Clinical Correlate #2 . Organ donation
Study questions:
1. How many persons in the US might be candidates for liver transplanation and how many livers are available?
2. What ethical issues arise with retransplantation?
3. Why is retransplantation a poor option for HCV-infected patients?
4. What is altruism? What obligations does the individual have to his friends and family? Are there limits to one’s obligations? Read the article on Kravinsky to enhance your discussion.
Reference Texts
A. Clin Liver Dis. 2003 Aug;7(3):615-29.
To transplant or not to transplant recurrent hepatitis C and liver failure.
Forman LM.
Division of Gastroenterology, and Hepatology, University of Colorado Health Sciences Center, 4200 East Ninth Avenue B-154, Denver, Colorado, CO 80262, USA. lisa.forman@UCHSC.edu
Ten % of liver transplants are re-transplantation procedures. Retransplantation involves increased resource use and the outcomes are less favorable than with primary liver transplantation. All HCV-infected persons who have received liver transplants will experience reinfection of their liver, and the longer they survive, the more inevitably the infection will occur. Survival is worse for HCV-positive patients who have had retransplantation than for uninfected persons, regardless of why retransplantion was indicated, with 57-65% HCV positive patients surviving compaed with 65-82% HCV-negative patients. Death is most commonly caused by sepsis, multi-organ failure and is not necessarily caused by HCV recurrence. However, reinfection from HCV may be accelerated in the second transplant. Preoperative serum bilirubin and creatinine influence outcomes and can help select out patients who are likely to have better survival. Better outcomes may also be achieved by using living donor livers, but this brings in a whole new problem. As the authors state:
"With the donor morbidity and mortality associated with LRLT currently estimated at 32% and 0.3%, respectively, one must determine how much risk is acceptable to the donor in relation to the outcome in the recipient." A major advantage of using liver donors would be not to siphon off the limited supply of cadaveric livers to do retransplantation from patients who are awaiting primary transplant. One way of adjudicating the ethical question of allocating resources would be to let those HCV-infected persons who first receiving a living donor liver be eligible for a cadaveric liver. In other words, the rule would be everyone is eligible for one cadaveric liver and no more. HCV-infection is resulting in increased case numbers of cirrhosis, while available cadaveric livers are scarce, so finding ways to improve survival after transplantation in HCV-infected persons should be an important focus of research. Knowing which candidates have higher survival potential is also important. Meanwhile, using combination antiviral therapy and newer immunosuppressive agents such as sirolimus and mycophenolate mofetil, preemptive antiviral therapy on HCV eradication and fibrosis modification may be helpful. Retransplantation should be reserved highly selected patients, whose bilirubin is controlled and who have not experienced renal failure.
B. Russo MW, Brown RS Ethical issues in living donor liver transplantation.Jr.Curr Gastroenterol Rep. 2003 Feb;5(1):26-30.
Center for Liver Disease and Transplantation, Columbia Presbyterian Medical Center, 622 West 168th Street, PH 14, New York, NY 10032, USA.
The cadaveric organ shortage and the high mortality rate while patients wait for an organ have driven the medical community to develop alternative strategies for treating patients with end-stage liver disease. Adult living donor liver transplantation (ALDT) has evolved in response to the cadaveric organ shortage. Although there are benefits for recipients of ALDT, donors may incur substantial risk, including death. In contrast to pediatric living donation, in which the left lateral segment of the liver is resected from a donor, ALDT generally requires right hepatectomy, which is associated with greater morbidity and mortality. Because ALDT places a healthy individual at risk for substantial morbidity and mortality, debate over the ethics of this procedure is ongoing. Two donor deaths have occurred in the United States, adding to the concern over donor safety. Despite the risks associated with ALDT, many individuals elect to proceed with living donation with the hope of improving the life of a relative or friend. When considering whether we as a society should support and encourage ALDT, we should examine the perspective of the donor, recipient, and medical community as well. The medical community has an obligation to study carefully the risks and outcomes associated with ALDT so that we can deliver the highest quality of care that is not at the expense of healthy individuals.
C. This is a review article. Use your library to access the full text. The links bring you to the reference as well as to articles that have subsequently been published which have cited the review. N Engl J Med. 2002 Apr 4;346(14):1038.
http://content.nejm.org/cgi/content/extract/347/8/615-a
Letter: N Engl J Med. 2002 Aug 22;347(8):615-8; author reply 615-8