Right hepatic lobe donation adversely affects donor life insurability up to one year after donation

Financial toxicity in living donor liver transplantation: A call to action for financial neutrality

After 2 decades of limited growth, living donor liver transplant (LDLT) has been increasingly accepted as a promising solution to the growing organ shortage in the US. With experience, LDLT offers superior graft and patient survival with low rates of rejection. However, not all waitlisted patients have equal access to LDLT, with financial toxicity representing a substantial barrier. Potential living liver donors face indirect, direct, and opportunity costs associated with donation as well as insurance-based discrimination and variable employer leave policies. There are multiple potential national, local, and patient-centered solutions to address some of the cost-related issues associated with living LDLT. These include standardization of employer leave policies, creation of federal and state-led tax relief programs, optimization of National Living Donor Assistance Center use, engagement of independent living donor advocates, creation of financial toolkits, and encouragement of recipient or donor-led fundraising. In this piece, members of the North American Living Liver Donation Group, a consortium of 37 LDLT programs, explore these financial challenges and discuss solutions to achieve financial neutrality, where individuals can donate free from financial constraints or gains. As a community, it is imperative that we confront factors driving financial toxicity to improve equity and access to LDLT.

Living Liver Donation Does not Significantly Affect Long-Term Life, Disability, or Medical Insurability

INTRODUCTION

The growing practice of living liver donation requires comprehensive understanding of the financial implications for living liver donors. While obtaining and maintaining insurance is important to financial health, little is known about the impact of liver donation on future insurability.

RESEARCH QUESTIONS

The purpose of this study was to evaluate the donors' experiences with insurance following donation and identify the insurance provider-driven factors that contribute to donor insurability.

DESIGN

A two center cohort of living donors with donation between January 2000 and December 2018 (N = 442) were surveyed about postdonation insurance experiences. To understand insurance provider practices towards liver donors, life (n = 11) and disability (n = 4) insurance underwriters were asked to provide policy quotes for a standardized living liver donor profile.

RESULTS

Responses (N = 101) were received by August 2020 (response rate = 22.9%). Living liver donors reported owning life (58%), disability (35%), and medical (87%) insurance at rates comparable to the general population with low proportions reporting difficulty obtaining these insurance types (9%, 9%, 4%, respectively). Post-donation life insurance ownership was associated with post-donation employment (P = 0.01). Underwriter responses indicate life and disability insurability were adversely affected up to 12 months following donation.

CONCLUSIONS

Living liver donors did not have difficulty maintaining insurance in the long-term but should be counseled to purchase insurance prior to surgery as short-term insurability may be affected. Perception of difficulty obtaining insurance following donation remains of significant concern among living donors. Further collaboration between the transplant community and insurance companies is warranted.

Implantation of healthy matrix-embedded endothelial cells rescues dysfunctional endothelium and ischaemic tissue in liver engraftment

OBJECTIVE

Liver transplantation is limited by ischaemic injury which promotes endothelial cell and hepatocyte dysfunction and eventually organ failure. We sought to understand how endothelial state determines liver recovery after hepatectomy and engraftment.

DESIGN

Matrix-embedded endothelial cells (MEECs) with retained healthy phenotype or control acellular matrices were implanted in direct contact with the remaining median lobe of donor mice undergoing partial hepatectomy (70%), or in the interface between the remaining median lobe and an autograft or isograft from the left lobe in hepatectomised recipient mice. Hepatic vascular architecture, DNA fragmentation and apoptosis in the median lobe and grafts, serum markers of liver damage and phenotype of macrophage and lymphocyte subsets in the liver after engraftment were analysed 7 days post-op.

RESULTS

Healthy MEECs create a functional vascular splice in donor and recipient liver after 70% hepatectomy in mouse protecting these livers from ischaemic injury, hepatic congestion and inflammation. Macrophages recruited adjacent to the vascular nodes into the implants switched to an anti-inflammatory and regenerative profile M2. MEECs improved liver function and the rate of liver regeneration and prevented apoptosis in donor liver lobes, autologous grafts and syngeneic engraftment.

CONCLUSIONS

Implants with healthy endothelial cells rescue liver donor and recipient endothelium and parenchyma from ischaemic injury after major hepatectomy and engraftment. This study highlights endothelial-hepatocyte crosstalk in hepatic repair and provides a promising new approach to improve regenerative medicine outcomes and liver transplantation.

Living donor liver transplantation: eliminating the wait for death in end-stage liver disease?

