Evaluation of Living Liver Donors

Comparing High- and Low-Model for End-Stage Liver Disease Living-Donor Liver Transplantation to Determine Clinical Efficacy: A Systematic Review and Meta-Analysis (CHALICE Study)

INTRODUCTION

Various studies have demonstrated that low-Model for End-Stage Liver Disease (MELD) living-donor liver transplant (LDLT) recipients have better outcomes with improved patient survival than deceased-donor liver transplantation (DDLT) recipients. LDLT recipients gain the most from being transplanted at MELD <25-30; however, some existing data have outlined that LDLT may provide equivalent outcomes in high-MELD and low-MELD patients, although the term "high" MELD is arbitrarily defined in the literature and various cut-off scores are outlined between 20 and 30, although most commonly, the dividing threshold is 25. The aim of this meta-analysis was to compare LDLT in high-MELD with that in low-MELD recipients to determine patient survival and graft survival, as well as perioperative and postoperative complications.

METHODS

Following PROSPERO registration CRD-42021261501, a systematic database search was conducted for the published literature between 1990 and 2021 and yielded a total of 10 studies with 2183 LT recipients; 490 were HM-LDLT recipients and 1693 were LM-LDLT recipients.

RESULTS

Both groups had comparable mortality at 1, 3 and 5 years post-transplant (5-year HR 1.19; 95% CI 0.79-1.79; p-value 0.40) and graft survival (HR 1.08; 95% CI 0.72, 1.63; p-value 0.71). No differences were observed in the rates of major morbidity, hepatic artery thrombosis, biliary complications, intra-abdominal bleeding, wound infection and rejection; however, the HM-LDLT group had higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay.

CONCLUSIONS

The high-MELD LDLT group had similar patient and graft survival and morbidities to the low-MELD LDLT group, despite being at higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The data, primarily sourced from high-volume Asian centers, underscore the feasibility of living donations for liver allografts in high-MELD patients. Given the rising demand for liver allografts, it is sensible to incorporate these insights into U.S. transplant practices.

Role of the Independent Donor Advocacy Team in Ethical Decision Making

Adult living donor liver transplantation has developed as a direct result of the critical shortage of deceased donors. Recent regulations passed by New York State require transplant programs to appoint an Independent Donor Advocacy Team to evaluate, educate, and consent to all potential living liver donors. Ethical issues surround the composition of the team, who appoints them, and the role the team plays in the process. Critics of living liver donation have questioned issues surrounding motivation and the ability of donors to provide true informed consent during a time of family crisis. This article will address issues surrounding the controversies and discuss how using the team can effectively evaluate and educate potential living liver donors and improve practice to ensure safety of living donors.

Practices for Supporting and Confirming Decision-Making Involved in Kidney and Liver Donation by Related Living Donors in Japan: A Nationwide Survey

This nationwide survey investigated the actual practices for supporting and confirming the decision-making involved in related living-organ donations in Japan, focusing on organ type and program size differences. Answers to a questionnaire survey were collected from 89 of the 126 (71%) kidney and 30 of the 35 (86%) liver transplantation programs in Japan that were involved in living-donor transplantations in 2013. In 70% of the kidney and 90% of the liver transplantation programs, all donors underwent "third-party" interviews to confirm their voluntariness. The most common third parties were psychiatrists (90% and 83%, respectively). Many programs engaged in practices to support decision-making by donor candidates, including guaranteeing the right to withdraw consent to donate (70% and 100%, respectively) and prescribing a set "cooling-off period" (88% and 100%, respectively). Most donors were offered care by mental health specialists (86% and 93%, respectively). Third parties were designated by more of the larger kidney transplant programs compared with the smaller programs. In conclusion, the actual practices supporting and confirming the decision to donate a living organ varied depending on the organ concerned and the number of patients in the program.

The role of the independent donor advocacy team in the case of a declined living donor candidate

Many controversies arise when living donor candidates present themselves for consideration as donors for urgent liver transplants. Nonparent living donors for urgent pediatric transplant recipients are a unique donor candidate population with specific considerations that need to be acknowledged and addressed by the independent donor advocacy team. Such a team educates about donation, identifies potential contraindications, examines the distant relationships between donor and recipient, and considers ethical issues about the ability to make an informed decision in an urgent situation. A center for living donation dealt with such ethical issues when a donor candidate with a distant relationship was evaluated for living donation. Multiple relative contraindications were identified, and the donor candidate was declined. Careful management by the independent donor advocacy team is necessary to ensure the psychosocial safety and to provide needed psychosocial support and intervention for donor candidates with psychological contraindications to donation. Standard follow-up protocols need to be developed for declined donor candidates.

