Voluntary living liver donors should undergo a careful, but quick, workup and their selflessness should not be hampered by negativism from the transplant community, say the authors of a new study in the issue of Liver Transplantation.
Over the past ten years, living donor liver transplantation has become a practical alternative to deceased donor transplantation. Through it, donors can save the life of a loved one; however, morbidity and mortality of donors remain major drawbacks. The workup of the potential donor is a serious procedure with potentially profound impacts on his or her psyche, decision and satisfaction, as well as on the outcome of the potential recipient.
Researchers, led by Professor Sheung Tat Fan of the University of Hong Kong, sought to analyze and report the experiences of donor workups at their center, which performs many more transplants from living donors than from deceased donors because of a major scarcity of the latter.
The researchers included 399 people who offered to become a living liver donor for a loved one between January 2001 and December 2004. To do so, each had to successfully complete a four-step process which ascertained their suitability for the surgery. First, they provided a detailed medical and drug history. Second, they underwent a comprehensive psychological assessment as well as medical testing including chest radiographs and an electrocardiogram. Third, they underwent liver biopsy, if there was any suggestion of fatty liver changes. Lastly, they gave informed consent.
A full 32 percent of the potential donors made it through the workup and went on to the donor surgery. Most of those who did not make it to the surgery dropped out after the first step; 144 due to medical reasons such as ABO incompatibility or because they were hepatitis carriers, though 42 dropped out voluntarily, and 24 because there was another better donor. From step two onward, there were very few dropouts. Only two potential donors were rejected for psychological reasons. An additional twenty had incompatible liver anatomy. Thirty-six did not proceed because of changes in the condition of the potential recipient.
"Step one of donor workup is logistically crucial and should be accomplished expeditiously," the authors report, since nearly 68 percent of donors who made it past the first step went on to the donor surgery. For recipients whose cases were urgent, the time for workup and evaluation of the donor was condensed, in one case completed in just 8 hours. "There was much concern on the question of coercion due the pressing situation of the rapid deterioration of the patient," the authors report, however, a gradually deteriorating patient could also be a source of pressure, they note.
"The voluntary donor should undergo careful and expeditious workup. This includes provision of salient information about donor risks, the possible harm and recipient benefit," the authors conclude. "Even though a live donor will not benefit from the operation physically, the loss from failure to save the recipient can result in much psychological remorse. Based on personal values of the donor and recipient, they should have a say."
An accompanying editorial by Robert Fisher of Virginia Commonwealth University applauds the high proportion of living donors who made it to surgery in the report by Chan et. al. He also supports expeditious workups at experienced transplant centers for "high urgency" recipients.
"To further the spirit of "voluntarism" and to increase the understanding of the potential donors," he says, "we have always included psychological and social work interview in the first step." They also encourage potential donors to contact past donors to learn about their experiences. "This simple addition has caused no inefficiency and has furthered the respect and transparency of the donor process," he concludes.