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A scoping review of inequities in access to organ transplant in the United States. Int J Equity Health 2022; 21:22. [PMID: 35151327 PMCID: PMC8841123 DOI: 10.1186/s12939-021-01616-x] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/24/2021] [Indexed: 02/06/2023] Open
Abstract
Background Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research. Methods We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes. Results Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant. Conclusions This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01616-x.
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Sim JH, Kwon HM, Jun IG, Kim SH, Kim KS, Moon YJ, Song JG, Hwang GS. Association of skeletal muscle index with postoperative acute kidney injury in living donor hepatectomy: A retrospective single-centre cohort study. Liver Int 2022; 42:425-434. [PMID: 34817911 DOI: 10.1111/liv.15109] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/27/2021] [Accepted: 11/21/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although living donor liver transplantation (LDLT) is the standard treatment option for patients with end-stage liver disease, it always entails ethical concerns about the risk of living donors. Recent studies have reported a correlation between sarcopenia and surgical prognosis in recipients. However, there are few studies of donor sarcopenia and the surgical prognosis of donors. This study investigated the association between sarcopenia and postoperative acute kidney injury in liver donors. METHODS This retrospective study analysed 2892 donors who underwent donor hepatectomy for LDLT between January 2008 and January 2018. Sarcopenia was classified into pre-sarcopenia and severe sarcopenia, which were determined to be -1 standard deviation (SD), and -2 SD from the mean baseline of the skeletal muscle index, respectively. Multivariate regression analysis was performed to evaluate the association between donor sarcopenia and postoperative AKI. Additionally, we assessed the association between donor sarcopenia and delayed recovery of liver function (DRHF). RESULTS In the multivariate analysis, donor sarcopenia was significantly associated a higher incidence of postoperative AKI (adjusted odds ratio [OR]: 2.65, 95% confidence interval [CI]: 1.15-6.11, P = .022 in pre-sarcopenia, OR: 5.59, 95% CI: 1.11-28.15, P = .037 in severe sarcopenia, respectively). Additionally, hypertension and synthetic colloid use were significantly associated with postoperative AKI. In the multivariate analysis, risk factors of DRHF were male gender, indocyanine green retention rate at 15 minutes, and graft type, however, donor sarcopenia was not a risk factor. CONCLUSIONS Donor sarcopenia is associated with postoperative AKI following donor hepatectomy.
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Affiliation(s)
- Ji-Hoon Sim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Hoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyoung-Sun Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Karatoprak S, Kutlu R, Karatoprak NB, Dağ N, Yılmaz S. Percutaneous radiological biliary interventions after failed endoscopic treatment in living liver donors: experience of a high-volume transplantation center. Transpl Int 2021; 34:2846-2855. [PMID: 34559926 DOI: 10.1111/tri.14118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 09/02/2021] [Accepted: 09/21/2021] [Indexed: 12/20/2022]
Abstract
This study aimed to evaluate the role of percutaneous radiological treatments for biliary complications (BCs) in donors after living donor liver transplantation (LDLT). We retrospectively evaluated BCs in donors involved in 1839 LDLTs between May 2009 and January 2019 at our centre. BCs were classified according to the modified Clavien-Dindo classification (MCDC). Patients treated with percutaneous transhepatic biliary intervention (PTBI) were identified. Complications requiring endoscopic, interventional or surgical treatment (MCDC grades III-IV) involved 123 (6.6%) donors. Complications comprised leakage, n = 73 (60%); stricture, n = 36 (29%); and both leakage and stricture, n = 14 (11%). Percutaneous drainage of biloma formations under ultrasound guidance was performed in 57 donors, endoscopic treatment in 83 and PTBI in 14. Of 83 patients who received endoscopic treatment, 13 were referred for PTBI due to failure or uncannulation. Eight of 14 patients were successfully treated with PTBI. Six patients were treated with a rendezvous procedure combining percutaneous and surgical treatments. In 13 patients, no BCs were developed after catheter or stent removal. In donors with BCs, the treatment should progress from the least invasive method to surgery. In some patients, percutaneous radiological treatments eliminate the need for surgery or can guide surgical treatment.
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Affiliation(s)
- Sinan Karatoprak
- Department of Radiology and Liver Transplantation Institute, School of Medicine, Inonu University, Malatya, Turkey
| | - Ramazan Kutlu
- Department of Radiology and Liver Transplantation Institute, School of Medicine, Inonu University, Malatya, Turkey
| | - Nur Betül Karatoprak
- Department of Radiology and Liver Transplantation Institute, School of Medicine, Inonu University, Malatya, Turkey
| | - Nurullah Dağ
- Department of Radiology, Malatya Training and Research Hospital, Malatya, Turkey
| | - Sezai Yılmaz
- Department of General Surgery and Liver Transplantation Institute, School of Medicine, Inonu University, Malatya, Turkey
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Risk of biliary tract disease in living liver donors: A population-based cohort study. PLoS One 2020; 15:e0230840. [PMID: 32226025 PMCID: PMC7105125 DOI: 10.1371/journal.pone.0230840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 02/25/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND & AIMS Whether living liver donors have a higher risk of biliary tract disease compared with non-donors remains unknown. METHODS Data were collected from the Taiwan Longitudinal Health Insurance Database for the 2003-2011 period. The study cohort comprised 1,446 patients aged ≥ 18 years who had served as living liver donors. The primary outcome was the incidence of biliary tract disease. Cox proportional hazards modeling was used to determine the hazard ratios. RESULTS The incidence density rate of biliary tract disease was 13.9-fold higher in the liver donor (LD) cohort than in the non-LD cohort (10.2 vs. 0.71 per 1,000 person-years), with an adjusted hazard ratio (HR) of 14.2 (95% confidence interval [CI] = 7.73-26.1). Stratified by comorbidity, the relative risk of biliary tract disease was higher in the LD cohort than in the non-LD cohort for both patients with or without comorbidity. The incidence density rate of biliary tract disease was significantly higher in the first 3 years (13.5 per 1,000 person-years in the LD cohort). The highest adjusted HR of biliary tract disease for LD patients compared with the non-LD cohort was 22.4 (95% CI = 10.8-46.1) in the follow-up ≤ 3 years. CONCLUSION Living liver donors had a higher risk of biliary tract disease compared with non-donors.
