Selection of the living liver donor

Liver paired exchange: Can the liver emulate the kidney?

Kidney paired exchange (KPE) constitutes 12% of all living donor kidney transplantations (LDKTs) in the United States. The success of KPE programs has prompted many in the liver transplant community to consider the possibility of liver paired exchange (LPE). Though the idea seems promising, the application has been limited to a handful of centers in Asia. In this article, we consider the indications, logistical issues, and ethics for establishing a LPE program in the United States with reference to the principles and advances developed from experience with KPE. Liver Transplantation 24 677-686 2018 AASLD.

Small for size syndrome difficult dilemma: Lessons from 10 years single centre experience in living donor liver transplantation

AIM

To analyze the incidence, risk factors, prevention, treatment and outcome of small for size syndrome (SFSS) after living donor liver transplantation (LDLT).

METHODS

Through-out more than 10 years: During the period from April 2003 to the end of 2013, 174 adult-to-adults LDLT (A-ALDLT) had been performed at National Liver Institute, Menoufiya University, Shibin Elkoom, Egypt. We collected the data of those patients to do this cohort study that is a single-institution retrospective analysis of a prospectively collected database analyzing the incidence, risk factors, prevention, treatment and outcome of SFSS in a period started from the end of 2013 to the end of 2015. The median period of follow-up reached 40.50 m, range (0-144 m).

RESULTS

SFSS was diagnosed in 20 (11.5%) of our recipients. While extra-small graft [small for size graft (SFSG)], portal hypertension, steatosis and left lobe graft were significant predictors of SFSS in univariate analysis (P = 0.00, 0.04, 0.03, and 0.00 respectively); graft size was the only independent predictor of SFSS on multivariate analysis (P = 0.03). On the other hand, there was lower incidence of SFSS in patients with SFSG who underwent splenectomy [4/10 (40%) SFSS vs 3/7 (42.9%) no SFSS] but without statistical significance, However, there was none significant lower incidence of the syndrome in patients with right lobe (RL) graft when drainage of the right anterior and/or posterior liver sectors by middle hepatic vein, V5, V8, and/or right inferior vein was done [4/10 (28.6%) SFSS vs 52/152 (34.2%) no SFSS]. The 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients with SFSS were 30%, 30%, 25%, 25%, 25% and 25% respectively, while, the 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients without SFSS were 70.1%, 65.6%, 61.7%, 61%, 59.7%, and 59.7% respectively, with statistical significant difference (P = 0.00).

CONCLUSION

SFSG is the independent and main factor for occurrence of SFSS after A-ALDLT leading to poor outcome. However, the management of this catastrophe depends upon its prevention (i.e., selecting graft with proper size, splenectomy to decrease portal venous inflow, and improving hepatic vein outflow by reconstructing large draining veins of the graft).

Is There a Role for Living Donor Intestine Transplants?

The use of living donors with intestinal transplantation is controversial because it may not significantly improve candidate access to organs when intestine-only grafts are needed, and may involve excessive donor risk when combined liver-intestine grafts are required. Although limited data are available for comparison at this time, graft and patient survival rates for intestinal transplantations using living donors are no different than for deceased donor transplantations. Potential benefits that may be provided to the intestine transplant recipient through the use of living donors include better HLA matching, shorter ischemia times, better bowel preparation, and better opportunities for introducing immunomodulatory strategies. Conversely, living intestine donors are at risk for mortality, significant morbidity, financial loss, and psychologic trauma. The long-term outcomes of living intestine donors have not yet been reported. Ultimately, these data are essential before the wider use of living donors can be advocated for intestinal transplantation.

Psychosocial Assessment of Living Organ Donors: Clinical and Ethical Considerations

This article outlines psychosocial and ethical issues to be considered when evaluating potential living organ donors. Six types of living donors are described: genetically related, emotionally related, “Good Samaritan” (both directed and nondirected), vendors, and organ exchangers. The primary domains to be assessed in the psychosocial evaluation are informed consent, motivation for donating and the decision-making process, adequacy of support (financial and social), behavioral and psychological health, and the donor-recipient relationship. Obstacles to the evaluation process include impression management, overt deception, minimization of behavioral risk factors, and cultural and language differences between the donor and the evaluator. Ethical concerns, such as the right to donate, donor autonomy, freedom from coercion, nonmaleficence and beneficence in donor selection, conflicts of interest, “reasonable” risks to donors, and recipient decision making are also explored. To fully evaluate living organ donation, studying psychosocial as well as medical outcomes is crucial.

Financial Considerations in Living Organ Donation

The shortage of cadaveric organs and increased success of living donor transplantation support the use of living organ donors. Clinical social workers have the opportunity to explore a variety of donor-specific issues when performing psychosocial evaluations of living donors, including motivation, psychological stability, and personal and family consequences of donation, as well as the direct and indirect financial consequences faced by living donors. Although most donor-related medical costs are covered, other associated expenses are not reimbursable and may put donors at risk for financial hardship. Out-of-pocket expenses also serve as a disincentive to donate for some volunteers. During the evaluation process, healthcare professionals should openly discuss how surgery, recovery, and any potential complications might impact prospective donors' financial situation. Donors can then decide whether they are able to realistically handle the costs of donation. We present the financial dilemmas experienced by many living donors and highlight efforts that have been made to deal with them.

