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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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Thomas EH, Bramhall SR, Herington J, Draper H. Live liver donation, ethics and practitioners: 'I am between the two and if I do not feel comfortable about this situation, I cannot proceed'. JOURNAL OF MEDICAL ETHICS 2014; 40:157-162. [PMID: 23533055 DOI: 10.1136/medethics-2012-101261] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This paper discusses the views of 17 healthcare practitioners involved with transplantation on the ethics of live liver donations (LLDs). Donations between emotionally related donor and recipients (especially from parents to their children) increased the acceptability of an LLD compared with those between strangers. Most healthcare professionals (HCPs) disapproved of altruistic stranger donations, considering them to entail an unacceptable degree of risk taking. Participants tended to emphasise the need to balance the harms of proceeding against those of not proceeding, rather than calculating the harm-to-benefits ratio of donor versus recipient. Participants' views suggested that a complex process of negotiation is required, which respects the autonomy of donor, recipient and HCP. Although they considered that, of the three, donor autonomy is of primary importance, they also placed considerable weight on their own autonomy. Our participants suggest that their opinions about acceptable risk taking were more objective than those of the recipient or donor and were therefore given greater weight. However, it was clear that more subjective values were also influential. Processes used in live kidney donation (LKD) were thought to be a good model for LLD, but our participants stressed that there is a danger that patients may underestimate the risks involved in LLD if it is too closely associated with LKD.
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Affiliation(s)
- Elin H Thomas
- College of Medical and Dental Sciences, University of Birmingham, , Birmingham, UK
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Gordon EJ. Informed consent for living donation: a review of key empirical studies, ethical challenges and future research. Am J Transplant 2012; 12:2273-80. [PMID: 22594620 DOI: 10.1111/j.1600-6143.2012.04102.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Given the organ scarcity, live organ donation is increasingly considered a viable alternative for kidney and liver transplantation. Yet living donation challenges the ethical principle of nonmaleficence by subjecting healthy individuals to medical, psychosocial and unknown risks. Therefore, transplant providers, policy-makers and donors are committed to ensuring that prospective donors provide adequate informed consent to undergo the procedure. Informed consent for living donation is ethically required as a means of demonstrating respect for donor's autonomy and protecting their safety. However, all elements of informed consent are fraught with difficulties due to the unique nature of the donation process and outcome. This paper reviews empirical research on informed consent for live kidney donors (LKD) and live liver donors (LLD) for both adult and pediatric recipients. As this review shows, studies that empirically assessed the quality of informed consent elements reveal considerable variability and deficiencies across the informed consent process, suggesting the need for improvement. This review highlights challenges to each element of consent for both LKDs and LLDs, and situates trends within broader policy contexts, ethical debates and avenues for future innovative research.
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Affiliation(s)
- E J Gordon
- Institute for Healthcare Studies, Comprehensive Transplant Center, Northwestern University Transplant Outcomes Research Collaborative, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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