Medico-legal issues associated with organ donation and transplantation: cadaver donors; living donors.
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Adult↗
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Psychosocial data of potential living donors before living donor liver transplantation.
In view of the scarcity of organ resources for transplantation, donation by living donors is assuming greater significance now that the technical-surgical problems involved have been solved. In the period between December 1999 and December 2000, 47 potential living liver donors were evaluated and a total of 27 hepatic lobes were transplanted at the Virchow-Klinikum of the Charité Hospital in Berlin. The close personal relationships between recipients and donors gives reason to anticipate high levels of psychosocial pressure during the pre-operative evaluation process; this process consists in part in looking into donor motivation, ambivalence and anxiety. The pre-operative psychometric evaluation of 40 potential living donors indicated that most of the potential donors see themselves as 'super-healthy' and tend to adapt to social expectations, while on the other hand those seven potential living donors not accepted for psychosocial reasons were marked by heightened values for anxious depression and pessimism. The results indicate in most cases a great willingness to donate and on the other hand a high level of obvious psychological pressure for a low number of potential donors. For the latter, both the clinical evaluation interview and the psychometric diagnostics used revealed clear-cut feelings of anxiety and ambivalence towards transplantation.
Adult↗
Increasing the pool of transplantable kidneys through unrelated living donors and living donor paired exchanges.
Renal transplantation is the best therapy for eligible patients with end-stage renal disease (ESRD). Unfortunately the ability to perform this procedure is limited by a severe shortage of transplantable kidneys. One of the most successful approaches to this serious problem has been to expand the pool of living donors. This has been accomplished primarily by lifting restrictions on the use of genetically unrelated volunteers. As a result, acceptable living kidney donors now include individuals who are related to their recipients only through emotional bonds (e.g., spouses) and, at some centers, even people who are not related to their recipients at all. Living donor paired kidney exchanges provide a novel means for increasing further the number of kidneys available for transplantation. Each of these approaches will be reviewed.
Ethics, Medical↗
Psychosocial outcome of living donors after living donor liver transplantation: a pilot study.
In view of the scarcity of organ resources available for transplantation, living donor liver transplantation (LDLT) is gaining growing importance in the treatment of chronically terminal liver diseases. In the period between December 1999 and October 2000, 47 potential living liver donors were evaluated and 24 right hepatic lobes and two left lateral segments were transplanted at the Virchow-Klinikum of the Charité Hospital in Berlin. The present study looks into biomedical and psychosocial parameters of 23 donors before and 6 months after LDLT. Our aims were to investigate the development of psychosocial parameters after donation and the relationship between psychosocial findings and post-operative complications. Most donors showed an improved quality of life (QoL) after LDLT when compared with pre-operative results. Twenty-six percent of donors show high values for 'tiredness', 'fatigue' and 'limb pain' following donation. The post-operative complications had no influence on the psychosocial outcome. In this pilot study the resection of the right hepatic lobe amounts to a safe operation for donors and holds promise of a good psychosocial outcome for most donors, irrespective of donation-related complications. The pronounced complaints appears to indicate psychological tension and distress in some donors following donation.
Adult↗
Psychosocial stress of living donors after living donor liver transplantation.
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Adult↗
Renal retransplantation of children: is a policy 'first cadaver donor, then live donor' an acceptable option?
Retransplantation is often a necessity for children with end-stage renal disease (ESRD), as kidney graft survival is still not infinite. If a suitable live donor is present, the current policy is to use the live donor first, in order to obtain excellent long-term outcome and to prevent human leucocyte antigen (HLA) sensitization. Data from the Eurotransplant International Foundation were analyzed to determine whether the sequence, first a cadaveric donor then a live donor, is acceptable. Between January 1 1983 and December 31 1995, 1305 children received a first renal transplant; 269 of them had a second transplant during the same period. Follow-up of at least 1 yr was available. Categories were made according to the sequence of renal donor source: 217 patients were classified as first cadaver and second cadaver (1cad-2cad) transplant, 26 as first cadaver and second live (1cad-2liv) donor transplant, 23 as first live donor and second cadaver (1liv-2cad) transplant and three patients had two subsequent live donor transplants (1liv-2liv). When a live donor transplant was carried out, either first or second, the donor age was always higher, and the chance of a pre-emptive transplantation or short stay on dialysis was higher, compared with a cadaver transplant. The re-graft survival rate of the '1cad-2liv' was better than the '1cad-2cad' and '1liv-2cad' transplants. At 5 yr, the survival was 76%, 49%, and 61%, respectively. These data suggest that, when a suitable live donor is not available for a first transplantation owing to medical and/or familial reservations, a policy of 'first a cadaver donor then a live donor' transplantation is a viable option and should even be promoted. The pre-emptive stage of the second transplant, probably with a live donor, is additionally advantageous.
