One Donor Liver, Two Lives Saved

The lives of two patients—one a baby, one a retired physician—crossed paths in the most unexpected way in the summer of 2017, when a single organ donor helped save both their lives at once.

Noah Hernandez, born in February 2017, and James Howell, MD, born in 1955, had never met, but both were facing life-threatening health conditions caused by liver disorders. Noah had been born healthy, but by his 4-month pediatric appointment, he was beginning to look yellowish, a condition associated with jaundice. After being admitted to his local hospital in Sacramento, a CT scan and liver biopsy indicated a problem with Noah’s bile ducts that was preventing his liver from draining properly—a condition called biliary atresia. That’s when he was transferred to Lucile Packard Children’s Hospital Stanford.

“With biliary atresia, no one really knows what the cause is,” says Carlos O. Esquivel, MD, PhD, Chief of the Division of Abdominal Transplantation at Stanford University School of Medicine and Director of the Liver Transplant Program at Lucile Packard Children’s Hospital Stanford. Most patients, he says, get an operation, called a Kasai, which attempts to get drainage of the liver. “In some children, it works and then they get better; but in some children, this procedure fails,” says Dr. Esquivel. “Their only chance for survival is liver transplant. And that was the case with Noah.”

Noah was placed on the waiting list for a donor liver. His parents, Alyssa and Reymon, understood it could be a long wait, because pediatric livers aren’t often available. “They can’t tell you how long you’ll wait,” says Alyssa. “They preferred to have an infant-sized liver, and felt that Noah was well enough that they could be picky and wait for the perfect liver.”

Noah soon began experiencing unusually high levels of ascites—an abnormal buildup of fluid in his abdomen. “Normally it’s there in the stomach,” says Alyssa, “But Noah had it only along his Kasai incision. “It was so bad that it kept getting bigger and bigger to the point that his entire right side was bulging out. He couldn’t sleep any more, wasn’t comfortable. He would just cry.”

Alyssa, who had stayed awake at her son’s side, was sent home to get some sleep. While she was gone, Noah started having trouble breathing. She rushed back to the hospital, where Noah had been transferred to the Pediatric Intensive Care Unit, and placed on life support. “Those were absolutely the worst days,” Alyssa says. Fearing the worst, she immediately called her husband, and also her pastor, to come right away. Noah was baptized that evening, on August 23.

Because of how sick he was, Noah’s position on the organ waiting list was moved up to the highest urgency, meaning he would get the first liver available. The paradox of organ transplant, however, is that the sicker a patient is, the higher they go on the organ waiting list; but a patient can be too sick to undergo transplant surgery, making them ineligible for organ donation. “Dr. Esquivel said they were doing everything in their power to prep Noah to get a liver,” Alyssa says. “That night, at about 9:30, we received the call.” A donor match was available—only it was not a pediatric liver, but one from an older teenager who had died tragically.

Almost 15 years earlier, in 2003, James Howell, MD, a retired physician in the South Bay, was diagnosed with cirrhosis of the liver. Cirrhosis is an irreversible liver disease that can be the beginning of other complications and diseases of the liver, including a 5 to 10 percent chance of developing cancer, which Dr. Howell was later diagnosed with. “I was just extraordinarily lucky to keep my cancer with only liver involvement,” he says.

“Once the tumor in the liver gets large enough, they can treat that by ablation,” Howell explains. “They put a probe into my liver and zapped it. I went through that procedure twice over two years. But the ablation was only buying time. I had two fatal illnesses going on at the same time. It was just a weight on my shoulders, just a burden that I felt every day.”

When his cancer came back for the third time, Dr. Howell was put on the waiting list for a liver. “I’d been cruising along, all things considered, keeping my ascites under control, strict dieting, staying with my medicines,” Howell says. “I was getting prepared to go in for another scan of my liver, when all of a sudden I got a call at about 10 o’clock at night.” Howell explained that they described the quality and condition of the liver. “They give you a little profile of it,” he says. “And it was almost too good to be true. It was like a gift from god, and from that family.”

