Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Cofusing mortality rate
- Deborah J Verran (19 September 2003)
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Operating on healthy people to remove parts of their livers
- David W Evans (19 September 2003)
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Re: Operating on healthy people to remove parts of their livers
- Innes Reid (19 September 2003)
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living liver donation.
- manan vasenwala (19 September 2003)
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Living Liver Donation - Now
- Roger S Williams (23 September 2003)
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Living Donor Transplantation and the Ends of Medicine
- Michael Potts (26 September 2003)
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Error in summary points
- jane e. young (10 October 2003)
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Reply to paper
- Nigel Heaton (21 November 2003)
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Deborah J Verran, Transplant Surgeon Royal Prince Alfred HospitalSydney, NSW 2050 Australia
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This is an execellent article putting forward the case for adult living donor liver transplantation to be adopted by liver transplant centers within the United Kingdom. However there is an error in the summary points with respect to what the mortality rate is for the adult living liver donor. This could confuse readers of the article. The statement'The risk of mortality to donors is 40-60%(an incorrect figure) and mortality is 0.5-1%(the correct figure). This needs to be rectified. Deborah Verran Competing interests: None declared |
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David W Evans, Retired physician 27 Gough Way, Cambridge, CB3 9LN
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How do the surgeons who perform these operations, which carry inevitable morbidity and some risk of mortality, square their actions with the fundamental "first do no harm" principle of good medical practice? Competing interests: None declared |
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Innes Reid, Researcher University of Leeds. LS2 9JT
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Consider the surgeon who refuses to perform this operation because it will harm the healthy patient. The result is that the healthy patient's close relative could die for want of a transplant. Has any harm occurred? Clearly it has. The question of whether it is the surgeon through their inaction who bears any responsibility for this harm is not easy to answer. But the question about how some surgeons might find it in themselves to "harm" healthy people, is. Competing interests: None declared |
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manan vasenwala, consultant-cardiologist (non-invasive) k.k.heart center, aligarh-202002.india
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this is an excellent article on the subject. several points mentioned needs to be highlighted. unlike the kidney donor who looses one of pair of kidneys, the same is not true here. if the right lobe of liver is removed, it will regenerate within 12months time. thus the donor, as i understand, will not be disadvantaged as in case of the kidney donor. the second point is the mortality and morbidity mentioned being higher than renal transplantation. i suppose this is technical and with greater experience it is likely to come down.also the surgery is a major one to start with. the ethical questions raised are similar to renal transplantation, but still merits further debate. Competing interests: None declared |
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Roger S Williams, Director, Institute of Hepatology, UCL Institute of Hepatology, UCL, 69 - 75 Chenies Mews, London WC1E 6HX
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James Neuberger and David Price make a good case that living liver donation should be available on the NHS and you might well ask why this is taking so long when the procedure has been used so widely over the past five years. There is certainly a need for more liver transplants as the figures quoted in their paper for 2002 show - 62 deaths on the waiting list and another 25 removed from it because they had become too ill. The waiting list for recipients requiring blood group O cadaver organs in some transplant centres is now around 12 months – surely an unacceptable wait. The UK transplant rate is already one of the lowest in the West and there is no evidence that the burden of liver disease is lower. Indeed the CMO in his Annual Report two years ago drew attention to the substantial and very worrying increase in the number of deaths from cirrhosis in males of working age. Cases may not be referred for a variety of reasons. Eligibility criteria are strict and many believe it is reasonable that these should be relaxed in the context of living liver donation. The small number of transplant centres in this country also perpetuates the myth that liver transplantation is a very difficult and expensive procedure, whereas in many countries elective grafting with cadaver organs has become almost a routine procedure. As to a full public debate being required, there have been dozens of meetings and publications on the results and ethics of living liver donation. Of course the necessary safeguards have to be in place for the donor. The Japanese reported in a recent paper in the Lancet, a 12.4% rate for operative morbidity among 1841 living liver donors from 46 transplant centres (1). After completion of the survey there was one death in a donor from liver failure and I know of three others in Europe and the USA. But there is also the view that psychologically and socially, relatives can benefit from the donation. Undoubtedly donation of the right lobe is a more major procedure for the donor than that of the left lobe, which was favoured initially in Japan. For the larger sized patients of the West it is considered that only a right lobe graft can give the recipient sufficient liver mass for recovery. Nevertheless the ‘small for size’ syndrome of liver deficiency in the recipient, when a smaller left lobe graft is implanted, has been shown to be at least partly related to the high portal bloodflow inflow and when this is reduced surgically the function of smaller grafts is considerably better. Finally, Neuberger and Price refer to a ‘few’ liver transplants having been done in the UK. In fact in the programme at the Cromwell Hospital, which I started in October 1998 with Mr.Nigel Heaton, Mr.Mohamed Rela and the King’s College Hospital surgical team, we have now treated 17 patients. Recipient survival is 77% and there have been no major complications in the donors. It was set up for overseas patients because of the time they were having to wait for a cadaver organ graft, being low down in the priority list and with many of them dying before a graft becomes available. Professor Roger Williams, CBE