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Koul A, Pant D, Rudravaram S, Sood J. Thoracic epidural analgesia in donor hepatectomy: An analysis. Liver Transpl 2018; 24:214-221. [PMID: 29205784 DOI: 10.1002/lt.24989] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/31/2017] [Accepted: 11/26/2017] [Indexed: 01/06/2023]
Abstract
The purpose of this study is to analyze whether supplementation of general anesthesia (GA) with thoracic epidural analgesia (TEA) for right lobe donor hepatectomy is a safe modality of pain relief in terms of changes in postoperative coagulation profile, incidence of epidural catheter-related complications, and timing of removal of epidural catheter. Retrospective analysis of the record of 104 patients who received TEA for right lobe donor hepatectomy was done. Platelet count, international normalized ratio, alanine aminotransferase, and aspartate aminotransferase were recorded postoperatively until the removal of the epidural catheter. The day of removal of the epidural catheter and visual analogue scale (VAS) scores were also recorded. Any complication encountered was documented. Intraoperatively, central venous pressure (CVP), hemodynamic variables, and volume of intravenous fluids infused were also noted. Statistical analysis was performed by using SPSS statistical package, version 17.0 (SPSS Inc. Chicago, IL). Continuous variables were presented as mean ± standard deviation. A total of 90% of patients had mean VAS scores between 1 and 4 in the postoperative period between days 1 and 5. None of the patients had a VAS score above 5. Although changes in coagulation status were encountered in all patients in the postoperative period, these changes were transient and did not persist beyond postoperative day (POD) 5. There was no delay in removal of the epidural catheter, and the majority of patients had the catheter removed by POD 4. There was no incidence of epidural hematoma. Aside from good intraoperative and postoperative analgesia, TEA in combination with balanced GA and fluid restriction enabled maintenance of low CVP and prevention of hepatic congestion. In conclusion, vigilant use of TEA appears to be safe during donor hepatectomy. Living liver donors should not be denied efficient analgesia for the fear of complications. Liver Transplantation 24 214-221 2018 AASLD.
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Affiliation(s)
- Archna Koul
- Department of Anesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Deepanjali Pant
- Department of Anesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Swetha Rudravaram
- Department of Anesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Jayashree Sood
- Department of Anesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
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Abougergi MS, Rai R, Cohen CK, Montgomery R, Solga SF. Trends in Adult-to-Adult Living Donor Liver Transplant Organ Donation: The Johns Hopkins Experience. Prog Transplant 2016; 16:28-32. [PMID: 16676671 DOI: 10.1177/152692480601600107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Adult-to-adult living donor liver transplantation is an increasingly important option for 17000 patients awaiting liver transplantation in the United States. However, adult-to-adult living donor liver transplantation volumes peaked in 2001 (N=518), and have gradually fallen in 2002 (N=362), 2003 (N=321), and 2004 (N=323). Recent concerns about donor safety and ethical considerations have made careful analysis of donor availability and selection criteria critically important. We conducted a retrospective review of our active liver transplant recipient registry (N=251) and compared it to our living donor registry (N=231), which included all potential living donors before the selection process. Fifteen percent of recipients accounted for the majority (53%) of donor evaluations, whereas 42% of recipients did not have even a single donor evaluation. Recipient diagnosis appears to have a significant impact on donor availability, with donors rarely evaluated for patients with alcoholic cirrhosis. Careful and stringent selection criteria rule out 67% of potential donors.
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Segedi M, Dhani G, Ng VL, Grant D. Living Donors for Fulminant Hepatic Failure in Children. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/978-3-319-29185-7_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Molinari M, Matz J, DeCoutere S, El-Tawil K, Abu-Wasel B, Keough V. Live liver donors' risk thresholds: risking a life to save a life. HPB (Oxford) 2014; 16:560-74. [PMID: 24251593 PMCID: PMC4048078 DOI: 10.1111/hpb.12192] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 09/19/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is still some controversy regarding the ethical issues involved in live donor liver transplantation (LDLT) and there is uncertainty on the range of perioperative morbidity and mortality risks that donors will consider acceptable. METHODS This study analysed donors' inclinations towards LDLT using decision analysis techniques based on the probability trade-off (PTO) method. Adult individuals with an emotional or biological relationship with a patient affected by end-stage liver disease were enrolled. Of 122 potential candidates, 100 were included in this study. RESULTS The vast majority of participants (93%) supported LDLT. The most important factor influencing participants' decisions was their wish to improve the recipient's chance of living a longer life. Participants chose to become donors if the recipient was required to wait longer than a mean ± standard deviation (SD) of 6 ± 5 months for a cadaveric graft, if the mean ± SD probability of survival was at least 46 ± 30% at 1 month and at least 36 ± 29% at 1 year, and if the recipient's life could be prolonged for a mean ± SD of at least 11 ± 22 months. CONCLUSIONS Potential donors were risk takers and were willing to donate when given the opportunity. They accepted significant risks, especially if they had a close emotional relationship with the recipient.
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Affiliation(s)
| | - Jacob Matz
- Department of Surgery, Dalhousie UniversityHalifax, NS, Canada
| | - Sarah DeCoutere
- Department of Infectious Disease, Dalhousie UniversityHalifax, NS, Canada
| | - Karim El-Tawil
- Department of Surgery, Dalhousie UniversityHalifax, NS, Canada
| | | | - Valerie Keough
- Department of Radiology, Dalhousie UniversityHalifax, NS, Canada
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Nasr AS, Rehm RS. Parental Live Liver Donation: A Transformational Experience. Prog Transplant 2014; 24:69-75. [DOI: 10.7182/pit2014286] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Parental live liver donation is an attractive alternative to deceased donation for pediatric patients with end-stage liver disease (ESLD), yet very little has been published about the long-term emotional consequences of live liver donations on donors and their families. Objectives To better understand the impact that a parental live liver donation has on the everyday life of the donor. Method Thirteen living parental donors from 2 West Coast transplant centers participated. Data included semistructured interviews, observations, and field notes about the donors and their physical, emotional, and familial lives since their donation. The perceived impact of donation on parental donors and their intrafamilial relationships are reviewed and the social and emotional context of parental liver donation, including impacts on the predonation decisions and life after donation are analyzed. Results Thematic analysis was used to analyze this set of interviews, and after open coding, 3 major categories emerged: a self-awareness process, a clarification of familial relationships, and a change in perspectives on community. The overarching theme that was constructed from the interviews suggested that the impact the donation had on the donors' lives was one of transformation.