Postoperative pulmonary complications in living-liver donors: a retrospective analysis of 188 patients

OBJECTIVES

Living-donor liver transplant has become a viable option and an important source of hepatic grafts. The goal of this study is to establish postoperative pulmonary complications of liver donation surgery in our center.

MATERIALS AND METHODS

Data from 188 subjects (median age, 33.7 ± 8.4 y; male/female, 51.1%/48.9%) who had liver donation surgery from 1988 to 2013 were analyzed retrospectively. Patient demographic and clinical features were recorded. Postoperative complications and the correlation of risk factors for postoperative pulmonary complications were investigated.

RESULTS

The incidence of early postoperative complications was 17% (n = 32), and 16 of these patients had postoperative pulmonary complications (8.5%); 2 of the postoperative pulmonary complications were detected on the day of surgery and the other 14 complications were observed between the second and seventh day after surgery. Most postoperative pulmonary complications were minor complications including atelectasis, pleural effusion, and pneumonia. There was 1 major postoperative pulmonary complication: pulmonary embolism that occurred on the fourth day after surgery in 1 patient. Late pulmonary complications also were reviewed and no late postoperative pulmonary complications were observed. There was no significant difference in early and late postoperative pulmonary complications between ex-smokers and smokers. Postoperative atelectasis was significantly higher in patients with body mass index ≤ 20 kg/m ² than patients with body mass index > 21 kg/m ² (P = .027). In our study population, no postoperative mortality was recorded.

CONCLUSIONS

We believe that preoperative weight reduction strategies and early mobilization with postoperative respiratory physiotherapy could be important factors to reduce postoperative pulmonary complications in liver donors.

Resilience and quality of life in 161 living kidney donors before nephrectomy and in the aftermath of donation: a naturalistic single center study

BACKGROUND

Due to the shortage of cadaveric organs, living kidney donation has begun to serve as the most crucial organ pool. Transplant centers have a legitimate interest in expanding the pool of donors. A psychosocial evaluation is established in transplantation centers to prevent donors from possible emotional harm in the aftermath of donation. We explored if the resilience questionnaire is an appropriate measure of the mental stability. To standardize procedures of psychosocial evaluation and to optimize donor recruitment, we present our evaluation protocol and analyze the causes of exclusion from donation.

METHOD

In a naturalistic design, we compared resilience and quality of life in eligible and excluded donors at the time point of donation. Potential living kidney donors (N = 161) participated in the obligatory psychosomatic evaluation. Quality of life (World Health Organization Quality of Life, WHOQOL-Bref) and resilience (Resilience Scale, RS-12) were measured. Three months after nephrectomy donors quality of life was screened in a follow-up.

RESULTS

In the evaluation interview donors were classified as eligible (n = 142) or excluded (n = 12). Nonrelated donors (n = 3) were excluded from donation significantly more often (p < .011). Eligible donors (M = 78.42, SD = 10.19) had higher values for resilience than excluded donors (M = 72.7, SD = 8.18, p < .04), who showed values comparable to the norm. In all domains of quality of life, eligible donors had significantly higher values than healthy normals (p < .001). After donation health-related quality of life decreased, but was comparable to the norm. A regression analysis showed that resilience was a significant predictor for all dimensions of quality of life before donation (R(2) = 10.2-24.6 %). Post-donation quality of life was significantly correlated with pre-donation resilience scores (p < .05).

CONCLUSIONS

The resilience score predicts high mental quality of life before and after donation. Therefor it can be implemented as a self-rating instrument to further objectify donor's mental stability. Despite the stressful life event of donation, donor candidates presented high resilience and high levels of quality of life. Therefor our findings support health care providers` intentions to improve living donation. In the group of excluded donors nonrelated persons were overrepresented. Guidelines for the admission of nonrelated donors are currently unclear and need to be optimized.

Review of anesthesia in liver transplantation

Liver transplantation (LT) is a well-accepted treatment modality of many end-stage liver diseases. The main issue in LT is the shortage of deceased donors to accommodate the needs of patients waiting for such transplants. Live donors have tremendously increased the pool of available liver grafts, especially in countries where deceased donors are not common. The main ethical concern of this procedure is the safety of healthy donors, who undergo a major abdominal surgery not for their own health, but to help cure others. The first part of the review concentrates on live donor selection, preanesthetic evaluation, and intraoperative anesthetic care for living liver donors. The second part reviews patient evaluation, intraoperative anesthesia monitoring, and fluid management of the recipient. This review provides up-to-date information to help improve the quality of anesthesia, and contribute to the success of LT and increase the long-term survival of the recipients.

Donor rejection before living donor liver transplantation: causes and cost effective analysis in an egyptian transplant center

BACKGROUND

In the living donor liver transplant setting, the preoperative assessment of potential donors is important to ensure the donor safety.

OBJECTIVES

The aim of this study was to identify causes and costs of living liver-donors rejection in the donation process.

