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Keywords:

  • Donor hepatectomy;
  • right lobe living donor liver transplantation

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Medical Complications
  8. Psychosocial and Psychiatric Complications
  9. Long-Term Follow-Up of Living Liver Donors
  10. Acknowledgment
  11. Conflict of Interest Statement
  12. References

Right lobe living donor liver transplantation is an effective treatment for selected individuals with end-stage liver disease. Although 1 year donor morbidity and mortality have been reported, little is known about outcomes beyond 1 year. Our objective was to analyze the outcomes of the first 202 consecutive donors performed at our center with a minimum follow-up of 12 months (range 12–96 months). All physical complications were prospectively recorded and categorized according to the modified Clavien classification system. Donors were seen by a dedicated family physician at 2 weeks, 1, 3 and 12 months postoperatively and yearly thereafter. The cohort included 108 males and 94 females (mean age 37.3 ± 11.5 years). Donor survival was 100%. A total of 39.6% of donors experienced a medical complication during the first year after surgery (21 Grade 1, 27 Grade 2, 32 Grade 3). After 1 year, three donors experienced a medical complication (1 Grade 1, 1 Grade 2, 1 Grade 3). All donors returned to predonation employment or studies although four donors (2%) experienced a psychiatric complication. This prospective study suggests that living liver donation can be performed safely without any serious late medical complications and suggests that long-term follow-up may contribute to favorable donor outcomes.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Medical Complications
  8. Psychosocial and Psychiatric Complications
  9. Long-Term Follow-Up of Living Liver Donors
  10. Acknowledgment
  11. Conflict of Interest Statement
  12. References

Living donor liver transplantation (LDLT) has gained worldwide acceptance as an effective therapy for advanced liver disease (1,2). The primary concern of LDLT programs is to minimize donor morbidity and mortality. This has led to the development of criteria for the establishment of LDLT programs (3,4), promotion of extensive and consistent documentation and reporting of donor morbidity and mortality (5,6,16) as well as establishment of ethical guidelines for the care of donors. (7,8). There is significant variability among protocols used by transplant centers to follow donors after right lobe liver donation (9).

The Liver Program of the University of Toronto established its right lobe adult LDLT program in 2000 and its activity has risen significantly over the past few years. In 2008, we performed 45 adult living donor procedures making our program one of the largest LDLT programs in the world. Currently, LDLT constitutes 35% of adult liver transplant activity at our center (1,10). This study reports results of the long-term follow-up of our first 202 right lobe adult liver donors who had a minimum follow-up of 1 year.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Medical Complications
  8. Psychosocial and Psychiatric Complications
  9. Long-Term Follow-Up of Living Liver Donors
  10. Acknowledgment
  11. Conflict of Interest Statement
  12. References

Two hundred and forty-seven (247) right lobe living donor hepatectomies were performed at the University of Toronto Liver Transplant Program between April 26, 2000 and March 12, 2008. Two hundred and two (202) of these donors had a minimum follow-up period of 12 months and were included in the analysis. All donor demographic data, abdominal complications and psychosocial parameters were recorded prospectively in an electronic patient medical record (OTTR, Kenyon Hicks, Omaha, Nebraska) and were obtained via retrospective chart review for the purposes of the current study. Complications were stratified according to the Clavien classification scheme (11) as modified by Broering et al. (12). Grade I was defined as minor complications; grade II described potentially life threatening complications requiring pharmacological intervention; grade III described complications requiring invasive intervention including ICU admission; grade IV was used for complications causing residual disability or death.

Donor selection process

Medical history, examination and laboratory analysis:  Donor suitability was determined after completing a multidisciplinary evaluation process that included blood tests, imaging studies and a psychiatric and medical assessment by professionals who were independent from the transplantation team. Liver biopsies were performed on donors suspected to have steatosis. Absolute exclusion criteria for donation were ABO incompatibility, underlying liver disease, positive hepatitis serology, steatosis >10%, inadequate graft size, abnormal biliary anatomy or any medical condition that was considered to pose an increased risk for donor complications. A history of depression, anxiety disorder or substance abuse was not an absolute contraindication to donation.