Adult-to-adult living donor liver transplantation (A2ALDLT), outside of Asia, remains an important yet underutilized gift of life. For patients with end-stage liver disease, A2ALDLT is a proven transplantation option, with lower waiting list mortality and suffering, and equivalent or better allograft and patient survival than deceased-donor liver transplantation (DDLT). The risks to living donors and the benefit to their recipients have been carefully defined with long-term level 1 and 2 evidence-based study. An overview of the development and practice of living donor liver transplant (LDLT), including donor and recipient surgical allograft innovation, is provided. The issues of recipient selection, outcomes and morbidity, including disease-variable study and challenges past and present are presented in comparison with DDLT cohorts, and future insights are described. Central to practice is the careful and concise review of donor evaluation and selection and donor outcome, morbidity, quality of life and present and future strategies for donor advocacy and growth of the technique.

Social and Financial Outcomes of Living Liver Donation: A Prospective Investigation Within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study 2 (A2ALL-2)

Because results from single-center (mostly kidney) donor studies demonstrate interpersonal relationship and financial strains for some donors, we conducted a liver donor study involving nine centers within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study 2 (A2ALL-2) consortium. Among other initiatives, A2ALL-2 examined the nature of these outcomes following donation. Using validated measures, donors were prospectively surveyed before donation and at 3, 6, 12, and 24 mo after donation. Repeated-measures regression models were used to examine social relationship and financial outcomes over time and to identify relevant predictors. Of 297 eligible donors, 271 (91%) consented and were interviewed at least once. Relationship changes were positive overall across postdonation time points, with nearly one-third reporting improved donor family and spousal or partner relationships and >50% reporting improved recipient relationships. The majority of donors, however, reported cumulative out-of-pocket medical and nonmedical expenses, which were judged burdensome by 44% of donors. Lower income predicted burdensome donation costs. Those who anticipated financial concerns and who held nonprofessional positions before donation were more likely to experience adverse financial outcomes. These data support the need for initiatives to reduce financial burden.

[Living liver donor: indications and technical aspects]

Living donor liver transplantation (LDLT) nowadays represents an important and safe alternative to conventional deceased donor liver transplantation (DDLT). A major concern related to the LDLT procedure is still represented by donor safety because a serious operation not without risks must be carried out on a healthy individual. In the present review of the indications for LDLT the technical concepts of donor surgery, criteria for donor selection and evaluation and morbidity and mortality results related to the procedure are presented. In general, the indications for LDLT are almost the same as for DDLT. The donor hepatectomy (right, left or left lateral) is presented in five main phases. The reported morbidity rates vary between 10 % and 60 % and are strongly related to the experience of the transplant center. The currently reported postoperative mortality rates for left and right hepatectomy are 0.1 % and 0.5 %, respectively. The results of LDLT are similar if not even better than those for DDLT depending on the specific indications.

Long-term follow-up after right hepatectomy for adult living donation and attitudes toward the procedure

OBJECTIVES

To determine the long-term health status of donors after right hepatectomy for adult live donor liver transplantation (ALDLT).

BACKGROUND

The long-term outcomes for ALDLT donors are unknown.

METHODS

ALDLT donors undergoing right hepatectomy from April 1998 to June 2007 were invited to complete a questionnaire regarding health status, satisfaction (1-10/worst-best scale), self-esteem, willingness to donate again, and suggestions for improvement. In addition, donor files and cholecystectomy specimens were reviewed. Fisher's exact test, Kaplan-Meier and logistic regression analyses were performed.

RESULTS

Eighty-three donors were contacted (median age: 36 years; median follow-up: 69 months). 39 (47%) were free of symptoms. The remaining 44 (53%) reported: intolerance to fatty meals and diarrhea (31%), gastroesophageal reflux associated with left liver hypertrophy (9%), incisional discomfort requiring pain medications (6%), severe depression requiring hospitalization (4%), rib pain affecting lifestyle (2%), and exacerbation of psoriasis (1%). Median satisfaction score was 8. Self-esteem diminished in 5%. Thirty-nine (47%) recommended improvements particularly more detailed informed donor consent and a centralized living donor liver registry. Seventy-eight (94%) were willing to donate again. There were no differences between donors with and without complaints with respect to: donor age, gender, early complications and follow-up time, young-to-old donation, recipient diagnosis of malignancy and death of the recipient. Noninflamed donor cholecystectomy specimens correlated with intolerance to fatty meals and diarrhea (P = 0.001).

CONCLUSIONS

ALDLT donors are at risk for long-term complaints that are neither reflected nor related to early complications. This information should be included in both the donor evaluation and the ALDLT decision-making process.