MATERIALS AND METHODS

From June 2010 to June 2012, all potential living liver donors for 66 liver transplant candidates were screened at the Ain Shams Center for Organ Transplantation. Potential donors were evaluated in 3 phases, and their data were reviewed to determine the causes and at which phase the donors were rejected.

RESULTS

One hundred and ninety two potential living liver donors, including 157 (81.7%) males, were screened for 66 potential recipients. Of these, 126 (65.6%) were disqualified for the donation. The causes of rejection were classified as surgical (9.5 %) or medical (90.5 %). Five donors (3.9 %) were rejected due to multiple causes. Factor V Leiden mutation was detected in 29 (23 %) rejected donors (P = 0.001), 25 (19.8 %) donors had positive results for hepatitis serology (P = 0.005), and 16 (12.7 %) tested positive for drug abuse. Portal vein trifurcation (n = 9, 7.1%) and small size liver graft estimated by CT volumetric analysis (n = 6, 4.8 %) were the main surgical causes which precluded the donation.

CONCLUSIONS

Among potential Egyptian living liver donors, Factor V Leiden mutation was a significant cause for live donor rejection. A stepwise approach to donor assessment was found to be cost-effective.

Rotational thromboelastometry and standard coagulation tests for live liver donors

PURPOSE

To study coagulation of live liver donors with standard coagulation tests (SCT) and rotational thromboelastometry (ROTEM) and investigate their relationship.

METHODS

A descriptive prospective study involving 50 right hepatotomy donors with epidural catheters. ROTEM (EXTEM, INTEM, and FIBTEM represent extrinsic and intrinsic pathways of coagulation and fibrinogen activity, respectively) was measured perioperatively and on days 1, 3, 5, 10, and 30. SCTs include prothrombin time (PT), international normalized ratio (INR) of PT, activated partial thromboplastin time (aPPT), fibrinogen, and platelets.

RESULTS

PT and INR reflect hypocoagulability reaching maximum on day one (16.9 ± 2.5 s, 1.4 ± 0.2, p < 0.05 compared with baseline). ROTEM was in normal ranges till day 30 with no hypercoagulability. Fibrinogen showed no correlation with maximum clot firmness (MCF) of FIBTEM (r = 0.35, p > 0.05). CFT of EXTEM was not in significant correlation with PT and INR (r = 0.16, 0.19, p > 0.05), respectively. Significant correlation between platelets and both MCF (EXTEM; r = 0.59, p = 0.004) and MCF (INTEM; r = 0.48, p = 0.027).

CONCLUSION

ROTEM disagreed with SCTs and did not show the temporary hypocoagulability suggested by SCTs. Both ROTEM and SCTs showed no signs of hypercoagulability. Future studies involving ROTEM could help develop new guidelines for coagulation monitoring.

Liver transplant-psychiatric and psychosocial aspects

Liver transplantation is a life saving surgical procedure that is associated with improved longevity and enhanced quality of life. The number of successful liver transplants is growing worldwide. The procedure requires a dedicated and trained team of experts. A psychiatrist plays an important role in such a team. Psychiatric and psychosocial assessment is considered imperative to evaluate the candidate's suitability as a transplant recipient. Many psychiatric disorders may lead to the need for liver transplant, and if kept unchecked can adversely affect outcomes. Psychiatric problems arising in the post-transplant period may also require intervention of the psychiatrist. The donor too needs to be evaluated adequately to assess for psychological fitness for the procedure. This article provides broad overview of the various psychiatric and psychosocial issues pertaining to liver transplantation.

Prevention of poor psychosocial outcomes in living organ donors: from description to theory-driven intervention development and initial feasibility testing

CONTEXT

Although some living donors experience psychological, somatic, and interpersonal difficulties after donation, interventions to prevent such outcomes have not been developed or evaluated.

OBJECTIVE

To (1) summarize empirical evidence on psychosocial outcomes after donation, (2) describe a theoretical framework to guide development of an intervention to prevent poor outcomes, and (3) describe development and initial evaluation of feasibility and acceptability of the intervention.

METHODS

Based on a narrative literature review suggesting that individuals ambivalent about donation are at risk for poor psychosocial outcomes after donation, the intervention targeted this risk factor. Intervention structure and content drew on motivational interviewing principles in order to assist prospective donors to resolve ambivalence. Data were collected on donors' characteristics at our institution to determine whether they constituted a representative population in which to evaluate the intervention. Study participants were then recruited to assess the feasibility and acceptability of the intervention. They were required to have scores greater than 0 on the Simmons Ambivalence Scale (indicating at least some ambivalence about donation).

RESULTS

Our population was similar to the national living donor population on most demographic and donation-related characteristics. Eight individuals who had been approved to donate either a kidney or liver segment were enrolled for pilot testing of the intervention. All successfully completed the 2-session telephone-based intervention before scheduled donation surgery. Participants' ratings of acceptability and satisfaction were high. Open-ended comments indicated that the intervention addressed participants' thoughts and concerns about the decision to donate.

CONCLUSIONS

The intervention is feasible, acceptable, and appears relevant to donor concerns. A clinical trial to evaluate the efficacy of the intervention is warranted.