Abdominal imaging:  Doppler ultrasound imaging was utilized for preliminary screening of hepatic anatomy. Triphasic computerized tomography (CT) was performed to assess venous and arterial anatomy, as well as to estimate the whole, right lobe and remaining left lobe liver volumes using OSIRIS imaging software (Digital Imaging Unit, University Hospital of Geneva, Geneva, Switzerland). Estimated graft to recipient weight ratio (GRWR) was acceptable if >0.8% provided that the residual liver weight/total liver weight ratio was greater than or equal to 30%. Magnetic resonance cholangiography (MRCP) was utilized to assess biliary anatomy. CT cholangiography was reserved for donors in whom biliary anatomy was unclear by MRCP. Donors with common vascular and biliary anatomical variants were generally accepted for donation.

Peri- and postoperative management

The technical aspects of the donor surgery have been previously described in detail (1,10,13). Epidural analgesia was used in 149 (74%) donors. Deep vein thrombosis prophylaxis which included pneumatic compression stockings and anticoagulation with 5,000 u heparin subcutaneously twice daily was employed routinely in hospital and was converted to once daily low molecular weight heparin (dalteparin injection; Pharmacia, Mississauga, ON) 5,000 u s/c daily for 6 weeks postsurgery. Anti-microbial therapy (cefazolin 1 g IV Q8H and metronidazole 500 mg IV Q12H) was administered prior to surgery and for 48 hours postoperatively.

Parenteral magnesium and phosphate infusions were administered until donors were able to tolerate oral supplementation. Doppler abdominal ultrasound imaging was performed routinely on the third postoperative day in order to assess hepatic artery, portal and hepatic vein flows.

Donor follow-up

Clinic visits:  Most donors were compliant with long-term follow-up (Table 1(A)). Overall, 92.5% of donors attended follow-up: 71.5% at our transplant center and 21% are followed by their family physicians with results forwarded to our center electronically. Ten donors were lost to follow-up (but we know from their recipients that at least 9 out of these 10 individuals are still alive and well) and three out of country donors were followed irregularly.

Table 1.  Psychosocial characteristics
(A) Compliance with long-term follow-up
Place of follow-upNumberPercent
  1. Mean time to return to work (weeks) 9.7 ± 3.6.

  2. Mean Length of follow-up period (months) 33.9 ± 21.

Followed at transplant center14471.5
Followed by primary care
In province2311
In country168
Out-of-country 42
Overall compliance187 92.5
Declined further follow-up (>2 years) 21
Lost to follow-up105
Followed irregularly (out-of-country) 31.5
 
(B) Donor marital status
StatusPre-donationAt last follow-up
 
Married/engaged/common-law115 (57%) 125 (62%) 
Single63 (31%)55 (27%)
Divorced/separated24 (12%)20 (10%)
Widowed0 (0%)2 (1%)
 
(C) Donor employment status
StatusPre-donationAt last follow-up visit
 
Working/student186 (92%)   189 (93.5%) 
Disability7 (3.5%)3 (1.5%)
Unemployment by choice (retired)9 (4.5%)9 (4.5%)
Other0 (0%) 1 (0.5%)

The donor follow-up protocol consisted of clinic visits at 2 weeks, 1 month, 3 months, 12 months and then annually postsurgery. These follow-up visits consisted of a physical exam and measurement of serum liver tests, complete blood count, coagulation profile and serum electrolytes/creatinine. An abdominal ultrasound was performed at 1, 3 and 12 months. Donors were specifically asked about changes in mental or physical health and these responses as well as demographic data, were recorded during clinic visits. Continuity of care was provided by a family physician (LA). All donors received supportive counseling by this physician and donors who required intensive counseling were referred to specialists.

