ILTS 2016: Professor John O’Grady (Kings College Hospital, London) and Professor Sung-Gyu Lee (Ulsan University Medical School, Seoul, Korea) discuss their key messages in LDLT for the UK transplant community. Also included associated article entitled 'Done correctly, living donation success is possible'

Done correctly, living donation success is possible
by Thomas R. Collins
Life expectancy and quality of life measures tend to be quite high among live liver donors, generally very similar to those in the general population.
Namjoon Yi, MD, PhD, Assistant Professor of Surgery at Seoul National University College of Medicine, reviewed data on donors that could be encouraging to centres considering an expansion of the living-donor procedure, which is far less common in Western transplant centres than those in the east.
In South Korea, life expectancy for men in the general population is 79 years and for women is 85.5 years, with cancers and circulatory problems the main causes of death, as is true for much of the world. According to the Korean Network for Organ Sharing, life expectancy for live donors is not far off, with about 78% of female donors living to at least age 80 and 57% of male donors living to at least 80.
A huge survey, published in 2013, found that mortality was very rare among live donors, with just 15 donor deaths reported, 8 of which occurred more than 60 days after transplant. The deaths, the survey found, were not only associated with surgery. There were also 4 suicides and 2 cases of lung cancer, through the surveying centres’ follow-up periods, which for some extended out at least 6 years. It could not be determined whether these were at all related to the transplantation.
But that doesn’t mean complications aren’t common. A 2012 study of 740 donors found that complications were experienced in 40% of cases, with 19% experiencing more than one. Researchers found that the complication types varied widely, Dr. Yi said.
Studies have found that the physical quality of life for donors is similar to that of the general population, but is generally below pre-operation levels.
The success with living donation at Seoul National has been the product of fine-tuning over time. A 2004 study surprised researchers when 6.5% of living donors reported that they felt regret at having been a donor; 15% felt coerced; and about half reported feeling at least some distress due to their body image because of scarring.
“It was a shock to our team,” Dr. Yi said.
That prompted more intensive psychological screening of patients. And shortly thereafter the centre began performing minimally invasive surgeries, with better satisfaction reported by donors and no adverse effects on the procedure itself.

Charles Miller, MD, Director of Liver Transplantation at Cleveland Clinic, said that living donor procedures, while a practice that is generally well-supported among transplant centres, can become a firestorm should a donor die, and should be used ideally under certain conditions. If a tragic event occurs, it can cause the whole transplant community to pull back from living donation, particularly in the West.
He has personal experience, having been forced out of a job at his previous centre after the death of a living liver donor. He emphasized the need to have a “disaster plan” in place and to have a formal spokesperson to handle communications in the aftermath of a death.
He offered an encouraging view of the prospects for living donor donation, but said they are best done in a “well-resourced program in a financially secure and politically stable institution.” He also said they should be done only in an environment of real patient need and by “experienced and collegial team members that are intellectually committed to the growth and development of the field.”

Arvinder Soin, MD, Chief Hepatobiliary and Liver Transplant Surgeon at the Medanta Institute of Liver Transplantation and Regenerative Medicine in India, said the most important risk factors to consider are inexperience of a surgeon or a centre, donor age of 50 or higher; steatosis, metabolic syndrome and smoking. While using the right lobe is a bigger risk to the donor, this risk can be mitigated in experienced centre, he said.
“Liver biopsy is safe” and should be used fairly frequently, he added, with “low threshold to assess risk better.”
 
References
Cheah YL, Simpson, MA, Pomposelli JJ, et al. Incidence of death and potentially life-threatening near-miss events in living donor hepatic lobectomy: a world-wide survey. Liver Transpl. 2013 May;19(5):499-506.
Suh W, Lee KW, Choi Y, et al. Clinical outcomes of and patient satisfaction with different incision methods for donor hepatectomy in livingdonor liver transplantation. 2015 Jan;21(1):72-8