Trends in liver transplantation 2011

This review will highlight some of the important recent trends in liver transplantation. When possible, we will compare and contrast these trends across various regions of the world, in an effort to improve global consensus and better recognition of emerging data.

Strategies for improving the outcomes of small-for-size grafts in adult-to-adult living-donor liver transplantation

Living-donor liver transplantation (LDLT) has been refined and accepted as a valuable treatment for patients with end-stage liver disease in order to overcome the shortage of organs and mortality on the waiting list. However, graft size problems, especially small-for-size (SFS) grafts, remain the greatest limiting factor for the expansion of LDLT, especially in adult-to-adult transplantation. Various attempts have been made to overcome the problems regarding SFS grafts, such as increasing the graft liver volume and/or controlling excessive portal inflow to a small graft, with considerable positive outcomes. Recent innovations in basic studies have also contributed to the treatment of SFS syndrome. Herein, we review the literature and assess our current knowledge of the pathogenesis and treatment strategies for the use of SFS grafts in adult-to-adult LDLT.

Retrospective analysis of the causes of rejection of potential donors for living related liver transplantation

BACKGROUND

A major prerequisite for living related liver transplantation is to ensure both donor safety and optimal graft quality. Therefore, excluding unsuitable donor candidates should be an important priority of the transplant team.

PURPOSE

To analyze the criteria for exclusion of potential living related liver donors.

PATIENTS AND METHODS

From November 2000 to March 2005, 327 potential living related donors for 136 potential recipients for liver transplantation were screened and worked up at the Liver Transplant Center, King Abdul Aziz Medical City. They were evaluated in a stepwise manner, including medical, physical, laboratory, psychosocial, and imaging assessment. Data regarding potential donors were retrospectively reviewed. Reasons for rejection of disqualified donors were analyzed.

RESULTS

Out of the 327 potential donors, 223 (68.2%) were rejected at an early stage. A total of 104 cases (31.8%) had computed tomographic (CT) volumetry and/or magnetic resonance cholangiography (MRCP). While 44 (42.3% of those who had CT volumetry and/or MRCP) had their workup completed and proved to be suitable candidates, 24 (23%) went for surgery. Causes for donor rejection were classified as donor-related factors (inadequate volume, unsafe anatomy, abnormal liver function tests, medical/psychiatric, fatty liver, etc.; n = 191) and recipient-related factors (too ill, died, received cadaveric transplant, etc.; n = 112).

CONCLUSION

In our experience, as well as in those from other centers, a small proportion of potential donors prove to be satisfactory candidates. Therefore, strict adherence to a stepwise evaluation process is of utmost importance, so unsuitable potential donors can be disqualified, as early as possible during workup.

Outcomes of donor evaluations for adult-to-adult right hepatic lobe living donor liver transplantation

The purpose of this study is to determine the role of liver biopsy and outcome of patients undergoing donor evaluation for adult-to-adult right hepatic lobe living donor liver transplantation (LDLT). Records of patients presenting for a comprehensive donor evaluation between 1997 and February 2005 were reviewed. Liver biopsy was performed only in patients with risk factors for abnormal histology. Two hundred and sixty patients underwent a comprehensive donor evaluation and 116 of 260 (45%) were suitable for donation, 14 of 260 (5.4%) did not complete evaluation and 130 of 260 (50%) were rejected. Four patients underwent unsuccessful hepatectomy surgery due to discovery of intraoperative abnormalities. Between 1997 and 2001, the acceptance rate of donor candidates (63%) was higher than 2002-2005 (36%), p < 0.0001. Sixty-six of the 150 eligible patients (44%) fulfilled criteria for liver biopsy and 28 of 66 (42%) had an abnormal finding. Less than half of the patients undergoing donor evaluation were suitable donors and the donor acceptance rate has declined over time. A large proportion of the patients undergoing liver biopsy have abnormal findings. Our evaluation process failed to identify 4 of 103 who had aborted donor surgeries.

Living donor liver transplantation--adult donor outcomes: a systematic review

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.

Living donor liver transplantation

The introduction of living donor liver transplantation (LDLT) has been one of the most remarkable steps in the field of liver transplantation (LT). First introduced for children in 1989, its adoption for adults has followed only 10 years later. As the demand for LT continues to increase, LDLT provides life-saving therapy for many patients who would otherwise die awaiting a cadaveric organ. In recent years, LDLT has been shown to be a clinically safe addition to deceased donor liver transplantation (DDLT) and has been able to significantly extend the scarce donor pool. As long as the donor shortage continues to increase, LDLT will play an important role in the future of LT.

Risks of donation and quality of donors' life after living donor liver transplantation

The purpose is to clarify risks of donation and quality of the donor's life after living-related donor liver transplantation (LDLTx). Sixty-eight donors were classified into four groups: lateral segment group (n = 30); left lobe group (n = 18); left lobe with the middle hepatic vein group (n = 11); right lobe group (n = 9). We investigated (i) the risks of donation, and evaluated the following: blood loss, operation time, postoperative liver function and duration of hospitalization; (ii) quality of donors' life: donors were mailed a structured questionnaire and the Short-Form Health Survey (SF-36), a generic measure assessing quality of life using eight scales. The results were: (i) there were no differences in liver function and duration of hospitalization between four groups; (ii) 48 donors (71%) responded. All donors returned to normalcy. The donors did not regret their decision to donate except two cases whose recipients had died. The donors' life was almost guaranteed regardless of the lobe we used as the graft.

