Samaritan donor interchange in living donor liver transplantation

Paired Exchange Living Donor Liver Transplantation: A Nine-year Experience From North India

BACKGROUND

Paired exchange liver transplantation is an evolving strategy to overcome ABO blood group incompatibility and other barriers such as inadequate graft-to-recipient weight ratio and low remnant liver volume in donors. However, for the transplant team to carry 4 major operations simultaneously is a Herculean effort. We analyzed our experience with liver paired exchange (LPE) program over the past 9 y.

METHODS

This prospective study included 34 of 2340 (1.45%) living donor liver transplantations performed between May 2012 and April 2021. The reason for LPE was ABO incompatibility in all (n = 34) patients included in the study. After donor reassignment through 2-by-2 paired exchange with directed donors, the ABO matching status changed from A to A (n = 17) and B to B (n = 17), which made all matches ABO-identical. Recipients (R) and donors (D) of each swap pair were prospectively divided into R1/D1 and R2/D2 groups for comparative and survival analyses.

RESULTS

The recipients (n = 34) had a median age of 45.5 y (11-59 y), and 31 were men. LPEs were performed in 4 operating rooms running simultaneously by 2 independent surgical teams. Donor survival was 100%. Baseline clinical and perioperative parameters, postoperative complications, median intensive care unit/hospital stay, and early deaths were comparable (P > 0.1) between the R1 and R2 groups. The median follow-up period was 27 mo (1-108 mo). The 30-d and 1-y survivals were 88.2% (n = 30) and 85.3% (n = 29), respectively.

CONCLUSIONS

Our experience suggests that with careful attention to ethical and logistical issues, the LPE program can expand the living donor liver pool and facilitate a greater number of living donor liver transplantations.

Global experience and perspective on anonymous nondirected live donation in living donor liver transplantation

Anonymous nondirected living liver donation (ANLLD), sometimes referred to as "altruistic" donation, occurs when a biologically unrelated person comes forward to donate a portion of his/her liver to a transplant candidate who is unknown to the donor. Here, we explore the current status of ANLLD with special consideration of published reports; US experience; impact on donor psychosocial outcomes; barriers to donation; and current global trends with respect to ethical considerations. Between 1998 and 2019, 105 anonymous nondirected living liver donor (ND-LLD) transplants have been documented in the US Scientific Registry of Transplant Recipients. Sixteen donors (15%) were reported to experience a postoperative complication. Currently, 89 donors remain alive (85%), 16 (15%) have unknown status, and none are confirmed deceased. Although there are only a handful of case series, these data suggest that ANLLD is a feasible option. While there are no liver-specific data, studies involving anonymous nondirected kidney donors suggest that anonymous donation does not adversely impact psychosocial outcomes in donors or recipients. There are substantial financial burdens and ethical considerations related to ANLLD. Further studies are required to assess donor demographics, psychosocial motivations, long-term health-related quality of life, and financial impact of ANLLD.