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Keywords:

  • Donor outcomes;
  • living donor liver;
  • quality of life

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Concern remains regarding the possibly higher risk to living liver donors of the right lobe (RL), as compared with the left lateral segment (LLS). We studied outcomes and responses to quality of life (QOL) surveys in the two groups.

From 1997 to 2004, we performed 49 living donor liver transplants (LDLTs): 33 RL and 16 LLS. Notable differences included a higher proportion of female and unrelated donors in the RL group. A significantly larger liver mass was resected in RL (vs. LLS) donors: 720 (vs. 310) g, p = 0.01; RL donors also had greater blood loss (398 vs. 240 mL, p = 0.04) and operative times (7.2 vs. 5.7 h, p = 0.05). However, those findings did not translate into significant differences in donor morbidity. The complication rate was 12.5% in LLS donors and 9.1% in RL donors (p = ns). Per a QOL survey at 6 months postdonation, no significant differences were noted in SF-12 scores for the two groups. Recovery times were somewhat longer for RL donors. Mean time off work was 61.0 days for RL donors and 32.4 days for LLS donors (p = 0.004).

RL donation is associated with greater operative stress for donors, but not necessarily with a more complicated recovery or differences in QOL.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Living donor liver transplants (LDLTs) have become a well-established therapeutic option for pediatric patients with end-stage liver disease. In fact, at some centers, LDLTs are the preferred option for that age group (1). And while surgery per se has been associated with some risk and morbidity for the donors, LDLTs for pediatric recipients have been well accepted by the transplant community and general public (2,3). Adult-to-adult LDLTs, a newer and larger procedure, are gaining popularity. However, significant concern exists in the transplant community and general public with this procedure (4,5). This concern was heightened by the highly publicized death of an adult liver donor in the United States in 2002, resulting in a drop in the number of such procedures in 2002 and 2003 (6). The concern centers mainly on the increased risk of donor mortality and of donor complications associated with adult-to-adult LDLTs. Short- and long-term recovery of these donors and their postdonation quality of life (QOL) are also worrisome issues.

Many studies have looked at surgical outcomes with LDLTs for adult and/or pediatric recipients (7–10), and some studies have looked at donor outcomes and QOL (11,12). But very few studies have compared, in detail, outcomes for these two types of donors, with attention not only to surgical outcomes but also to QOL issues. The purpose of own study, therefore, was to compare these two types of donors at a single center.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Patient population

Our patient population consisted of 49 living liver donors who underwent partial hepatectomy from January 1, 1997 to June 30, 2004, as part of an LDLT. Of these 49 donors, 16 underwent left lateral segmentectomy (LLS) for a pediatric recipient and 33 underwent right lobe (RL) hepatectomy for an adult recipient. Medical and surgical outcomes on these donors were based on their most recent follow-up.

Surgical procedures

The preoperative evaluation for all donors was similar. We chose only donors who were 18 to 55 years old, whose blood group was compatible with the recipient and who were medically in good health. A complete medical evaluation of potential donors was performed by a physician not involved in the care or evaluation of the potential recipient. To ensure their mental fitness and the voluntary nature of their donation, all donors underwent a psychological evaluation with a dedicated transplant social worker and psychologist.

The surgery for both groups of donors was done in a similar fashion by the same surgical team using similar techniques. All donors underwent CT angiography preoperatively, with detailed evaluation of anatomy and segmental volumes. The surgical incision with regard to size and placement was similar for the two groups—a bilateral subcostal incision was used. Intraoperative ultrasonography was performed to verify hepatic venous anatomy. Transection of the liver parenchyma was performed without inflow occlusion. Resection of the LLS involved transecting the liver just to the right of the falciform ligament and then removing segment 2 and 3; segment 1 was preserved in the donor. RL donors underwent resection of segment 5, 6, 7 and 8; the line of transection was just to the right of the middle hepatic vein, which was preserved in the donor. A surgical drain was left in place for all donors and usually removed after 5 or 6 days.

Postoperative care did not differ for RL and LLS donors. After their discharge from the hospital, donors continued to be followed in the surgery clinic for the first year postdonation. Their laboratory test values were checked on a regular basis to monitor recovery of liver function. All complications were recorded.

