Quality of life and psychiatric complications after adult living donor liver transplantation

Authors


Abstract

We investigated the psychosocial effects of a right hepatectomy on donors for adult living donor liver transplantation (ALDLT). Questionnaires were sent to 66 actual donors, who had undergone ALDLT between August 1998 and September 2003, as well as to 139 potential donors, who had been examined as possible candidates for ALDLT; the latter had been excluded and had not undergone surgery. All actual donors reported full recovery within an average period of 14.41 (standard deviation = 8.86) weeks; all had returned to their preoperative employment. In preparation for ALDLT, they had received significantly more support from their families in the decision-making process than the potential donors had (t = 2.02; degree of freedom = 79; P = 0.047); they also felt better informed about donation than the potential donors (t = 2.04; df = 64; P = 0.045). Psychiatric problems occurred in 6 (14%) female donors in the perioperative period, mostly in connection with unrealistic outcome expectations. Donors with severe postoperative complications (n = 3) demonstrated higher scores of psychiatric symptoms (chi-square = 6.39; df = 2; P = 0.041). When we compared potential and actual donors, a significant difference in emotional quality of life was not demonstrated (t = 0.41; df = 76; P = 0.684), and it corresponded to that of the normative sample. For donors, perceived emotional quality of life did not depend on the course of recovery of the recipients. Six to 9 months after donation, potential donors reported a significantly higher physical quality of life than actual donors (t = 2.20; df = 56; P = 0.032). In conclusion, female donors, donors with their own major complications, or donors with unrealistic outcome expectations should be provided with adequate psychosocial care. With regard to the psychosocial outcome, ALDLT is a safe intervention for the donor. Liver Transpl 12:1782–1790, 2006. © 2006 AASLD.

The method of living liver donation was first developed as a method for overcoming the shortage of donations available for children by providing living liver donations from a family member.1 In recent years, a remarkable increase in adult living donor liver transplantation (ALDLT) could be observed, as approximately 10% of all liver transplants in the United States are ALDLTs.2 In Germany, of 976 liver transplants carried out in 2005, 78 (8%) involved pediatric and adult living liver donations.3

Little is known about psychosocial outcome and psychiatric complications after ALDLT. In a series of studies, donors had normal or above-normal values for quality of health measured with the Short Form (SF)-36 Health Survey after ALDLT.4–7 Diffuse abdominal symptoms,4, 5 sexual dysfunction,6 and abdominal pain8 have been reported after ALDLT. From a psychosomatic point of view, Walter et al.9 detected a subgroup of donors with higher values for anxious depression and higher overall complaints. Psychiatric symptom strain has not been measured, and clinical psychiatric complications have not been described regularly.

The goal of this single-center study was to research the psychosocial effects of a right hepatectomy on an adult living donor. We examined surgical complications of the recipient and the donor as possible stressors determining psychological distress on the donors. So-called potential donors, who were excluded from surgery for medical reasons,10 were observed as a control group to investigate additive stress factors due to physical complaints. The procedures of psychosocial selection at our institution are summarized in the appendix.

Abbreviations

ALDLT, adult living donor liver transplantation; SF, short form health survey; df, degree of freedom; t, t-value; BSI, brief symptom inventory.

PATIENTS AND METHODS

Included in this study were donor candidates (n = 205), who were evaluated for ALDLT in the Department of Visceral and Transplantation Surgery and were admitted to the Department for Psychosomatic Medicine (both located in Essen, Germany) between August 1998 and September 2003. Potential (n = 139) and actual donors (n = 66) subjected to psychosomatic evaluation for ALDLT (right hepatectomy), who had a good command of the German language and permanent-resident status in Germany, were included in the study.