Donor selection for adult-to-adult living donor liver transplantation: well begun is half done

BACKGROUND

Donor selection criteria for adult-to-adult living donor liver transplantation vary with the medical center of evaluation. Living donor evaluation uses considerable resources, and the nonmaturation of potential into actual donors may sometimes prove fatal for patients with end-stage liver disease. On the contrary, a thorough donor evaluation process is mandatory to ensure safe outcomes in otherwise healthy donors. We aimed to study the reasons for nonmaturation of potential right lobe liver donors at our transplant center.

METHODS

A retrospective data analysis of all potential living liver donors evaluated at our center from 1998 to 2010 was done.

RESULTS

Overall, 324 donors were evaluated for 219 potential recipients, and 171 (52.7%) donors were disqualified. Common reasons for donor nonmaturation included the following: (1) donor reluctance, 21%; (2) greater than 10% macro-vesicular steatosis, 16%; (3) assisted donor withdrawal, 14%; (4) inadequate remnant liver volume, 13%; and (5) psychosocial issues, 7%, and thrombophilia, 7%. Ten donors (6%) were turned down because of anatomic variations (8 biliary and 2 arterial anomalies). Donors older than 50 years and those with body mass index of more than 25 were less likely to be accepted for donation.

CONCLUSIONS

We conclude that donor reluctance, hepatic steatosis, and assisted donor withdrawal are major reasons for nonmaturation of potential into actual donors. Anatomic variations and underlying medical conditions were not a major cause of donor rejection. A system in practice to recognize these factors early in the course of donor evaluation to improve the efficiency of the selection process and ensure donor safety is proposed.

Development of the Center for Living Donation: Incorporating the Role of the Nurse Practitioner as Director

For decades, live organ donors have been cared for within the transplant program by the same team that cared for the recipient without any standardization, practice guidelines, or evidence-based evaluation. In an effort to improve the care of living donors, regulations and guidelines to dictate care and follow-up have been instituted. Practices still vary from center to center, and the quality of care that live donors receive also varies. A “Living Donor Center” focused solely on the care of actual and potential donors before and after donation is one way to provide the infrastructure to comply with regulatory mandates and deliver high-quality care to this specialized population of patients. A Center for Living Donation was developed within a Transplantation Institute to address the short- and long-term needs of live donors and confine all donor care to a team of experts led by a doctorally prepared nurse practitioner as the director. A transplant nurse practitioner is uniquely poised to assume such a role because of such competencies as clinical and professional leadership, ability to act as a change agent, communication skills, and ability to lead a multidisciplinary team.

Quality Improvement in the Care of Live Liver Donors: Implementation of the Designated Donor Nurse Program

Publications on living donor liver transplant have focused on the medical aspects of donor selection, postoperative management, surgical procedures, and outcomes, but little attention has been given to the nursing implications for care of live liver donors during their inpatient stay. Donor advocates from various disciplines are involved during the initial education and evaluation, but most care after surgery is delivered by an inpatient medical team and bedside nursing staff who are not as familiar with the donor and concepts related to donor advocacy. In an effort to improve the overall donor experience and provide safe, high-quality care to patients undergoing elective partial hepatectomy, our academic medical center began a quality improvement project focused on improving the inpatient stay. Inpatient nursing standards and policies and procedures were developed to ensure that consistent care is delivered. However, the infrequency of living donor liver transplantation makes it nearly impossible to have all transplant program staff on a nursing unit be “experts” on donor care. Therefore, our center determined that, similar to the Independent Donor Advocacy Team, a transplant program needs live donor champions on the nursing unit to mirror the goals of the team. To that end, we developed the concept of the Designated Donor Nurse to care for and advocate for live liver donors during the inpatient stay and also to serve as a resource to their colleagues.

The living donor advocate: a team approach to educate, evaluate, and manage donors across the continuum

Living donor transplant has developed as a direct result of the critical shortage of deceased donors. Federal regulations require transplant programs to appoint an independent donor advocate to ensure safe evaluation and care of live donors. Ethical and pragmatic issues surround the donor advocate. These issues include the composition of a team versus an individual advocate, who appoints them, and the role that the advocate(s) play in the process. A team approach to donor advocacy is recommended. Common goals of the independent donor advocacy team should be protocol development, education, medical and psychosocial evaluation, advocacy, support, and documentation throughout the donation process. The team's involvement should not end with consent and donation but should continue through short- and long-term follow-up and management. Ultimately it is the goal of the independent donor advocacy team to assist donors to advocate for themselves. Once deemed medically and psychologically suitable, donors must determine for themselves what they wish to do and must be free to vocalize this to their team. The decision to donate or not affects the donor first. Optimal outcomes begin with prepared, educated, uncoerced, and motivated donors, and it is the team's goal to help donors reach this point.

