Who decides? Living donor liver transplantation for advanced hepatocellular carcinoma

Liver Living Donation for Cancer Patients: Benefits, Risks, Justification

LDLT covers all standard indications for liver transplantation, and the results are similar or even better than for standard DDLT. Due to the donor shortage and long waiting time, LDLT has become a relevant option for patients with liver tumors, provided the expected five-year survival rate is comparable to that of patients receiving a DDLT. Nowadays, LDLT offers the possibility to extend the standard morphometric selection by considering the biological parameters. In the setting of LDLT, we are not only faced with surgical morbidity in the donor, but long-term non-medical problems like psychological complications and financial burden also have to be considered. On the other hand, the benefits to the donor are mainly social and psychological. In LDLT, the donor's altruism is the fundamental ethical principle and it is based on the principles of (1) beneficence (doing good), (2) non-maleficence (avoiding harm), (3) respect for autonomy, and (4) respect for justice (promoting fairness). On top of that, the concept of double equipoise of living organ donation evaluates the relationship between the recipient's need, the donor's risk, and the recipient's outcome. It considers each donor-recipient pair as a unit, analyzing whether the specific recipient's benefit justifies the specific donor's risk in particular oncologic indications. In this light, it is essential to seek adequate informed consent focused on risk, benefits and outcome benefits of both donor and recipient supported by an independent living donor advocate. Finally, the transplant team must protect donors from donation if harm does not justify the expected benefit to the recipient.

Should living donor liver transplantation be an option when deceased donation is not?

When a liver transplantation candidate is declined for listing to receive a deceased organ, sometimes a loved one comes forward and offers to be a living donor. This raises the ethical question of whether a patient who is not eligible for deceased donor liver transplantation should be eligible for living donor liver transplantation. We compare living organ donation in kidney and liver transplantation and explore key ethical concepts of justice, fairness, and societal trust. Ultimately, because there is no alternative life-preserving therapy in end-stage liver disease, and because transplantation with a living donor organ does not involve removing a resource from the common pool of transplant organs, we argue that a standard of "slightly less benefit" than that required for deceased transplantation should be used to determine the acceptability of living donor liver transplantation.

Live liver donors' risk thresholds: risking a life to save a life

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.

Prospective study on the outcome of patients with hepatocellular carcinoma registered for living donor liver transplantation: how long can they wait?

BACKGROUND.: In countries where cadaveric organ donation is limited, living donor liver transplantation (LDLT) has been reserved as a rescue option for the patients with uncontrollable hepatocellular carcinoma (HCC). PATIENTS AND METHODS.: Between March 2002 and June 2006, 56 patients with HCC had been registered as a LDLT candidate after HCC cannot be treated conventionally. We compared the survival rates between the patients who underwent LDLT (living donor liver transplantation group: LT, n=29) and those who did not undergo LDLT (no transplantation group: NLT, n=27). In the NLT group, we examined the periods suitable for resection or ablation (from first diagnosis to registration), suitable for LDLT, and unsuitable for LDLT. RESULTS.: Even among the patients who did not meet Milan criteria (LT: n=10, NLT: n=16), 1- and 3-year survival rates were significantly higher in the LT group than in the NLT group: 90.0% and 60.0% vs. 75.0% and 8.3%, respectively (P=0.046). In the NLT group, the median periods suitable for resection or ablation, suitable for LDLT, and unsuitable for LDLT were 28.9, 12.2, and 3.5 months, respectively. CONCLUSIONS.: LDLT is acceptable for the patients who gave up the conventional treatment. Approximately 12 months remain for the LDLT candidates with HCC to decide to undergo it.

Live donor adult liver transplantation

PURPOSE OF REVIEW

Because the gap between liver organ supply and demand continues to increase, adult living-donor liver transplantation continues to represent a significant pool of organs.

RECENT FINDINGS

With this in mind, we discuss recent issues in adult living-donor liver transplantation, including issues with donor evaluation and selection, donor liver biopsy, orphan organ allocation, donor morbidity and mortality, outcomes compared with deceased donor liver transplant from time of evaluation, death on the waiting list, and evolving recipient indications for living-donor liver transplantation.

SUMMARY

Increasing the number of living-donor liver transplants would allow us to expedite transplant, avoid death on the waitlist, and possibly save more lives by expanding the criteria for transplant. These benefits must always be weighed against the potential risks and complications to the donor, which can be significant.

A decade of right liver adult-to-adult living donor liver transplantation: the recipient mid-term outcomes

OBJECTIVE

We analyzed a single center's experience over a decade of right liver living donor liver transplantation (RLDLT).

SUMMARY BACKGROUND DATA

To define the donor risk and recipient benefit ratio, midterm outcome of this life-saving treatment modality ought to be known.

METHODS

Consecutive patients from 9 May 1996 were included. Era I comprised the first 50 patients and Era II comprised the remaining 184 patients. Their midterm outcomes were compared with patients receiving deceased donor liver transplantation (DDLT) of the same period in the same center.

