Living donor liver transplantation (LDLT) is seldom simple and is frequently controversial. The technical challenges of donor hepatectomy and recipient implantation have been studied in great detail since the first report of a successful LDLT, which was performed by Dr. Christopher Broelsch at the University of Chicago Medical Center in November 1989 in a 2-year-old girl with end-stage liver disease due to biliary atresia.1 In this issue of Liver Transplantation, Takada et al.2 reiterate that “for healthy living donors, no medical benefit is derived from LDLT; the potential endpoint of donation is primarily psychological.” In light of this stark realization, there is still much to learn about the extent of the benefit that is actually gained by these living donors and about what motivates an individual to risk his or her life for a psychological benefit.
Mortality and morbidity after living donation have been well characterized and include biliary complications, postoperative infections, blood transfusions, and the need for reoperation and rehospitalization.3 Whether the occurrence of these complications, the outcomes of the recipients after transplantation, the indications for transplantation, and/or the socioeconomic demographics of the donors have any influence on the psychological well-being of the donors after donation has yet to be clearly understood. In a comprehensive review of 19 studies, Parikh et al.4 concluded that “there is a lack of long-term data on donor quality of life after LDLT.” Specifically, although donor quality of life (QOL) was equal to or greater than the QOL of normal populations before donation, there have been reports of decreased QOL after donation in up to 20% of surveyed living donors. Interestingly, there appears to be an association with diminished mental QOL in donors who have donated to recipients with acute liver failure or recipients undergoing transplantation for the indication of hepatocellular carcinoma.
In this issue of the journal, Takada et al.2 report on one of the largest series (578 donors) evaluating QOL after LDLT. These 578 individuals represented 58% of the 997 donors who were sent questionnaires concerning the 1000 LDLT procedures performed between June 1990 and June 2004 at Kyoto University Hospital in Japan. There were no responses to 419 of the 997 questionnaires. The authors had 2 goals: (1) to investigate the long-term effects of LDLT on donor QOL with the well-established Short Form 36 (SF-36) health survey and (2) to determine the risk factors for poor donor QOL outcomes.
The magnitude of the number of living donors and the length of the mean postdonation follow-up period (6.8 years) are the greatest strengths of this study for interpreting the results. It should be noted, however, that between the responders and nonresponders, there were significant differences in the relationships with the recipients, the incidence of postoperative complications, and the recipient mortality rate, and these differences may have influenced the findings.
The conclusions were 2-fold: (1) donor health-related QOL in the long term was better than that for the Japanese norm population, and (2) the risk factors for poor donor QOL outcomes were the prolongation of symptoms or sequelae related to donation and the emergence of 2 or more comorbidities after donation (donors were asked about 22 comorbidities, and the number was classified as none, only 1, or more than 1). In particular, those donors who had repeated outpatient visits or who could not go back to work showed lower mental component scores on the SF-36 health survey; interestingly, this was unrelated to the existence of surgical complications. This particular finding correlated with the similar QOL reported for left lobe donors (Clavien classification grade III or greater: 2.6%) and right lobe donors (17.0%). Unlike previous reports, recipient outcomes did not correlate with the health-related QOL of donors. The association between the emergence of 2 or more comorbidities and decreased QOL across all 3 domains of the SF-36 questionnaire (Physical Component Summary, Mental Component Summary, and Role/Social Component Summary) is a significant finding to which we must pay closer attention, and we must ensure ongoing follow-up and appropriate management of these complications after donation.
The ever-increasing shortage of organs in the setting of an increasing population of patients needing liver transplantation has brought us to the current state of performing LDLT as the only realistic option for saving lives in many patient situations. The technical aspects of the donor surgery have advanced tremendously since Broelsch's pioneering operation in 1989,1 and although there are always intrinsic risks to any procedure, the surgical expertise to minimize complications currently exists. As we continue to advance with surgical innovations and head into the future, the psychological well-being of the donor must remain paramount. With the largest cohort to date, this study is a beginning at understanding the long-term needs of living liver donors. As is true of any good study, this article appropriately does more to stimulate questions than provide definitive answers. Is there a living donor risk assessment tool that can be developed to identify individuals at risk for prolonged psychological distress after donation? Should we provide financial coverage? Should absence-from-work benefits be considered? Would routine psychiatric counseling for some period of time after donation improve donors' QOL?
We must strive to study and comprehend the motivations leading to donation and the financial and economic impact of donation and learn to alleviate the fears before and after donation with the single goal of safely getting living donors through the donor process medically, surgically, and psychologically.