Correspondence
Transplantation of Liver Grafts from Living Donors into Adults
N Engl J Med 2001; 345:923-924September 20, 2001
- Article
To the Editor:
Cronin et al. (May 24 issue)1 suggest that there has been a lack of oversight in the evolution of liver transplantation involving living donors. They overlook recent reports and conferences that show widespread concern for living organ donors.
Last year, more than 100 representatives of the transplantation community participated in a national conference on living organ donors. The recommendations of Cronin et al. with respect to informed consent are thoroughly detailed in the consensus statement of that conference.2 The American Society of Transplant Surgeons published a position paper on living donors of liver grafts, in which recommendations similar to those of Cronin et al. are conveyed,3 except for the call for government regulation. Centers involved in the transplantation of liver grafts from living donors were well represented at major symposiums held in Pittsburgh in 1999 and Rome in 2000. In December 2000, the National Institutes of Health held a conference on the use of liver grafts from living donors. Cronin et al. participated in this conference (and cite it as a reference4), but the conclusions of the other participants are not underscored. The 2001 Winter Symposium of the American Society of Transplant Surgeons was devoted to the transplantation of liver grafts from living donors and included an update on complications in donors. Cronin spoke at that conference.
These conferences and reports bespeak concern for the well-being of living donors in a transplantation community that does indeed monitor itself. The debate and dialogue that have been fostered by this community constitute the best way to optimize the use of this innovative technology in a manner that will allow it to achieve its greatest potential.
4 ReferencesCharles M. Miller, M.D.
Mount Sinai School of Medicine, New York, NY 10029
charles.miller@mountsinai. org Francis L. Delmonico, M.D.
Harvard Medical School, Boston, MA 021151
Cronin DC II ,Millis JM ,Siegler M . Transplantation of liver grafts from living donors into adults -- too much, too soon. N Engl J Med 2001;344:1633-1637
Full Text | Web of Science | Medline2
Abecassis M ,Adams M ,Adams P , et al. Consensus statement on the live organ donor. JAMA 2000;284:2919-2926
CrossRef | Web of Science | Medline3
American Society of Transplant Surgeons' position paper on adult-to-adult living donor liver transplantation. Liver Transpl 2000;6:815-817
CrossRef | Web of Science | Medline4
Brown R. Survey on current practice of LDLT in adults. Presented at the Workshop on Living Donor Liver Transplantation, Bethesda, Md., December 4–5, 2000.
To the Editor:
Cronin et al. assert that only patients who meet minimal criteria for cadaveric liver transplantation should be accepted for the transplantation of a liver graft from a living donor. However, the criteria for selection for access to a limited resource, such as cadaveric liver grafts, are not a priori equally appropriate as criteria for access to therapy that relies on donor organs outside the pool of cadaveric organs.1 This issue is best exemplified by current criteria for transplantation in patients with cirrhosis and coexisting hepatocellular carcinoma. When the selection is limited to patients with tumors 5 cm or less in diameter, long-term survival approaches 75 percent at four years, whereas transplantation in those with tumors larger than 5 cm has been associated with less than 30 percent survival.2,3 These data led to the exclusion of patients with larger tumors from the waiting list for cadaveric organs. We suggest that if the supply of cadaveric organs were to exceed the current demand, patients with the worst outcomes would be considered candidates. Can we now refuse to offer these patients transplantation when a healthy living donor provides the graft?
3 ReferencesAbraham Shaked, M.D., Ph.D.
University of Pennsylvania, Philadelphia, PA 19104
abraham.shaked@uphs. upenn. edu Michael R. Lucey, M.D.
University of Wisconsin School of Medicine, Madison, WI 53792-51241
Lucey MR ,Brown KA ,Everson GT , et al. Minimal criteria for placement of adults on the liver transplant waiting list: a report of a national conference organized by the American Society of Transplant Physicians and the American Association for the Study of Liver Diseases. Liver Transpl Surg 1997;3:628-637
CrossRef | Medline2
Mazzaferro V ,Regalia E ,Doci R , et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996;334:693-699
Full Text | Web of Science | Medline3
Yao FY ,Ferrell L ,Bass NM , et al. Liver transplantation for hepatocellular carcinoma: expansion of the tumor size limits does not adversely impact survival. Hepatology 2001;33:1394-1403
CrossRef | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We agree with most of the views of Miller and Delmonico, including their conclusions that the “transplantation community . . . does indeed monitor itself” and that it shows “concern for the well-being of living donors.”1,2 In our article, we never question this commitment. We also agree that the surgical model of innovation based on professional self-regulation rather than administrative regulation has proved to be an extremely effective way to advance the field of surgery to benefit patients.
