Liver transplants: Live donor liver transplantation
Live donor liver transplants are a vital addition to cadaveric (after death) liver transplants. Such transplants are not without controversy, however: the risks are greater for live liver donors than live kidney donors, for example, and some argue that more effort should be put into maximising the use of cadaveric donations. Professor Krishnakumar Madhavan examines the issues surrounding live donor liver transplants.
- Live liver donor transplants are a valuable addition to the UK’s short supply of cadaveric donor livers.
- The risks of mortality and morbidity are significantly higher for live liver donors than live kidney donors.
- There are strict criteria that surgical teams must meet before live donor liver transplants can take place; there are also strict criteria for donor assessment and pre- and post-operative care.
- Live liver donor tranplantation is not without controversy: some argue greater utilisation should be made of cadaveric livers; there are also debates as to whether recipients of live donor livers should have the same criteria of need as recipients of cadaveric donor livers.
Declaration of interests: None declared.
While living donor kidney transplantation is on the increase in many transplant units in the UK, similar use of living donors for liver transplantation has not yet made a similar impact. Following the first successful living donor liver transplant reported by Strong et al. in 1990,1 several units in the US, Europe and Asia have developed programmes and performed many such transplants successfully. Initially there was no registry of living donor liver transplants, but recent momentum to register all such procedures in Europe and the US has brought to the public domain the results so far.2.
Although recipient data in such registries have been more or less complete and reliable, data on donor mortality and morbidity were lacking. A paper in the Lancet from the Japanese Liver Transplantation Society3 reported no donor mortality from 1,852 live donor liver transplants in that country, but an editorial comment in the same issue reported a donor death from liver failure in Japan. While the British Journal of Surgery saw fit to debate the ethics of laparoscopic live donor nephrectomy,4 many in liver transplant units across the country feel it is time to debate the ethics of live donor liver transplantation in the UK.
Mortality and morbidity
The expected mortality for a live liver donor is between 20 and 30 times greater than for a kidney donor. Major morbidity is also greater by a similar factor. Therefore, like any other surgical procedure, live donor liver transplantation should only be embarked upon for the right reasons, and thought should be given to whether such a step is necessary in the UK where cadaveric liver transplant programmes are strictly controlled and monitored. The answer to this question will best be provided by the transplant units in the UK, all of which have reported an increased death rate for patients awaiting liver transplants.5
Cadaveric vs. live donations
Some will blame this situation on the unexploited full potential of cadaveric donation in the UK, which is well below that of other European countries. The solution to the problem, according to these experts, is to look at ways of increasing cadaveric donation. Busuttil,6 in his plea to maximise cadaveric liver transplants by adopting the technique of split liver transplantation, concludes that this is a better approach to organ shortage than increasing living donor transplants. However, for patients who are currently on a liver transplant waiting list, as well as their families and transplant unit staff, any alternative source of a liver graft is worth considering. Neuberger and Price5 clearly set out the justification for such a living donor transplant initiative in the UK under the umbrella of the National Health Service.
Like any other living donation, donating a hemi-liver will need to be totally altruistic and free of coercion, although most will be conditional (that is, for a specific patient). Most people find the consent process for a living donation unsuitable for fulminant hepatic failure patients because of the lack of time to fully assess a potential donor. Indeed, the Council of Europe recommendation on living donor liver transplantation is that living donation should not be considered for fulminant situations.7 By contrast, Lo et al8 in Hong Kong consider that they were able to meet criteria for donor assessment satisfactorily in fulminant hepatic failure transplants.
Indications for live donor transplants
Another point of contention in a living donor programme is the matter of ‘extended indications’. While most will agree with live donor liver transplantation for standard indications (indications accepted for cadaveric liver transplant under the prevailing system), use of live donor liver transplantation for extended indications, where one would not contemplate a cadaveric liver transplant, is controversial. In the UK, live donor recipients and their donors are eligible for retransplantation from the cadaveric donor list, if necessary as a super-urgent listing. The live donor liver transplants performed so far in the UK have been without incident, but this situation will arise sooner or later and another patient from a different or the same unit on the cadaveric waiting list will be denied a liver.
The agreement on retransplantation is the principal argument for having the same indications for living donor and cadaveric liver transplantation, but that has not prevented pressure to allow extended criteria (for example, larger liver tumours). Certainly, every opportunity for a live donor liver transplant should be seen as increasing the donor pool and, under these circumstances, it is not only right but morally correct for these patients to have a back-up provided by the national cadaveric system.
Surgical and care requirements
Finally, there is the matter of the actual surgical techniques of donor hepatectomy and graft implantation. The New York State Committee on Quality Improvement in Living Liver Donation9 makes very clear the requirements for the surgical teams involved in both aspects of live liver donor transplantation. It requires two experienced consultant surgeons with experience in live liver donor transplants for the donor procedure. These surgeons should have demonstrated experience in major hepatobiliary resectional surgery and acquired hands-on experience in live donor hepatectomy at an institution with an established programme.
Criteria are also laid out for donor assessment and pre- and post-operative care of the donor and recipient. In essence, a unit aspiring to undertake live liver donor transplantation should have an established cadaveric transplant programme, a proven track record in major liver resectional surgery, extensive experience of donor work-up for living donation (for example, for kidney donation) and a team of dedicated surgeons, intensivists, hepatologists, psychiatrists and nursing staff, and an interested and reliable non-transplant team of medical personnel who can act as independent medical assessors and as patients’ (donor) advocates.
A prospective audit should always be maintained and the results regularly compared against national and international standards. Continuing professional development for the staff involved, with regular attendance at national and international meetings discussing live liver donor transplantation, is also mandatory. Only then will those embarking on live liver donor transplantation be able to learn from history rather than repeating its mistakes.
The UK has embarked on live donor liver transplantation, and so far a small number have been done successfully. Hopefully, this will help the problem of shortage of donor livers, but as most transplants will continue to be from cadaveric donors, efforts to improve UK cadaveric donor rates are needed urgently.
- Strong RW, Lynch SV, Ong TH. Successful liver transplantation from a living donor to her son. N Eng J Med 1990; 322:1505–7.
- Brown RS Jr., Russo MW, Lai M et al. A survey of liver transplantation from living adult donors in the United States. N Eng J Med 2003; 348:818–25.
- Umeshita K, Fujiwara K, Kiyosawa K et al. Operative morbidity of living liver donors in Japan. Lancet 2003; 362:687–90.
- Brook NR, Nicholson ML. Laparoscopic live donor nephrectomy. Br J Surg 2003; 90:1313–4 .
- Neuberger J, Price D. Role of living liver donation in the United Kingdom. BMJ 2003; l327:676–9.
- Busuttil RW. Changing faces of liver transplantation: partial grafts for adults. The Paul Russell lecture in transplantation. Boston: Massachusetts General Hospital; 24 March 2003.
- Council of Europe. Recommendation No. R (97) 16 on liver donation from living related donors. 1997.
- Lo CM, Fan ST, Chan JKF et al. Minimum graft volume for successful adult-to-adult living donor transplantation for fulminant hepatic failure. Transplantation 1996; 62:696–8.
- New York State Committee on Quality Improvement in Living Liver Donation. A report to the New York State Transplant Council and New York State Department of Health. New York; 2002.