Is there a role for living donor intestine transplants?

The use of living donors with intestinal transplantation is controversial because it may not significantly improve candidate access to organs when intestine-only grafts are needed, and may involve excessive donor risk when combined liver-intestine grafts are required. Although limited data are available for comparison at this time, graft and patient survival rates for intestinal transplantations using living donors are no different than for deceased donor transplantations. Potential benefits that may be provided to the intestine transplant recipient through the use of living donors include better HLA matching, shorter ischemia times, better bowel preparation, and better opportunities for introducing immunomodulatory strategies. Conversely, living intestine donors are at risk for mortality, significant morbidity, financial loss, and psychologic trauma. The long-term outcomes of living intestine donors have not yet been reported. Ultimately, these data are essential before the wider use of living donors can be advocated for intestinal transplantation.

Evolution of donor morbidity in living related liver transplantation: a single-center analysis of 165 cases

OBJECTIVE

During the last 14 years, living donor liver transplantation (LDLT) has evolved to an indispensable surgical strategy to minimize mortality of adult and pediatric patients awaiting transplantation. The crucial prerequisite to performing this procedure is a minimal morbidity and mortality risk to the healthy living donor. Little is known about the learning curve involved with this type of surgery.

PATIENTS AND METHODS

From January 1991 to August 2003, a total of 165 LDLTs were performed in our center. Of these, 135 were donations of the left-lateral lobe (LL, segments II and III), 3 were of the left lobe (L, segments II-IV), 3 were full-left lobes (FL, segments I-IV), and 24 were of the full-right lobe (FR, segments V-VIII). We divided the procedures into 3 periods: period 1 included the years 1991 to 1995 (LL, n = 49; L, n = 2; FR, n = 1), period 2 covered 1996 to 2000 (LL, n = 47), and period 3 covered 2001 to August 2003 (LL, n = 39; FR, n = 23; FL, n = 3; L, n = 1). Perioperative mortality and morbidity were assessed using a standardized classification. Length of stay in intensive care unit, postoperative hospital stay, laboratory results (bilirubin, INR, and LFTs), morbidity, and the different types of grafts in the 3 different periods were compared.

RESULTS

One early donor death was observed in period 1 (03/07/93, case 30; total mortality, 0.61.%). Since 1991, the perioperative morbidity has continually declined (53.8% vs. 23.4% vs. 9.2%). In period 1, 28 patients had 40 complications. In period 2, 11 patients had 12 complications, and in period 3, 6 patients had 9 complications. Within the first period, 1 donor underwent relaparotomy because of bile leakage. Postoperative hospital stay was 10 days, 7 days, and 6 days, respectively. Donation of the full right lobe, in comparison with that of the left lateral lobe, resulted in a significantly diminished liver function (bilirubin and INR) during the first 5 days after donation but did not increase morbidity. One donor from period 1 experienced late death caused by amyotrophic lateral sclerosis.

CONCLUSIONS

In a single center, morbidity after living liver donation strongly correlates to center experience. Despite the additional risks associated with temporary reduction of liver function, this experience enabled the team to bypass part of the learning curve when starting right lobe donation. Specific training of the surgical team and coaching by an experienced center should be implemented for centers offering this procedure to avoid the learning curve.

Experience after the evaluation of 700 potential donors for living donor liver transplantation in a single center

Adequate selection of donors is a major prerequisite for living donor liver transplantation (LDLT). Few centers report on the entire number of potential donors considered or rejected for living donation. From April 1998 to July 2003, a total of 111 living donor liver transplantations were performed at our institution, with 622 potential donors for 297 adult recipients and 78 potential donors for 52 pediatric recipients evaluated. In the adult group, only 89 (14%) potential donors were considered suitable, with a total of 533 (86%) potential donors rejected. Of these, 67% were excluded either at initial screening or during the first and second steps of the evaluation procedure. In 31% of all cases, the evaluation of donors was canceled because of recipient issues. In the pediatric group, 22 (28%) donors were selected, with the other 56 (72%) rejected. Costs of the complete evaluation process accounted for 4,589 Euro (Euro) per donor. The evaluation of a potential living donor is a complex and expensive process. We present the results on the evaluation of the largest group of potential donors for adults reported in the literature. Only 14% of potential donors in our series were considered suitable candidates. It has not yet been established who should cover the expenses of the evaluation of all rejected donors. In conclusion, all efforts should be made in order to develop an effective screening protocol for the evaluation of donors with the aim of saving time and resources for a liver transplantation program.