Our disagreement with Miller and Delmonico focuses on whether the professional regulatory model involving conferences, colloquiums, and position papers will prove adequate for dealing with the transplantation of liver grafts from adult living donors and for protecting potential donors. We believe that the best way to optimize the use of this innovative technology is to define clearly the experimental protocol, standardize the operation, ensure the “field strength” of the surgical team, and record and share all data on outcomes (including program-specific data) with the professional community and with patients. If the professional community can accomplish these tasks quickly — and thus far they have not — there may not be a need for formal regulatory control.
Shaked and Lucey highlight an unresolved issue with regard to recipients. Since the four-year survival among patients who have hepatocellular carcinomas larger than 5 cm and undergo transplantation is so poor,3 this group has been excluded from the waiting list for cadaveric organs. Shaked and Lucey suggest that living donors be subjected to complications and possibly death to provide grafts to recipients with hepatocellular carcinomas, even though the transplantation community has declined to use cadaveric grafts in such patients. In our article, we refer to the need to balance the short-term and long-term risks to the donor with the potential benefits to the recipient. The proposal offered by Shaked and Lucey demonstrates the need for the transplantation community to specify what outcomes in a recipient are acceptable before a living donor is subjected to surgical risk. It also raises the question of whether individual programs can be required to comply with standards established by the surgical transplantation community through professional self-regulation.
3 ReferencesDavid C. Cronin, II, M.D., Ph.D.
J. Michael Millis, M.D.
Mark Siegler, M.D.
University of Chicago, Chicago, IL 60637
dcronin@surgery.bsd. uchicago. edu 1
Abecassis M ,Adams M ,Adams P , et al. Consensus statement on the live organ donor. JAMA 2000;284:2919-2926
CrossRef | Web of Science | Medline2
American Society of Transplant Surgeons' position paper on adult-to-adult living donor liver transplantation. Liver Transpl 2000;6:815-817
CrossRef | Web of Science | Medline3
Mazzaferro V ,Regalia E ,Doci R , et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996;334:693-699
Full Text | Web of Science | Medline
- Citing Articles (7)
Citing Articles
1
Arun Thenappan, Reena C. Jha, Thomas Fishbein, Cal Matsumoto, J. Keith Melancon, Raffaele Girlanda, Kirti Shetty, Jacqueline Laurin, Jeffrey Plotkin, Lynt Johnson. (2011) Liver allograft outcomes after laparoscopic-assisted and minimal access live donor hepatectomy for transplantation. The American Journal of Surgery 201:4, 450-455
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Takeshi Yuasa, Norimi Niwa, Shinya Kimura, Hiroaki Tsuji, Kimiko Yurugi, Hiroto Egawa, Koichi Tanaka, Hiroaki Asano, Taira Maekawa. (2005) Intraoperative blood loss during living donor liver transplantation: an analysis of 635 recipients at a single center. Transfusion 45:6, 879-884
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Kim M. Olthoff, Robert M. Merion, Rafik M. Ghobrial, Michael M. Abecassis, Jeffrey H. Fair, Robert A. Fisher, Chris E. Freise, Igal Kam, Timothy L. Pruett, James E. Everhart, Tempie E. Hulbert-Shearon, Brenda W. Gillespie, Jean C. Emond. (2005) Outcomes of 385 Adult-to-Adult Living Donor Liver Transplant Recipients. Transactions of the ... Meeting of the American Surgical Association 123:&NA;, 21-31
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Mary D. Ellison, Maureen A. McBride, Sarah E. Taranto, Francis L. Delmonico, H. Myron Kauffman. (2002) Living kidney donors in need of kidney transplants: a report from the organ procurement and transplantation network. Transplantation 74:9, 1349-1351
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Charles Cha, Ronald P. DeMatteo, Leslie H. Blumgart. (2002) Surgery and Ablative Therapy for Hepatocellular Carcinoma. Journal of Clinical Gastroenterology 35, S130-S137
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