Adolescent↗
Select utilization of obese donors in living donor liver transplantation: implications for the donor pool.
Living donor liver transplantation evolved in response to donor shortage. Current guidelines recommend potential living donors (LD) have a body mass index (BMI) <30. With the current obesity epidemic, locating nonobese LD is difficult. From September 1999 to August 2003, 68 LD with normal liver function test (LFTs) and without significant comorbidities underwent donor hepatectomy at our center. Post-operative complications were collected, including wound infection, pneumonia, hernia, fever, ileus, biliary leak, biliary stricture, thrombosis, bleeding, hepatic dysfunction, thrombocytopenia, deep venous thrombosis, pulmonary embolism, difficult to control pain, depression and anxiety. Complication rates for LD with BMI >30 (n = 16) and BMI <30 (n = 52) were compared. The incidence of wound infection increased with BMI, 4% for nonobese and 25% for obese LD (p = 0.024). There were no statistically significant differences for all other complications. No LD died. Recipient survival was 100% with obese LD and 80% with nonobese LD (p = 0.1). Select donors with a BMI >30 may undergo donor hepatectomy with acceptable morbidity and excellent recipient results. Updating current guidelines to include select LD with BMI >30 has the potential to safely increase the donor pool.
Adolescent↗
Patients' attitudes about living donor transplantation and living donor nephrectomy.
BACKGROUND: The growing shortage of organs available for transplantation has resulted in an increased use of living donors for kidney transplantation. The laparoscopic nephrectomy is a new procedure used to remove kidneys from donors. The study objective was to explore the attitudes of recipients and donors toward living donor kidney transplantation and the impact of the laparoscopic donor nephrectomy on donors' and recipients' acceptance of living donor kidney transplantation. METHODS: Tailored self-administered questionnaires were mailed to kidney donors, potential donors, recipients and potential recipients who visited the University of Maryland School of Medicine Division of Transplantation between January 1998 and May 2001. RESULTS: The laparoscopic donor nephrectomy helped recipients and potential recipients with their decision to accept a kidney from a living donor (recipients: 53% strongly agreed, 36% agreed; potential recipients: 42% strongly agreed, 46% agreed). To a lesser extent, the laparoscopic donor nephrectomy assisted donors and potential donors with their decision to donate (donors: 19% strongly agreed, 20% agreed; potential donors: 20% strongly agreed, 20% agreed). Potential recipients and recipients identified 2 barriers to accepting living donor kidney transplantation: they were unwilling to accept a kidney if it meant this would financially burden their donors, and they worried that their donors might succumb to a future kidney problem. CONCLUSION: Overall, the study found a positive attitude toward living donor kidney transplantation and laparoscopic donor nephrectomy. This new surgical procedure seemed to positively influence recipients and potential recipients to accept a kidney. In contrast, it had less impact on donors' and potential donors' willingness to give their kidney.
Adult↗
Hepatic arterial anatomy for right liver procurement from living donors.
Living donor liver transplantation (LDLT) using right liver grafts is now widely performed. Anatomic classifications of the hepatic artery for right liver procurement, however, are limited. In this study, celiac and mesenteric angiograms of 223 consecutive living donors in a single institution were evaluated. Details of the arterial anastomosis and results were reviewed in 72 patients who underwent primary LDLT using right liver grafts. There was a 6% incidence of hepatic arterial bifurcations that might provide multiple orifices in a right liver graft. Only one right liver graft (1%) had multiple arterial orifices. Single arterial anastomosis without interposition was possible in all patients with right liver grafts and none of them were complicated with hepatic arterial thrombosis. Single arterial anastomosis, therefore, has a high probability of success in right liver graft implantation.
Adolescent↗
Endoscopic management of postoperative biliary complications in donors for living donor liver transplantation.