All protocols of the survey were reviewed and approved by the medical faculty's ethics committee (approval number: 02-2030). During the donor evaluation process, all patients gave their written informed consent to participate in follow-up studies. Survey questionnaires were sent to donors 6 months after evaluation for living liver donation. Donors received a second letter after 4 weeks and were contacted by telephone after an additional 4 weeks. A full report of donors, who described psychiatric complaints in the perioperative period, was drawn up from the psychosomatic and the surgical records. Psychiatric diagnoses are reported according to the International Classification of Diseases (ICD-10).11

As research questions, we investigated differences between the actual and potential donors in the decision making process, psychiatric symptoms, and the quality of life 6 months after right lobectomy. In addition, we were interested in a possible influence of the recipients' or the donors' postoperative surgical complications on their quality of life, respectively. Finally, we investigated clinically relevant psychiatric symptoms emerging after a living related liver donation. Outcome parameters are defined as the degree of psychiatric symptoms, and physical and emotional quality of life.

Survey Questionnaires

The following standardized instruments were applied in addition to the demographic and medical parameters: SF-12 (Short Form SF-36 Health Survey, German version),12 and the Brief Symptom Inventory (BSI, German version),13 and The European Multicenter Study Transplantation of Organs from Living Donors (EUROTOLD) (German Version).7

The SF-3614 is a commonly used self-assessment questionnaire of the emotional, physical, and social aspects of quality of life often applied in the field of transplantation medicine. The short version, SF-12, is considered reliable and valid.

The BSI, which is the short form of the SCL-90-R15 is a questionnaire used to measure psychiatric symptoms. Subscales of BSI are somatization, compulsion, social phobia, depression, anxiety, aggression, phobia, paranoid ideation, and psychoticism. Validity and reliability are well established.

The EUROTOLD study16 was originally developed for kidney donors and has been revised to fit the demands of liver donors.7 The questionnaire includes 5-point Likert-scaled questions on the family relationship between donor and recipient, family problems, the decision-making process, occupational and financial aspects, and the extent of satisfaction with medical care. Potential donors received a revised version excluding questions focusing on transplant surgery.

Statistical Analysis

All statistical analyses were performed using SPSS Statistical Software for Windows, version 13.0 (SPSS Inc., Chicago, IL). To evaluate the differences between the groups of potential and actual donors, parametric tests (t test for independent samples) were carried out analogous to group size, level of scales, and distribution parameters. To analyze the samples' representativity and in the case of smaller samples, nonparametric procedures (chi-square test, Mann-Whitney U test and Kruskall-Wallis test) were applied. Spearman correlation tests were calculated. For all tests, a significance level of P = 0.05 was predetermined.

Patient Population

The patient population was comprised of actual donors (n = 42) and potential donors (n = 42. Actual donors are those subjected to both the physical burden of a surgical procedure and the preoperative and postoperative psychological burdens. Potential donors are family members who are excluded as donors due to medical and/or psychological reasons and therefore are not subjected to surgery. The primary burden for this group is the emotional connection with the course of the recipient's illness. They constitute a suitable control group for the emotional stress induced by transplant surgery.

RESULTS

Rate of Return

Actual donors (n = 42; 64 %) responded more often than potential donors (n = 42; 30.2%). Of the whole group (n = 205), 9 patients (4.3 %) were not accessible; the remaining donors did not respond, although they were repeatedly invited to do so.

Demographics and Group Differences

Taking the whole group (n = 205; 66 actual and 139 potential donors) into consideration, there were 2 significant demographic differences between the 2 groups: Actual donors had a higher social status with regard to education (chi-square = 10.56; degree of freedom = 3; P = 0.014) and employment rate (chi-square = 9.25; df = 1; P = 0.002), compared to the potential donors.

In Table 1, we focused on the donors who responded to our survey. In this sample, no significant differences according to the demographic aspects have been estimated. Respondent donor demographics are depicted in Tables 1 and 2.