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Affiliation(s)
- Annette Sue Nasr
- Lucile Packard Children's Hospital at Stanford, Palo Alto, California (ASN), University of California, San Francisco (RSR)
| | - Roberta S. Rehm
- Lucile Packard Children's Hospital at Stanford, Palo Alto, California (ASN), University of California, San Francisco (RSR)
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11
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Public awareness and attitudes to living organ donation: systematic review and integrative synthesis. Transplantation 2013; 96:429-37. [PMID: 23677051 DOI: 10.1097/tp.0b013e31829282ac] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The deceased-donor organ shortage has driven widespread adoption of living-donor transplantation. Yet, public views on living donation are not well understood. This study aims to synthesize studies on public awareness and attitudes toward living organ donation. METHODS Electronic databases and reference lists were searched to September 2012. Summary estimates from survey data were obtained by random effects meta-analysis. Qualitative descriptive synthesis of each study was performed. RESULTS Forty-seven studies involving 34,610 respondents were included. The proportion of respondents aware of living organ donation was 76.7% (4 studies, n=3248; 95% confidence interval, 46.2%-97.0%; I=99.7%). The majority were in favor of living directed donation (85.5% (11 studies, n=15,836; 95% confidence interval, 81.6%-89.6%; I=98%), with recipient and community benefit as the rationale provided. However, barriers included fear of surgical and health risks, lack of knowledge, respect for cultural norms, financial loss, distrust in hospitals, and avoiding recipient indebtedness. The public voiced concern about possible risks or an obligatory pressure exerted on the donor. Many supported reimbursement for out-of-pocket expenses, paid leave, wait-listing priority, health insurance, and donor acknowledgment. There was strong opposition to financial incentives, which they believed risked exploitation and inequity and diminished voluntary altruistic donation. CONCLUSIONS The public is generally supportive of living donation and articulated important equity and ethical considerations for protecting the health and safety of living donors. This supports increased public engagement and strengthening of a shared view among professionals and the public in living donation practice and policy.
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Abstract
Hepatitis B is endemic in many regions of Asia, including China, Korea and India. This results in a heavy burden of hepatocellular carcinoma (HCC) because hepatitis B virus is a major risk factor in the development of the disease. In addition, the incidence of hepatitis-C-related HCC is on the rise in the United States. HCC patients with poor liver function reserve are not suitable candidates for resection, and liver transplantation (LT) has emerged as the treatment of choice for small unresectable HCCs. To treat more HCC patients with LT, the standard patient selection criteria have been expanded at a number of centers. Careful and well-considered selection of patients is the key to success in LT for HCC. Although tumor size and tumor number are used to predict whether transplantation is likely to be successful, the weighting that should be attached these two parameters has not been determined. In addition to the size and number of lesions, the morphology of HCC is also predictive of its behavior. Well-circumscribed lesions, in general, are less aggressive than those with poorly defined borders. On the waiting list for LT, HCC patients compete with liver failure patients. It is essential that the criteria used for selecting HCC patients for LT should be easily applicable and fair to other transplant candidates. In the face of the scarcity of deceased-donor livers and the inevitable risks for living liver donors, a predictably low rate of recurrence of HCC after LT is mandatory.
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Affiliation(s)
- See Ching Chan
- *See Ching Chan, MBBS, MS, PhD, MD, Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, SAR (China), Tel. +852 2255 3025, E-mail
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Living Donor Liver Transplant is not a Transparent Activity in India. J Clin Exp Hepatol 2013; 3:66-9. [PMID: 25755473 PMCID: PMC3940284 DOI: 10.1016/j.jceh.2012.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 10/10/2012] [Indexed: 12/12/2022] Open
Abstract
Living donor liver transplant has gained rapid popularity in India as a life saving procedure for end stage liver disease. The undoubted benefit for the recipient is clouded by a few unfavorable outcomes in donors which have led to allegations of lack of transparency. These factors are easily remediable with an attitude of self audit and self disclosure by transplant centers, enabling a truly informed consenting procedure.
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Carlisle EM, Angelos P, Siegler M, Testa G. Adult living-related liver donation for acute liver failure: is it ethically appropriate? Clin Transplant 2011; 25:813-20. [PMID: 21320164 DOI: 10.1111/j.1399-0012.2011.01413.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute liver failure (ALF) results in the annual death of approximately 3.5 per million people in the United States. Unfortunately, given the marked shortage of cadaveric liver donations and the ethical questions that plague utilization of living donor liver transplantation (LDLT) for ALF, many patients with ALF die before a liver is allocated to them. In this review, we discuss how the consistent utilization of LDLT for ALF could decrease the mortality rate of ALF. Additionally, we examine a key underlying issue: is LDLT for ALF ethically appropriate?
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Affiliation(s)
- Erica M Carlisle
- Department of Surgery, University of Chicago Medical Center, Chicago, IL 60637, USA
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Araújo C, Balbi E, Pacheco-Moreira L, Enne M, Alves J, Fernandes R, Steinbrück K, Martinho J. Evaluation of Living Donor Liver Transplantation: Causes for Exclusion. Transplant Proc 2010; 42:424-5. [DOI: 10.1016/j.transproceed.2010.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hyde MK, White KM. Exploring donation decisions: beliefs and preferences for organ donation in Australia. DEATH STUDIES 2010; 34:172-185. [PMID: 24479180 DOI: 10.1080/07481180903492604] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The authors explored common beliefs and preferences for posthumous and living organ donation in Australia where organ donation rates are low and little research exists. Content analysis of discussions revealed the advantage of prolonging/saving life whereas disadvantages differed according to donation context. A range of people/groups perceived to approve and disapprove of donation were identified. Barriers for posthumous donation included a family's objection, with the type of organ needed important for living donation. Motivators included knowledge about potential organ recipients. Donation preferences favored loved ones, with weaker preferences for recipients who were perceived as morally questionable or responsible for their illness.
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Affiliation(s)
- Melissa K Hyde
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Queensland, Australia.
| | - Katherine M White
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Queensland, Australia
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Hyde MK, White KM. Student and community perceptions about organ donors, non-donors and transplant recipients. JOURNAL OF COMMUNITY & APPLIED SOCIAL PSYCHOLOGY 2009. [DOI: 10.1002/casp.979] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Donor morbidity after living donation for liver transplantation. Gastroenterology 2008; 135:468-76. [PMID: 18505689 PMCID: PMC3731061 DOI: 10.1053/j.gastro.2008.04.018] [Citation(s) in RCA: 315] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 03/25/2008] [Accepted: 04/17/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Reports of complications among adult right hepatic lobe donors have been limited to single centers. The rate and severity of complications in living donors were investigated in the 9-center Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). METHODS A retrospective observational study design was used. Participants included all potential living donors evaluated between 1998 and 2003. Complication severity was graded using the Clavien scoring system. RESULTS Of 405 donors accepted for donation, 393 underwent donation, and 12 procedures were aborted. There were 245 donors (62%) who did not experience complications; 82 (21%) had 1 complication, and 66 (17%) had 2 or more. Complications were scored as grade 1 (minor; n = 106, 27%), grade 2 (potentially life threatening; n = 103, 26%), grade 3 (life threatening; n = 8, 2%), and grade 4 (leading to death; n = 3, 0.8%). Common complications included biliary leaks beyond postoperative day 7 (n = 36, 9%), bacterial infections (n = 49, 12%), incisional hernia (n = 22, 6%), pleural effusion requiring intervention (n = 21, 5%), neuropraxia (n = 16, 4%), reexploration (n = 12, 3%), wound infections (n = 12, 3%), and intraabdominal abscess (n = 9, 2%). Two donors developed portal vein thrombosis, and 1 had inferior vena caval thrombosis. Fifty-one (13%) donors required hospital readmission, and 14 (4%) required 2 to 5 readmissions. CONCLUSIONS Adult living liver donation was associated with significant donor complications. Although most complications were of low-grade severity, a significant proportion were severe or life threatening. Quantification of complication risk may improve the informed consent process, perioperative planning, and donor care.