Dr. Esquivel was among the first surgeons to do transplants in children—especially tiny babies—and has been doing them for nearly three decades. When the industry advanced to using split-livers, it was a leap that made sense, he says, because of the difficulty in finding pediatric donors.

“Because of the shape of the liver, it is common to split it between recipients of varying ages,” says Dr. Esquivel. “The anatomy of the liver is such that what we call the right lobe amounts to about two-thirds of the entire liver volume. So, let’s say it’s a three-pound liver: the adult will get about two and half pounds, and the child one-half pound.”

But transplanting an adult-sized liver into an infant is still a complex procedure. “The blood vessels are more of a mismatch, because they are adult-sized,” he says. “A child who is only a few months old—their blood vessels are tiny.”

Noah was prepped for surgery around 8:30 the next morning, August 24. “They told us it would take about 8 to 10 hours,” Alyssa says. “When it was done in seven and a half, that just blew our minds.” Clark Andrew Bonham, MD, associate professor of surgery, performed the removal of Noah’s liver, while Dr. Esquivel would transplant Noah’s new liver. At the same time, Dr. Bonham also performed the transplant of the new liver for James Howell.

“I woke up the next day and thought they had not done the transplant,” recalls Dr. Howell. “I had absolutely no pain.” The surgeons soon came in to tell Dr. Howell everything had gone well. He made a quick recovery, which he attributes to the constant support of his wife, Denise, and a round-the-clock team of nurses who were “absolutely incredible,” he says. “They were the most awesome human beings I have ever met.” For his surgeons, and the entire transplant team, he felt equal appreciation. “I can’t say enough about the people who took care of me,” he added. “They were just awesome— skilled, compassionate, and caring. It made a huge difference for me, obviously.”

Dr. Howell went home just five days after his surgery.

Recovery was rockier for Noah, who stayed in the hospital for two more months. The transplant itself was successful, but the difficulty he’d had keeping his ascites low before transplant worsened afterward. “The fluid started going around his lungs, and then into them,” says Alyssa. Noah needed surgery to place, and later re-place, a chest tube to drain the fluid, and also needed a respirator to support his breathing.

Alyssa recalls the day that Dr. Esquivel stopped by Noah’s bedside and advised taking him off all fluids, because they worsened ascites. Noah was also on diuretics and other medications to balance his fluid retention. “I adjusted his medications,” recalls Dr. Esquivel, “and it worked.” Noah’s ascites were gone within a week. “It was definitely a turning point,” says Dr. Esquivel. “Noah began to look happy and more like a normal child.”

“The man is a miracle worker,” Alyssa says of Dr. Esquivel. A few weeks later, the Hernandez family left the hospital, stayed nearby at the Ronald McDonald House for a few weeks while Noah was still under observation, and then went home to Sacramento in early November, 2017. “We were so happy to be out of the hospital and to be a family again,” Alyssa says.

Now home, Noah is thriving. “He’s doing great,” says Alyssa. “We couldn’t be happier. He’s now at 60th percentile for weight. His medications have been cut in half, and he’s eating like crazy.” Noah is also getting ready to crawl, and loves dancing every time Elmo comes on Sesame Street. “He’s just a very happy, active baby.”

Dr. Esquivel agrees, “Now he has as good a chance as any other kid to have a normal life.”

Meanwhile, Dr. Howell is getting back to enjoying his retirement, eating whatever he likes and taking time to enjoy the simple things in life. “I think a lot about the bravery and the courage of the donor family, for allowing their loved one to donate the organ that changed two lives immensely,” he says. “I don’t know why he was on the earth for such a short time, but I’m truly grateful.”

You can help patients who are currently waiting for a life-saving transplant by registering as an organ, eye and tissue donor. For more information or to register, visit www.donornetworkwest.org or register in-person at your local DMV.