Ethical considerations in live donor transplantation: should complications be tolerated?

A systematic review of the factors significantly influencing the quality of life of living liver donors

Objectives

This systematic review aimed to synthesize the literature on factors influencing the quality of life in living liver donors post-donation and to provide a reference for developing targeted interventions in clinical practice.

Methods

A systematic search guided by the PRISMA 2020 approach was performed on specific databases: PubMed, EMBASE, CINHAL with full text, Web of Science, and ProQuest Dissertations & Theses databases. Peer-reviewed articles published in English from inception to October 2022 covering cross-sectional studies and longitudinal studies on factors affecting the quality of life of living liver donors after donation were included in this systematic review. The methodological quality of the studies was examined using a modified version of the National Institutes of Health Quality Assessment Tool.

Results

A total of 6,576 studies were retrieved, and 16 eligible studies were finally included. Four types of independent influencing factors: sociodemographic (gender, donor age, education, ethnicity, and marital status), donation-related (length of hospital stay and number of hospitalizations/hospital visits related to donation surgery, recipient outcome, time from donation, complications, donation decision, ambivalence about donating, donor-recipient relationship), health-related (body mass index and pre-donation physical symptoms), and psychosocial (pre-donation physical and mental score, household income, anxiety, depression), were extracted from the included studies. Several studies consistently identified old age, recipient death, recent donation, postoperative complications experienced by donors, and donor concerns about their well-being as negative influencing factors on physical function. Female donors, low education levels, longer hospital stays, and/or more hospital visits due to donation, poor recipient outcome, recent donation, pre-donation concerns regarding their well-being, and first-degree relative and spouse/partner donors were reported in several studies as negative predictors for psychological status. Factors affecting social function were considered by only two included articles.

Conclusions

The quality of life of living liver donors could be affected by both donation surgery and psychosocial factors. Based on the above-influencing factors, clinical nurses can develop targeted interventions to improve the quality of life of living liver donors.

Right lobe living-donor hepatectomy-the Toronto approach, tips and tricks

Living-donor liver transplantation (LDLT) is a well-established treatment for end-stage liver disease. Nevertheless, it has not been extensively accepted in North America or Europe as it has been in Asia. At the University of Toronto we initiated our LDLT program in 2000 and since then our program has grown each year, representing today the largest LDLT program in North America. Our right-lobe LDLT experience from 2000-2014 includes 474 right lobes. Only 30% of our grafts have included the middle hepatic vein. We present excellent outcomes in terms of graft and patient survival which is not different to that achieved with deceased donor liver transplantation. In the present study we will discuss the evolution, challenges and current practices of our LDLT program. We will discuss what is and has been the program philosophy. We will also discuss how we evaluate our donors and the extensive workup we do before a donor is accepted for live donation. Furthermore we will discuss some tips and tricks of how we perform the right hepatectomy for live donation.

Informed consent for live liver donors: A qualitative, prospective study

BACKGROUND & AIMS

Adult-to-adult live donor liver transplantation (LDLT) poses serious health risks and no direct health benefits to donors. Ensuring live donors' autonomy through informed consent is critical. We assessed live liver donors' (LD) comprehension, information needs, risk perceptions, and demographics.

METHODS

Semi-structured interviews were prospectively conducted with LDs after completing donor evaluation and informed consent at our transplant center. Likert scales measured informed consent domains. Open-ended responses underwent thematic analysis.

RESULTS

Thirty LDs participated (100% participation rate). Although 90% of LDs reported being informed about donation 'a great deal', only 66% reported understanding information about donation 'a great deal.' Many (40%) reported difficulty understanding medical terminology. Information LDs most desired to feel comfortable with their decision included: incidence and type of donor complications (67%), description of donation procedure (57%), and the process of donor preparation (43%). Most (83%) LDs rated risks to themselves as 'not at all' to 'somewhat' risky, and minimized these risks.

CONCLUSIONS

Although LDs perceived that they were adequately informed, their actual comprehension about donation was inadequate. Findings suggest the value of informed consent for preparation for the procedure and potential periprocedural risks rather than for decision-making. More comprehensible information disclosure may optimize informed consent.

Development of a Donor-Centered Approach to Risk Assessment: Rebalancing Nonmaleficence and Autonomy

Living kidney donors are often excluded from the shared decision making and patient-centered models that are advocated in medical practice. Thresholds for acceptable risk vary between transplant centers, and between clinicians and donors. Although donor selection committees commonly focus on medical risks, potential donors also consider nonmedical risks and burdens, which may alter their assessment of an acceptable level of medical risk. Thus, transplant centers may encounter ethical tensions between nonmaleficence and respect for donor autonomy. A donor-centered model of risk assessment and risk reconciliation would integrate the donor's values and preferences in a shared decision about their eligibility to donate. This paper argues for shifting to a donor-centered model of risk assessment, and presents a research agenda to facilitate the greater participation of donors in their own evaluation and approval processes.

Reclaiming their lives: the decision-making process in living liver donation--an interpretative phenomenological case study analysis of one couple

OBJECTIVES

Adult-to-adult living liver donation (LLD) is a controversial procedure due to the risk to the healthy donor. The decision to proceed with LLD is an important, yet under-researched area. This study aims to explore the decision-making process of the donor and recipient independently, and within the donor-recipient dyad.

DESIGN

A longitudinal, qualitative analysis of the LLD decision from the perspective of a LLD donor-recipient dyad.

METHODS

In-depth interviews were conducted with the donor and recipient separately on three occasions: pre LLD, six weeks post and six months post LLD. Transcripts were subject to interpretative phenomenological analysis.

RESULTS

During the pre-LLD interviews, a series of intra- and interpersonal negotiations were reported as both the donor and recipient grappled to make a decision about LLD. Following the decision, the focus then centred on the consequences of the decision and making sense of unanticipated outcomes. By six months post LLD, both were able to reflect on adapting to the changes their decision had ultimately caused.

CONCLUSIONS

This case study offers a unique insight into the risk assessment and decision-making demands of LLD and the results can help support future LLD candidates.