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Kóbori L, Máthé Z, Fazakas J, Gerlei Z, Doros A, Fehérvári I, Sárváry E, Hartmann E, Németh A, Mándli T, Tóth S, Szőnyi L, Korponay Z, Kiss M, Görög D, Járay J. Surgical aspects of pediatric liver transplantation. Living donor liver transplant program in Hungary. Orv Hetil 2008; 149:1271-5. [DOI: 10.1556/oh.2008.28336] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A májátültetés jelenti a gyermekkori végstádiumú májbetegségek egyetlen kezelési módját. A split, majd az ezt követően kifejlesztett élő donoros májátültetés ma már rutinbeavatkozásnak számít, és a gyermekkori átültetések alapját jelentik. Az átlagos Kaplan–Meier-féle meghatározás szerinti 1, illetve 5 éves túlélés 80–90% feletti. A donormáj splittelése során két májbetegen segíthetünk. A bal oldali laterális szegmenteket általában gyermekeknek, a nagyobb jobb oldalt felnőtteknek ültetjük át. Természetesen többféle kombináció jön szóba attól függően, hogy élő donoros vagy split-, vagy redukált májátültetésről van szó. Az átültetéshez szükséges májszövet mennyisége a testsúly minimum 1%-át jelenti. A hazai több mint 340 májátültetés során 27 gyermek (14 parciális graft) májátültetéséről számolhatunk be, és elindult az élődonor-program is. Az alkalmazott technikák eredményeit és szövődményeit is figyelembe véve elmondható, hogy megfelelően szigorú kivizsgálási protokollok betartásával, a sebészi, aneszteziológiai és intenzív osztályos kezelés megfelelő szintű fejlesztésével a hazai átültetések eredményei nemzetközi szintre emelkedtek. Az utolsó 5 év átlagos túlélése 80% feletti volt.
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Affiliation(s)
- László Kóbori
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Zoltán Máthé
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - János Fazakas
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Zsuzsanna Gerlei
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Attila Doros
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Imre Fehérvári
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Enikő Sárváry
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Erika Hartmann
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Andrea Németh
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Tamás Mándli
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Szabolcs Tóth
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - László Szőnyi
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar I. Gyermekgyógyászati Klinika Budapest
| | - Zsuzsanna Korponay
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar II. Gyermekgyógyászati Klinika Budapest
| | - Mátyás Kiss
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Dénes Görög
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Jenő Járay
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
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McGregor LM, Hayes PC, O'Carroll RE. Living liver donation: Attitudes of the general public and general practitioners in Scotland. Psychol Health 2008; 23:603-16. [DOI: 10.1080/08870440701864512] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Brown RS. Live donors in liver transplantation. Gastroenterology 2008; 134:1802-13. [PMID: 18471556 PMCID: PMC2654217 DOI: 10.1053/j.gastro.2008.02.092] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Revised: 01/31/2008] [Accepted: 02/06/2008] [Indexed: 12/13/2022]
Abstract
Living donor liver transplantation (LDLT) has been controversial since its inception. Begun in response to deceased donor organ shortage and waiting list mortality, LDLT was initiated in 1989 in children, grew rapidly after its first general application in adults in the United States in 1998, and has declined since 2001. There are significant risks to the living donor, including the risk of death and substantial morbidity, and 2 highly publicized donor deaths are thought to have contributed to decreased enthusiasm for LDLT. Significant improvements in outcomes have been seen over recent years, and data, including from the National Institutes of Health-funded Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL), have established a survival benefit from pursuing LDLT. Despite this, LDLT still composes less than 5% of adult liver transplants, significantly less than in kidney transplantation where living donors compose approximately 40% of all transplantations performed. The ethics, optimal utility, and application of LDLT remain to be defined. In addition, most studies to date have focused on posttransplantation outcomes and have not included the effect of the learning curve on outcome or the potential impact of LDLT on waiting list mortality. Further growth of LDLT will depend on defining the optimal recipient and donor characteristics for this procedure as well as broader acceptance and experience in the public and in transplant centers.
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Affiliation(s)
- Robert S. Brown
- Center for Liver Diseases and Transplantation, Columbia College of Physicians and Surgeons, New York, NY
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Donor evaluation and hepatectomy for living-donor liver transplantation. ACTA ACUST UNITED AC 2008; 15:79-91. [DOI: 10.1007/s00534-007-1294-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 12/10/2007] [Indexed: 02/07/2023]
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Ríos A, Ramírez P, Rodríguez MM, Martínez L, Rodríguez JM, Galindo PJ, Parrilla P. Attitude of hospital personnel faced with living liver donation in a Spanish center with a living donor liver transplant program. Liver Transpl 2007; 13:1049-56. [PMID: 17600353 DOI: 10.1002/lt.21226] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In Spain, despite its high rate of cadaveric donation, death while on the liver transplant waiting list is high. For this reason, living liver donation is being encouraged despite of the risk of morbidity for the donor. The objective of this study was to analyze attitudes toward living liver donation among hospital personnel in a hospital with a recently authorized living donor liver transplantation program. A random sample was taken and was stratified by type of service and job category (n = 1,262). Attitude was evaluated by means of a validated psychosocial questionnaire. The questionnaire was completed anonymously and was self-administered. Statistical analysis included the Student t test, the chi(2) test, and logistical regression analysis. The questionnaire completion rate was 93% (n = 1,168). Only 15% (n = 170) of respondents were in favor of living liver donation if it were unrelated. An additional 65% (n = 766) were in favor if this donation, but only for relatives. Of the rest, 9% (n = 107) did not agree with living liver donation, and the remaining 11% (n = 125) were undecided. The variables related to this attitude were age (P = 0.044); job category (P = 0.002); type of service (according to whether it is related to organ donation and transplantation) (P = 0.044); participation in prosocial activities (P = 0.026); attitude toward cadaveric organ donation (P <0.001); attitude of a respondent's partner toward organ donation (P = 0.010); a respondent's belief that in the future, he or she may need a transplant (P < 0.001); and a willingness to receive a donated living liver organ if one were needed (P < 0.001). There is also a close relationship between attitude toward living kidney donation and living liver donation (P < 0.001). In the multivariate analysis, the only common independent variable from the bivariate analysis was a willingness to receive a living donor liver transplant if one were needed (odds ratio = 9.3). Attitude toward living liver donation among hospital personnel in a hospital with a solid organ transplant program is favorable and is affected by factors related to cadaveric donation, altruistic activity, and feelings of reciprocity. Physicians and the youngest hospital workers are those who are most in favor, which leads us to think that there is a promising future for living liver transplantation, which is essential given the cadaveric organ deficit and the high mortality rate while on the waiting list.