Table 1. Demographics
 Potential donors (n = 42)Actual donors (n = 42)
Age39.02 years37.49 years
Gender22 male (52.4%)19 male (45%)
 20 female (47.6%)23 female (55%)
Family Status    
Single1535.7%1740.5%
Married2354.8%1740.5%
Separated/divorced37.1%716.6%
Widowed12.4%12.4%
Education    
Public school1740.5%1433.3%
High school1535.7%1023.8%
University qualification921.4%1740.5%
Without certificate12.4%12.4%
Professional Training    
apprenticeship2252.4%2661.9%
college of higher education/university716.7%1023.8%
without degree1023.8%49.5%
miscellaneous37.1%24.8%
Professional status    
employed3173.8%3481%
unemployed921.4%716.6%
pensioned24.8%12.4%
Table 2. Relationship to Recipient
Mother10 (23.8%)
Father7 (16.7%)
Spouse4 (9.5%)
Good friend4 (9.5%)
Wife4 (9.5%)
Brother3 (7%)
Stepfather2 (4.8%)
Uncle2 (4.8%)
Son2 (4.8%)
Sister1 (2.4%)
Brother-in-law1 (2.4%)
Niece1 (2.4%)
Cousin1 (2.4%)

Medical Parameters of the Recipients Provided With ALDLT

The following diagnoses were reported among the 42 recipients for whom ALDLT could be provided and who participated in the study: posthepatic cirrhosis (n = 12), liver malignancies (n = 12), cirrhosis of unknown cause (n = 5), alcoholic cirrhosis (n = 6), primary sclerosing cholangitis (n = 2), secondary sclerosing cholangitis (n = 2), primary biliary cirrhosis (n = 2), and metabolic disease (n = 1).

Surgical Complications

Surgical complications of the recipients

According to the Clavien classification17 of the medical outcome after liver transplantation, recipients were subdivided into 4 groups. The Clavien classification system was developed for negative outcomes of general surgical procedures and was adapted for complications in solid-organ transplantation. The grading is as follows:

Grade 1 (29 patients): This group includes patients with non-life-threatening moderate problems that can be controlled easily with interventions performed at the bedside. In this group we included patients with mild forms of transplant rejection, ascites, and complications that did not indicate reoperation.

Grade 2 and 3 (3 patients): This group includes patients with potentially life-threatening complications without residual disease or disability. Rejections, primary nonfunction of the organ, and infections were categorized in this group. Here, we also included recipients with the indication of reoperation due to complications, intensive care unit care longer than 5 days, or hospital stay longer than 4 weeks.

Grade 4a (5 patients): Patients who undergo retransplantation are classified as Grade 4a.

Grade 4b (5 patients): This classification is used for patients who have died.

Surgical complications of the donors

In our opinion, the Clavien classification is not adaptable to donors, because these individuals are healthy, and trivial surgical events should, therefore, be deemed as serious complications in the assessment of donor outcomes. We therefore determined donor complications according to a classification developed especially for living liver donors in our institution:

No complications (20 patients): Discharge after a regular course without interventions. Medication is not required other than parenteral infusion, analgesics, antipyretics, or antiemetics.

Minor complications (15 patients): All events that, if left untreated, have a spontaneous resolution, or events requiring drug therapy or simple bedside procedures. Minor complications include pleural effusion (3 patients), neuromuscular syndrome (3 patients), neurological complications (1 patient), prolonged ileus (1 patient), sepsis (1 patient), urinary tract infection (2 patients), keloid (1 patient), vascular complications (1 patient), pneumonia (1 patient), gynaecological infection (1 patient), glomerulonephritis (1 patient), gluteal burn (1 patient).

Major complications (4 patients): All non-life-threatening events requiring invasive procedures, reoperation, hospital stay longer than 30 days, or rehospitalization. Major complications include subphrenic abscess (1 patient), minor bile leak, and moderate liver insufficiency (1 patient), incisional hernia (1 patient), and severe wound infection requiring reoperation (1 patient).