BACKGROUND & AIMS: Biliary leakage and stricture are serious complications that occur in donors whose liver is resected for living donor transplantation. We assessed the usefulness of endoscopic nasobiliary drainage and endoscopic biliary stenting, respectively, in repairing biliary leakage and stricture. METHODS: Between July 1999 and December 2001, a total of 276 donors underwent liver resection (left side, 118; right side, 158) for living donor transplantation at Kyoto University Hospital. Seven (2.5%) donors developed biliary leakage, which required endoscopic nasobiliary drainage; 3 of these donors also had biliary stricture. RESULTS: All 7 patients who developed biliary leakage were the right-lobe donors. Endoscopic retrograde cholangiography identified the site of the biliary leakage in all 7 of the donors. In 6 of these donors, the biliary leakage resolved within an average of 15 days after an endoscopic nasobiliary drainage tube was placed. In the seventh donor, the biliary leakage resolved after percutaneous transhepatic biliary drainage was performed. Three patients developed biliary stricture that required endoscopic biliary stenting. The angles between common hepatic duct and the left hepatic duct were more acute in patients with stricture than in those without stricture (62 degrees vs. 119 degrees). CONCLUSIONS: Biliary complications requiring endoscopic treatment developed exclusively in donors for right-lobe living donor transplantation. Endoscopic retrograde cholangiography is a favorable modality for diagnosing and treating postoperative biliary complications in donors for living donor liver transplantation.
Adult↗
[Personality and donor-recipient relationships of potential donors before living donor liver transplantation--diagnostics with the repertory-grid technique].
BACKGROUND: Living-donor liver transplantation (LDLT) is developing into an established therapy for terminal liver diseases in adults. Potential donors are faced with the risk of postoperative complications and are subject to a high level of psychological pressure and ambivalent feelings. Our assumption is that ambivalent feelings before donation are crucially influenced by the personality and the quality of the donor-recipient relationship. In highly motivated donors we expected a positive description of the recipient and a similarity in the characterisation of the donor and recipient. METHODS: 58 potential living donors were evaluated between March 2000 and June 2001. On the basis of the clinical interview 10 were rated as unsuited for donation. Among those potential donors assessed as unsuited, we found a high level of ambivalent feelings. For 50 potential donors we gained a set of completed psychometric diagnostic questionnaires. A Repertory-grid investigation was conducted with a total of 28 potential donors. Seven of them were not recommended as living donors. The relationship between donors and recipients was analysed concerning constructs that were most important to the characterisation of the donor or recipient. By means of inter-element distances self-concept of donors and donor-recipient relation were analysed. RESULTS: Ambivalent candidates who were not recommended as living donors tended to describe the recipient negatively (selfish, carping, and unable to take criticism) and did not show a similarity in the characterisations of self and ideal-self. Whereas the highly motivated candidates were marked by a closeness of self and ideal-self concepts. Both groups saw the recipient as indifferent. CONCLUSION: Closeness between self and ideal-self-indicating satisfaction with the decision to donate seems to be one suitable criterion to distinguish between highly motivated potential donors on the one hand and ambivalent candidates on the other hand. Another criterion appears to be a description of the recipient that indicates either a functioning or ill-functioning communication between donor and recipient with respect to the donation.
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Selection of donors for living donor liver transplantation in a single center of a developing country: lessons learned from the first 100 cases.
The selection of donors for living donor liver transplantation (LDLT) is one of the most important features in this kind of surgery. The aim of this study is to describe our initial experience in the donor evaluation process. From December 2001 to January 2005, 104 donors were evaluated for 70 recipients (65 potential donors were evaluated for 39 adult recipients, and 39 donors for 31 pediatric recipients). Only 30 donors were able to donate: 13 for the adult group, and 17 for the pediatric one. In general, the utilization rate of potential donors was 28.8% (30/104). For the adult patients, 65 potential donors were seen to perform 13 LDLT, which represents a utilization rate of potential donors of 20%. For the pediatric patients, this rate was 43.6%. The exclusion criteria were clinical in 22 cases (21%), anatomical in 13 cases (13%), psychosocial in nine cases (9%), and others in 12 (12%). Death of recipients led to exclusion 18 of donors (17%). Thirty-three percent of adults and 55% of pediatric recipients who had at least one potential donor to start the evaluation process were able to identify a living donor. In conclusion, the first limit for LDLT is the rigorous donor evaluation.
