Editorial: Living Donor Liver Transplantation in emergencies: Is it time to say

[Clark]

http://onlinelibrary.wiley.com/doi/10.1111/ajt.13205/full

Editorial
Living Donor Liver Transplantation in emergencies: Is it time to say yes?
C. B. Rosen1 andJ. C. Emond2,*
Article first published online: 19 MAR 2015
DOI: 10.1111/ajt.13205
American Journal of Transplantation
Volume 15,  Issue 6, pages 1455–1456, June 2015

Though living donor liver transplantation (LDLT) is well established in the elective setting, its use in emergencies has been limited. In a recent debate, a proponent of LDLT for acute liver failure argued that it is natural to leap into danger to rescue a drowning loved one. The misguided metaphor fails in that the would-be rescuer often drowns in the attempt.
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[/size]The challenge in extending LDLT is to first establish that it is effective, and then to confirm that donor risk is not increased. Lo et al first reported LDLT for emergencies in 1999 [1]. In this experience from Hong Kong, the premise that emergency evaluation of a donor can be conducted safely is put forward convincingly. The ethical imperative to use LDLT is most compelling in Asian countries where deceased donation is not readily available.
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[/size]In the current issue of the American Journal of Transplantation, the Toronto group demonstrates the efficacy of LDLT for patients with acute liver failure, “Live Donor Liver Transplantation: A Valid Alternative for Critically Ill Patients Suffering From Acute Liver Failure” [2].This contribution, however, does not dispel the controversies associated with LDLT in emergencies as noted in the A2ALL experience [3].
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[/size]The New York State Health Department Guidelines list acute liver failure as a contraindication for living donor liver transplantation [4]. Nevertheless, the deceased donor supply is not timely enough for the patient with acute liver failure creating an ethical premise similar to that in Asian countries. In Toronto, during the period of this study, 46 patients were listed for emergency liver transplantation, and 11 (24%) died before a liver became available. Undoubtedly, some of the seven living donor liver recipients may have died as well had living donor liver transplantation not been available for them.This work demonstrated several key findings, (1) donor evaluations for LDLT can be accomplished within a short period of time (18–72 h, median 24 h); (2) emergency LDLT can be performed safely with results comparable to those achieved with nonemergency donation; (3) living donor recipient outcome is comparable to results achieved for deceased donor liver recipients; and (4) the availability of LDLT probably reduced mortality and morbidity for patients with acute liver failure.
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[/size]The success achieved by this effort raises equally important issues prior to wider application of emergency living donor liver transplantation. Introduction of LDLT in the emergency setting leads to an increased potential for donor coercion, undue stress on donors, recipients, and their friends and families confronted with urgent decisions combined with limited opportunities for education and counseling, and remorse with either reluctance to proceed or an urgent decision to donate. For the transplant team, there is a higher potential for mistakes or overlooked donor risk factors and an increased risk of an adverse recipient outcome.
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[/size]The authors mitigate the risk of coercion by involving a psychiatrist in the evaluation, conducting the interview in a remote location without any family members present. It remains unknown, however, whether or not their efforts were successful. A thorough psychosocial evaluation often takes more time than is available for patients requiring emergency liver transplantation, and a follow-up survey by an objective party may identify donor and family concerns not recognized by the transplant team. This study also did not include any follow-up on potential donors who opted out of the evaluation; were found to be unsuitable donors; or for whom living donation was obviated by a deceased donor organ becoming available, recipient death, or recipient improvement. Future studies will need to address these questions. Though the authors dismissed the occurrence of pyschosocial complications in their donors, the baseline risk of psychiatric morbidity in the population at large is high enough that a more careful search for these issues is warranted [5].
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[/size]We congratulate the Toronto transplant team for their pioneering work in LDLT. The current study of LDLT in FHF was conducted by a highly experienced team which had performed and carefully studied over 100 living donor liver transplants prior to attempting emergency living donor transplantation [6]. For the past 15 years, this group has pushed the envelope with living donor liver transplantation for recipients with high MELD scores [7] and renal dysfunction [2]. They have also carefully studied donor adaptation and the quality of life after donation [8].Although LDLT is an option for patients with acute liver failure, the minimal time required for a safe donor evaluation would likely exclude the sickest candidates who deteriorate in the first 24 h with progressive brain injury.
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[/size]In addition, further experience is necessary to demonstrate that urgent evaluations can be done safely, accurately, and with avoidance of coercion and undue stress on potential donors and their families. In the West, it may be reasonable to limit emergency LDLT to experienced centers that have addressed the challenges outlined above. There should be a demonstrable need based on local deceased donor organ availability. Data should be collected in a prospective manner to enable comparison of emergency versus elective work-up with respect to accuracy, transplant results, and short and long-term donor outcome (including psychosocial adjustment and results for those who did not donate). Future studies may address whether availability of a living donor should change the both the threshold and the timing for transplantation (earlier or later in the course of the disease).