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Keywords:

  • Allocation;
  • ethics;
  • pediatric;
  • segmental liver transplantation

Abstract

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

Split liver transplantation (SLT) benefits society by increasing the total number of transplants that can be performed, but it is yet unknown if a decreased post-transplant survival (in comparison to whole liver transplantation) would make participation in SLT less appealing to adult liver transplant candidates. A 20-item questionnaire was administered to 50 adult candidates to assess attitudes toward SLT and organ sharing. The overall attitudes of 60% of participants were classified as utilitarian (maximizing benefit to greatest number of candidates), while 26% were classified as self-preserving (maximizing individual benefit) and 14% were undecided. Ninety percent of participants would be willing to share even if expected survival was less than that of whole liver transplantation, and 69% felt that pediatric candidates should have priority over adult candidates. In conclusion, attitudes toward graft sharing and the possibility of compromised survival benefit are not barriers to SLT for most adult liver transplant candidates.


Abbreviations: 
OLT

orthotopic liver transplantation;

SLT

split liver transplantation.

Introduction

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

A recent analysis of national split liver transplantation (SLT) outcomes by Merion et al. has demonstrated that the individual life-years gained by adult SLT recipients was only 6% less than the life-years gained by adult recipients of whole liver orthotopic liver transplantations (OLTs) (1). Although SLT required retransplantation at a slightly higher rate, the technique did benefit the aggregate liver transplant candidate population by increasing the total number of transplants that may be performed and the individual life-years gained by pediatric patients. An accompanying editorial (2) mentions a discrepancy between benefit to the transplant community and cost to individual transplant recipients and attempted to address the ‘ethics’ of transplant physicians serving the needs of individual and society.

While the potential for decreased post-transplant survival as compared to whole liver OLT may make SLT less appealing to individual liver transplant candidates, the attitudes of individual candidates toward organ sharing and SLT have not been assessed to see if indeed adult candidates would prefer to maximize their individual outcomes at the cost of increasing the overall number of transplants that can be performed. In the current study, we administered a questionnaire to 50 adult liver transplant candidates to better evaluate attitudes toward organ sharing and SLT among individuals in this population.

Materials and Methods

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

Study population

Fifty adult liver transplant candidates voluntarily participated in this study. Median age of these participants was 55 years (range: 31–70 years). Twenty-eight participants (56%) were female and 22 (44%) were male. Seventeen percent of participants had not completed high school, 29% had only a high school degree, 19.5% had some college coursework, 17% had a college degree and 17% had a post-graduate degree. The median time spent on the wait list was 263 days (range: 17–1426 days), and the median MELD score was 13 points (range: 6–24 points). Forty-six percent of candidates were listed with chronic active hepatitis C virus as their primary indication, while 21% had Laennac's cirrhosis, 12% had cryptogenic cirrhosis and 7% had autoimmune hepatitis listed as the primary indication for transplantation. Several less common indications were the reason for listing the remaining 14%, including primary biliary cirrhosis, primary sclerosing cholangitis, cholestatic liver disease and nonalcoholic steatohepatitis.

Participants were randomly selected from a list of adult liver transplant candidates at our institution. All adult candidates contacted agreed to participate. The study was performed under a Baylor College of Medicine institutional review board exemption.

Questionnaire

Participants completed a 20-item questionnaire assessing attitudes toward SLT and sharing a left lateral segment graft with a child, assuming that the graft was initially allocated to the adult candidate. The questionnaire was administered by nontransplant personnel, and the participants were reassured that their responses would remain anonymous, would not affect their position on the liver transplant candidate list and would not commit them to either accepting or rejecting an offer to participate in either whole liver OLT or SLT.

The questionnaire administered to the adult liver transplant candidate participants had three sections. The first section of the questionnaire began with open-ended questions that assessed both the participants' awareness and understanding of SLT and living donor liver transplantation. After participants explained their understanding of each of these procedures, a standardized paragraph briefly describing the procedure and its potential impact on the availability of liver grafts was read to them.

In the second section of the questionnaire, a series of statements regarding organ sharing and utilization of health-care resources in the context of liver transplantation were then read to the participants, who were asked to rate their agreement or disagreement with the statement by choosing one of five Likert-type responses: (1) strongly agree; (2) agree; (3) neutral; (4) disagree or (5) strongly disagree. Selected statements from the questionnaire are listed in the Table 1. Of note is that there was some redundancy incorporated into these statements to assess the reliability of the participants' responses and attitudes.

