor or the transplant center so you can be monitored for these illnesses.

What kind of emotional issues will I face?

Having an organ transplant may cause many emotional issues both for you and those who care about you. When your organ comes from a deceased donor, you may sometimes think about that and what it meant to the donor's family. It is common to have some depression after an organ transplant, although not everyone does. If you think you may be depressed, it is important to tell your transplant coordinator, doctor, or someone who cares about you. The earlier depression is treated, the more quickly you will recover and the better you will feel.

Staying Healthy

You can keep your new organ healthy and prolong your life after an organ transplant by:

• Keeping your doctor appointments. Regular contact with your doctor means new illnesses such as infections or other possibly life-threatening problems may be detected and treated early. Also, regular follow-up with your doctor is important for monitoring rejection, a concern that never goes away. Your doctor will also check you closely for medicine side effects.
• Getting regular blood and tissue tests. This is the only way that your doctor will be able to tell if your body is rejecting the new organ, if you are having serious side effects from the medicines, or if you are getting a new illness. Remember that just because you develop rejection does not mean that you will lose the new organ. If it is caught early, you may be given additional or different medicines to prevent rejection. But in order to catch the rejection or new illness early, you must have regular blood monitoring.
• Taking your medicines exactly as prescribed. Medicines after a transplant are critical to your health. Talk with your doctor to make sure you understand what to do if you miss a dose. For some people, it helps to organize daily medicines by placing the pills in containers marked with the days of the week. Other people find it easier to set an alarm for the times they need to take medicines. When you make your own plan for taking your daily medicines, it will be easy to remember.
• Telling your doctor immediately if you have an adverse reaction to a medicine.
• Not taking any nonprescription medicines, such as cold remedies, before talking with your doctor. These medicines may interact poorly with your antirejection medicines. Also, do not take any herbal remedies without first talking about it with your doctor.

Lifestyle activities that you can do to keep healthy and prolong the life of your new organ may include:

• Getting regular exercise. It is important to keep your muscles strong or it will become harder for you to walk, dress, or do other daily activities. Staying in shape and not gaining weight will help keep your body and new organ healthy. Many diseases (such as diabetes) are associated with being overweight, and some of the medicines may put you at a higher risk for getting these diseases. Gentle exercise such as walking, exercises in the water, and yoga can help you stay in shape and can also help reduce stress. For more information, see:

  Fitness: Walking for wellness.

• Eating regular, healthy meals. Healthy eating can control your weight, blood pressure, cholesterol, and blood sugar levels. Eating a balanced diet will give you energy and help your body fight disease and illness. Your doctor may suggest that you eliminate or reduce salt and high-fat foods from your diet. Be sure to get plenty of calcium and vitamin D because a side effect of corticosteroids is osteoporosis, or thinning bones. For more information, see the topic Healthy Eating.
• Paying attention to your body so you can detect new illness. Knowing how you normally feel, how much energy you have, and how active you are can help you quickly identify new problems as they arise, because you will notice a change in your energy level.
• Telling your dentist that you have had an organ transplant. Special precautions may be needed in teeth cleaning or other dental work. It is always important to keep your gums and teeth clean and healthy, but it is especially true after a transplant. The antirejection medicines may increase your risk of mouth infections.
• Staying away from people who are sick. Your immune system is weakened by the antirejection drugs. It is important that you stay healthy. Before you do any traveling, talk with your doctor to see if you need to take any precautionary measures.
• Carrying a medical identification card or wearing a medical ID bracelet or necklace that states that you have had an organ transplant. This information helps emergency personnel in the event you are unconscious, severely injured, or unable to answer questions.

What kind of emotional issues will I face?

Having an organ transplant may cause many emotional issues both for you and those who care about you. If your organ came from a deceased donor, you may sometimes think about that and what it meant to the donor's family. It is common to have some depression after an organ transplant, although not everyone does. If you think you may be depressed, be sure to tell your transplant coordinator, doctor, or someone who cares about you. The earlier depression is treated, the more quickly you will recover and the better you will feel.

Why should I keep in contact with the transplant center?

You will likely have a primary care doctor or specialist to provide for your regular health care after your transplant. Also, your transplant coordinator is a very helpful resource for questions you may have about medicines or what to expect in the months and years after your transplant or if new health issues arise.

Donor Information

Donor organs are in demand—there are currently more than 100,000 people on the national organ transplant waiting list. If you are interested in donating an organ, contact the United Network for Organ Sharing (UNOS) at 1-888-894-6361 or go online at www.unos.org to get more information and to locate the nearest transplant center.

Many people choose to donate their organs upon their death. If you decide to be an organ donor upon your death, make sure your family, friends, and doctor know about your wishes. You may want to fill out a donor card. Or you can prepare a living will or advance care directive that describes your wishes to be an organ donor. For more information, see the topic Planning to Be an Organ Donor.

People can also donate some organs (such as a kidney or portion of liver) while they are still living. These people are called "living donors." For more information, see the topic Living Organ Donation.

Although controversial, Internet donor-matching services have appeared in recent years to help people who need an organ transplant to contact potential living donors. Some experts believe these services undermine the current system, which is based on donated organs going to people who are most in need and those waiting the longest for a donor. Others believe online donor matching services provide a useful resource for helping people who have had problems finding a donor within the current system. For more information about these services, talk to your doctor.

Two types of surgery are commonly used to remove an organ or a portion of an organ from a living donor.

• Open surgery involves cutting the skin, muscles, and tissues to remove the organ. When open surgery is done, the person may have more pain and a longer recovery time.
• Laparoscopic surgery is a procedure in which a surgeon makes a number of small incisions and uses scopes to remove a kidney from a living donor.

You do not have to be a blood relative (such as a sibling or parent) of a living donor to receive a donor organ. A living donor can be someone who is emotionally related to you such as a close friend or spouse, or the donor can even be a stranger. In order to become a living donor, the person must be in good health, physically fit, free from chronic diseases such as diabetes or high blood pressure, free from psychiatric conditions, and between the ages of 18 to 60. Race and gender are not important considerations for becoming a living donor.