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IMPROVING STANDARDS OF LIVING LIVER DONATION

2002; Wolters Kluwer; Volume: 73; Issue: 11 Linguagem: Inglês

10.1097/00007890-200206150-00002

1534-6080

Marc Karliova, Massimo Malagó, C Valentín-Gamazo, Jens Reimer, U Treichel, Gabriele Helga Franke, Silvio Nadalin, A. Frilling, Guido Gerken, C. E. Broelsch,

Liver Disease and Transplantation

Living-Related Liver Transplantation from the View of the Donor: A 1-Year Follow-Up Survey. Transplantation 2002; 73: 1799. In recent years living donation has expanded considerably as a means of providing solid organs for transplantation. One major difference between living liver donation (LLD) and living kidney donation is that the stakes are considerably higher for both donor and recipient in LLD. It is timely then that Karliova and colleagues should address the question of the emotional and social welfare of donors after LLD. Their study raises a number of important issues of relevance to the whole transplant community. In many centers, LLD is almost exclusively an undertaking performed between parents and their children for whom it was often difficult to find a suitable donor liver (before volume-reducing procedures became widely practiced). In such cases the motivation and decision-making process are easy to understand. In the experience presented by Karliova et al., more than 80% of donors were donating to their parents or relatives of a similar age. To put this study into a clearer perspective, it would have been useful to know what the likelihood would have been of the patients receiving a cadaveric liver. It is clear from the study of Karliova et al. that the source of information about the procedure and the associated risks varied widely among donors, and one might surmise that the quality of information given to them may also have been subject to such variation. The ethical background of live donation is often a difficult balance between paternalism and autonomy. Paternalism classically accords predominant weight to clinicians’ judgment on the wisdom of an intervention. Autonomy, the respect for the dignity, integrity, and authenticity of the person, is a basic right that assumes informed consent. Information regarding the frequency of medical complications after LLD is accumulating in the literature; however, this experience is still evolving and it is difficult to give fully informed consent when the boundaries remain fluid. Not all units will be able to replicate the low complication rates of the most experienced centers (1), but whatever the complication rates, it is clear that donors must have adequate information upon which to base their decision to donate. It is equally important that the enthusiasm and pride of a unit involved in performing a new technique does not affect the clarity and objectivity of the information given to donors. Donors must be informed early enough in the assessment process, before their decision gains unstoppable momentum; however, this may be difficult in LLD in which circumstances may impose a time pressure and in which the consequences of not proceeding to donation may be fatal for the potential transplant recipient. Many of these issues were discussed at the consensus meeting on the live organ donor from the National Kidney Foundation and American Societies of Transplantation, Transplant Surgeons, and Nephrology (2). It is reassuring that Karliova et al. report that the majority of donors in their study felt no coercion to donate. In the United Kingdom, when the donor and recipient are not genetically related, it is a legal requirement for potential donors to be seen by an independent medical assessor and for all such cases to be referred to the Unrelated Live Transplant Regulatory Authority. It is our impression that coercion may be likely to occur when donation is proposed within a family. Indeed a case can be made that all patients, whether being assessed for living-related or unrelated organ donation, should have the opportunity to see an independent medical assessor in the absence of the potential recipient. This may provide an environment where we can be more assured that a decision to donate is genuine and made without external pressure or coercion. The concerns of the donors about the procedure reported by Karliova et al. are interesting because they reflect the high degree of altruism associated with live donation. Indeed, almost more concern was expressed by donors for the recipient than for the donor themselves. In an interesting study from Chicago, Cotler et al. (3) reported that in a survey of attitudes to LLD, 60% of respondents would prefer to donate and die rather than forego donation and have the potential transplant recipient die of liver failure. Furthermore, participants stated that the threshold for living donation was a donor survival of 79%, while they would require that their loved one had a survival of 55% before they would agree to donate. It is similarly reassuring that in the experience of Karliova and colleagues, almost all of the donors considered the procedure to be acceptable and worthwhile and something that they would consider undergoing again. This suggests that the whole process and organization of LLD in their center is highly satisfactory. Financial difficulties may well be experienced by live organ donors. It is generally accepted that employers are not obliged to pay sickness benefit to employees who choose to undergo a procedure that is of no benefit to themselves and requires absence of work. Similarly private medical insurers will often refuse to cover costs or loss of earnings associated with live donation. Karliova et al. report that half of their donors were financially disadvantaged as a result of LLD and that only four donors received financial compensation, three from their family and one by an insurance company. Although it would of benefit to donors if some system of compensation were established, it is equally important that this should be seen to be compensation and not payment, which would be considered unethical. It might be that all donors should be advised to check whether their life insurance would cover LLD before agreeing to participate. The issue of the recognition of the value of living organ donation in this fiscal context is something that should be dealt with at a national and international level. In the meantime, as Karliova et al. point out, it is important that when obtaining consent from donors, the likely time to full recovery from surgery and the possible financial implications of this are made clear. As the indications for live liver donation and transplantation widen, it is important to acknowledge that a single death in a live donor transplant program represents a disaster. The transplant community has a duty to ensure that the highest standards of care are applied to donors who, through an act of love and charity, subject themselves to considerable risk. It is important that we continue to monitor and document not only the medical outcomes of donors, but that like Karliova et al. we look at the broader issues associated with LLD with a view to continually improving the quality of our services.