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Affiliation(s)
- A Ríos
- Coordinación Regional de Trasplantes de la Comunidad Autónoma de Murcia, Consejería de Sanidad, Murcia, Spain. mailto:
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Volk ML, Marrero JA, Lok AS, Ubel PA. Who decides? Living donor liver transplantation for advanced hepatocellular carcinoma. Transplantation 2007; 82:1136-9. [PMID: 17102762 DOI: 10.1097/01.tp.0000245670.75583.3d] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Michael L Volk
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI 48109-0362, USA.
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Ríos A, Ramírez P, Galindo PJ, Rodríguez MDM, Martínez L, Montoya MJ, Lucas D, Alcaraz J, Parrilla P. [Physicians faced with living liver donation: an attitudinal study in a Spanish hospital with a living donor liver transplant program]. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 29:597-601. [PMID: 17198635 DOI: 10.1157/13095194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Mortality on the waiting list for liver transplants is high. Consequently, alternatives such as living donation are being sought. Therefore, one of the aspects that should be improved is the attitude of healthcare professionals toward this type of donation in order to create a favorable climate. The objective of this study was to identify attitudes toward living liver donation among physicians in a hospital with a living donor liver transplant program and to analyze the variables that affect these attitudes. PATIENTS AND METHODS A random sample stratified by type of service (n = 369) was performed among physicians in the hospital. Attitudes were evaluated using a survey validated in our geographical area. In each service, the head of service, or in their absence, an attending physician, was contacted. This person was given an explanation of the study and was made responsible for distributing the questionnaire in selected work shifts. The questionnaire was completed anonymously and was self-administered. Statistical analysis consisted of chi2 test, Student's t-test, and a logistic regression analysis. RESULTS The survey completion rate was 93% (n = 345). Of those surveyed, 15% (n = 52) were in favor of living liver donation whether related or unrelated. This percentage increased to 85% (n = 292) if donation was related. Of the remainder, 8% (n = 27) did not accept living liver donation and the remaining 7% (n = 26) were undecided. This attitude was associated with only two factors: the respondent's belief that he or she might need a transplant in the future (p = 0.003) -90% of those who believed that they might need a transplant at some point in the future were in favor-, and the respondent's acceptance (if transplantation were necessary at some point in the future) of a living donated liver from a family member or a friend (p = 0.000). Thus, 96% of those who would be prepared to accept a living organ were in favor. In the multivariate analysis, both variables remained significant: the respondent's belief that he or she might need a transplant in the future (odds ratio [OR] = 2.36) and, if this were the case, the respondent's acceptance of a living donated liver (OR = 7.11). CONCLUSIONS Attitudes toward living liver donation among physicians in a hospital with a living donor transplant program were highly favorable. Consequently, these health professionals may be a key element for the promotion of living donation at the present time when this form of donation is being encouraged to avoid mortality on waiting lists.
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Affiliation(s)
- Antonio Ríos
- Coordinación Regional de Trasplantes de la Comunidad Autónoma de Murcia, Consejería de Sanidad, España
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Castaing D, Azoulay D, Danet C, Thoraval L, Tanguy Des Deserts C, Saliba F, Samuel D, Adam R. Medical community preferences concerning adult living related donor liver transplantation. ACTA ACUST UNITED AC 2006; 30:183-7. [PMID: 16565648 DOI: 10.1016/s0399-8320(06)73151-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To assess acceptance and acceptable estimated mortality levels for right lobe adult-to-adult living related liver transplantation for the medical and allied professions. METHODS A paper questionnaire was sent to the physicians practicing with the French Graft Agency (Etablissement Français des Greffes) and to all nurses and ancillary staff of the Paul Brousse Hospital Hepatobiliary Center. Responses were received from surgeons: 38/73; internists specialized in hepatology: 44/120; nurses: 98/100; health care assistants: 45/86; others: 17/20. RESULTS Acceptance of living donor transplantation is above average for all professional categories and indications may be extended including patients with cancer. Acceptable mortality for the donor was 4%, except among internists (0.7%). Currently, the real risk of mortality for the donor (1%) is lower. Acceptable mortality for the recipient was between 15 and 20%. CONCLUSIONS Acceptance of adult living donor liver transplantation among health care professionals is clearly above average. Thus the psychological involvement of transplantation teams, which is very strong in such situations, should not hamper the development of this type of transplantation.
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Affiliation(s)
- Denis Castaing
- Centre Hépato-Biliaire, Hôpital Paul Brousse, UPRES 1596, Université Paris Sud, Villejuif.
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Ghobrial RM, Busuttil RW. Challenges of adult living-donor liver transplantation. ACTA ACUST UNITED AC 2006; 13:139-45. [PMID: 16547675 DOI: 10.1007/s00534-005-1020-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2005] [Accepted: 05/30/2005] [Indexed: 01/25/2023]
Affiliation(s)
- Rafik Mark Ghobrial
- The Department of Surgery, The Dumont-UCLA Transplant Center, David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, California 90095, USA
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Abougergi M, Rai R, Cohen C, Montgomery R, Solga S. Trends in adult-to-adult living donor liver transplant organ donation: the Johns Hopkins experience. Prog Transplant 2006. [DOI: 10.7182/prtr.16.1.t680887634p6820v] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Middleton PF, Duffield M, Lynch SV, Padbury RTA, House T, Stanton P, Verran D, Maddern G. Living donor liver transplantation--adult donor outcomes: a systematic review. Liver Transpl 2006; 12:24-30. [PMID: 16498709 DOI: 10.1002/lt.20663] [Citation(s) in RCA: 190] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The objective of this study was to evaluate the safety and efficacy of adult-to-adult living donor liver transplantation, specifically donor outcomes. A systematic review, with searches of the literature up to January 2004, was undertaken. Two hundred and fourteen studies provided information on donor outcomes. The majority of these were case series studies, although there were also studies comparing living donor liver transplantation with deceased donor liver transplantation. Both underreporting and duplicate reporting is likely to have occurred, and so caution is required in interpretation of these results. Overall reported donor mortality was 12 to 13 in about 6,000 procedures (0.2%) (117 studies). Mortality for right lobe donors to adult recipients is estimated to be 2 to 8 out of 3,800 (0.23 to 0.5%). The donor morbidity rate ranged from 0% to 100% with a median of 16% (131 studies). Biliary complications and infections were the most commonly reported donor morbidities. Nearly all donors had returned to normal function by 3 to 6 months (18 studies). In conclusion, there are small, but real, risks for living liver donors. Due to the short history of adult-to-adult living donor liver transplantation, the long-term risks for donors are unknown.