Table 1.  Selected statements from questionnaire assessing attitudes toward graft sharing and split liver transplantation among adult liver transplant candidates
‘I would feel good about sharing part of my new liver with a child if it helped him or her survive liver disease’.
‘It would be ok if split liver transplants weren't as good as whole liver transplants if it meant that more people could get new livers’.
‘I would want to keep all of my new liver to maximize my chances of living as long as possible’.
‘I feel that children should have priority over adults for liver transplants’.
‘I have or someone close to be has considered living donor liver transplantation’.
‘Liver transplants should be done in a way to maximize the time recipients survive, even if it means that fewer patients get new livers’.
‘Split liver transplants sound like a good way to help children waiting for a liver, but I would rather get a whole liver’.
‘I trust my transplant surgeon and transplant coordinator to help me decide if sharing part of my new liver was a good option’.

Finally, participants were presented with a series of hypothetical situations involving SLT. Participants were asked if they would be willing to participate in SLT (i.e. donate the left lateral segment from a whole cadaveric allograft offered to them) if the survival of adult split liver transplant recipients was known to be equal to that of adult whole liver OLT recipients. If the participant responded in the affirmative, a similar hypothetical scenario was presented, only with adult split liver transplant recipients living an additional 9 years for every 10 years gained by adult whole liver OLT recipients. This series of hypothetical scenarios continued, with the survival of adult split liver recipients incrementally worsening in comparison to adult whole liver OLT recipients, until the participant indicated that he or she would no longer consider participating in SLT.

Upon completion of the questionnaire, a ‘debriefing’ reassured participants that they would be free to accept or reject any offers to participate in SLT. Results of the most recent comparison of adult SLT and whole liver OLT recipient post-transplant survival were also reviewed with the participants to reaffirm that the outcomes of both SLT and whole liver OLT are quite good, with post-SLT survival being only slightly less than that of whole liver OLT (1).

Analysis of responses

Responses to open-ended questions were recorded and reviewed. The Likert-type responses to statements in the second section of the questionnaire were tallied, and overall attitudes were characterized as ‘utilitarian’ (distributing health-care resources among the greatest number of people), ‘self-preserving’ (maximizing individual outcomes at the expense of others) or ‘undecided’ based on these responses. Participants whose responses were characterized as both utilitarian and self-preserving (i.e. inconsistent responses) or who chose the ‘neutral’ response for statements eliciting attitudes toward organ distribution were classified as ‘undecided’. SPSS version 11.0 (SPSS Corporation, Chicago, IL) was used for all statistical analyses. A p-value of <0.05 was considered statistically significant.

Results

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

Awareness of SLT and LDLT

Most patients (62%) were aware of living donor liver transplantation, and 44% of these candidates indicated that they have considered the option of living donor liver transplantation for themselves. Only 14% of candidates were correctly able to describe SLT as the transplantation of a ‘partial’ or segmental liver graft from a cadaveric adult donor. All patients that correctly described SLT were also aware of living donor liver transplantation. The remaining 38% of candidates had heard of neither SLT nor living donor liver transplantation

Overall attitudes toward graft sharing in SLT

Overall attitudes of adult candidates were classified as utilitarian for 30 candidates (60%), self-preserving for 13 candidates (26%) and undecided for 7 candidates (14%) (Figure 1). Almost all patients (98%) agreed or strongly agreed that they would feel good about sharing a part of their liver graft with a pediatric liver transplant candidate. Most patients (62.5%) agreed or strongly agreed with the idea that pediatric liver transplant candidates should have priority over adults in the allocation of liver allografts, while 18% felt neutral and 18% disagreed. No significant association was found between overall attitude toward graft sharing and either wait time or MELD score.

image

Figure 1. Classification of overall attitudes toward organ sharing in split liver transplantation among adult liver transplant candidates (n = 50).

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Willingness to participate in SLT

Even though only 60% of candidates held an overall attitude classified as utilitarian, 90% of candidates would be willing to share even if their expected survival after SLT was shorter than after whole liver OLT. In particular, 69% of adult candidates said they would participate in SLT even if it conferred only 7 years of survival benefit for every 10 conferred by whole liver OLT (Figure 2). Only five candidates (10%) said that the survival for adults undergoing SLT would have to be as good as the survival for adults undergoing whole liver OLT for them to consider participating. Virtually all patients (98%) indicated that they would trust their transplant surgeon and transplant coordinator to help them decide if SLT would be a good option in their situation.

image

Figure 2. Bar graph showing the cumulative percentage of patients willing to participate in SLT given varying degrees of survival benefit. Horizontal axis represents the number of years of additional survival gained by SLT per 10 years of additional survival gained by whole liver OLT (n = 50).