QOL surveys

All donors were sent a QOL survey at 6 months postdonation; results reported here with regard to QOL are based on those responses at approximately 6 months postdonation. Filling out the survey was voluntary, but donors were sent several reminders and encouraged to complete it. The survey included a Short Form (SF)-12 questionnaire, a standard QOL measure that provides information on 12 health dimensions and gives a physical and mental component summary score. The survey also included several additional questions regarding the time to recovery of various functions and activities, employment, and satisfaction with the donation process. Specifically, donors were asked about the time required to achieve predonation level of daily activity, length of time before regular exercise was initiated and time off from employment. This information was collected in the form of number of days and analyzed as continuous variables. Donors were also asked about any new medical problems that developed since donation (either related or unrelated to the donation process), and whether they had encountered any difficulty in obtaining life or health insurance.

Statistical analysis

Categorical variables were analyzed using the Chi-square test, and when applicable, Fisher's exact test. Continuous variables were analyzed parametrically using the Student's t-test. A p-value of ≤0.05 was considered significant.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Donor characteristics

The main characteristics of the two donor groups are shown in Table 1. Very little difference was noted between the two groups with regard to age or weight, but donor gender and relationship to the recipient differed notably. Most LLS donors were male (75%), but the majority of RL donors were female (61%, p = 0.04). Most LLS donors were parents, donating to their child: no unrelated donors were in this group. For RL donors, however, much more variety was seen with regard to relationship to their recipient: donors included siblings, spouses and parents. Moreover, 30% of the RL donors were unrelated, a significantly higher proportion as compared with LLS donors (0%, p = 0.03).

Table 1.  Donor characteristics and operative data for the two donor groups
CharacteristicsLLS (n = 16)RL (n = 33)p
  1. LLS = left lateral segment, RL = right lobe.

Mean donor age (years)3336ns
Male donors (%)75390.04
Unrelated donors (%)0330.03
Donor weight (kg)7676ns
Size of resected liver mass (g)3107530.01
Operative time (h)5.77.00.05
Operative blood loss (mL)2403790.04

Surgical and postdonation outcomes

Several intraoperative variables are presented in Table 1. A larger liver mass was resected for RL donors, who had longer operative times and greater blood loss. However, none of the donors (whether RL or LLS) required transfusion of nonautologous blood. Only one of the RL donors required transfusion of two units of autologous blood that they had donated before the surgery. RL donors had a longer mean hospital stay, but this difference was not statistically significant.

The mean length of follow-up was 65 ± 28 months for LLS donors vs. 25 ± 15 months for RL donors (p < 0.001). Recovery of liver function for the two groups is shown in Figures 1 and 2. Serum alanine transferase (ALT) levels were slightly higher in RL donors the first day after surgery. However, by 1 week postdonation, we found virtually no difference in ALT levels between the two groups. At 1 month postdonation, all donors had levels within the normal range. The mean serum bilirubin levels were significantly higher in RL donors at 1 day postdonation, but by 1 month postdonation, all donors had levels within the normal range.

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Figure 1. Mean serum ALT levels for the two donor groups.

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Figure 2. Mean serum bilirubin levels for the two donor groups.

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There were no cases of donor mortality. The overall morbidity rate was similar in the two groups: 12.5% for LLS donors and 9.1% for RL donors (p = ns). No donor (whether RL or LLS) had a major complication that required early readmission or reoperation. Only one bile leak occurred in the entire group (incidence = 2%). This bile leak was in an LLS donor who was noted to have bile-stained drainage in the Jackson–Pratt surgical drain. This problem persisted for a few days postdonation, but resolved spontaneously without the need for any intervention. Additionally, one other LLS donor developed an incisional hernia at 1 year postdonation that was then surgically repaired. Of the RL donors, three had minor complications: one with Clostridium difficile colitis that required treatment with oral metronidazole, one with a central line infection that resolved with removal of the line, and one with worsening of underlying carpal tunnel syndrome (presumably related to positioning on the operating room table) that improved after a few months.

At most recent follow-up, 31 of the 33 (91%) RL recipients are alive and doing well. Of the 16 LLS recipients, 12 (75%) are alive and doing well.

