Practices and Perceptions of Living Donor Liver Transplantation, Nondirected Donation, and Liver Paired Exchange: A National Survey

A scoping review of nonmedical barriers to living donor liver transplant

This study aims to identify and categorize nonmedical barriers encountered by recipients, donors, and health care providers in the context of living donor liver transplantation (LDLT). Liver transplantation is vital for individuals with liver failure, yet high mortality rates on the transplant waitlist persist. LDLT was introduced to address deceased donor organ shortages; however, its adoption varies widely across regions, prompting the need to explore barriers hindering its implementation. The scoping review employed inclusion and exclusion criteria to identify studies focusing on nonmedical barriers to LDLT in both adult and pediatric populations. Qualitative, quantitative, and mixed-method studies were considered, covering the period from January 2005 to February 2023. The review's search strategy was conducted in the Ovid MEDLINE and Ovid EMBASE databases. Studies meeting the criteria were assessed for their characteristics and findings, which were synthesized into recipient, donor, and provider-level barriers. Among 2394 initially screened articles, 17 studies were eligible for inclusion. Recipient-level barriers encompassed systemic disparities in access, limited social support, immigration status, and inadequate awareness of LDLT. Donor-level barriers involved surgery-related risks, recovery time concerns, financial burdens, and religious beliefs. Provider-level barriers highlighted institutional support inadequacies and specialized surgeon shortages. The scoping review underscores nonmedical barriers to LDLT across recipient, donor, and provider levels. These barriers include socioeconomic disparities, information gaps, and inadequate institutional support. The findings underscore the need for comprehensive national efforts to raise awareness about LDLT and provide essential financial support.

Expanding Opportunities for Living Donation: Recommendations From the 2023 Santander Summit to Ensure Donor Protections, Informed Decision Making, and Equitable Access

A strategic vision toward global convergence in transplantation must encourage and remove barriers to living organ donation and transplantation. Here, we discuss deliberations of a working group of the 2023 Santander Summit charged with formulating recommendations for the safe expansion of living donor kidney transplantation and living donor liver transplantation worldwide. Living donor kidney transplantation has grown to be the preferred treatment for advanced kidney failure. Living donor liver transplantation emerged more recently as a strategy to reduce waitlist mortality, with adoption influenced by cultural factors, regional policies, clinical team experience, and the maturity of regional deceased donor transplant systems. Barriers to living donor transplantation span domains of education, infrastructure, risk assessment/risk communication, and financial burden to donors. Paired donor exchange is a growing option for overcoming incompatibilities to transplantation but is variably used across and within countries. Effectively expanding access to living donor transplantation requires multifaceted strategies, including improved education and outreach, and measures to enhance efficiency, transparency, and shared decision making in donor candidate evaluation. Efforts toward global dissemination and vigilant oversight of best practices and international standards for the assessment, informed consent, approval, and monitoring of living donors are needed. Fostering greater participation in paired exchange requires eliminating disincentives and logistical obstacles for transplant programs and patients, and establishing an ethical and legal framework grounded in World Health Organization Guiding Principles. Sharing of best practices from successful countries and programs to jurisdictions with emerging practices is vital to safely expand the practice of living donation worldwide and bring the field together globally.

Retransplantation in Living Donor Liver Transplantation

The need for retransplantation after living donor liver transplantation can occur early, mainly because of technical difficulties such as hepatic artery thrombosis or as a result of early allograft dysfunction as a symptom of small-for-size syndrome. Patients with autoimmune diseases may develop progressive graft failure from recurrent disease. The ethics of retransplantation can be complicated by the cause of the initial liver disease, which may be self-inflicted or the outcome of malignancy. This is especially true in countries without the availability of deceased donors for salvage, and a second living donor would be needed. Nevertheless, patients who experience early or late graft failure should be considered for retransplant if they are deemed acceptable candidates. When a living donor is required for retransplant, the equipoise between donor risk and autonomy and recipient outcome should be considered.

Financial toxicity in living donor liver transplantation: A call to action for financial neutrality

After 2 decades of limited growth, living donor liver transplant (LDLT) has been increasingly accepted as a promising solution to the growing organ shortage in the US. With experience, LDLT offers superior graft and patient survival with low rates of rejection. However, not all waitlisted patients have equal access to LDLT, with financial toxicity representing a substantial barrier. Potential living liver donors face indirect, direct, and opportunity costs associated with donation as well as insurance-based discrimination and variable employer leave policies. There are multiple potential national, local, and patient-centered solutions to address some of the cost-related issues associated with living LDLT. These include standardization of employer leave policies, creation of federal and state-led tax relief programs, optimization of National Living Donor Assistance Center use, engagement of independent living donor advocates, creation of financial toolkits, and encouragement of recipient or donor-led fundraising. In this piece, members of the North American Living Liver Donation Group, a consortium of 37 LDLT programs, explore these financial challenges and discuss solutions to achieve financial neutrality, where individuals can donate free from financial constraints or gains. As a community, it is imperative that we confront factors driving financial toxicity to improve equity and access to LDLT.

Liver paired exchange: A US single-center experience-Pairs, chains, and use of compatible pairs

In the United States, the discrepancy between organ availability and need has persisted despite changes in allocation, innovations in preservation, and policy initiatives. Living donor liver transplant remains an underutilized means of improving access to timely liver transplantation and decreasing waitlist mortality. Liver paired exchange (LPE) represents an opportunity to overcome living donor liver transplant pair incompatibility due to size, anatomy, or blood type. LPE was adopted as a strategy to augment access to liver transplantation at our institution. Specific educational materials, consent forms, and selection processes were developed to facilitate LPE. From 2019 through October 2023, our center performed 11 LPEs, resulting in 23 living donor liver transplant pairs. The series included several types of LPE: those combining complementary incompatible pairs, the inclusion of compatible pairs to overcome incompatibility, and the use of altruistic nondirected donors to initiate chains. These exchanges facilitated transplantation for 23 recipients, including 1 pediatric patient. LPE improved access to liver transplantation at our institution. The ethical application of LPE includes tailored patient education, assessment and disclosure of exchange balance, mitigation of risk, and maximization of benefit for donors and recipients.