Thromboelastogram monitoring in the perioperative period of hepatectomy for adult living liver donation

Living donor liver transplantation (LDLT) is becoming a widespread procedure. However, the risk of surgical and medical complications in healthy donors is still a major concern. Hypercoagulability contributes to thromboembolic complications after surgery, but alterations of hemostasis after liver resection are difficult to predict. This study aims to define the perioperative coagulation profile of living liver donors by the use of both routine tests and thromboelastogram (TEG). Ten subjects undergoing right hepatectomy for LDLT were studied. A complete coagulation screening was performed before operation. The coagulation profile was evaluated by platelet count, prothrombin time-international normalized ratio (PT-INR), activated partial thromboplastin time (aPTT), and TEG at the beginning and at the end of surgery, and on days 1, 3, 5, and 10 after operation, while the donors were under low molecular weight heparin (LMWH) prophylaxis. At preoperative screening, no subject showed evidence of a prothrombotic state. In all cases, TEG was normal at the beginning of surgery. In the postoperative period, despite decreased platelet counts, increased PT-INR, and normal aPTT values, TEG evidenced the progressive development of hypercoagulability in 4 subjects on day 5 and in 6 subjects on day 10. One donor with a definitely hypercoagulable TEG on day 5 experienced deep venous thrombosis (DVT) on day 8, which was resolved with therapeutic doses of LMWH. In conclusion, despite routine tests suggesting hypocoagulability and LMWH prophylaxis, TEG monitoring showed the unexpected occurrence of hypercoagulability in the majority of the subjects after hepatectomy for LDLT. TEG monitoring could be useful in the perioperative management of donors to guide antithrombotic treatment and increase the safety of the procedure.

Financial considerations in living organ donation

The shortage of cadaveric organs and increased success of living donor transplantation support the use of living organ donors. Clinical social workers have the opportunity to explore a variety of donor-specific issues when performing psychosocial evaluations of living donors, including motivation, psychological stability, and personal and family consequences of donation, as well as the direct and indirect financial consequences faced by living donors. Although most donor-related medical costs are covered, other associated expenses are not reimbursable and may put donors at risk for financial hardship. Out-of-pocket expenses also serve as a disincentive to donate for some volunteers. During the evaluation process, healthcare professionals should openly discuss how surgery, recovery, and any potential complications might impact prospective donors' financial situation. Donors can then decide whether they are able to realistically handle the costs of donation. We present the financial dilemmas experienced by many living donors and highlight efforts that have been made to deal with them.

Living liver donation: preoperative assessment, anatomic considerations, and long-term outcome

BACKGROUND

A major prerequisite for living donor liver transplantation (LDLT) as an acceptable treatment modality is thoughtful consideration of the donor. However, there has been no comprehensive audit of living liver donation focusing on issues such as donor selection, anatomic surveys, and long-term outcome.

METHODS

Between June 1990 and January 2002 at our institution, 160 LDLTs were performed and 177 patients were referred for LDLT. For these patients, a total of 203 potential donors were screened. The process of donor selection, safety of donor hepatectomy, and postoperative morbidity were investigated. Additionally, an anonymous questionnaire was administered to 100 donors who had undergone LDLT more than 3 years previously.

RESULTS

Thirty-eight (19%) of the 203 donor candidates were excluded. Precise estimation of the hepatic anatomy was indispensable for donor safety. None of the donors showed prolonged postoperative liver dysfunction nor developed complications requiring reoperation or readmission. There was no donor mortality. The responses to the questionnaire indicated that 95% of the living donors had not felt coerced to donate and that 5% were neutral about coercion pressure. There were no severe postoperative aftereffects, but minor problems were reported by 51% of the respondents.

CONCLUSIONS

Our appraisal of the perioperative and long-term postoperative course of LDLT donors revealed that although most donors are satisfied after undergoing LDLT, there is a need for strict attention to the process of donor selection and long-term postoperative follow-up. The outcome of the present series seems to confirm the safety of donor hepatectomy.

Evaluation of living liver donors

Preoperative evaluation of donors for living-donor liver transplantation aims to select a suitable donor with optimal graft quality and to ensure donor safety. There are minor variations in the donor selection process among different centers, but the safety of the donor remains central to the entire process. The potential donors are evaluated in a stepwise manner including medical, physical, laboratory, psychosocial, and imaging assessment to disqualify unsuitable donors as early as possible in the evaluation process. The main goal of the imaging study is to provide an accurate picture of liver vascular anatomy and liver volume measurement for surgical guidance or for exclusion of unsuitable donors. All imaging studies can now be obtained using noninvasive modalities, thereby decreasing the risk associated with the donor evaluation process. This article describes the donor selection practice in our center including the details of the imaging evaluation.

Psychosocial outcome of living donors after living donor liver transplantation: a pilot study

In view of the scarcity of organ resources available for transplantation, living donor liver transplantation (LDLT) is gaining growing importance in the treatment of chronically terminal liver diseases. In the period between December 1999 and October 2000, 47 potential living liver donors were evaluated and 24 right hepatic lobes and two left lateral segments were transplanted at the Virchow-Klinikum of the Charité Hospital in Berlin. The present study looks into biomedical and psychosocial parameters of 23 donors before and 6 months after LDLT. Our aims were to investigate the development of psychosocial parameters after donation and the relationship between psychosocial findings and post-operative complications. Most donors showed an improved quality of life (QoL) after LDLT when compared with pre-operative results. Twenty-six percent of donors show high values for 'tiredness', 'fatigue' and 'limb pain' following donation. The post-operative complications had no influence on the psychosocial outcome. In this pilot study the resection of the right hepatic lobe amounts to a safe operation for donors and holds promise of a good psychosocial outcome for most donors, irrespective of donation-related complications. The pronounced complaints appears to indicate psychological tension and distress in some donors following donation.