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Affiliation(s)
- Philippa F Middleton
- Australian Safety and Efficacy Register of New Interventional Procedures-Surgical (ASERNIP-S), Royal Australasian College of Surgeons, SA
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Zink S, Weinreib R, Sparling T, Caplan AL. Living donation: focus on public concerns. Consensus statement. Clin Transplant 2005; 19:581-5. [PMID: 16146547 DOI: 10.1111/j.1399-0012.2004.00281.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In December 2002, a conference was held in Philadelphia to discuss public concerns about living organ transplantation with the goal of reaching a consensus about new strategies for such transplants. The conference was hosted by the Hospital of the University of Pennsylvania and the Center for Bioethics. A multidisciplinary group of leading experts and stakeholders was called to assess the current status of living donation and suggest productive changes to ensure safer and more ethically sound procedures for both donors and recipients. Prior to the meeting, the research team from the University of Pennsylvania, Center for Bioethics, conducted literature reviews and extensive background research on living organ transplantation. Summary briefs were prepared for all conference participants. Issues were divided into four subcategories; two or three experts led the discussion on each topic. At the conclusion of the conference, the points raised were summarized and discussed, and additional comments were offered before general agreement was reached on each subject. Transcribed minutes and summary statements were reviewed and circulated among participants to allow for additional comments and clarification. All feedback was incorporated into the statement, and a draft of the article was recirculated. Participants who have endorsed the following statements have agreed that these points represent the intent and spirit of the discussion, yet each participant reserves the right to disclaim the document in its entirety. The views represented in the consensus points are held by members of the consensus group and do not necessarily represent the views of the sponsor. A consensus was reached to propose new strategies and make improvements on existing practices and protocols. Specific attention was paid to the widely accepted needs of consistent and responsible communication with the public and press, standardization in donor assessment, a national living donor registry and new research focusing on larger sample numbers and long-term donor follow-up. These consensus points support the work carried out by other advisory transplant organizations and should assist in advocating for living organ donors, the live donor transplant process and the concerns of the public.
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Affiliation(s)
- Sheldon Zink
- Center for Bioethics, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Northup PG, Berg CL. Living donor liver transplantation: the historical and cultural basis of policy decisions and ongoing ethical questions. Health Policy 2005; 72:175-85. [PMID: 15802153 DOI: 10.1016/j.healthpol.2004.08.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Adult-to-adult living donor liver transplantation (LDLT) is in a state of flux. Technical innovations and demand have outpaced internal and external regulatory efforts. This has led to a wide array of centers performing LDLT for a variety of indications without clear evidence on the risks to the donor or recipient or the system as a whole. The birth from necessity of LDLT in Asia has led to the extrapolation of the technique in America and Europe that has not been sufficiently studied in the appropriate populations. While there is a clear benefit in some patients, the appropriate donors and recipients have not been defined. Regulatory and ethical consideration should be focused on minimizing acceptable risk in donors and recipients and expanding the investigation into the costs and outcomes of this challenging procedure. The recently funded adult-to-adult living donor liver transplantation cohort sponsored by the National Institutes of Health aims to answer some of these questions over the next five years.
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Affiliation(s)
- Patrick Grant Northup
- Division of Gastroenterology and Hepatology, Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, VA, USA.
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Surman OS, Fukunishi I, Allen T, Hertl M. Live Organ Donation: Social Context, Clinical Encounter, and the Psychology of Communication. PSYCHOSOMATICS 2005; 46:1-6. [PMID: 15765814 DOI: 10.1176/appi.psy.46.1.1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Organ transplantation is increasingly available to the thousands of patients who suffer from end-organ failure. There has been an attendant increase in demand for living donor participation. This combined with a bioethical focus on autonomy increases the burden of decision on donor candidates. The authors review the history of living donor participation in organ transplantation and explore the psychological dynamics of the clinical encounter between donor and transplant surgeon. The field of communication psychology lends to the understanding of coercion and to the importance of donors possessing a status of patient-hood in the classical Hippocratic condition.
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Affiliation(s)
- Owen S Surman
- Departments of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA.
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Thuluvath PJ, Yoo HY. Graft and patient survival after adult live donor liver transplantation compared to a matched cohort who received a deceased donor transplantation. Liver Transpl 2004; 10:1263-8. [PMID: 15376301 DOI: 10.1002/lt.20254] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Live donor liver transplantation (LDLT) has become increasingly common in the United States and around the world. In this study, we compared the outcome of 764 patients who received LDLT in the United States and compared the results with a matched population that received deceased donor transplantation (DDLT) using the United Network for Organ Sharing (UNOS) database. For each LDLT recipient (n = 764), two DDLT recipients (n = 1,470), matched for age, gender, race, diagnosis, and year of transplantation, were selected from the UNOS data after excluding multiple organ transplantation or retransplantation, children, and those with incomplete data. Despite our matching, recipients of LDLT had more stable liver disease, as shown by fewer patients with UNOS status 1 or 2A, in an intensive care unit, or on life support. Creatinine and cold ischemia time were also lower in the LDLT group. Primary graft nonfunction, hyperacute rejection rates, and patient survival by Kaplan-Meier analysis were similar in both groups (2-year survival was 79.0% in LDLT vs. 80.7% in case-controls; P = .5), but graft survival was significantly lower in LDLT (2-year graft survival was 64.4% vs. 73.3%; P < .001). Cox regression (after adjusting for confounding variables) analysis showed that LDLT recipients were 60% more likely to lose their graft compared to DDLT recipients (hazard ratio [HR] 1.6; confidence interval 1.1-2.5). Among hepatitis C virus (HCV) patients, LDLT recipients showed lower graft survival when compared to those who received DDLT. In conclusion, short-term patient survival in LDLT is similar to that in the DDLT group, but graft survival is significantly lower in LDLT recipients. LDLT is a reasonable option for patients who are unlikely to receive DDLT in a timely fashion.