References: 1. Surman, OS, Hertl, M. Liver donation: donor safety comes first. Commentary, The Lancet, August 30 2003;362:674 2. Williams, RS, Alisa, AA, Karani, JB, Muiesan, P, Rela, MS, Heaton, ND. Adult to adult living donor liver transplant: UK experience.Eur.J of Gastroenterology & Hepatology, 2003;15:1 Competing interests: Director of the Living Donor Liver Transplant Programme at the Cromwell Hospital, London |
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Michael Potts, Head, Philosophy and Religion Department Methodist College, Fayetteville, North Carolina, USA 28311
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Neuberger and Price admit that there is a significant morbidity and an up to 1% mortality among living liver donors. They argue that a combination of the potential benefits to the recipient, the right of donors to make an altruistic decision to help someone else, an acceptable “societal ceiling” concerning mortality and morbidity, and an acceptable risk-benefit ratio, are sufficient for living liver donation to be morally acceptable. However, the fundamental goals of medicine, without which medicine could not exist as a practice, are more important than either the notion of patient autonomy or a utilitarian “cost-benefit” analysis. The fundamental end of medicine is to help an individual sick or injured patient; from this prime goal stem the principles of nonmaleficence, “do no harm,” and beneficence, “benefit the patient.” The surgery to remove a portion of a healthy person’s liver may indeed benefit the recipient, but at considerable risk to the donor’s health, with some risk to the donor’s life. The surgery is not for the benefit of the donor’s health; the surgery can only cause bodily harm to an individual who would have remained healthy otherwise. This violates both the ends of helping this individual patient and not harming this individual patient. Utilitarian considerations, such as the benefit to the recipient or even the potential satisfaction of the donor should the transplant be successful with minimal complications to both parties, do not change this fact. Neither does the principle of patient autonomy, which is not an absolute right (as Neuberger and Price themselves recognize), but is valid insofar as it fits into the fundamental goal of medicine to help an individual patient in need. Since surgery on the donor does not benefit the health of that individual patient, and is potentially harmful, it violates both the principles of beneficence and autonomy, and should not be considered a morally acceptable part of the practice of medicine. Competing interests: None declared |
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jane e. young, gpr The surgery, 53 borough street castledonington de742lb
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Presumably morbidity (not mortality) is 40-60%. I am slightly concerned for patients contemplating this procedure otherwise. Competing interests: None declared |
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Nigel Heaton, Consultant Surgeon/Honoary Senior Lecturer SE5 9RS
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Dear Sir We welcome the article advocating living donation of the liver which follows on from a meeting of interested parties in January at which we presented the United Kingdom experience of 56 cases performed by the King’s surgical team (one adult case has been performed by The Royal Free). The article states that there is no NHS living liver donation, however, there has been an NHS living related liver paediatric transplant programme for the past 10 years at King’s College Hospital. We perform 3-4 living related liver transplant per year in children and this followed a successful initial pilot of 5 NHS cases. The pilot programme was approved both by the Department of Health and United Kingdom Transplant Support Services Authority in 1993. There has been no scope for the program to expand further because of the continuing success of split liver transplantation, using the left lateral segment and the right lobe, which has significantly reduced waiting lists for children without compromising the adult donor pool. Currently the King’s team, either at King’s or at the Cromwell Hospital has performed 57 living related transplants including 20 right, 2 left and 36 left lateral segment grafts. We plan to continue both paediatric and adult programmes of living related liver transplantation according to our well-established protocols. What requires emphasis is that the ethics, risks of donation, and recipient outcome between paediatric and adult living transplantation are very different and need to be considered separately. In left lateral segment transplantation (living adult liver transplantation to child) the donors are invariably parents, donating only 20 – 25% of their liver mass, significant morbidity is approximately 5% and the risk of donor death is currently 0.1.%. The bile duct is divided at the level of the left hepatic duct, which has a relatively long course and can be divided well away from the hilum. The child recipient gets a `normal’ or appropriate sized liver with satisfactory vessels for anastamosis and the long-term outcome is excellent (97% 3 year recipient survival at King’s College Hospital). The contrast with adult living transplantation is that donation is more commonly from a sibling or child with different ethical implications. As the authors point out the risks are greater for right lobe donation, with an estimated mortality of approximately 0.5%, and morbidity of 20 – 25%. In addition, the recipient of the right lobe is placed at a potential disadvantage in receiving a graft weighing approximately 650g, and current graft survival is approximately 70% at 1 year, inferior to that observed for cadaveric whole livers. Biliary complications occur in 10 – 40% of recipients and also play a part in the increased graft loss observed and prolonged hospital stay associated with this procedure. Studies of donor and recipient suitability suggest that only 15% of cases currently on the waiting list in the U.S.A. for cadaveric transplantation will be suitable for living donation. Adult living donation accounted for only 5% of adult liver transplantation in USA in 2002. The number of living donations had reduced from a peak of enthusiasm in 2001. Whilst living donation should play a role in supplementing cadaveric donation and possibly extending the indications for transplantation, greater efforts should be directed towards increasing cadaveric donation – both heart beating and non-heart beating. If we as a nation donated to the same extent as in Spain, the availability of liver grafts would at least be double if not treble the current numbers. Public, healthcare and political interests need to be directed to making this a reality. Splitting of livers into right and left lobe grafts to transplant two adults could also have an impact – but as with living donation at the expense of lower recipient survival rates. Yours sincerely Nigel Heaton
Competing interests: None declared |
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