Living Partial-liver Lobe Transplantation

Abstract: Living-donor versus Non-living-donor in Liver Transplantation

What is the viability of continuing partial-liver lobe transplants (PLLT) from the living donors taking into consideration the scarcity of quality brain-dead liver organs and the ethics behind the living donation process? This procedure could have a significant impact on liver transplantation in the United States because it provides a greater pool of opportunity for end-stage liver failure patients to receive a transplant that could extend their life span and enhance quality of life. Yet, simultaneously, this procedure is marked by many ethical concerns for the donor.

The regenerative properties of the liver were known by the Greeks over 2,500 years ago, but it wasn’t until 1987 that PLLT was first attempted. The first successful PLLT was in 1987 in Australia as an initiative to benefit children and used the left lateral segment containing 20% of the adult liver (Florman, et al 2006). In Japan, approximately 99% of liver donors were living, and as this operation was proved viable it was attempted in adults in the United States during the mid nineties (Jabbour 2004). Yet the racial difference in body size and mass complicated the liver regeneration and functioning, therefore medical teams began using the right lobe about 1997 (Jabbour 2004). As of December 2007, 3522 PLLT have been performed.

The main issue relating to successful transplantation is to ensure the graft given to the recipient is large enough to maintain proper blood flow in order to achieve full functioning and regeneration (Jabbour 2004). The liver is anatomically divided into eight segments, where three different grafts can be formed for liver transplantation (Florman, et al 2006). Donor assessments includes blood and HLA typing, liver biopsy, compatibility of hepatic artery size through anteriograms, and testing liver size through Chromotagraphy (CT) Scan (Abougergi, et al 2006). When liver graft is sufficient and transplant is successful, near-complete regeneration and functioning of the liver returns in 1-2 weeks while the patient remains in the hospital (Florman, 2006).

The main argument in favor of PLLT involves gaining additional transplant resources for end-stage liver failure patients. PLLT grants more opportunities for patients suffering from liver failure to embrace a healthier lifestyle. Split-liver (cadaver) and whole liver (cadaver) transplantable organs are not plentiful enough to supply the liver-organ demand, and partial-liver lobe donors would increase the availability. Recipients have the advantage of receiving a liver transplant as soon as diagnosed with end-stage liver failure, which also prevents the body from experiencing further deterioration. Ischemia time is minimized and the liver received is of better quality coming from a healthy, living donor (Jabbour, 2004).

The main argument against PLLT is the experience of the donor during the donation process and recovery. To compromise the life of a healthy individual to save the life of an end-stage liver failure patient has its ethical concerns. The informed consent from patient may be motivated by obligation and a sense of duty to relative or friend, especially in an emergency situation. The donor is affected by the surgery recovery time, which involves on average one to two weeks of hospitalization and several more weeks for regaining pre-donation health (Florman, et al 2006). There are several potential medical complications for donor, including difficulties regenerating the liver, blood clotting, bile-duct blockage or leakage, and severe scarring of the abdominal wall and skin. Also, the procedure of PLLT is more costly than cadaver liver donation (Abougergi, et al 2006).

The PLLT has a significant and direct impact on the nursing practice. Nurses need to consider the ethnicity and culture of the patients when approaching the topic of assigning a liver donor, considering factors that affect potential donor decision (Abougergi, et al 2006). They must provide emotional support to both recipient and donor during the process and have sensitivity toward donor obligation and recipient guilt. Informed consent of the donor should be obtained only after being thoroughly explained by the nurse. Nurses must understand the psychosocial origins of the disease causing liver failure in the patient (Abougergi, et al 2006). Nurses should remain the patient advocate as well as the donor advocate in maintaining a neutral, unbiased help to both sides.

Further research needs to be conducted to prevent donor complications post-surgery focusing on correct graft sizing to enhance regeneration and functioning (Humar, et al 2004). Research should be conducted concerning the ethics of nonmaleficence towards the donor and recipient, focusing on the psychiatric state of donors in post-operation. UNOS needs to regulate the PLLT testing process for quality control between transplant centers (Brown, et al 2003). Also, improved cadaveric donation to minimize the need for PLLT altogether, including more public education conducted by UNOS.

-Rachel Streams and Kaitlin Rich