The Living Donor Advocate: A Team Approach to Educate, Evaluate, and Manage Donors across the Continuum

Living donor transplant has developed as a direct result of the critical shortage of deceased donors. Federal regulations require transplant programs to appoint an independent donor advocate to ensure safe evaluation and care of live donors. Ethical and pragmatic issues surround the donor advocate. These issues include the composition of a team versus an individual advocate, who appoints them, and the role that the advocate(s) play in the process. A team approach to donor advocacy is recommended. Common goals of the independent donor advocacy team should be protocol development, education, medical and psychosocial evaluation, advocacy, support, and documentation throughout the donation process. The team's involvement should not end with consent and donation but should continue through short- and long-term follow-up and management. Ultimately it is the goal of the independent donor advocacy team to assist donors to advocate for themselves. Once deemed medically and psychologically suitable, donors must determine for themselves what they wish to do and must be free to vocalize this to their team. The decision to donate or not affects the donor first. Optimal outcomes begin with prepared, educated, uncoerced, and motivated donors, and it is the team's goal to help donors reach this point.

Critical care management of the liver transplant recipient

Liver transplantation is an acceptable treatment modality for complications of end-stage liver disease from chronic and acute liver failure. In the United States, 16 377 people are currently awaiting liver transplant but only 6492 transplantations were performed in 2007. All options for liver transplantation including Model for End stage Liver Disease allocated, expanded criteria deceased donors, and live donor liver transplantation should be discussed with potential recipients on the waitlist to create an early access plan for safe and expeditious transplantation. After transplantation, careful management to avoid complications and intervene early is necessary. Common postoperative complications include graft dysfunction, vascular thrombosis, biliary tract complications, infection, rejection, neurologic injury, electrolyte imbalances, and drug interactions. A multidisciplinary approach to care including the critical care nurse is necessary for successful long-term outcomes.

Consideration of Psychosocial Factors in the Evaluation of Living Donors

Results of donor outcome studies indicate that most living donors report a positive psychosocial response to donation. However, negative psychosocial outcomes have also been reported. Evaluation guidelines have been proposed, although a standardized evaluation specific to living donors is not yet available. In an effort to determine what psychosocial factors should be considered in a comprehensive evaluation of living donors, an extensive literature review was undertaken that was focused on previously proposed guidelines for the psychosocial evaluation of living donors, research on outcomes among living donors, and other relevant psychosocial data.

Outcomes of donor evaluation in adult-to-adult living donor liver transplantation

The purpose of donor evaluation for adult-to-adult living donor liver transplantation (LDLT) is to discover medical conditions that could increase the donor postoperative risk of complications and to determine whether the donor can yield a suitable graft for the recipient. We report the outcomes of LDLT donor candidates evaluated in a large multicenter study of LDLT. The records of all donor candidates and their respective recipients between 1998 and 2003 were reviewed as part of the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). The outcomes of the evaluation were recorded along with demographic data on the donors and recipients. Of the 1011 donor candidates evaluated, 405 (40%) were accepted for donation. The donor characteristics associated with acceptance (P < 0.05) were younger age, lower body mass index, and biological or spousal relationship to the recipient. Recipient characteristics associated with donor acceptance were younger age, lower Model for End-stage Liver Disease score, and shorter time from listing to first donor evaluation. Other predictors of donor acceptance included earlier year of evaluation and transplant center.

CONCLUSION

Both donor and recipient features appear to affect acceptance for LDLT. These findings may aid the donor evaluation process and allow an objective assessment of the likelihood of donor candidate acceptance.

Psychosocial evaluation of candidates for living related kidney donation

Living kidney donation has raised practical and ethical questions since renal transplantation became possible 50 years ago. Nevertheless, living donors are a common source for badly needed organs in the pediatric population. The safety and well being of the living donor are important concerns. Among the risks of living donation are those of a psychological and social nature. To protect these donor interests, psychosocial evaluations of donors are done at some transplant centers, but there is a lack of consistency regarding standardization of the evaluation, the content of the evaluation, and the role of the interviewer. Goals of the overall living donor evaluation for kidney transplantation at The Children's Hospital of Philadelphia, and the components of the psychosocial evaluation protocol in particular, are presented. The protocol's strengths are discussed, including the standardization of evaluations for all potential donors; the broad spectrum of psychosocial domains assessed; the psychometric measures administered; the systematic handling of negative results and some donors' desire to opt out; and the protection of confidentiality. Future directions with regard to long-term psychosocial outcomes and research protocols are discussed.