Emergency Adult to Adult Living Donor Liver Transplantation For Fulminant Hepatic Failure ??? Is It Justifiable?

Although Dr. Marcos and hiscolleagues at the MCV, Richmond, VA are to be congratulated for theirexcellent work in Adult to Adult Live Donor Liver Transplantation as anelective procedure, one is very concerned about their recent report(Transplantation 2000; 69: 2202) of carrying out an emergency live donor livertransplantation using the right lobe of the liver from an adult to his siblingwith fulminant hepatic failure (FHF) due to viral hepatitis. Such a majorprocedure of taking the right lobe of liver from a healthy donor for anemergency transplant into a patient with FHF raises serious ethical, medical,logistic, and economic concerns, particularly when the condition of therecipient is potentially reversible. First, it is wellrecognized that the risk of right hepatic lobectomy carried out for othermedical indications is quite considerable and some centers have reported amortality of up to 11%. Since live donor liver transplantation started in 1989in Brazil and in 1990 in the US some 800 live donor liver grafts have beencarried out worldwide mostly as elective procedures and several living donorshave died including 2 in the US, 1 in Germany, and others in Asia(undocumented) (1, 2). In addition major posthepatectomy complications in the donor, includingbiliary stricture have been reported. Second, theevaluation of donors for liver transplantation is a complicated process and itusually takes 1 to 2 weeks. Most centers have reported that only 20–30%of potential donors are found to be suitable. Indeed, Marcos has previouslyemphasized the need for thorough evaluation of potential liver donors thatmust be carried in four consecutive steps including: clinical, laboratory,imaging, special studies of organ function, angiography, liver biopsy, fullpsychological evaluation, and obtaining two consents from the donor. In anemergency situation it is unlikely that these can be accomplished in 18 hrs aswas done in this case. Also the urgency of carrying out these complicatedevaluation procedures, places the donor in a very compromising situation andsuch a scenario cannot be in the donors bestinterest. In a recent “Position Paper” bythe ASTS some of these issues are discussed, guidelines and criteria aresuggested, and a national registry of live donor liver transplantationproposed. It is also stated: “While it may not be possible to firmlystate that adult-to-adult living donor transplantation should not be done insituations in which the recipient has a poor chance of overall survival, theadded risk to the donor must be balanced with a realistic estimate of thechances of success.” Third, another importantreason for not subjecting healthy donors to major and potentially high riskright lobe hepatectomy for emergency transplant for patients with FHF is thatthere are now successful extracorporeal procedures available for the supportof such patients as a bridge to cadaveric liver transplantation or betterstill, to full regeneration of the patient’s own liver and avoiding therisky hepatectomy in the donor and the costly operation of transplantation andthe need for immunosuppression in the recipient (3–6). Since the early 1970s we have used extracorporeal liver perfusion for thetreatment of patients with FHF and while working at the MCV in Richmond, threepatients with FHF were successfully treated with ex vivo baboon and pig liverperfusions. Two of these patients are still alive and well today (4). We also treated another patient in Denver, CO and brought him out of grade IVhepatic coma nine times with intermittent multi-species liver perfusions andkept him alive for 76 days while awaiting liver transplant (5). We have redesigned our perfusion device, which recreates the normalphysiological conditions of the liver in vivo together with prior removal ofpreformed xeno-antibody by a temporary kidney transplant. In a recentpreclinical trial in dogs with induced FHF, although all the control animalsdied in hepatic coma those treated with bovine liver perfusion fully recoveredfrom coma and 65% became long-term survivors after having regenerated theirown liver (6). We are currently preparing to carry out a clinical trial using this effectiveliver support system. Thus in view of the real risk tothe living donor as well as carrying out a major and costly liver transplantoperation in the recipient, emergency live donor liver transplant for patientswith FHF is not really justifiable. Instead, an extracorporeal hepatic supportsystem, such as our liver perfusion device, should be used as a bridge toregeneration of the patient’s own liver or until a cadaver liver becomesavailable. To subject a healthy donor to an emergency right lobe hepatectomyis really like asking a man to take the risk of jumping into the ocean torescue another man who is about todrown. George J.M. Abouna