Severe complications (3 patients): All life-threatening events requiring invasive procedures, reoperations, hospital stay longer than 30 days, or rehospitalization. Severe complications include wound infection, abscess, bile leak, neuromuscular syndrome, and pleural effusion (1 patient), bile leak requiring endoscopic intervention, pancreatitis, pleural effusion and wound infection (1 patient), and bile leak requiring 2 reoperations with prolonged ileus (1 patient).

Chronic complications (0 patients): Complications leading to long-term disability or in need of continuous medical treatment did not occur in this sample.

Death (0 patients): Death did not occur in this sample.

Psychiatric Complications of the Donors in the Perioperative Period

Six female donors reported psychological problems or required professional help (Table 3). Three had a moderate depressive episode, 2 had a depressive adjustment disorder (1 also had marital problems), and 1 had a posttraumatic stress disorder. Three patients had unrealistic outcome expectations toward ALDLT (Table 3). Two of the patients with a moderate depressive episode were treated psychotherapeutically as inpatients for a 2 and 3 months, respectively. The third patient received outpatient psychotherapeutic treatment and was on sick leave for over 6 months. One of the patients with an adjustment disorder received supportive psychotherapeutic sessions prior to transplantation. The other 2 did not seek professional help. Clinically, the symptoms had resolved after the aforementioned interventions. In the psychometric measurements of the survey, 3 of these 6 patients had pathological BSI and SF-12 emotional health scores.

Table 3. Psychiatric Complications (n = 6)
Donor for RecipientAgeDonor's Surgical ComplicationsRecipient OutcomePsychiatric DiagnosisFamily DynamicsPsychotherapy
  1. Abbreviations: ICD, International Classification of Diseases; F, Chapter F: Mental and Behavioral Disorders; UOE, unrealistic outcome expectation.

Daughter for mother25NoneSuccessfulModerate depressive episode (ICD 10: F32.1)UOE: Wanted a privileged place at her mothers side, rivalry with younger brother.8-week inpatient psychotherapy
Wife for husband42NoneDeathModerate depressive episode (ICD 10: F32.1)Under great strain after long illness and death of husband.12 week inpatient psychotherapy, antidepressant therapy for an additional 3 months, sick leave for a total of 6 months
Daughter for stepfather25MinorDeathModerate depressive episode (ICD 10: F32.1)UOE: Wanted to avert any damage from her family. Under great strain after death of stepfather.Outpatient psychotherapy, sick leave for 6 months
Mother for son46NoneSuccessfulDepressive adjustment disorder (ICD 10: F43.2)UOE: Expected her son, the recipient with a schizophrenic disorder, to be cured after transplantation.Cured without psychotherapy
Daughter for mother42NoneSuccessfulDepressive adjustment disorder, marital problems (ICD 10: F43.2)Husband opposed to her donation and accused her of disloyalty toward her own family.Supportive outpatient therapy before donation
Female donor for her daughter's ex-boyfriend52MinorSuccessfulPosttraumatic stress disorder (ICD 10: F43.1)Donation for former boyfriend of daughter.Cured without psychotherapy

Survey Results

Decision-making process: comparison of actual and potential donors

With regard to the decision-making process, actual and potential donors reported having received good to very good support through their families. However, actual donors reported better family support than potential donors (t = 2.02; df = 79; P = 0.047).

Retrospectively, both actual and potential donors reported their knowledge about the risks of donation to be very good or good; however, actual donors estimated their knowledge about the risks of donation better than potential donors (t = 2.04; df = 64; P = 0.045). Potential (mean [M] = 4.4) and actual (M = 4.65) donors reported on few or no worries during the evaluation for ALDT; there was no difference between the 2 groups (t = −1.51; df = 71; P = 0.142). Most of the donors (95.2%) reported perceiving no or little coercion or external pressure to donate during their decision-making process; there was no difference between actual or potential donors (t = 0.25; df = 80; P = 0.804).

Special Questions for Actual Donors

Satisfaction with the decision to donate: “Would you donate again?”