National survey of second opinions for hospitalized patients in need of liver transplantation

Decisions about patient candidacy for liver transplant (LT) can mean the difference between life and death. We surveyed LT centers across the United States to assess their perceptions of and barriers to second-opinion referrals for inpatients declined for transplant. The medical and surgical directors of 100 unique US LT programs that had done >20 LTs in 2021 were surveyed with a 33-item questionnaire including both multiple-choice and free-response questions. The response rate was 60% (60 LT centers) and included 28 larger-volume ( ≥100 LTs in 2021) and 32 smaller-volume (<100 LTs in 2021) programs. The top 3 reasons for inpatient denial for LT included lack of social support (21%), physical frailty (20%), and inadequate remission duration from alcohol use (11%). Twenty-five percent of the programs reported "frequently" facilitating a second opinion for a declined inpatient, 52% of the programs reported "sometimes" doing so, and 7% of the programs reported never doing so. One hundred percent of the programs reported that they receive referrals for second opinions. Twenty-five percent of the programs reported transplanting these referrals frequently (over 20% of the time). Neither program size nor program location statistically impacted the findings. When asked if centers would be in favor of standardizing the evaluation process, 38% of centers would be in favor, 39% would be opposed, and 23% were unsure. The practices and perceptions of second opinions for hospitalized patients evaluated for LT varied widely across the United States. Opportunities exist to improve equity in LT but must consider maintaining individual program autonomy.

Practice patterns and considerations in liver transplantation from living donors with high BMI: A review

Living Donor Liver Transplantation (LDLT) is a valuable solution to the shortage of donor organs for patients with end-stage liver disease. However, the eligibility of obese donors for LDLT remains a subject of debate. This literature review explores global practices and perceptions of LDLT, identifies donor eligibility criteria, and discusses special considerations and ethical caveats. The review highlights the need for standardized guidelines for donor selection, considering the global distribution of Body mass index and variations in population-specific criteria. It also emphasizes the importance of non-invasive testing and pre-operative optimization of liver steatosis for select obese donors. Furthermore, the review examines the outcomes and complications associated with obese donors in LDLT. The findings of this review contribute to the ongoing discussion on the inclusion of obese donors in LDLT and provide insights for future research and guideline development.

A survey of transplant providers regarding attitudes, barriers, and facilitators to living donor liver transplantation in the United States

INTRODUCTION

A successful living donor liver transplant (LDLT) is the culmination of a multifaceted process coordinated among key stakeholders.

METHODS

We conducted an electronic survey of US liver transplant (LT) centers (August 26, 2021-October 10, 2021) regarding attitudes, barriers, and facilitators of LDLT to learn how to expand LDLT safely and effectively in preparation for the American Society of Transplantation Living Donor Liver Transplant Consensus Conference.

RESULTS

Responses were received from staff at 58 programs (40.1% of US LT centers). There is interest in broadening LDLT (100% of LDLT centers, 66.7% of non-LDLT centers) with high level of agreement that LDLT mitigates donor shortage (93.3% of respondents) and that it should be offered to all suitable candidates (87.5% of respondents), though LDLT was less often endorsed as the best first option (29.5% of respondents). Key barriers at non-LDLT centers were institutional factors and surgical expertise, whereas those at LDLT centers focused on waitlist candidate and donor factors. Heterogeneity in candidate selection for LDLT, candidate reluctance to pursue LDLT, high donor exclusion rate, and disparities in access were important barriers.

CONCLUSION

Findings from this study may help guide current and future expansion of LDLT more efficiently in the US. These efforts require clear and cohesive messaging regarding LDLT benefits, engagement of the public community, and dedicated resources to equitably increase LDLT access.

Innovative Technique Avoiding Bleeding After Reperfusion in Living Donor Liver Transplant Using a Modified Right Lobe Graft

BACKGROUND

Living donor liver transplant (LDLT) is a valuable therapeutic option for overcoming the deceased donor shortage. Modified right lobe graft (MRLG) keeps the middle hepatic vein (MHV) trunk with the remnant liver to improve donor safety. Hemostasis in the MHV tributary reconstruction can be tricky; surgical stitches and energy coagulation are ineffective. Fibrin glues are excellent vascular sealants but are poor in maintaining hemostasis in an active hemorrhage or preventing resection surface-related complications after liver resection. We propose applying fibrin sealant during back table graft preparation to seal the hepatic edge and MHV reconstruction to avoid bleeding after graft revascularization.

METHODS

Our retrospective cohort study included all adult patients undergoing LDLT between August 2017 and December 2021. During the back table procedure, we performed the reconstruction of the inferior right hepatic vein and/or MHV tributaries from segment 5 (V5) and segment 8 (V8) using a vein harvested from a nonrelated deceased donor. Before initiating the hepatic graft implantation, we applied fibrin sealant in the resected parenchyma, especially in the V5 and V8 anastomosis, to seal the hepatic edge and hepatic vein reconstruction.

RESULTS

No bleeding was identified in the hepatic edge, and blood product transfusion was unnecessary for any recipients after reperfusion.

CONCLUSION

In LDLT using MRLG with MHV reconstruction, the fibrin sealant, when applied on the raw hepatic surface, and vascular reconstruction during back table graft preparation avoided bleeding after graft revascularization.