QOL surveys

The response rate for LLS donors was 13 out of 16 (81%)—one had not reached the 6-month mark yet and two did not return surveys (both of these were cases in which there was an early recipient mortality). The response rate for RL donors was 24 out of 33 (73%)—six had not reached the 6-month mark yet and three did not return surveys (of these three, one recipient had a poor outcome posttransplant while the other two recipients did well). Samples of responses from the QOL surveys are shown in Tables 2 and 3. SF-12 results were not significantly different between the two groups, in either the physical or the mental component summary scores (p = ns). Overall health at 6 months postdonation was reported as good or excellent in 90% of all donors, with no significant differences between the two groups.

Table 2.  Postdonation surgical outcomes and recovery times for the two donor groups
 LLS donors (n = 16)RL donors (n = 33) p
  1. LLS = left lateral segment, RL = right lobe.

Nonautologous blood transfusion (units)00ns
Autologous blood transfusion (units)00.08ns
Hospital stay (days)7.17.7ns
ComplicationsSelf-limited bile leak (n = 1)Central line infection (n = 1) 
 Incisional hernia (n = 1)C difficile colitis (n = 1) 
 Worsening of carpal tunnel (n = 1) 
Total complication rate12.5%9.1%ns
Hospital stay (days)7.17.7ns
No persistent pain requiring medications (days)17.625.6ns
Return to normal daily activity with no restriction (days)54.766.2ns
Predonation level of exercise (days)99.686.9ns
Return to work (days)32.461.00.004
Table 3.  Responses to selected questions from the QOL survey for the two donor groups
 LLS donors (n = 12)RL donors (n = 24)
  1. QOL = quality of life, LLS, left lateral segment, RL, right lobe.

Current healthExcellent: 50%Excellent: 38%
 Very good: 42%Very good: 38%
 Good: 8%Good: 13%
 Fair: 13%
Health as compared with predonationBetter: 0%Better: 13%
 Same: 92%Same: 75%
 Worse: 8%Worse: 13%
New medical problems related to surgeryYes: 0%Yes: 13%
New medical problems not related to surgeryYes: 8%Yes: 13%
Pain interferes with normal workNot at all: 82%Not at all: 100%
 A little: 18%A little: 0%
 Moderate: 0%Moderate: 0%
Looking back, would still donate100%100%
Problems with health insurance0%0%
Problems with life insurance0%0%

Recovery times were slightly longer for RL donors, who noted persistent pain for a mean of 25.6 days postdonation vs. 17.6 days for LLS donors (p = 0.30). Time until donors noted no major restriction in daily activity was 66.2 days for RL donors vs. 54.7 days for LLS donors (p = ns). The mean time off work was 61.0 days for RL donors and 32.4 days for LLS donors (p = 0.004). RL donors reported that it took 92.4 days before they reached their predonation level of exercise; LLS donors, 100 days. Among LLS donors, 50% reported that their recovery was shorter than expected; the other 50%, as expected. Of RL donors, 38% noted that their recovery was shorter than expected; 38% as expected; 24% longer than expected. Of RL donors, 93.7% reported that their current health was the same or better as compared with predonation; LLS donors, only 87.5%. Of RL donors, 93.7% described their health currently as excellent or very good; LLS donors, 75.0%.

While the incidence postdonation of new medical problems related or unrelated to surgery was low, there were a few donors who noted problems. Among the LLS donors, no donor reported a problem directly attributed to surgery, and one donor reported new onset of persistent lower back pain, which he felt was not related to surgery. Among the RL donors, one complained of chronic gastrointestinal difficulties including diarrhea and bloating since surgery, one noted increased problems with her underlying carpal tunnel syndrome (onset immediately postsurgery) and one man noted an area of alopecia in the back of his head that was persistent since surgery. Medical problems not related to surgery in RL donors included new onset of diabetes and hypertension.

None of the donors (whether RL or LLS) reported problems in obtaining health or life insurance postdonation. When asked if, looking back, they would still donate, all donors said yes.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

As LDLTs become increasingly popular, growing attention is being focused on the short- and long-term outcomes for donors. When examining donor outcomes, it is important to realize that donors differ significantly from recipients in that they are not ill prior to their surgery and do not need the surgery. Therefore, measurement of donor vs. recipient outcomes—and the importance given to certain outcomes—will differ. Donor mortality and morbidity rates are obviously of essential importance, and should be very low. Also, key outcomes are return to work or normal activity, length of recovery, psychosocial problems and financial impact. The goal of any living donor procedure must be to return donors to their predonation level of health in the shortest time possible.

