Sister Saves Her Brother’s Life Through Liver Transplant at the Recanati/Miller Transplantation Institute at Mount Sinai

When he was 17, Zachary Castro was diagnosed with primary sclerosing cholangitis (PSC), a bile duct disease that can lead to irreparable damage to the liver. By the time he was in his mid-20s, the condition of his liver had severely deteriorated, and he needed a transplant.

In 2023, Zachary underwent a successful live donor transplant at the Recanati/Miller Transplantation Institute at Mount Sinai, one of the largest and most comprehensive abdominal transplantation centers in the world. His sister, Kayla, donated half of her liver and ultimately saved his life.

“We take very seriously our responsibility to ensure that donation be as safe as possible for these truly selfless people who literally give a piece of themselves to save another person’s life,” says Sander S. Florman, MD, Director of the Recanati/Miller Transplantation Institute.

Zachary’s medical journey with Mount Sinai started in 2014 after blood tests revealed that he had extremely high liver enzymes. He was referred to Jaime Chu, MD, Associate Chief of Pediatric Hepatology at Mount Sinai Kravis Children’s Hospital.

Dr. Chu sent Zachary for a magnetic resonance cholangiopancreatography, an imaging test used to detect biliary (bile duct) issues. He was diagnosed with PSC. In this condition, the bile ducts inside and outside the liver become inflamed and strictured. This leads to poor drainage of bile from the liver, leading to repeated infections (cholangitis), formation of bile duct stones, build-up of scar tissue (fibrosis) and a risk of cirrhosis and cancer of the bile ducts (cholangiocarcinoma). A liver biopsy also showed signs of inflammation (due to autoimmune hepatitis) that could be contributing to his symptoms. Dr. Chu prescribed ursodiol for treatment of the PSC, along with immunosuppression treatment with prednisone and azathioprine for the autoimmune hepatitis. His condition stabilized over the next few years.

A Declining Condition

In May 2018, Zachary was transitioned to the care of Jawad Ahmad, MD, Professor of Medicine (Liver Diseases) at the Icahn School of Medicine at Mount Sinai. By October 2018, his condition had worsened, and he had become jaundiced. He underwent an endoscopic retrograde cholangiopancreatography (ERCP), which examines the bile ducts. During the procedure, blockages were found in Zachary’s bile ducts, and they were dilated with balloons and stents.

By January 2019, another liver biopsy showed that the PSC had progressed to biliary cirrhosis (scarring of the liver). Dr. Ahmad sent Zachary for a transplant evaluation. Liver transplant eligibility is measured by several criteria, but the Model for End-Stage Liver Disease (MELD) score, which is based on results from several lab tests, is the most accurate determinant of the risk of death due to liver disease. The MELD score is used to determine priority on the waiting list for liver transplantation from deceased donors. The MELD score ranges from 6 (lowest priority) to 40 (highest priority).

Zachary’s MELD score was only 9, and despite the cirrhosis, he did not have any signs of liver decompensation (complications of cirrhosis), so the decision was made to not yet consider transplant. By October 2022, his condition had started to deteriorate, and Dr. Ahmad requested a further liver transplant evaluation. This time, Zachary’s MELD score had increased to more than 20, demonstrating a worsening of his liver disease and a substantially increased risk of dying.

Unfortunately, a person’s blood type influences how likely they are to receive a liver transplant. Zachary’s O blood type (the most common blood type but also the blood type with the smallest pool of compatible organs) meant that his chance of getting a liver transplant from a deceased donor was still very low. However, Zachary was put on the waiting list for liver transplantation, and the medical team suggested that a living donor transplant would be the best option.

Living donation is an opportunity for ordinary people to do the extraordinary: save the life of another person by donating part of a liver or kidney.

Successful Surgeries

“The evaluation to be a living donor is probably more intense than the evaluation for the recipient,” says Dr. Florman, the Charles Miller MD Professor of Surgery at Icahn Mount Sinai. “Donors are, almost by definition, healthy people who shouldn't be having operations but are doing it because they want to save somebody else. In our program, they have to be over 18 and under 55 and be otherwise healthy.”

Both Zachary’s mother and father offered to be donors, but neither was a viable candidate. His sister, Kayla, then offered to be tested. “Even if my blood work was perfect, the anatomy of my liver had to work,” Kayla says. “They explained that I needed the left lobe of my liver to be at least 30 percent of my overall liver for it to be viable for me post-surgery. If it was too small, I would put myself at risk afterward.”

The liver is composed of a larger right lobe and a left lobe (usually one third of the total size). In general, for adult-to-adult liver donation, the right lobe is taken from the donor for the recipient, leaving behind the left lobe in the donor. Based on the weight of the donor and recipient, the preoperative testing has to show the donor right lobe is big enough for the needs of the recipient, and the remaining left lobe big enough to safely regenerate for the donor.  

The results came back positive—she was the right blood type, and her liver was a good candidate for her to undergo the procedure with a minimal risk of complications. “Dr. Ahmad came into the donor room the first day I was there, and as he was leaving he said ‘You’re a life saver, remember that,’” Kayla says.

“Dr. Florman, Dr. Ahmad, and the transplant coordinator, Theresa, went over the whole process of transplantation,” Zachary says. “They walked me through what would happen during the surgery and everything that would take place after. They answered every question my parents, sister, and I had.”

The transplant was arranged for February 2023, with the two operations taking place in adjoining operating rooms. Marcelo Facciuto, MD, Professor of Surgery and Director of Live Donor Liver Transplantation at the Recanati/Miller Transplantation Institute, carried out Kayla’s procedure with Chiara Rocha, MD, Assistant Professor of Surgery at Icahn Mount Sinai. In the adjoining operating room, Dr. Florman worked on the recipient procedure for Zachary with Guy Meyerovich, MD, fellow at the Mount Sinai Health System. The transplant was a success for both patients.

As Dr. Florman explains, the liver has an extraordinary ability to regenerate quickly: “As soon as we cut the liver in half, it starts to regrow in the donor and in the recipient. It takes about four weeks for it to regrow back to 90 percent.”

Kayla has made a complete recovery from the operation, and after seven weeks was able to return to her work as a physiotherapist.

“My brother was a completely different person the day after surgery,” Kayla says. “I am grateful that I was able to do that for him. We went to the best surgeons and best hospital, so everything went without a flaw. To be able to give my brother a new life is enough to make me happy and satisfied for the rest of mine.”

As of June 2023, Zachary was also well on the way to recovery. After years of debilitating illness that restricted his ability to work, he was accepted into training to become a court officer.

“I felt very grateful that my sister was the donor,” Zachary says. “She inspired me by the bravery and courage shown to step up during a turbulent time in my life. I was nervous because I didn’t want her to feel obligated that she had to do this, but she made us certain that this was something she wanted to truly do. She saved my life.”