Liver transplantation for hepatocellular carcinoma: an Asian perspective

Liver transplantation is an established treatment modality for patients with hepatocellular carcinoma (HCC), creating a potential for disease-free, long-term survival. In Asia, due to a severe shortage of donors, resection remains the treatment of choice for patients with HCC and good liver functional reserve. The use of marginal donors, split liver grafts and grafts from living donors are potential solutions that are best performed in experienced liver transplant centres to ensure an optimal outcome. Ethical issues relating to living donor liver transplantation have yet to be fully addressed. The roles of therapies to limit tumour progression during the waiting period, such as transarterial chemoembolization, need to be further investigated in the setting of a prospective trial and their benefits better defined.

Liver transplantation in the UK

INTRODUCTION

This paper provides a review of the practice of liver transplantation with the main emphasis on UK practice and indications for transplantation.

REFERRAL AND ASSESSMENT

This section reviews the process of referral and assessment of patients with liver disease with reference to UK practice.

DONOR ORGANS

The practice of brainstem death and cadaveric organ donation is peculiar to individual countries and rates of donation and potential areas of improvement are addressed.

OPERATIVE TECHNIQUE

The technical innovations that have led to liver transplantation becoming a semi-elective procedure are reviewed. Specific emphasis is made to the role of liver reduction and splitting and living related liver transplantation and how this impacts on UK practice are reviewed. The complications of liver transplan-tation are also reviewed with reference to our own unit. Immunosuppression:The evolution of immunosuppression and its impact on liver transplantation are reviewed with some reference to future protocols.

RETRANSPLANTATION

The role of retransplantation is reviewed.

OUTCOME AND SURVIVAL

The results of liver transplantation are reviewed with specific emphasis on our own experience.

FUTURE

The future of liver transplantation is addressed.

Quality of life after lobectomy for adult liver transplantation

INTRODUCTION

Adult-to-adult living donor liver transplants are being increasingly performed. Although considerable data are available on the quality of life after kidney donation, there is little comparable information on liver donors.

METHODS

Between August 1998 and July 2000, 48 adults received liver grafts from living donors. At least 2 months after donation, donors were mailed a structured questionnaire and the standardized Medical Outcomes Study Short-Form Health Survey (SF-36), a generic measure assessing health-related quality of life outcomes using eight scales: mental health, emotional limits, vitality, social function, physical function, physical limits, pain, general health.

RESULTS

Thirty donors (62.5%) responded at a mean of 280+/-157 days after donation. Fifteen (50%) of their recipients had major complications (two deaths, four retransplants, nine biliary complications). Regarding overall satisfaction, all said they would donate again. Compared to published U.S. norms (n=2474), our group of donors scored higher than the general population in seven of eight domains on the SF-36. Donors whose recipients had no complications scored significantly higher in mental health (P<0.007) and general health (P<0.008) compared with U.S. norms. Donors whose recipients had major complications scored significantly lower on the mental health scale than those with recipients without major complications.

CONCLUSIONS

Donors did not regret their decision to donate; several felt the experience had changed their lives for the better. Donors scored as well as or better than U.S. norms in general health. Quality of life after donation must remain a primary outcome measure when we consider the utility of living-donor liver transplants.

Psychosocial data of potential living donors before living donor liver transplantation

In view of the scarcity of organ resources for transplantation, donation by living donors is assuming greater significance now that the technical-surgical problems involved have been solved. In the period between December 1999 and December 2000, 47 potential living liver donors were evaluated and a total of 27 hepatic lobes were transplanted at the Virchow-Klinikum of the Charité Hospital in Berlin. The close personal relationships between recipients and donors gives reason to anticipate high levels of psychosocial pressure during the pre-operative evaluation process; this process consists in part in looking into donor motivation, ambivalence and anxiety. The pre-operative psychometric evaluation of 40 potential living donors indicated that most of the potential donors see themselves as 'super-healthy' and tend to adapt to social expectations, while on the other hand those seven potential living donors not accepted for psychosocial reasons were marked by heightened values for anxious depression and pessimism. The results indicate in most cases a great willingness to donate and on the other hand a high level of obvious psychological pressure for a low number of potential donors. For the latter, both the clinical evaluation interview and the psychometric diagnostics used revealed clear-cut feelings of anxiety and ambivalence towards transplantation.

Living donor liver transplantation: summary of a conference at The National Institutes of Health

Living donor liver transplantation for adults was developed only recently in an attempt to increase the pool of donor organs; to reduce morbidity and mortality; and to improve the long-term survival of patients in need of liver transplant. Within a few brief years, this procedure has gained widespread support by both the public and transplant community. The procedure will soon be performed by nearly 80% of all liver transplant programs in the United States. Unfortunately, the long-term risks of the procedure to the recipient and especially the donor remain undefined. In response to the rapid growth and enthusiasm for this procedure, the National Institutes of Health sponsored a workshop, the goals of which were to review the scientific, medical, and nonmedical issues associated with living donor liver transplantation, and to define questions for future basic and clinical investigations which could improve the success and applicability of this procedure.