Most of the actual donors 73.8% (n = 31) reported that they would donate again, whereas 19.2% (n = 8) would not; 7% (n = 3) did not answer this question. In the group of the patients who would not donate again, there were 2 donors who lost their recipients and 4 donors who themselves had complications.

Recovery from surgery

Patients were asked if they had completely recovered from surgery. All patients reported full recovery within an average time of 14.41 (s = 8.86) weeks. All patients had returned to their preoperative employment. Six donors (14%) were admitted to a physical rehabilitation clinic, and 15 donors (35%) reported that they thought rehabilitation treatment would have been helpful.

Financial impact

Although all expenses related to donation are paid by the recipients' health insurance, 21 (50%) donors reported financial expenses that were not covered by health insurance; 15 (35%) reported moderate expenses, and 6 donors (14%) indicated a great financial burden because of the donation. The expenses included cost of travel to and from the hospital, loss of working hours, and cost for babysitters and telephone calls.

Satisfaction with treatment

During the preparation period prior to operation, 78.6% of the donors were satisfied (well or very well) with the medical care; this was the case for 71% during in-patient treatment; after discharge from the hospital, only 54% were satisfied, indicating a decrease in treatment satisfaction between the second and the last treatment phase (t = −3.05; df = 39; P = 0.004).

Twenty-three donors specified complaints about treatment. Two donors would have liked the opportunity to get in touch with former LDLT donors. For the inpatient treatment phase, the following deficits were stated: not enough time, particularly for the information session given by the surgeon (8 donors); not enough nursing care in the first postoperative phase (5 donors); and the recipient is given greater care than the donor (1 donor). Also, a donor who was recommended to stay in a room separate from the recipient felt forced out and complained about this procedure. With regard to postdismissal care, 12 donors reported that they had missed professional psychosocial support. Six donors wanted to have more information on public endorsement for childcare or rehabilitation. Two donors criticized the inaccessibility of the physicians; 2 other donors complained about a longer recovery period than had been expected and about being left alone.

Quality of Life

Differences between actual and potential donors

In applying the SF-12 health survey, we were able to measure quality of life in 2 subscales: physical and emotional. Six months after surgery, potential donors reported a significantly higher physical quality of life (t = 2.20; df = 36; P = 0.032) than actual donors (Table 4). But both groups reported higher scores of physical quality of life was higher than in a healthy representative population (for potential donors: t = 11.809; df = 36; P < 0.001; for actual donors: t = 3.049; df = 40; P = 0.004).

Table 4. SF-12 and BSI Total Scores of the Responders (n = 84)
 Excluded Donors (n = 8)Remaining Potential Donors (n = 34)Actual Donors (n = 42)
  1. NOTE: No significant group differences could be found.

  2. Abbreviations: QoL, quality of life; M, mean; s, standard deviation; GSI, Global Severity Index.

SF-12   
Physical QoLM = 54.57s = 3.55M = 54.77s = 2.81M = 52.21s = 6.67
Emotional QoLM = 52.81s = 6.55M = 50.88s = 7.93M = 50.45s = 10.02
BSI   
GSIM = 0.25s = 0.22M = 0.33s = 0.42M = 0.38s = 0.49

The emotional quality of life corresponds to the normative sample. In a t test for independent samples that we conducted for potential and actual donors, there was no significant difference between the 2 groups (t = 0.41; df = 76; P = 0.684).

Influence of recipient and donor surgical complications on the donors quality of life

A Kruskall-Wallis test revealed no significant difference in quality of life (SF-12) between the groups concerning postoperative complications of the recipient. However, the donors' recovery course, according to the aforementioned classification, demonstrated a negative correlation to perceived physical quality of life (r = −0.354; P = 0.023); in other words, the more severe the donors' complications the poorer the donors' perceived physical quality of life.