Adolescent↗
Experience after the evaluation of 700 potential donors for living donor liver transplantation in a single center.
Adequate selection of donors is a major prerequisite for living donor liver transplantation (LDLT). Few centers report on the entire number of potential donors considered or rejected for living donation. From April 1998 to July 2003, a total of 111 living donor liver transplantations were performed at our institution, with 622 potential donors for 297 adult recipients and 78 potential donors for 52 pediatric recipients evaluated. In the adult group, only 89 (14%) potential donors were considered suitable, with a total of 533 (86%) potential donors rejected. Of these, 67% were excluded either at initial screening or during the first and second steps of the evaluation procedure. In 31% of all cases, the evaluation of donors was canceled because of recipient issues. In the pediatric group, 22 (28%) donors were selected, with the other 56 (72%) rejected. Costs of the complete evaluation process accounted for 4,589 Euro (Euro) per donor. The evaluation of a potential living donor is a complex and expensive process. We present the results on the evaluation of the largest group of potential donors for adults reported in the literature. Only 14% of potential donors in our series were considered suitable candidates. It has not yet been established who should cover the expenses of the evaluation of all rejected donors. In conclusion, all efforts should be made in order to develop an effective screening protocol for the evaluation of donors with the aim of saving time and resources for a liver transplantation program.
Adolescent↗
Graft size assessment and analysis of donors for living donor liver transplantation using right lobe.
BACKGROUND: Modality of living donor liver transplantation (LDLT) has been expanded to adult cases. However, the safety of right lobectomy from living donors has not yet been proven. METHODS: A total of 62 cases of LDLT, using the right lobe, were reviewed. Study 1: Discrepancy between estimated graft volume and actual graft weight was evaluated. Study 2: Postoperative liver functions were analyzed in relation to residual liver volume (RLV) or age. Residual liver volume of donors was defined using two indices, (RLV = estimated whole liver volume - estimated graft volume and %RLV = RLV/estimated whole liver volumex100). Donors were divided into two groups on the basis of either %RLV (<40%; 40%< or =) or age (<50 years old; 50 years old < or =). Study 3: Right lobe donors were compared with left lobe donors (35 cases) in terms of their postoperative liver functions. RESULTS: Study 1: The relationship between estimated graft volume and actual graft weight was linear (y=159.136+0.735x, R2=0.571, P<0.001). Study 2: %RLV ranged from 23.5% to 55.8% (mean +/- SD: 43.2+/-6.0). Fifteen cases showed %RLV less than 40%. Postoperative bilirubin clearance was delayed in that group (%RLV<40%). Serum total bilirubin values on postoperative day 7 in the older group (age > or =50) were significantly higher than those in the younger group (age<50). Study 3: Postoperative liver functions of right lobe donors were significantly higher than those of left-lobe donors. Eleven donors (17.7%) had surgical complications, all of which were cured with proper treatment. CONCLUSIONS: Right lobectomy from living donors is a safe procedure with acceptable morbidity, but some care should be taken early after the operation for donors with small residual liver and aged donors.
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[The immunological barrier in renal transplantation from living donor].
Living donor kidney transplantation is uncommon in our country, mostly due to the high rate of cadaveric donation. However, such a rate has been held back in recent years and it is thought that there will be great problems in organ shortage in the next years, especially for young patients. Thus, living donation seems to be an alternative. Such a practice is particularly useful in hypersensitized patients with positive crossmatch and in ABO incompatibility. In these two cases, the waiting time for kidney transplantation goes on for many years. With the development of desensitizing protocols that employ high-dose intravenous immunoglobulins and/or plasmapheresis, together with the use of more sensitive and objective assays for immunological monitoring, patients that were not candidates for kidney transplantation in the past are now being transplanted. In the present work, immunological factors that participate in living kidney transplantation are revised, with special focus on hypersensitized patients. Available data show that living donation is a feasible alternative for future, once all the ethical problems have been solved.
Adult↗
3D-multidetector CT angiography in the evaluation of potential donors for living donor lung transplantation.