The system of health insurance for living donors is a disincentive for live donation

The health insurance system for living donors is derived from insurance policies designed to cover accidental death or dismemberment. The system covers only the direct consequences of organ removal, and recoups the costs of related medical services from the transplant recipient's health insurance provider. The system forces transplant programs to differentiate between health services that are, or are not directly attributable to donation and may compromise the pretransplant evaluation, postoperative care and long-term care of living donors. The system is particularly problematic in the United States, where a significant proportion of donors do not have medical insurance. The requirement to assign donor costs to a particular recipient is poorly suited to facilitate advances in living donation such as the use of nondirected donors and living-donor paired exchange programs. We argue that given the current understanding regarding the long-term risks of living donation, the provision of basic medical insurance is a necessity for living donation and that the system of attributing donor costs to the recipient's insurance is inefficient, has the potential to undermine the care of living donors and is a disincentive to the expansion of living donation.

Life insurance for living kidney donors: a Canadian undercover investigation

Some living kidney donors encounter difficulties obtaining life insurance, despite previous surveys of insurance companies reporting otherwise. To better understand the effect of donation on insurability, we contacted offices of life insurance companies in five major cities in Canada to obtain $100 000 of life insurance (20-year term) for 40 fictitious living kidney donors and 40 paired controls. These profiles were matched on age, gender, family history of kidney disease and presence of hypertension. The companies were blinded to data collection. The study protocol was reviewed by the Office of Research Ethics. The main study outcomes were the annual premium quoted and total time spent on the phone with the insurance agent. All donor and control profiles received a quote, with no significant difference in the premium quoted (medians $190 vs. $209, p = 0.89). More time was spent on the phone for donor compared to control profiles, but the absolute difference was small (medians 9.5 vs. 7.0 min, p = 0.046). Age, gender, family history of kidney disease and new-onset hypertension had no further effect on donor insurability in regression analysis. We found no evidence that kidney donors were disadvantaged in the first step of applying for life insurance. The effect donation has on subsequent phases of insurance underwriting remains to be studied.

Insurability of living organ donors: a systematic review

Being an organ donor may affect one's ability to obtain life, disability and health insurance. We conducted a systematic review to determine if insurability is affected by living organ donation, and if concern about insurability affects donor decision making. We searched MEDLINE, EMBASE, SCI, EconLit and Cochrane databases for articles in any language, and reviewed reference lists from 1966 until June 2006. All studies discussing the insurability of living organ donors or its impact on donor decision making were included. Data were independently abstracted by two authors, and the methodological quality appraised. Twenty-three studies, from 1972 to 2006, provided data on 2067 living organ donors, 385 potential donors and 239 responses from insurance companies. Almost all companies would provide life and health insurance to living organ donors, usually with no higher premiums. However, concern about insurability was still expressed by 2%-14% of living organ donors in follow-up studies, and 3%-11% of donors actually encountered difficulties with their insurance. In one study, donors whose insurance premiums increased were less likely to reaffirm their decision to donate. Based on available evidence, some living organ donors had difficulties with insurance despite companies reporting otherwise. If better understood, this potential barrier to donation could be corrected through fair health and underwriting policies.

Current trends in live liver donation

The introduction of living donor liver transplantation (LDLT) has been one of the most remarkable steps in the field of liver transplantation (LT), able to significantly expand the scarce donor pool in countries in which the growing demands of organs are not met by the shortage of available cadaveric grafts. Although the benefits of this procedure are enormous, the physical and psychological sacrifice of the donors is immense, and the expectations for a good outcome for themselves, as well as for the recipients, are high. We report a current overview of the latest trends in live liver donation in its different aspects (i.e. donor's selection, evaluation, operation, morbidity, mortality, ethics and psychology). This review is based on our center's personal experience with almost 200 LDLTs and a detailed analysis of the international literature of the last 7 years about this topic. Knowing in detail how to approach to the different aspects of living liver donation may be helpful in further improve donor's safety and even recipient's outcome.

Who decides? Living donor liver transplantation for advanced hepatocellular carcinoma

Few effective treatment options are available for patients with advanced hepatocellular carcinoma (HCC). Some transplant centers have begun offering living donor liver transplantation (LDLT) for selected patients whose HCC exceeds Milan criteria by a small margin. However, this remains a controversial subject. In this article, we weigh the arguments for and against LDLT for advanced HCC. Because donor autonomy forms the crux of this dilemma, the real question becomes: to whom does the decision belong, the individual donors or the medical community? We argue that donor autonomy should not be paramount in settings where the recipient benefit is uncertain.

Living donor transplantation between twins: guidance for Donor Advocate Teams

Using a clinical case, this paper explores the ethical complexities of assessing potential living organ donors when the proposed donor-recipient pair consists of monozygotic (identical) or dizygotic (fraternal) twins. While all donor-recipient pairs can present various ethical and psychosocial challenges, the challenges of twin pairs are unique and especially complex. Donor Advocate Teams need to be aware of these unique issues and address them during their assessment process.