RESULTS

With a median follow-up of 48 months, the 1-, 3-, and 5-year overall survival rates were 93.2%, 85.7%, and 82.4%, respectively and were comparable with those of DDLT (n = 131) (90.1%, 87.7%, and 85.2%) (P = 0.876). Hospital mortality decreased from 16% in Era I to 2.2% in Era II (P = 0.000). Reduced hospital mortality improved the overall survival rates from Era I to Era II (78%, 74%, and 72% vs. 97.3%, 88.7%, and 85.1%, respectively) (P = 0.003). The 5-year survival rate of recipients with hepatocellular carcinoma (HCC) (n = 65) was 65.7%. Starting from Era II, excellent 5-year survival of recipients without HCC was achieved as compared with DDLT in the same period (93.4% vs. 88.2%) (P = 0.493). The 5-year survival rates of recipients with HCC within the Milan criteria of Era II and DDLT in the same period were 72.0% and 100%, respectively (P = 0.091). Multivariate analysis indicated that only Era I (relative risk = 2.606; P = 0.005) and pretransplant HCC (relative risk = 2.729; P = 0.002) adversely affected overall survival.

CONCLUSIONS

High midterm survivals were achieved by reduction of hospital mortality through accumulation of experience and transplanting recipients with low chance of recurrence of HCC. RLDLT could be considered as a legitimate alternative to DDLT.

Early detection of liver cancer: diagnosis and management

Hepatocellular carcinoma (HCC) is the fifth most common cause of cancer deaths worldwide, and the incidence is rising. Despite a wide array of treatment options, fewer than half of candidates for potentially curative treatments receive them. The diagnosis and management of HCC require a multidisciplinary approach involving various clinical specialties. The foundation of diagnosis is high-quality imaging, with MRI being the test of choice. Some patients also require guided biopsy when MRI is equivocal. Treatment options depend upon the tumor stage and the degree of underlying synthetic dysfunction. Potentially curative treatments include surgical resection and transplantation. Other treatments that prolong survival include percutaneous ablation and transarterial chemoembolization. A new oral agent, sorafenib, was recently shown to prolong survival in patients with advanced HCC. By increasing surveillance and treatment of HCC, outcomes for these patients may be improved.

Liver transplantation for hepatocellular carcinoma

Background

Orthotopic liver transplantation (OLT) is the best available option for early hepatocellular carcinoma (HCC), although its application is limited by stringent selection criteria, costs, and deceased donor graft shortage, particularly in Asia, where living donor liver transplant (LDLT) has been developed.

Methods

This article reviews the present standards for patient selection represented by size-and-number criteria with particular references to Milan Criteria and novel prediction models based on results achieved in patients exceeding those limits, with consideration of the expanded indication represented by the UCSF Criteria.

Results

The expected outcomes after deceased donor liver transplant (DDLT) or LDLT are favorable if predetermined selection criteria are applied. However, selection bias, difference in waiting time, and ischemia-regeneration injuries of the graft among DDLT vs LDLT may influence long-term results. In the article, the differences between East and West in first-line treatments for HCC (resection vs transplantation), indications, and ethics for the donor, are summarized as well as possible novel predictors of tumor biology (especially DNA mutation and fractional allelic loss, FAI) to be considered for better outcome prediction.

Conclusions

Liver transplantation remains the most promising product of modern surgery and represents a cornerstone in the management of patients with HCC.

Preliminary experience with gemcitabine and cisplatin adjuvant chemotherapy after liver transplantation for hepatocellular carcinoma

AIM

Liver transplantation (LT) criteria for treatment of hepatocellular carcinoma (HCC) were refined to improved survival and disease-free rates. Adjuvant chemotherapy might eliminate disseminated tumor cells after removal of the primary liver cancer and thereby benefit LT recipients. Our purpose was to evaluate the effect of an adjuvant chemotherapy (gemcitabine and cisplatin) on outcome of patients treated with LT for HCC.

METHODS

Of the 99 patients who underwent liver transplantation from October 2001 through February 2006, there were 58 with HCC. Nine patients with extra-hepatic metastasis and four who died for noncancer-related reasons were excluded. Three groups (total n=45) were compared: Group A (n=15) met the Milan criteria and did not receive study chemotherapy, Group B (n=13) did not fit the Milan criteria and did not receive chemotherapy, and Group C (n=17) did not fit the Milan criteria and received gemcitabine and cisplatin.

RESULTS

The chemotherapy regimen was well tolerated. Leukopenia, the need for granulocyte colony-stimulating factor treatment, or both occurred in four patients. The disease-specific survival rates were better for groups A and C than for group B (p=0.02) and the disease-free survival rates were also better for groups A and C than for group B (p=0.01).

CONCLUSIONS

Systemic gemcitabine and cisplatin may improve disease-specific and disease-free survival in HCC patients who do not meet the Milan criteria after LT.

Insurability of living organ donors: a systematic review

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