INTRODUCTION: In living donor lung transplant, donor lobectomies from 2 donors provide right and left lower lobes for transplantation. In the past, routine evaluation of pulmonary anatomy was not performed preoperatively. Intraoperatively, surgeons were often forced to sacrifice the lingular artery or right middle lobe segmental artery to obtain an adequate arterial cuff for safe reimplantation. This study was performed to evaluate the utility of preoperative 3D-multidetector CT angiography (3D-MDCTA) as a noninvasive method of assessing pulmonary arteries to improve donor selection and surgical planning for living lung donors. SUBJECTS AND METHODS: Five potential lung donors for 2 recipients were included in the study. CT scanning with 4 channel multidetector-row CT was performed, using a modified pulmonary embolism protocol. Post-processing was performed using volume rendering techniques on a commercially available workstation. RESULTS: 3D-MDCT demonstrated that there are a number of variations in pulmonary arterial anatomy and that ideal anatomy was seldom encountered. Comparison of different donors determined which lower lobes were most favorable for transplantation. Surgery confirmed the accuracy of 3D-MDCTA. There were no pulmonary arterial complications, and no vessels were sacrificed. CONCLUSION: Safely explanting lower lobes from living donors for lung transplantation poses challenges not encountered in harvesting cadaveric donors or performing lobectomies for malignancy. 3D-MDCTA of pulmonary arteries can noninvasively delineate the often-complex pulmonary anatomy, which may assist in donor selection as well as reduce donor intraoperative and postoperative vascular complications.
Adult↗
Documented deaths of hepatic lobe donors for living donor liver transplantation.
The actual risk of death in hepatic lobe donors for living donor liver transplantation (LDLT) is unknown because of the lack of a comprehensive database. In the absence of a definitive estimate of the risk of donor death, the medical literature has become replete with anecdotal reports of donor deaths, many of which cannot be substantiated. Because donor death is one of the most important outcomes of LDLT, we performed a comprehensive survey of the medical and lay literature to provide a referenced source of worldwide donor deaths. We reviewed all published articles from the medical literature on LDLT and searched the lay literature for donor deaths from 1989 to February 2006. We classified each death as "definitely," "possibly," or "unlikely" related to donor surgery. We identified 19 donor deaths (and one additional donor in a chronic vegetative state). Thirteen deaths and the vegetative donor were "definitely," 2 were "possibly," and 4 were "unlikely" related to donor surgery. The estimated rate of donor death "definitely" related to donor surgery is 0.15%. The rate of donor death which is "definitely" or "possibly" related to the donor surgery is 0.20%. This analysis provides a source document of all identifiable living liver donor deaths, provides a better estimate of donor death rate, and may provide an impetus for centers with unreported deaths to submit these outcomes to the liver transplantation community.
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Prevention of de novo hepatitis B infection from HbcAb-positive donors in living donor liver transplantation.
Hepatitis B virus (HBV) prophylaxis is necessary to prevent de novo hepatitis B infection from HbcAb-positive donors. However, which protocol is more effective is somewhat controversial. Also, it is uncertain whether it is necessary to administer HBV prophylaxis for HbsAb-positive recipients. This study attempted to determine whether it is necessary to administer HBV prophylaxis for HbsAb-positive patients and to evaluate the efficacy of an HBIG monotherapy protocol. From May 1996 to July 2001, among 128 donors examined for HbcAb, 58 donors (45.3%) were HbcAb-positive. Eighteen HbcAb-positive grafts were transplanted to HbsAg-negative recipients. The 4 patients who died of unrelated causes were excluded from this study. Of 14 study cases, 12 recipients were HbsAb-positive, and 2 were HbsAb-naive. Prior to late 1998, we used HBV vaccination only for de novo infection prophylaxis. However, starting from December 1998, HBIG was administered from the time of the liver transplantation regardless of HBsAb positivity. The overall rate of de novo HBV infections from HbcAb-positive donors was 21.4% (3 of 14). All 3 recipients without HBIG prophylaxis presented with de novo HBV infections. Two were HbsAb-positive preoperatively. No de novo HBV infections occurred among recipients with HBIG prophylaxis. Therefore, it is essential to administer HBV prophylaxis even for vaccinated HbsAb-positive patients. HBIG monotherapy is effective to prevent de novo hepatitis B infections from HbcAb-positive donors in living donor liver transplantation.
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