LDLTs for pediatric recipients have become well established and well accepted. Several centers across the world have presented good data on medical and QOL outcomes (13,14). LDLTs for adult recipients are newer and not as well accepted, but their number has increased dramatically. In fact, in the United States, most LDLTs are now performed for adult recipients (15).

Many researchers have stated that donor morbidity and mortality rates associated with LDLTs for adult (vs. pediatric) recipients are significantly higher (16,17). In fact, a recent analysis of the Japanese LDLT database showed a significantly higher donor morbidity rate for LDLTs for adult recipients (18). Indeed, one would expect this to be the case, because a significantly larger liver resection is involved for donors in LDLTs for adult recipients. The advantage of a multicenter analysis like the Japanese study is the large number of patients; however, multicenter analyses also group together results from several centers that may have different levels of experience with the surgical procedure.

In contrast, in our single-center study, the two types of donors underwent the same preoperative evaluation, and their operative and postoperative course was managed by the same team of surgeons, physicians, coordinators and social workers. This consistency makes for a more meaningful comparison between the two donor groups. The main disadvantage of such an analysis is the small number of patients; certainly, our study included only a small group of donors. The length of follow-up was statistically different between the two groups of donors, with longer follow-up being available for LLS donors. Similar to many other centers, we were initially performing living donor transplants for pediatric recipients and then later started to perform them for adult recipients. This may create a slight bias with regard to medical and surgical outcomes where there might have been more of a learning curve involved for resections.

Nonetheless, our study did not find a major difference in surgical outcome for RL vs. LLS donors. The surgical procedure was of greater magnitude for RL donors, as demonstrated by the longer operative times, greater mass of liver tissue resected and greater blood loss. However, postoperatively, these differences did not translate into significantly more liver dysfunction or a higher complication rate for RL donors. By one week postdonation, we found essentially no difference in serum measurements of liver function between the two groups. Length of hospital stay also did not differ significantly, nor did the incidence of complications. None of the donors (whether RL or LLS) had an early complication that required reoperation or invasive intervention. Only one bile leak (which resolved spontaneously) was noted—in an LLS donor.

With regard to QOL, again we found no major differences in RL vs. LLS donors. Our QOL survey was voluntary and unfortunately the response rate was not perfect. The response rate was poor from donors of recipients who had a poor outcome posttransplant—two of the four LLS donors whose recipient had a poor outcome posttransplant did not return the survey. While medical outcomes in donors did not differ because of recipient outcomes, it is difficult to know if the QOL responses may not be different depending on recipient outcomes. Failure to respond to the survey from these donors may skew the data. Nonetheless, in questions related to general health, no significant differences between the two donor groups were noted: >90% of all donors reported good to excellent health. About the same percentage reported their current health to be the same or better, as compared with predonation.

Recovery times also did not seem to differ significantly between the two groups. Both groups reported roughly the same number of days that persistent pain was noted and the same number of days before return to normal daily activity with no restriction. Interestingly, LLS donors returned to work more quickly than RL donors, though other measures of activity (such as return to predonation level of exercise) were not different. Lastly, the psychological benefits of donation were present equally for both groups. No donor regretted their decision to donate. All donors stated that they would “do it again if they had to do it over.” This finding tends to be fairly universal among living donors; it has been a consistent finding in other studies (19,20). While there seemed to be psychological benefit to donation, donors did not volunteer that there was any obvious psychological detriment. None of the donors reported problems with depression postdonation. However, it should be remembered that our study is based purely on voluntary responses to a voluntary survey. It is difficult to know the degree of psychological detriment in those who did not return the surveys. This important question needs to be further addressed.

In conclusion, even though RL donation entails a longer operative procedure than LLS donation, and likely has some increased risk associated with it, the differences to the donor may not be vastly different. Both procedures carry risks: with careful attention, these risks can be minimized.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Special thanks to Mary Knatterud and DeAnn Ronning for their help in the preparation of this manuscript.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References