Safe donor hepatectomy for living related liver transplantation

Minimizing the risk of donor hepatectomy while preserving graft viability is an important concern in living related liver transplantation. This report describes clinical outcomes for living donor hepatectomy with reference to the type of hepatectomy. Donor hepatectomy was performed in 130 consecutive living donors. They were divided into three groups: left lateral or extended left lateral segmentectomy (group S; n = 50), left hepatectomy with or without caudate lobe or right lateral resection (group L; n = 64), and right hepatectomy (group R; n = 16). Intraoperative and postoperative data were examined and compared among the groups. No critical complications were observed in any group. However, there were differences in donor age, surgical and ischemia times, volume of blood loss, graft weight, and aspartate aminotransferase level elevation among the groups. Livers showed a substantial increase in volume, tending to the standard liver volume 1 month after surgery. Regardless of the extent of donor hepatectomy, serious complications did not occur after surgery. Surgical risk for a living donor is minimal if the operation is performed by experienced surgeons using present procedures.

Perioperative management and complications in donors related to living-donor liver transplantation

BACKGROUND

Living-donor liver transplantation has become a legitimate alternative to cadaveric liver transplantation. However, information on the perioperative management of donors is still scarce.

METHODS

Between October 1996 and May 2001, 52 consecutive living-donor liver transplantations have been performed at the authors' institution. The preoperative and postoperative management of donors, operative technique, and complications are herein described.

RESULTS

All donors were discharged from the hospital alive and well, and all returned to their normal lifestyle without any significant adverse sequelae after a mean hospital stay of 13 days after the operation. Overall, 24 complications occurred, all of which could be managed conservatively, except for one case of hepatic duct stricture that required a relaparotomy. A learning curve has been observed in terms of blood loss during donor hepatectomy.

CONCLUSIONS

These results indicate that our approach toward the selection and management of donors was appropriate. Because of the use of meticulous operative techniques, blood loss could also be minimized.

Is there still a need for living-related liver transplantation in children?

OBJECTIVE

To assess and compare the value of split-liver transplantation (SLT) and living-related liver transplantation (LRT).

SUMMARY BACKGROUND DATA

The concept of SLT results from the development of reduced-size transplantation. A further development of SLT, the in situ split technique, is derived from LRT, which itself marks the optimized outcome in terms of postoperative graft function and survival. The combination of SLT and LRT has abolished deaths on the waiting list, thus raising the question whether living donor liver transplantation is still necessary.

METHODS

Outcomes and postoperative liver function of 43 primary LRT patients were compared with those of 49 primary SLT patients (14 ex situ, 35 in situ) with known graft weight performed between April 1996 and December 2000. Survival rates were analyzed using the Kaplan-Meier method.

RESULTS

After a median follow-up of 35 months, actual patient survival rates were 82% in the SLT group and 88% in the LRT group. Actual graft survival rates were 76% and 81%, respectively. The incidence of primary nonfunction was 12% in the SLT group and 2.3% in the LRT group. Liver function parameters (prothrombin time, factor V, bilirubin clearance) and surgical complication rates did not differ significantly. In the SLT group, mean cold ischemic time was longer than in the LRT group. Serum values of alanine aminotransferase during the first postoperative week were significantly higher in the SLT group. In the LRT group, there were more grafts with signs of fatty degeneration than in the SLT group.

CONCLUSIONS

The short- and long-term outcomes after LRT and SLT did not differ significantly. To avoid the risk for the donor in LRT, SLT represents the first-line therapy in pediatric liver transplantation in countries where cadaveric organs are available. LRT provides a solution for urgent cases in which a cadaveric graft cannot be found in time or if the choice of the optimal time point for transplantation is vital.

Liver transplantation in the UK

INTRODUCTION

This paper provides a review of the practice of liver transplantation with the main emphasis on UK practice and indications for transplantation.

REFERRAL AND ASSESSMENT

This section reviews the process of referral and assessment of patients with liver disease with reference to UK practice.

DONOR ORGANS

The practice of brainstem death and cadaveric organ donation is peculiar to individual countries and rates of donation and potential areas of improvement are addressed.

OPERATIVE TECHNIQUE

The technical innovations that have led to liver transplantation becoming a semi-elective procedure are reviewed. Specific emphasis is made to the role of liver reduction and splitting and living related liver transplantation and how this impacts on UK practice are reviewed. The complications of liver transplan-tation are also reviewed with reference to our own unit. Immunosuppression:The evolution of immunosuppression and its impact on liver transplantation are reviewed with some reference to future protocols.

RETRANSPLANTATION

The role of retransplantation is reviewed.

OUTCOME AND SURVIVAL

The results of liver transplantation are reviewed with specific emphasis on our own experience.

FUTURE

The future of liver transplantation is addressed.