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Affiliation(s)
- Paul J Thuluvath
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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Forsberg A, Nilsson M, Krantz M, Olausson M. The essence of living parental liver donation--donors' lived experiences of donation to their children. Pediatr Transplant 2004; 8:372-80. [PMID: 15265165 DOI: 10.1111/j.1399-3046.2004.00187.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The use of living parental liver donors will continue and probably increase because of lack of cadaveric livers for paediatric transplantation and the excellent graft survival of parental livers. Therefore, it is important for the health care professionals involved in living parental liver donation to understand the experience of being a liver donor. The aim of this study was to investigate the expressed deeper feelings of parents who donated a part of their liver to their own child. The study took the form of in-depth interviews with 11 donors. All donors were biological parents of the recipient, nine fathers and two mothers. The interpretive phenomenology method was used, and interpretive analysis was carried out in three interrelated processes in line with Benner. Data collection was guided by the researcher's preliminary understanding of the donor experience from being involved in the surgery and care of the donors as well as the paediatric recipients. However, the research question was approached from the perspective of holistic care for the donor. In this study, the essence of living parental liver donation was found to be the struggle for holistic confirmation. There were three categories leading to this central theme; the total lack of choice, facing the fear of death and the transition from health to illness. There was total agreement among the respondents that there is no choice when it comes to the question of donation. The findings in this study stress the importance of organizing the parental liver donation programme with as much focus on the donor as on the child. Based on the results of this study, several clinical implications are suggested for the formation of guidelines for living parental liver donation.
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Affiliation(s)
- Anna Forsberg
- Department of Nursing, The Sahlgrenska Academy at Göteborg University, SE-405 30 Göteborg, Sweden.
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Fujita M, Slingsby BT, Akabayashi A. Three patterns of voluntary consent in the case of adult-to-adult living related liver transplantation in Japan. Transplant Proc 2004; 36:1425-8. [PMID: 15251350 DOI: 10.1016/j.transproceed.2004.04.088] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To elucidate the psychosocial aspects of the donors' decisions to engage in adult-to-adult living related liver transplantation, we interviewed a total of five institutional ethics committee members who had experience with reassessing informed consent prior to surgery. Qualitative analysis revealed several nuances of voluntary consent consisting of three patterns: "unconditional consent" is consent from the bottom of one's heart to save a family member's life; "pressured consent" describes a donor who feels implicit pressure to donate despite fear; and "ulterior-motivated consent" defines a donor who has a hidden motive. This study diverges from previous work in that it employs a qualitative approach to deconstructing the psychosocial intricacies of the informed consent process in adult-to-adult LRLT. This initial study raises several questions on the meaning of voluntary informed consent in adult-to-adult living related liver transplantation.
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Affiliation(s)
- M Fujita
- Biomedical Ethics, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan
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37
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Neuberger J, Farber L, Corrado M, O'Dell C. Living liver donation: a survey of the attitudes of the public in Great Britain. Transplantation 2003; 76:1260-4. [PMID: 14578769 DOI: 10.1097/01.tp.0000087835.09752.70] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Living liver donation (LLD) is becoming an accepted way of increasing the donor pool for liver transplantation. The procedure is associated with major ethical difficulties because there is a significant risk of death to the healthy donor. METHODS We therefore conducted two surveys of the Great Britain population to determine their attitudes to LLD. RESULTS Approximately three quarters of the population of 1734 adults aged more than 15 years were supportive of LLD. Those in favor were more likely to be men, better educated, and younger. Seventy-four percent were supportive of the donor being reimbursed for costs incurred in donation, and 19% agreed that the donor should be paid for donation, although there was great variation in the amount suggested. Forty-two percent of the population believed that a risk of 1:200 or less was acceptable when donating to a family member, and only 14% believed that this risk was acceptable when donating to a friend. CONCLUSIONS Most adults in Great Britain are in favor of LLD, although more than half believe that a donor risk of mortality of 1:200 is acceptable.
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Affiliation(s)
- James Neuberger
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom. J.M.Neuberger.ac.uk
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Affiliation(s)
- R Mark Ghobrial
- Department of Surgery, Division of Liver and Pancreas Transplantation, The Dumont-UCLA Transplant Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA 90095-7054, USA
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Cotler SJ, Cotler S, Gambera M, Benedetti E, Jensen DM, Testa G. Adult living donor liver transplantation: perspectives from 100 liver transplant surgeons. Liver Transpl 2003; 9:637-44. [PMID: 12783411 DOI: 10.1053/jlts.2003.50109] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The involvement of healthy living donors and the degree of technical difficulty make adult living donor liver transplantation (LDLT) different from any other surgical procedure. We surveyed 100 liver transplant surgeons to assess their views on the complex issues raised by LDLT. Data were collected at meetings on LDLT and by electronic mail. The study instrument was divided into general, donor, surgeon, recipient, and donor and recipient issues. Subjects provided the projected 1-year survival threshold that they would require for the recipient before they would perform LDLT. They listed the three topics that they thought were most critical for transplant fellows to know about LDLT. A majority agreed that transplant programs have a duty to their patients to offer LDLT, that the increasing success of the procedure will expand indications for liver transplantation, and that the risk to the donor causes them a moral dilemma. There was more divergence of opinion regarding who should have the final say about a potential donor's candidacy, whether it is difficult for donors to comprehend the risks of the procedure, and whether repeat cadaveric transplantations should be offered for failed LDLT performed for extended indications. Surgeons' median recipient survival threshold was a conservative 79%. Priorities for educating trainees focused on understanding complications and risks, technical factors, and ethical concerns such as putting the donor first. In conclusion, the findings of this survey indicate that transplant surgeons are working to balance their moral imperative to provide life-saving therapy for transplantation candidates with the risks posed to living donors.
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Affiliation(s)
- Scott J Cotler
- RUSH-Presbyterian-St. Luke's Medical Center, Chicago, IL, USA.
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40
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Häussinger D. Fulminant liver failure: is living related liver transplantation justified with respect to donor risk? Transplant Proc 2003; 35:920-1. [PMID: 12947800 DOI: 10.1016/s0041-1345(03)00164-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- D Häussinger
- Department of Gastroenterology, Hepatology and Infectiology, University of Düsseldorf, Düsseldorf, Germany
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41
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Abstract
The cadaveric organ shortage and the high mortality rate while patients wait for an organ have driven the medical community to develop alternative strategies for treating patients with end-stage liver disease. Adult living donor liver transplantation (ALDT) has evolved in response to the cadaveric organ shortage. Although there are benefits for recipients of ALDT, donors may incur substantial risk, including death. In contrast to pediatric living donation, in which the left lateral segment of the liver is resected from a donor, ALDT generally requires right hepatectomy, which is associated with greater morbidity and mortality. Because ALDT places a healthy individual at risk for substantial morbidity and mortality, debate over the ethics of this procedure is ongoing. Two donor deaths have occurred in the United States, adding to the concern over donor safety. Despite the risks associated with ALDT, many individuals elect to proceed with living donation with the hope of improving the life of a relative or friend. When considering whether we as a society should support and encourage ALDT, we should examine the perspective of the donor, recipient, and medical community as well. The medical community has an obligation to study carefully the risks and outcomes associated with ALDT so that we can deliver the highest quality of care that is not at the expense of healthy individuals.
