Are Living Liver Donors at Risk from Life-Threatening Near Miss Events?

[Michael]

http://www.alphagalileo.org/Organisations/ViewItem.aspx?OrganisationId=575&ItemId=130617&CultureCode=en

Are Living Liver Donors at Risk from Life-threatening "Near-miss" Events?
25 April 2013 Wiley

A study published in Liver Transplantation, a journal of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, reports that donor mortality is about 1 in 500 donors with living donor liver transplantation (LDLT). Research of transplant centers around the world found that those with more experience conducting live donor procedures had lower rates of aborted surgery and life-threatening “near-miss” events.

For patients with end-stage liver disease, liver transplantation is their only option to prolong life. However, more than 16,000 Americans are currently on the waiting list for a liver according to the Organ Procurement and Transplantation Network (OPTN). The critical shortage of deceased donor organs has increased LDLT—a procedure that uses a healthy portion of the liver from a living donor for transplant. Although prior research shows that LDLT is an effective treatment, a 2007 study by de Villa et al. found that LDLT accounts for less than five percent of liver transplants in the U.S. and Europe.

“Donors who decide to provide a portion of their liver to a loved one in need are making an extremely difficult decision to save the life of another,” explains lead author Dr. Elizabeth Pomfret, Professor of Surgery at Tufts University and Chair of the Department of Transplantation and Hepatobiliary Diseases at Lahey Hospital & Medical Center in Burlington, Mass. “It is our responsibility as transplant specialists to provide donors with comprehensive information and education relating to LDLT, including any risks, so they may make informed decisions about donation.”

To extend understanding of potential risks for liver lobe donors, the team conducted a web-based survey of 148 transplant centers around the world that perform LDLTs. Center representatives were asked to provide donor demographics; morbidity and mortality incidence; “near-miss” event data, and number of aborted procedures. Potentially life-threatening “near-miss” events included severe intraoperative bleeding, reoperation for bleeding, biliary reconstruction and pulmonary embolism.

A total of 71 centers (48%) responded to the survey, representing 21 countries, and performing 11,553 LDLTs procedures. Analysis shows that donor morbidity was 24% including five donors who required liver transplantation. Donor mortality was 0.2% (23/11,553), with the majority of deaths occurring within 60 days post-transplant and 19 deaths were a direct result of transplant surgery. Researchers reported that “near-miss” event and aborted surgery incidence was 1.1% and 1.2%, respectively.

Dr. Pomfret concludes, “It appears that the 0.2% donor mortality rate was consistent and independent of the center’s experience performing LDLTs. However, increased experience—centers performing more than 50 total LDLTs—is associated with lower rates of aborted procedures and “near-miss” events. These potentially life-threatening complications must be discussed as part of the informed consent with any potential liver donor.”

In a related editorial, Dr. Daniela Ladner, Assistant Professor of Surgery at Northwestern University Feinberg School of Medicine in Chicago, IL agrees, “Living liver donation is arguably the most invasive operation we as surgeons perform in willing patients with no demonstrable medical benefit, allowing them to donate a portion of their liver to save the life of someone with end-stage liver disease. As Dr. Pomfret and colleagues suggest, transplant surgeons are obligated to fully disclose all potential risk to donors.” Dr. Ladner also suggests that all complications as well as near-miss events that did not reach the patient should be captured and systematically examined to identify areas of improvement with LDLT procedures and reduce life-threatening events for living donors.

[Clark]

http://onlinelibrary.wiley.com/doi/10.1002/lt.23575/abstract

Incidence of death and potentially life-threatening near-miss events in living donor hepatic lobectomy: A world-wide survey
Yee Lee Cheah, Mary Ann Simpson, James J. Pomposelli, Elizabeth A. Pomfret*
DOI: 10.1002/lt.23575
Liver Transplantation
Volume 19, Issue 5, pages 499–506, May 2013

Abstract
The incidence of morbidity and mortality after living donor liver transplantation (LDLT) is not well understood because reporting is not standardized and relies on single-center reports. Aborted hepatectomies (AHs) and potentially life-threatening near-miss events (during which a donor's life may be in danger but after which there are no long-term sequelae) are rarely reported. We conducted a worldwide survey of programs performing LDLT to determine the incidence of these events. A survey instrument was sent to 148 programs performing LDLT. The programs were asked to provide donor demographics, case volumes, and information about graft types, operative morbidity and mortality, near-miss events, and AHs. Seventy-one programs (48%), which performed donor hepatectomy 11,553 times and represented 21 countries, completed the survey. The average donor morbidity rate was 24%, with 5 donors (0.04%) requiring transplantation. The donor mortality rate was 0.2% (23/11,553), with the majority of deaths occurring within 60 days, and all but 4 deaths were related to the donation surgery. The incidences of near-miss events and AH were 1.1% and 1.2%, respectively. Program experience did not affect the incidence of donor morbidity or mortality, but near-miss events and AH were more likely in low-volume programs (≤50 LDLT procedures). In conclusion, it appears that independently of program experience, there is a consistent donor mortality rate of 0.2% associated with LDLT donor procedures, yet increased experience is associated with lower rates of AH and near-miss events. Potentially life-threatening near-miss events and AH are underappreciated complications that must be discussed as part of the informed consent process with any potential living liver donor.