Statistical analyses

All study analyses were conducted using SPSS version 14.0. Data are reported as mean ± standard deviation unless otherwise specified. Recipient graft and patient survival were determined by Kaplan–Meier survival analysis.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Medical Complications
  8. Psychosocial and Psychiatric Complications
  9. Long-Term Follow-Up of Living Liver Donors
  10. Acknowledgment
  11. Conflict of Interest Statement
  12. References

Adult right lobe living donation

All 202 donors survived and were discharged home at 7.1 ± 1.9 days posttransplant. Actuarial 1, 3 and 5 year graft and recipient survival rates were 87.1%, 80.5%, 77.6% and 89.6%, 83.4%, 78.2%, respectively (Figure 1). Five recipients were retransplanted with a mean retransplantation time of 205 ± 261 days and reasons for retransplantation included hepatic artery thrombosis (2), chronic rejection (2) and portal vein thrombosis (1).

image

Figure 1. Kaplan–Meier curves of donor, recipient and graft survival. The insert shows the number of recipients/donors at risk and their survival percentage at the specific time points examined.

Download figure to PowerPoint

Donor demographics

The demographic data of all living donors analyzed is presented in Table 2. Mean donor age was 37.3 ± 11.5 years. Most donors were either an offspring or sibling of the recipient (62%). Mean donor body weight was 75.2 ± 13.9 kg with a mean body mass index (BMI) of 26 ± 4. At the time of donor surgery, 186 (92.1%) donors were employed or studying, nine donors (4.5%) were retired or unemployed by choice and seven (3.5%) were supported by long-term disability pensions. The majority of donors (57%) were in a stable relationship, 31% were single and 12% were separated or divorced. At the time of donation, 6 donors (3%) had a Mood Disorder, and 11 (5.4%) had an anxiety disorder. Nine donors (4.5%) had a past history of a Mood Disorder and 7 (3.5%) had history of substance abuse.

Table 2.  Donor demographics
CharacteristicNumber (%)
  1. Values are mean ± standard deviation.

  2. BMI = body mass index [weight (kg)/height (m)2].

Donor202
Age (years)37.3 ± 11.5 (18–60)
Sex
 Male108 (53%) 
 Female94 (47%)
Body weight (kg) 75.2 ± 13.9
BMI26.0 ± 3.9
Relationship
 Offspring83 (41%)
 Sibling43 (21%)
 Friend25 (12%)
 Spouse18 (9%) 
 Other non-biologic relative14 (7%) 
 Other biologic relative9 (4%)
 Parent8 (4%)
 Anonymous2 (1%)
Marital status at time of donation
 Married, engaged, common-law115 (57%) 
 Single63 (31%)
 Divorced/separated24 (12%)
Employment status at time of donation
 Working/student186 (92%) 
 Disability 7 (3.5%)
 Unemployed by choice/retired 9 (4.5%)

Operative characteristics

Resected liver volume was 930 ± 153 mL, leaving a donor residual volume of 573 ± 143 mL (Table 3). Mean GRWR was 1.3 ± 0.3 % and was not affected by the inclusion or exclusion of the MHV. The mean number of bile ducts for anastomosis was 1.31 ± 0.52 and the mean number of veins requiring revascularization was 1.78 ± 0.83. Mean operative time was 443 ± 85 minutes. Mean estimated blood loss was 997 ± 484 mL. Autologous blood transfusion was received by 24 (12%) of the donors intra or postoperatively, and 60% received blood from the cell saver during surgery. The mean donor length of postoperative hospital stay was 7.1 ± 1.9 days (range 4–17).

Table 3.  Operative characteristics of RLDLT
CharacteristicNumber (%)    
  1. Values are mean ± standard deviation.

  2. RLD + MHV: right lobe donor with middle hepatic vein.

  3. RLD – MHV: right lobe donor without middle hepatic vein.

  4. GRWR = graft recipient weight ratio.

Procedure
RLD + MHV121 (60%)    
RLD – MHV 81 (40%)    
Total liver volume (mL)1532 ± 278     
Volume of liver removed (mL)930 ± 153    
Volume of liver retained (mL)573 ± 143    
GRWR1.3 ± 0.3    
Graft anatomy  1234total
Donor arteries193900202
Donor hepatic veins 9070 36 6202
Donor bile ducts14650 60202
Procedure time (minutes)443 ± 85     
Estimated blood loss (mL)997 ± 484    
Blood transfusion
Allogenic  3 (1.5%)    
Autologous 24 (12%)    
Cell saver122 (60%)    
Length of hospital stay (days)7.1 ± 1.9    

Donor medical complications

Mean follow-up of donors was 33.9 ± 21 months (range 12–84). The overall donor complication rate was 41%. Complication rate within the first year was 39.6%. Complications are described as early (first 30 days) (Table 4), delayed (1–12 months) and late (>1 year) (Table 5). Complications were grades I–III. To date, no donor has experienced residual disabilities, significant organ dysfunction or death.