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Affiliation(s)
- Mark W Russo
- Center for Liver Disease and Transplantation, Columbia Presbyterian Medical Center, 622 West 168th Street, PH 14, New York, NY 10032, USA
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42
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García-Valdecasas JC, Fuster J, Charco R, Bombuy E, Fondevila C, Navasa M, Rodríguez-Laiz G, Ferrer J, Amador MA, Llovet JM, Forns X, Rimola A. Trasplante hepático de donante vivo en adultos. Análisis de los 30 primeros casos. GASTROENTEROLOGIA Y HEPATOLOGIA 2003; 26:525-30. [PMID: 14642237 DOI: 10.1016/s0210-5705(03)70406-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION In the last 2-3 years, adult living donor liver transplantation (ALDLT) has been developed on an international scale, multiplying the number of procedures performed. Despite this, analysis of the results is still incomplete. The aim of the present study was to perform a descriptive analysis of the results after the first 3 years of the initiation of the program. MATERIAL AND METHODS During this period, 30 ALDLT were performed. In all procedures, right lobe grafts were used. The mean age of donors and recipients was 31.8 and 52.7 years, respectively. The main indication for liver transplantation was liver cirrhosis due to hepatitis C virus (70%) and 38% of recipients were stage C in the Child-Pugh classification. A total of 46.7% of recipients had hepatocellular carcinoma. RESULTS Donors: The mean volume of the remnant liver was 632 cc (40.5% of the previous hepatic mass). Ten donors (33%) presented complications. The most frequent complication was biliary fistula (20%) and three patients required reintervention. The mean length of hospital stay among donors was 11.7 days. Recipients: The mean weight of the graft was 775 g, with a mean difference between graft weight and that of the recipient of 1.11. Fifteen recipients (50%) presented biliary leaks and nine of these (30%) required reintervention. There were no graft losses for technical reasons. Four patients died. With a median follow-up of 14 months, actuarial survival at 18 months was 92.9%. CONCLUSION ALDLT is an effective method for reducing the number of patients on the waiting list. The probability of survival is similar to that of cadaveric transplantation. Biliary complications in the recipient constitute a problem, the long-term repercussions of which remain to be resolved.
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Affiliation(s)
- J C García-Valdecasas
- Sección de Cirugía Hepática y Trasplante, Institut de Malalties Digestives, Hospital Clínic, Universidad de Barcelona, Barcelona, España.
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Abstract
Spurred on by the critical shortage of cadaveric livers, adult-to-adult right hepatic lobe living donor liver transplantation has grown rapidly as a therapeutic option for selected patients. In the USA alone, the number of living donor liver transplantations has increased six-fold in the last 4 years. The therapy can be complex, bringing together a variety of disciplines, including transplantation medicine and surgery, hepatology, psychiatry and medical ethics. Moreover, living donor liver transplantation is still defining itself in the adult-to-adult application. Uniform standards, guidelines and long-term outcomes are yet to be determined. Nevertheless, initial success has been remarkable, and a basic understanding of this field is essential to any physician contemplating options for their liver failure patients. This review covers a range of topics, including recipient and donor selection and outcomes, donor risk, controversies and future issues.
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Affiliation(s)
- P H Hayashi
- Division of Gastroenterology/Hepatology, University of Colorado Health Sciences Center, Denver, CO 80262, USA
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Surman OS, Cosimi AB, Fukunishi I, Kawaii T, Findley J, Kita Y, Makuuchi M. Some Ethical and Psychiatric Aspects of Right-Lobe Liver Transplantation in the United States and Japan. PSYCHOSOMATICS 2002; 43:347-53. [PMID: 12297602 DOI: 10.1176/appi.psy.43.5.347] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cadaver sources are insufficient for the increasing demand for liver transplantation. Right-lobe liver transplantation from living donors is fully developed in Japan and has been rapidly increasing in the United States during the past 2 years, although donor risk is greater than in other types of solid organ transplantation. The authors examine the psychiatric and ethical aspects of right-lobe liver transplantation in light of cultural differences between the United States and Japan.
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Affiliation(s)
- Owen S Surman
- Transplant Unit and the Department of Psychiatry, Massachusetts General Hospital, MA 02114-3117, USA.
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Wigmore SJ, Forsythe JJR. Living-related liver transplantation from the view of the donor: a 1-year follow-up survey. Transplantation 2002; 73: 1799. Transplantation 2002; 73:1701-2. [PMID: 12084989 DOI: 10.1097/00007890-200206150-00002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Stephen J Wigmore
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW, Scotland, UK
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46
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Trotter JF, Wachs M, Everson GT, Kam I. Adult-to-adult transplantation of the right hepatic lobe from a living donor. N Engl J Med 2002; 346:1074-82. [PMID: 11932476 DOI: 10.1056/nejmra011629] [Citation(s) in RCA: 371] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- James F Trotter
- Division of Gastroenterology and Hepatology, University of Colorado Health Sciences Center, Denver 80262, USA.
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47
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Kam I. Adult-adult right hepatic lobe living donor liver transplantation for status 2a patients: too little, too late. Liver Transpl 2002; 8:347-9. [PMID: 11965578 DOI: 10.1053/jlts.2002.33194] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
1. Lifelong monitoring of graft function, immunosuppressive levels, and screening for drug toxicity is required in all liver recipients. 2. Late hepatic allograft dysfunction is common and is caused by a variety of etiologies including rejection, infection, biliary/vascular abnormalities, recurrence of disease, and drug hepatotoxicity. 3. In all patients with late hepatic allograft dysfunction, liver biopsy should be performed to assess for the presence of rejection, and to thus avoid excessive use of bolus corticosteroid therapy and guide appropriate immunosuppressive management. 4. Recurrence of disease is the most common cause of late hepatic allograft dysfunction. 5. Hepatitis C universally reinfects the hepatic allograft, and is associated with decreased patient and graft survival and leads to the recurrence of cirrhosis in 28% of patients within 5 years of transplantation. 6. Major advances have been made in preventing recurrence of hepatitis B by the use of hepatitis B immune globulin in combination with lamivudine therapy. 7. Autoimmune liver diseases such as primary biliary cirrhosis, primary sclerosing cholangitis, and autoimmune hepatitis have a recurrence rate of approximately 20% to 30%. 8. In patients developing recurrence of autoimmune hepatitis, steroid withdrawal is the most common cause. 9. Recurrent hepatocellular cancer can be markedly reduced if strict guidelines are adhered to in selecting patients. 10. Drug hepatotoxicity must always be considered in the differential diagnosis of late hepatic allograft dysfunction.
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Affiliation(s)
- R H Wiesner
- Mayo Clinic Liver Transplant Center, Rochester, MN 55905, USA.
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