Psychiatric Symptomatology

Differences between actual and potential donors

The actual and the potential donors did not differ with regard to occurrence and intensity of psychiatric symptoms (t = 0.35; df = 81; P = 0.729).

Influence of recipient and donor surgical complications on donor symptom strain

More severe complications of the donors were correlated, but not significantly, to a higher BSI total score (r = 0.303; P = 0.051) and high scores in the subscales compulsion (r = 0.326; P = 0.035), depression (r = 0.390; P = 0.011), and paranoia (r =.396; P = 0.009).

Group Differences Among Excluded and Remaining Actual and Potential Donors

Twenty-seven donors had been excluded for psychosomatic reasons during donor selection. The reasons for exclusion are shown in Table 5. Eight (29.6%) of the 27 patients responded to our survey. According to the SF-36 emotional quality of life (z = 0.33; P = 0.745) and BSI (z = −0.01; P = 0.989) scores, there were no significant differences between actual donors and excluded donors. Furthermore, there are no group differences between the excluded donors and the remaining potential donors regarding emotional quality of life (z = −0.54; P = 0.592) and psychiatric symptom strain (z = −0.03; P = 0.974).

Table 5. Reasons for Exclusion of Donor Candidates in the Psychosomatic Evaluation (n = 27)
Questionable mental stabilityn = 11
Continuous ambivalence/relief through our supportn = 3
Coercion by familyn = 6
Participation declined after additional informationn = 3
Direct medical excuse demandedn = 2
No obvious close relationshipn = 2

1

Figure 1.

Subscales of the BSI according to the recovery course of the donors. White bar denotes zero complications (n = 20), light gray bar denotes minor complications (n = 15), dark gray bar denotes major complications (n = 4), and black bar denotes severe complications (n = 3).

DISCUSSION

In our study, for the first time, a complete list of psychiatric complications of ALDLT donors in the perioperative period and 6 months after donation is given. Furthermore, the psychological strain and quality of health of actual donors in comparison with potential donors as a natural control group is investigated.

In a careful examination of our records, we were able to determine 6 cases (14%) with temporary but serious clinical psychiatric complaints. It is remarkable that all 6 patients are women. We consider the extent of the psychotherapeutic efforts to be a signal for serious psychiatric impairment. Several groups reported temporary psychiatric symptoms, such as impairment of sexual function6 or lasting diffuse abdominal complaints,4 that were not discussed as possible psychological complications after ALDLT. Three groups reported on distinct negative psychosocial outcomes. Verbesey et al.18 described 2 cases (4 %) of clinical depression. Walter et al.9 identified a subgroup of 5 donors (19%) as an unfavorable psychosocial outcome group. They had higher values for anxious depression and higher overall complaints; however, it was not indicated whether the patients fulfilled diagnostic criteria for psychiatric disorders. Fukunishi et al.19 reported 2 (4.9 %) cases of psychiatric disease among 41 donors for adult recipients—1 patient with major depression and 1 patient with a somatization disorder. Furthermore, 3 female donors in their sample developed temporary somatoform pain disorders after ALDLT.8 Six (14%) of our patients had psychiatric problems of clinical importance, resulting in a relatively high prevalence of psychiatric complications in comparison to the reported groups. This may be due to more severe distress experienced by our donors because ALDLT was extended to include indications such as liver malignancies, which was not the case in other institutions. On the other hand, the sample we described resembled patients of the implementation phase of ALDLT. At this point, uncertainties within our team may also have affected the patients. Finally, these outcome results may indicate that temporary psychiatric complications after ALDLT are more frequent than has been assumed up to now. The psychometric measurements demonstrated no differences concerning the emotional quality of health or psychiatric symptom strain between previously excluded donors and the remaining sample. This finding is concordant with the fact that the measurements were conducted 6 months after LDLT and no donors reported disabling psychiatric symptoms at that time. Therefore, we conclude that it is most important to integrate a psychosomatic interview in follow-up studies and not rely only on questionnaires to evaluate the patients' emotional quality of life. Including a psychosomatic interview allows an overall view of psychiatric disorders in the perioperative period.

