Rapid Liver Donor Workup, While Altruism Is High, Gets Organs

HONG KONG, April 4 -- A quick but thorough workup of living liver donors, completed before the altruistic spirit fades, can increase the number of volunteer organs that are actually transplanted, found surgeons here.

A four-step workup of volunteer donors resulted in 32% of potential transplants coming to fruition, a comparatively high rate, reported Sheung Tat Fan, M.D., the University of Hong Kong, and colleagues, in the April issue of Liver Transplantation.

The acceptance rate of volunteer donors is similar to that seen in some U.S. centers, but double that reported by German surgeons in a series of 700 patients, the authors noted. In this city, where livers from deceased donors are scarce, there is a premium on volunteers, who face a greater risk of morbidity and mortality than that encountered by live kidney donors.

Performing the donor workup in about eight to 12 hours, rather than a period of days or weeks, can minimize the number of late-stage dropouts and increase the likelihood of timely surgery in patients at the top of the waiting list, the authors wrote.

"All too frequently, the risks and potential harm that the potential donor faces overcast the benefit of live donor liver transplantation of saving the potential donor's child, spouse, parent, and other beloved," the authors wrote. "Our data indicated that a high proportion of potential donors were subsequently determined suitable candidates and underwent the donor operation (32.1%)."

The findings of the Hong Kong group provide further evidence that a step-wise donor evaluation program can eliminate a majority of incompatible donors early on, wrote Robert A. Fisher, M.D., a transplant surgeon at Virginia Commonwealth University in Richmond, in an accompanying editorial.

About 66% of all liver transplants in Hong Kong are performed with living donors, the authors noted. In contrast, of the 6,650 liver transplants performed in the United States in 2006, only 288 (4%) were from living donors, according to data from the United Network for Organ Sharing (UNOS).

The Hong Kong investigators reported results on a cohort of 399 potential donors, 128 of whom (32.1%) became donors.

The potential donors underwent a four-step workup, consisting of a medical history and examination (step 1); clinical psychological assessment (step 2a); chest x-ray, electrocardiogram, and liver imaging (step 2b); biopsy if liver CT showed signs of steatosis, and visceral angiogram if CT was ambiguous (step 3); and informed consent of both the living donor and recipient, plus HLA typing and cross match (step 4).

The authors found that 28.4% of potential donors for high-urgency patients actually became donors, compared with 36.8% of potential donors for those who undergo elective transplants (P=0.049).

Slightly more than half of potential donors (52.6%) dropped out after step 1, primarily because of ABO incompatibility, positive hepatitis serology, comorbidities, or voluntary withdrawal. Of the 189 potential donors who went forward in the evaluation process, 11.6% (22) subsequently dropped out, two because they were psychologically unsuitable and 10 because of anatomical problems; reasons for the remaining dropouts were not specified.

Among recipients with one or more potential matched donors, 55% of high-priority patients and 51% of elective patients went on to receive grafts.

"Even though a live donor will not benefit from the operation physically, the loss from failure to save the recipient can result in much psychological remorse," the authors wrote. "Based on the personal values of the donor and the recipient, they both should have a say. Voluntarism should not be hampered by negativism from the transplant community."

Pointing out that his center has used a four-step donor evaluation process since 1998, Dr. Fisher noted that it has resulted in 44% of potential donors going to surgery.

"To further the spirit of 'voluntarism' and to increase the understanding of the potential donors, we have always included psychological and social work interview in the first step," he wrote. "In the last 50 living donors, starting in Step 2 and continuing in Step 3, we have advised potential donors to contact past volunteer donors who have voluntarily organized to consult with potential donors on an on-call basis. This simple addition has caused no inefficiency and has furthered the respect and transparency of the donor process."