Progress in Transplantation

Living donor liver transplantation is an acceptable alternative for many patients awaiting a liver transplant. The benefits of living donor liver transplantation to the recipient are many; however, there is also an appreciable risk to the donor. Many people, including healthcare professionals, believe that living donor liver transplantation is not ethically justified because any risk to a donor outweighs the benefit to the recipient. Recent studies show adverse events in this population do not include only medical complications; any complication—medical, social, psychological, financial, or other—must be examined to analyze the true incidence of adverse outcomes in living liver donors.

Living donation is an increasingly common option offered to patients in most transplant programs. Staff involved in the education, assessment, and care of this patient group is faced with increasingly complicated assessments both medically and psychologically. Supporting arguments for dedicated care teams for living organ donors include the large number of transplantations performed using living donors, the continued need to promote living organ donation, and the growing complexity of both medical and psychological factors in donor assessments. In addition, there is a need to implement the standards proposed by the 2000 Consensus Group, as well as to develop a body of evidence-based research related both to short- and long-term issues for this patient group. The ethical issues related to simultaneous involvement with both donors and recipients, and a need to ensure confidentiality are additional supporting arguments for the need to provide separate care providers for donors and recipients.

We report a living related kidney donor incidentally found to have a renal cortical adenoma at nephrectomy. The patient is a 53-year-old man accepted for living related kidney donation. Predonation workup revealed a solitary left renal artery and, on the right kidney, a main artery with a small accessory artery in the upper pole. No other abnormalities were found in the medical history, physical examination, or laboratory and radiological studies. A left laparoscopic nephrectomy was planned. However, during dissection of the upper pole, a 5-mm mass was noted. The nephrectomy was completed, and the organ was preserved in cold University of Wisconsin solution. Permanent section histology showed that the lesion was mostly likely a renal cortical adenoma. As the risk of malignant transformation with immunosuppression could not be adequately determined, the kidney was not transplanted into the recipient. The donor elected not to have the kidney replaced, and the organ was discarded.

Psychosocial evaluation of potential organ donors ensures that these patients are prepared for donation and that their psychosocial issues have been addressed. The determination that the decision to donate an organ has been made voluntarily by a competent individual is a primary concern for living donor transplant programs, which must work to the highest ethical standard in this unique area of medicine. Identification of potential vulnerabilities on the part of the donor permits monitoring and/or intercession both before and after donation. Ensuring the confidentiality of patient information is important and represents a cornerstone of social work practice. At our institution, social workers have developed an electronic recording tool for use in evaluating organ donors; this tool is designed to maximize quality and ease of information gathering, ensure standardization of practice across programs, simplify record keeping, and enhance communication while minimizing time investment and ensuring patient confidentiality.

Living donor kidney transplantation comprises approximately 30% of kidney transplantations in the United States and is an effective form of renal replacement therapy, with low risk to the donor. Twenty percent of living donors do not have a genetic relationship with their recipients. In the selection of living donors, guiding ethical principles include altruism, the absence of coercion or monetary reward, patient autonomy, beneficence, and nonmaleficence. In order for the benefit of living donor kidney transplantation to outweigh the risk, evidence that the proposed recipient will care for the transplanted organ must exist. Nonadherence to treatment has been identified as a major risk factor for graft rejection. When nonadherence to treatment regimens leads to loss of the graft, the consequences are felt by the recipient, donor, and the treatment team. The decision to transplant an organ to a noncompliant patient from a cadaveric or a living donor raises issues of patient autonomy, justice, paternalism, and benevolence versus nonmaleficence.

As a result of the cadaveric organ shortage, the number of centers performing living donor liver transplantation has increased. Living donor liver transplantation provides immediate organ availability and avoids the risk of life-threatening complications that occur with long waiting times for cadaveric organs; however, it puts a healthy person at risk for little personal gain. A standardized approach to donor evaluation ensures safety to potential donors. Careful medical (physical examination as well as laboratory and radiological evaluation) and psychological evaluation is imperative to reduce donor complications and ensure good outcomes in recipients. A social worker and psychiatrist assess for mental competency, provide emotional support, and can serve as independent donor advocates. Informed understanding and consent are crucial aspects of the evaluation and include ensuring that the donor understands all potential complications and is free of coercion. Safety of the donor must be the highest priority.

The shortage of cadaveric organs and increased success of living donor transplantation support the use of living organ donors. Clinical social workers have the opportunity to explore a variety of donor-specific issues when performing psychosocial evaluations of living donors, including motivation, psychological stability, and personal and family consequences of donation, as well as the direct and indirect financial consequences faced by living donors. Although most donor-related medical costs are covered, other associated expenses are not reimbursable and may put donors at risk for financial hardship. Out-of-pocket expenses also serve as a disincentive to donate for some volunteers. During the evaluation process, healthcare professionals should openly discuss how surgery, recovery, and any potential complications might impact prospective donors' financial situation. Donors can then decide whether they are able to realistically handle the costs of donation. We present the financial dilemmas experienced by many living donors and highlight efforts that have been made to deal with them.

Although living kidney donors' experiences with donation have been studied, questions of potential bias in retrospective donor reports remain. This study examined the experience of living kidney donation from 3 perspectives: those of the donor, the recipient, and a third party involved with the donation (ie, a donor triad). Surveys were completed with 174 donor triads to examine triad members' perceptions of donors' concerns before transplantation, whether these concerns came true after transplantation, the donors' experiences with surgery and recovery, and whether they would make the same decision again today. Triad members all agreed that donors were highly satisfied with their donation experience and that the relationship between recipient and donor improved after transplantation. Although recipients and third parties correctly identified the donors' primary concerns, they underestimated the prevalence of 16 of 18 donor concerns, including the donors' willingness to make the same decision again. Recipients also overestimated how painful and difficult the surgery and recovery were for donors. The results suggest that retrospective studies of donors may not be marred by significant misreporting or memory biases and that better education about the donation experience for the entire donor triad might provide better social support for donors, reduce recipients' guilt about donors' pain, and increase donation rates overall.

This case study describes a domino liver transplantation in which a patient with familial amyloid polyneuropathy received a cadaveric liver, and the explanted liver was in turn transplanted into a second recipient. Familial amyloid polyneuropathy is an autosomal dominant inherited disease associated with a mutant form of the protein transthyretin. Liver transplantation is the only definitive treatment for this disease. Transplantation removes the source of mutant transthyretin, halts the progression of this otherwise fatal disease, and significantly palliates many underlying symptoms. This case study illustrates that domino transplantation is a practical option to provide a liver transplant for a patient with this disease and a second listed patient from a single cadaveric liver organ, thus alleviating the organ donor shortage. Transplantation offers the only cure for the genetic defect that causes familial amyloid polyneuropathy, appears to result in subjective and objective improvement in neurological function, and eliminates the mortality associated with the disease. A signed informed consent was provided for publication of this case study.