The actual and potential donors as a group have normal values concerning psychological distress as measured with the BSI. When looking at the surgical outcome of recipients and donors, only the group of donors with severe complications had above-normal scores for psychological distress; they had higher scores of depression, compulsion, and paranoid ideation. We interpret these symptoms as a psychological defense mechanism in a stressful life situation.

In our survey, potential donors reported significantly less family support and less information on risk factors than the actual donors. The actual donors in the group of possible candidates are, therefore, the ones with better psychosocial resources. This corresponds to and explains the good psychosocial results after donation.

One of the most relevant principles of living organ donation is that the decision to donate must be free of external pressure. Before LDLT, 3 donors were excluded because of their continuous ambivalence and their incapacity for decision-making, and 6 were excluded because they were obviously pressured by their families (Table 5). As in the studies of Verbesey et al.18 and Diaz et al.,20 all donors except 1 reported, after LDLT, not to have perceived external pressure. We therefore conclude that actual donors felt an inner freedom to donate despite the difficult decision-making situation.

Some of our findings about the decision-making and recovery processes are replications of previous findings.4, 6, 20 The donors in those studies also reported retrospectively on no or only slight pressure and good family support, and that they had been well or very well informed on the risks. In most of the studies,4–6 all or a majority of the donors21 confirmed that they would again consent to donate. This finding could not be replicated in our sample; a small fraction of the donors reported not to be willing to donate again. This may be because in our center ALDLT is also offered as a method of treatment for patients with advanced disease and an urgent indication. Unfortunately, 12 of the 42 investigated recipients had liver malignancies. Although the donors regard the donation by all means as positive, some are not willing to repeat this life event.

Despite legal agreements that the recipients' health insurance would cover the costs, the donors had considerable financial expenses to cover. In the future, the transplantation centers must confer with health insurance companies to ensure a better collaboration.

Our survey detected a decrease in treatment satisfaction after discharge from the hospital. Possible reasons for this may be that professional and family care efforts are devoted mainly to the donor during the evaluation period and thereafter only to the recipient. This shift in attention has been also described in the study of Beavers et al.,5 where 40% of the donors reported postoperative conditions that they subjectively attributed to complications; only 60% of these conditions had been noted as complications in regular documentation.

Our results also demonstrated an above-normal physical quality of life after the operation. The emotional quality of life is equal to normal values, with no difference between the actual and potential donors. In reports on the psychosocial outcome of ALDLT that are based on the SF-12 or SF-36 health surveys, equal7 or higher4, 6 scores than is the case for the general population have been established. Since donor selection is also based on good emotional and physical health, it is quite feasible that their scores for emotional quality of life were normal or above normal.

In our survey, a significant impact of the recipient outcome on the donor emotional quality of life was not estimated. Diaz et al.20 demonstrated a similar result in a group of donors for pediatric LDLT. However, in a group of adult living liver donors, Kim-Schlüger et al.6 established a positive correlation between recipient outcome and donor emotional health scale scores. This issue cannot be addressed definitely and requires further research.

For the first time, we investigated potential donors as a control group. We were able to demonstrate that the potential donors, as a group, did not display higher scores of mental distress; in other words, being approached by family members to donate is not an impairing stress factor and therefore is quite legitimate.

Limitations

A major limitation of our study is the low response rate of potential donors. This may be interpreted as disappointment in being excluded as donor but may also be seen as a way of coping with the extremely difficult event; in addition, the questionnaires were not blinded. This fact may have compelled some donors to not report negative experiences and to therefore not respond at all; however, critical comments (e.g., lacking willingness to donate again) were also made by donors who did respond. The possible occurrence of psychiatric problems after LDLT was discussed in the preparation meetings, and as a rule, donors attended, because most of them live in Essen or in the environs of Essen. We cannot, however, exclude the possibility of further psychiatric problems among the nonresponders.

