Ethical Analysis and Policy Recommendations Regarding Domino Liver Transplantation

Abstract

Due to the widening gap between supply and demand, patients who need a liver transplant due to metabolic disease may be asked to serve as domino liver donors-to have their native liver transplanted into another candidate. We here analyze the ethical problems surrounding informed consent for the implant and explant procedures in transplant candidates who will serve as domino donors, using the case of a child with maple syrup urine disease. We discuss the need for 2 distinct consent processes separated in time to ensure that potential domino donors (or their surrogates) give a truly voluntary consent. We propose a Domino Donor Advocate-based on the concept of the independent living donor advocate to help the patient and/or his or her surrogates consider the risks, benefits and alternatives. Finally, we evaluate the Organ Procurement and Transplantation Network policy regarding "therapeutic organ donation" and propose several modifications to ensure that the decision by the potential domino donor (and/or his or her surrogate) is voluntary and informed.

Benefits and ethical issues in domino liver transplant

“…Even if the risk to develop a metabolic disorder after domino liver transplantation seems to be re-duced, the recipient and its family should be carefully informed about these risks and should give their consent in order to proceed to this surgical gesture (11). Moreover, certain authors proposed creating a specific informed consent for such cases (15) through which the domino donor is assured that he will not be exposed to any supplementary risk while the domino receiver is informed about the risk of developing the metabolic disease at a certain moment. In the meantime, the Portuguese researchers also added in this type of consent the necessity of assuring the patient that he would have the opportunity to receive a "healthy" graft from a deceased donor at a certain moment (16).…”

Domino-liver transplantation: toward a safer and simpler technique in both donor and recipient

“…DLT is normally only used in elderly and/or cancer patients [6,7]. The non-use of these potentially excellent liver allografts has four reasons: (a) ethical concerns about putting the domino-donor at risk of a more complex surgical procedure and the domino-recipient for a possible disease transmission (reported in 3.3-21% of domino-recipients); (b) fear of technical complications related to a more difficult arterial inflow and venous outflow reconstruction of the domino-allograft; (c) increased logistics linked to the organization of two simultaneous, LT procedures, and finally (d) the (intra-operative) discovery of advanced liver fibrosis ('cardiac liver') caused by the underlying amyloidotic cardiopathy [8][9][10][11][12][13][14].…”

Maple Syrup Urine Disease and Domino Liver Transplantation: When and How?

“…Hence, the recipient of the domino liver from a patient with MSUD does not have the risk of disease transmission and can tolerate a normal dietary protein intake after LT. However, longterm outcome results still need to be evaluated further …”

“…However, longterm outcome results still need to be evaluated further. (3) In domino donation, modifications of the surgical technique (greater care for the liver explant, possible longer time of surgery and anesthesia, the level of vessel transection, and any need of hepatic venoplasty) and a modification of the preoperative management that is required to obtain a transplantable liver graft (some programs use anticoagulation in the MSUD domino donor (3) ) should not expose the MSUD patient to additional risks. Although there are not yet data comparing LT outcomes in MSUD domino donors versus nondonors, the European data showed no differences in morbidity and survival rates in the FAP patients.…”