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Responses to open-ended questions

The comments of most adult liver transplant candidates accurately reflected their attitude toward graft allocation. In particular, many candidates expressed sentiments that any additional survival afforded by a liver transplant would be welcomed, and these candidates understood that sharing of their liver graft in the context of SLT could benefit the transplant candidate population as a whole. Several candidates named the ‘shortage of organs’ for their willingness to participate in SLT even if the adult SLT recipient survival was inferior to that of whole liver OLT. One candidate referred to a quote from Dr. Spock in Star Trek in explaining his opinion that liver transplantation should be ‘for the good of all’. Another candidate mentioned that he might also take the pediatric candidate's projected post-SLT survival into account in deciding whether to participate in SLT and said it seemed like a matter of ‘playing percentages’. Another candidate who stated he would consider participating in SLT if it provided only 8 years of additional survival for every 10 years of additional survival afforded by whole liver OLT, said he would accept an even larger survival benefit discrepancy if it would decrease his own waiting time in addition to decreasing that of the pediatric liver transplant candidate. Finally, several candidates that said they would accept large decreases in survival to participate in SLT noted that the SLT graft could act as a ‘bridge’ of sorts, allowing them time until they could receive a whole liver allograft.

In contrast, several patients mentioned that adult SLT recipient survival would have to be ‘as good or better’ than adult whole liver OLT survival for them to consider participation. One of the candidates whose attitude was classified as self-preserving expressed no desire to help pediatric candidates: ‘when you're sick you're sick…[I'm] not in the mode to be a humanitarian’. The patients whose overall attitudes were classified as undecided said that they understood both viewpoints but would need more time to consider which viewpoint would best describe their attitudes toward organ sharing.

Incidentally, several participants said they felt it was unfair that candidates whose liver disease was perceived as unavoidable (such as sclerosing cholangitis or primary biliary cirrhosis) had no priority over those candidates whose liver disease was perceived as avoidable (such as chronic active hepatitis C or alcoholic cirrhosis). The underlying sentiment seemed to be that the organ shortage would not be so acute if candidates whose irresponsible behavior resulted in their liver disease were not eligible for transplantation and candidates who ‘followed the rules’, as one participant remarked, were given priority.

Discussion

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

SLT, introduced by Pichylmayr et al. in 1988 (3), consists of dividing a liver into two separate allografts, typically allocated to one pediatric recipient and one adult recipient. Although the mortality and complication rates seen in early series were higher than those seen in whole liver OLT (4,5), recent series demonstrate that rates of mortality and complications comparable to that of whole liver OLT can be achieved at experienced transplant centers (6,7). In addition, it has been estimated that a policy to split all appropriate livers would increase the U.S. liver supply by 15–25%, and SLT could decrease or eliminate the wait time for U.S. pediatric liver transplant candidates (8). Although such benefits have been observed in European centers performing SLT (9), the recent United Network for Organ Sharing policy toward splitting appropriate whole adult donor organs (10) has not been uniformly implemented in the United States (11).

The ethics concerning the subjecting of a healthy donor to major hepatectomy in the setting of adult living donor transplantation have often been questioned (12–15), but only recently has a concern regarding the ethics of SLT been raised (2). This concern stems from an analysis of the outcomes of SLT by Merion et al. (1), a study that demonstrated that adult SLT recipients experience a small decrease in post-transplant survival as compared to adult whole liver OLT recipients. A formal statistical comparison of these two patient groups is lacking, however, and although it is not known if this difference in post-transplant survival is statistically significant, it has nonetheless served to raise the issue (2) of whether the transplant physicians owe their primary allegiance to individual patients or to society as a whole. In particular, do transplant physicians have an obligation to maximize transplantation's benefit to individual patients, regardless of its cost to society, or should transplant physicians sacrifice some of the benefit to individual patients in order to increase the total number of transplants performed and maximize the benefit to society as a whole? Although this ethical dilemma will likely be discussed well into the future, the following recent UNOS statement may, at least provisionally, give the transplant community some basis for action: ‘The transplant community has an ethical obligation to maximize the number of potential recipients successfully transplanted. Splitting medically suitable livers is therefore ethically proper’ (10).