Table 4.  Early complications of RLDLT by severity (<30 days) N = 202
ComplicationNumber (%)Operative intervention (n)
  1. Severity based on the Broering et al. modification of the Clavien classification (6). Endoscopic indicates ERCP or radiologically placed drainage catheter.

Grade I
 Urinary tract infection/ recatheterization 13 (6.0%) 
 Rash 3 (1.5) 
 Arrhythmia  1 (0.5%) 
Grade II
 Wound infection  5 (2.5%) 
 Pulmonary emboli 2 (1%) 
 Subphrenic/pleural effusions  4 (2.0%) 
 Postoperative bleeding (transfusion only) 2 (1%) 
 Bile leak (observation)  1 (0.5%) 
 Left hepatic duct stricture  1 (0.5%) 
Grade III
 Subphrenic/Pleural effusions11 (5%) 11 Percutaneous
 Bleeding (re-operation)  5 (2.5%)5 operative
 Bile leak (endoscopic intervention) 4 (2%)4 Endoscopic
 Dehiscence (operative repair)  3 (1.5%)3 Operative
 Thermal bile duct injury  1 (0.5%)1 Intraoperative
 Pneumothorax-chest tube insertion  1 (0.5%)1 Intraoperative chest tube
 Grade IVNone 
 Total 57 (28%) 
Table 5.  Late complication of RLDLT by severity (>30 days) time period
Complication1–12 months1–2 years2–5 years>5 years
N = 202N = 152N = 98N = 54
  1. Median length of follow-up (months) 27.5 (range 12–96).

Grade I
 Keloid 4 (2%)1 (0.7%)00
Grade II
 Mental health issues  4 (2.0%)   
 Small bowel obstruction  2 (1.0%) 1 (1.0%)0
 Pulmonary emboli and DVT  2 (1.0%)   
 Pneumonia  2 (1.0%)   
 Wound infection  2 (1.0%)   
Grade III
 Incisional hernia repair  6 (3.0%)1 (0.7%)00
 Pleural effusion 1 (0.5)    
Grade IV
 None
Total 23 (11%)2 (1.3%)1 (1.0%)0

Complications during the first 30 days:  The most serious early complication was an intra-operative thermal injury to the common bile duct (CBD), which required a choledochojejunostomy for repair (Table 4). This donor is now 2 years postdonation and has not experienced any long-term biliary tract complications. Another donor was found to have a mild narrowing of the left hepatic duct on the postresection cholangiogram. This complication resulted in elevation of the alkaline phosphatase level at 3 months and mild intrahepatic bile duct dilation on an MRCP although further intervention was cancelled when all biochemistry normalized and an MRCP conducted 10 months postdonor surgery showed normal biliary tree. Postoperative bleeding requiring re-operation occurred in five donors: a small hilar plate artery was the source of bleeding in all cases. Other early complications included subphrenic collections or pleural effusions in 15 donors (7%) requiring percutaneous drainage (11) or diuretic therapy (4). In 12 of these donors the MHV had been taken with the graft. Bile leaks occurred in five donors, four of whom were treated with stent placement and papillotomy, and one with observation. Two donors experienced pulmonary emboli within 1 week of hepatectomy. Reclosure of a partial fascial dehiscence was required in three donors. Five donors required drainage and antibiotic treatment for early wound infections.

Complications at 30 days to 1 year posttransplant:  Readmission to hospital for the treatment of Clavien Grade III complications was required in 15 (7.4%) donors. The most common complication during this time period was incisional hernia (6), which was surgically corrected in all cases. Two donors experienced late wound infections. