Living Donor Liver Transplantation When Deceased Donor Is Not Possible or Timely: Case Examples and Ethical Perspectives

Abstract

This article analyzes the ethical soundness of living donor liver transplantation (LDLT) in situations where the transplant team does not consider deceased donor liver transplantation (DDLT) a clinical or timely option. Given that patients with end‐stage liver disease have a high risk of death without DDLT, the option of LDLT becomes compelling and may save lives. We present 3 representative cases from our center that raise concerns over social behavior, limited time constraints for decision making, and high potential for disease recurrence that render DDLT an unlikely option. Thereafter, we discuss ethical issues for each patient, which predominantly pertain to compromises to the living donor informed consent process and the feasibility of LDLT. We conclude with recommendations regarding whether LDLT is an acceptable ethical option for those patients, which may inform clinical practice in the broader transplant community.

Analysis of Survival Benefits of Living Versus Deceased Donor Liver Transplant in High Model for End‐Stage Liver Disease and Hepatorenal Syndrome

“…Secondly, there have been concerns whether urgent donor workup protocol might pose additional psychological and physical risks to living donation. ( 11 ) In the current study, hospital mortality was very low in patients with LDLT (4/115, 3.5%) and was comparable with patients with DDLT (2/110, 1.8%); 96.5% of patients with LDLT underwent transplantation using right‐lobe grafts with a median GRWR of 0.9%. There was also no difference in hospital/ICU stay and vascular or biliary complication after LDLT and DDLT.…”

“…On the other hand, the benefits of recipients should be weighed against the risk and cost of living donation, which includes donor coercion under an emergent and expedited workup process and possibly inferior transplant outcomes. (11) In the literature, all reports that compared LDLT and deceased donor liver transplantation (DDLT) for patients with high MELD and hepatorenal syndrome (HRS) only analyzed outcomes and survival after transplant, without any analysis of the effect of type of transplant on waitlist mortality. (3)(4)(5)(6)8,9,(12)(13)(14)(15)(16) Furthermore, it is unclear whether the use of expedited living donor workup will reduce waitlist mortality and what the impact will be on perioperative donor and recipient outcomes.…”

Ethical Issues When Considering Liver Donor Versus Deceased Donor Liver Transplantation

“…This practice raises several concerns regarding the ethical soundness of LDLT. Our group’s review in LT discusses various ethical concerns based on actual cases, as well as potential approaches to optimize the informed consent process 3 …”