While opinions of the transplant community toward liver allograft allocation in the setting of SLT have been voiced (2,10), the opinions of adult liver transplant candidates—the persons most often asked to participate in SLT by ‘donating’ a part of the liver allograft allocated to them—have not yet been examined. Such was the purpose of the current study. The results of this study demonstrate that most patients (60%) held a ‘utilitarian’ attitude toward graft sharing, i.e. they believed that liver grafts should be distributed in a manner that would maximize the total number of transplants performed. Although 26% of recipients held an attitude that was described as ‘self-preserving'—preferring to maximize their own individual outcomes rather than maximizing the benefit to the transplant candidate population as a whole—89.6% said they would participate in SLT even if the survival benefit for adult recipients was inferior to that of whole liver OLT. Clearly, most of the study participants were aware of the donor livers and felt it was appropriate to share their liver graft even though this may have differed from their ideal of organ allocation.

The results of the current study are consistent with previous studies of the general public's attitudes toward organ distribution. In general, these studies have demonstrated that most people feel that consideration of a candidate's prognosis, waiting time, age and family circumstances (16–18) are factors that should be incorporated in the organ allocation process. The general public values equity (giving everyone an opportunity for receiving an organ) over utility (prioritizing the distribution of organs to those with the highest likelihood of long-term post-transplant survival).

The recent study by Merion et al. (1) found that the predicted survival of adult liver transplant recipients was decreased by 0.3 months (approximately 9 days) during the first two post-transplant years if the recipient underwent SLT rather than whole liver OLT. This is equivalent to a 6% decrease in individual life-years gained. In the current study, we found that 68.8% of adult liver transplant candidates were willing to accept a 30% decrease in post-transplant survival in order to participate in SLT (Figure 2). Clearly, most adult candidates are willing to accept a much higher decrease in post-transplant survival in order to participate in SLT than that found by Merion et al. (1). It acknowledged, however, that while this 6% decrease in individual life-years may seem to be a negligible cost for individual adult liver transplant candidates to bear, the aggregate decrease in life-years gained after SLT may be more noticeable (1,2).

Organ allocation strategies should not be based on public opinion, but an awareness of the attitudes of prospective liver transplant candidates is important to transplant physicians. Without data to suggest otherwise, one may have assumed that adult liver transplant candidates would prioritize maximizing their own outcomes. The attitudes of most adult liver transplant candidates are not, in fact, so selfish. Although adult liver transplant candidates do retain the right to refuse participation in SLT, the attitudes of most adult liver transplant candidates toward liver allograft allocation are similar to those of UNOS (10) and should not act as a deterrent to the application of SLT.

The focus on the attitudes of adult liver transplant candidates (rather than those of the general public) is a unique strength of this study. These adult candidates are the persons who may be making decision regarding participation in SLT, and as such the opinions of this group seemed most relevant. The hypothetical scenarios presented in the questionnaire would not be difficult for the adult liver transplant candidate to imagine, and these candidates are much more likely to have given prior consideration to organ distribution than members of the general public. This study does have some weaknesses, however. First, the hypothetical scenarios presented may not have accurately elicited the participants’ attitudes toward organ sharing and SLT, a problem to which questionnaire-based research is prone (16). In addition, the candidates that participated in this study may differ significantly from candidate populations at other institutions in demographics and educational background. This too may affect the ability to generalize our results. Finally, Merion et al. demonstrated that adult SLT recipients have a higher retransplantation rate than adult whole liver OLT recipients (1). Our study focused on post-transplant patient survival to the exclusion of retransplantation to avoid the problem of presenting participants with hypothetical situations that have a prohibitively high number of variables to consider. The question of whether an increased retransplantation rate may act as a deterrent to participation in SLT would need to be addressed in a separate study. In spite of these potential weaknesses, however, we feel that this study is a valuable survey of the adult liver transplant candidates we serve and an important start to understanding the ethics and attitudes of these patients.

In summary, the results of this study demonstrate that most patients hold a utilitarian attitude toward graft sharing, and that attitudes toward graft sharing and the possibility of compromised survival benefit are not barriers to SLT for most adult liver transplant candidates.

Acknowledgment

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

The authors would like to acknowledge The Methodist Hospital Foundation for financial support.

References

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