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Wanis KN, Sarvet A, Ruffolo LI, Levstik MA, Tomiyama K, Al-Judaibi BM, Stensrud MJ, Hernandez-Alejandro R. Estimating the effect of increasing utilization of living donor liver transplantation using observational data. Transpl Int 2021; 34:648-656. [PMID: 33527506 DOI: 10.1111/tri.13835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/22/2020] [Accepted: 01/29/2021] [Indexed: 11/30/2022]
Abstract
There has been a recent increase in enthusiasm for expansion of living donor liver transplantation (LDLT) programmes. Using all adults initially placed on the waiting list in the United States, we estimated the risk of overall mortality under national strategies which differed in their utilization of LDLT. We used a generalization of inverse probability weighting which can estimate the effect of interventions in the setting of finite resources. From 2005 to 2015, 93 812 eligible individuals were added to the waitlist: 51 322 received deceased donor grafts while 1970 underwent LDLT. Individuals who underwent LDLT had more favourable prognostic factors, including lower mean MELD score at transplant (14.6 vs. 20.5). The 1-year, 5-year and 10-year cumulative incidence of death under the current level of LDLT utilization were 18.0% (95% CI: 17.8, 18.3%), 41.2% (95% CI: 40.8, 41.5%) and 57.4% (95% CI: 56.9, 57.9%) compared to 17.9% (95% CI: 17.7, 18.2%), 40.6% (95% CI: 40.2, 40.9%) and 56.4% (95% CI: 55.8, 56.9%) under a strategy which doubles LDLT utilization. Expansion of LDLT utilization would have a measurable, modest effect on the risk of mortality for the entire cohort of individuals who begin on the transplant waiting list.
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Affiliation(s)
- Kerollos Nashat Wanis
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Surgery, Western University, London, ON, Canada
| | - Aaron Sarvet
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Luis I Ruffolo
- Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Mark A Levstik
- Division of Transplant Hepatology, University of Rochester, Rochester, NY, USA
| | - Koji Tomiyama
- Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Bandar M Al-Judaibi
- Division of Transplant Hepatology, University of Rochester, Rochester, NY, USA
| | - Mats J Stensrud
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Roberto Hernandez-Alejandro
- Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, Rochester, NY, USA
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Levitsky J, Gordon EJ. Living Donor Liver Transplantation When Deceased Donor Is Not Possible or Timely: Case Examples and Ethical Perspectives. Liver Transpl 2020; 26:431-436. [PMID: 31872945 DOI: 10.1002/lt.25708] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 12/11/2019] [Indexed: 01/02/2023]
Abstract
This article analyzes the ethical soundness of living donor liver transplantation (LDLT) in situations where the transplant team does not consider deceased donor liver transplantation (DDLT) a clinical or timely option. Given that patients with end-stage liver disease have a high risk of death without DDLT, the option of LDLT becomes compelling and may save lives. We present 3 representative cases from our center that raise concerns over social behavior, limited time constraints for decision making, and high potential for disease recurrence that render DDLT an unlikely option. Thereafter, we discuss ethical issues for each patient, which predominantly pertain to compromises to the living donor informed consent process and the feasibility of LDLT. We conclude with recommendations regarding whether LDLT is an acceptable ethical option for those patients, which may inform clinical practice in the broader transplant community.
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Affiliation(s)
- Josh Levitsky
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elisa J Gordon
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
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Teodorescu DI, Muñoz Sastre MT, Kpanake L, Sorum PC, Mullet E. Romanian Laypeople's and Health Professionals' Views Regarding Living Organ Donation. Transplant Proc 2019; 51:1644-1650. [PMID: 31255357 DOI: 10.1016/j.transproceed.2019.04.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Romanian laypeople's and health professionals' views on living organ donation were examined. METHODS From July 2015 to May 2016, 263 adults (among them 31 physicians and 20 nurses) judged the acceptability of living organ donation in 42 realistic scenarios composed of varying levels of 6 factors: 1. type of organ, 2. whether it could have been obtained from a cadaver, 3. donor-recipient relationship, 4. donor's level of autonomy, 5. financial compensation, and 6. patients' level of responsibility for their illness. In all scenarios, the patients were in need of either a kidney or liver transplantation. RESULTS The ratings were subjected to cluster analysis and analyses of variance. Seven qualitatively different positions were found that were termed never acceptable (12%), free market (44%), compensation (12%), altruism (6%), always acceptable (16%), responsibility (4%), and undetermined (6%). Physicians were more frequently in the free market or in the compensation clusters (81%) than laypeople (51%). CONCLUSION Only a few participants held the altruism model, even though this model has been promoted as the normative model by the World Health Organization and by most national legislations, including the legislation in Romania. Instead, the free market position and its variant-the compensation position-can be considered the majority positions (66%) in Romania.