Another limitation is that we do not have predonation measurements with psychometric instruments. A current prospective study, in which we also recorded quality of life prior to donation, will allow for a predonation and postdonation comparison.

Future Perspectives

In our institution, ethical concerns played an important role in the discussion about ALDLT. During the preparation of the first candidates, we were concerned about preventing any mental harm that could affect the donors. Cases in which patients did not have a mental disorder and were mentally stable at the time of evaluation, but because of the family dynamics involved, it was feared that they might have psychological problems after donation were considered difficult. These were donor candidates with unrealistic expectations, or adult children, who were not yet completely psychologically separated from their parents for whom they wanted to donate. Three of them presented with psychiatric disorders after donation (s.a.) but did not regret having donated. We came to the conclusion that we have to inform about possible psychological complications as we would with somatic complications; therefore, we informed donor candidates about possible psychological complications but left the decision-making to them.

In summary, living liver donors represent a healthy sample who are subjected to emotional and physical stress. However, our results show that the group of actual donors has better psychosocial resources at their disposal than potential donors and are therefore able to cope with the stress of the operation. Our results suggest that female donors and donors with a more complicated postoperative course more often develop psychiatric symptoms and should receive adequate care. Temporary psychiatric complications may emerge more frequently, as previously reported. Because of the relatively small size of our sample, these findings need further replication.

In employing standardized questionnaires and regular psychosomatic follow-up, psychosocial results may be compared in different centers. Doing so will allow guidelines to be established for the selection and care of donors for ALDLT.

APPENDIX

Criteria and Course of the Psychosomatic Assessment

The psychological selection procedure is based on 2 steps, the aim being to establish a frame for an autonomous decision-making process and protection of the donor. It is an integral part of the donor-selection protocol.10 The objectives of the first-step interviews are verification of informed consent and assessment of mental stability. The objectives of the second-step interviews are to evaluate the dynamics of the relationship between donor and recipient and to anticipate the transplantation procedures.22

First-step Interviews

Each donor and recipient is evaluated separately by 2 different members of the psychosomatic team. This procedure allows the interviewer to address the life situation of the donor or the recipient individually and to focus on their respective perspectives. In this confidential setting, each donor is informed of the possibility of declining with a medical excuse without hurting the recipient. If donor candidates are ambivalent and cannot make a decision after several separate meetings with the surgeon and the psychosomatic specialist, they are excluded, the aim being to ease the psychological strain.

The psychosomatic interview takes place after the information session with the surgeon. It serves to verify whether the donor fully understands the information on possible complications involved with his or her own operation and on the recipients' chances of recovery.

Another important topic is the mental stability of the donor. Previous psychiatric disturbances and their current impact on the donor's coping skills are taken into consideration. Social functioning and health behavior of the donor is investigated with a semistructured interview that includes the assessment of the compliance of the donor in previous medical consultations. Health behavior according to weight, regular physical activities, drug abuse, and family and social support are examined. The objective existence of support- and care-giving persons and access to emotionally supportive and responsive persons is investigated. Former psychological coping is examined to assess whether the donor candidate is able to employ different coping skills in a flexible way. The assessment of current psychological coping focuses on the coping styles with which the candidate reacts to the donor operation, such as denial or awareness of affects. Finally, the donor's anxious or depressive mood are evaluated.

Second-step Interviews

Together with their respective supporters, both donor and recipient participate in the second-step interviews. Here the psychodynamics of their relationship are investigated. In our experience, stable relationships with sufficient autonomy of recipient and donor and realistic outcome expectations are preconditions for a successful psychosocial outcome. Further topics in the second-step interviews aim at the psychological preparation for the LDLT. They may include the shift in attention from donor to recipient, coping with pain after the transplantation, accommodation in different rooms, and the emotional care of both those operated on and further family members after transplantation.

Ancillary