Role of living liver donation in the United Kingdom
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7416.676 (Published 18 September 2003) Cite this as: BMJ 2003;327:676
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Director of the Institute of Hepatology, University College London
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Reply to paper
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
Consultant Surgeon
Liver Transplantation & Hepatobiliary/Pancreatic Surgery
Competing interests:
None declared
Competing interests: No competing interests