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Affiliation(s)
| | | | - Lonzozou Kpanake
- Department of Psychology, University of Québec-TELUQ, Montréal, Canada.
| | - Paul Clay Sorum
- Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Etienne Mullet
- Department of Ethics, Institute of Advanced Studies (EPHE), Paris, France
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Muñoz Sastre M, Pajot E, Kpanake L, Sorum P, Mullet E. Mapping French Laypeople's Views Regarding Living Organ Donation. Transplant Proc 2019; 51:613-618. [DOI: 10.1016/j.transproceed.2018.12.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/31/2018] [Indexed: 12/13/2022]
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Shazi L, Abbas Z. Ethical dilemmas related to living donor liver transplantation in Asia. Ir J Med Sci 2019; 188:1185-1189. [PMID: 30798504 DOI: 10.1007/s11845-019-01989-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/12/2019] [Indexed: 12/23/2022]
Abstract
Living donor liver transplantation (LDLT) has evolved rapidly in Asia with good outcomes for both donor and recipient. Nonetheless, LDLT remains a highly demanding technique and complex surgery. The potential risks to the donors provide the basis for many of the ethical dilemmas associated with LDLT. The transplant team must have a good knowledge of the principles of bioethics in order to handle these matters. To look after the need, donor's safety and the chance for good recipient outcomes, the principles of respect for the donor's autonomy, beneficence, and non-maleficence should be practiced. In accordance with the concept of equipoise, the risk to the donor must balance the benefit to the recipient. The transplant center should have adequate experience and proven expertise in LDLT. There are concerns regarding the validity of informed consent given by the donor. While donations to non-relative patients may, at first sight, indicate radical altruism, it is important to apply careful scrutiny. Though organ trading is strictly prohibited by the law, there seems to be an inherent risk with directed donations to strangers. Transplant tourism has flourished in some countries in spite of the existence of strict laws. There are reservations regarding transplantation done by foreign visiting teams. Donor websites facilitating patients and donors and Facebook pages bear no responsibility for the outcomes of their matches and cannot ensure sufficient and accurate information about donation, transplantation, and post-operation life. Telemedicine and virtual consultations appeared to work better when the clinician and the patient know and trust each other.
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Affiliation(s)
- Lubna Shazi
- Department of Gastroenterology and Hepatology, Dr. Ziauddin University Hospital, Ziauddin University, Clifton, Karachi, Pakistan
| | - Zaigham Abbas
- Department of Gastroenterology and Hepatology, Dr. Ziauddin University Hospital, Ziauddin University, Clifton, Karachi, Pakistan.
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Hays R, Matas AJ. Ethical review of the responsibilities of the patient advocate in living donor liver transplant. Clin Liver Dis (Hoboken) 2016; 7:57-59. [PMID: 31041030 PMCID: PMC6490254 DOI: 10.1002/cld.533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/08/2016] [Accepted: 01/17/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
- Rebecca Hays
- University of Wisconsin Hospital and ClinicsTransplant ClinicMadisonWI
| | - Arthur J. Matas
- Division of Transplantation, Department of SurgeryUniversity of MinnesotaMinneapolisMN
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Ethical Considerations in the Psychosocial Evaluation of Pediatric Organ Transplant Candidates, Recipients and Their Families. ETHICAL ISSUES IN PEDIATRIC ORGAN TRANSPLANTATION 2016. [DOI: 10.1007/978-3-319-29185-7_15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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Moorlock G, Neuberger J, Draper H. Split liver transplantation: Papering over the cracks of the organ shortage. CLINICAL ETHICS 2015; 10:83-89. [DOI: 10.1177/1477750915599703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
Splitting livers allows two people (usually an adult and a child) to receive a liver transplant from one donated adult liver, but the risks to the adult recipient are greater than if they had received the equivalent whole liver. It has been suggested, therefore, that splitting livers harms adult recipients. Without liver splitting, however, there would be few livers available for children, and paediatric waiting time and waiting list mortality would significantly increase. In this paper, we argue that although splitting livers makes adults worse off, this should be considered sub-optimal benefit rather than harm. We explore justifications for sub-optimally benefitting adults in this way and consider alternatives to the current approach. We argue that splitting livers masks the more fundamental problem of low paediatric donation rates and that increasing the number of paediatric donations would improve the situation for both adult and paediatric liver patients.
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Affiliation(s)
- Greg Moorlock
- Institute of Applied Health Research, University of Birmingham, UK
| | | | - Heather Draper
- Institute of Applied Health Research, University of Birmingham, UK
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Burnell P, Hulton SA, Draper H. Coercion and choice in parent-child live kidney donation. JOURNAL OF MEDICAL ETHICS 2015; 41:304-309. [PMID: 25378550 DOI: 10.1136/medethics-2013-101988] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This paper explores whether donor-parents felt coerced to donate a kidney to their child. There is a paucity of UK literature on parental live kidney donors and the voluntariness of their decision-making. Data were gathered as part of a study exploring parental experiences of consenting for live donation at a UK specialist children's hospital. Parents who donated a kidney to their child between September 2006 and December 2010 and who consented at their child's hospital to be referred to an adult unit for consideration for live donation were invited to participate. Of the 19 eligible parents, seven fathers and three mothers consented to be interviewed. Their primary motivation for donation was being a parent (more specifically, the parent of a sick child). Participants expressed this in terms of parental love and concern. Participants conveyed certainty about their decision and viewed live donation as a positive opportunity. Most participants regarded the decision to donate, or not donate, as one every parent is entitled to make for their own reasons. In discussing our findings, we argue that when parents do not separate their child's interests from their own, this does not necessarily compromise autonomous decision-making: using one's own moral values to constrain one's own choices can be compatible with voluntary decision-making. Indeed, choices may be more constrained when parents are unable to donate, because this reduces the options available to parents to help their child.
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Affiliation(s)
- Philippa Burnell
- Department of Acute Internal Medicine, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Sally-Anne Hulton
- Department of Paediatric Nephrology, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Heather Draper
- School of Health and Population Science, University of Birmingham, Birmingham, UK
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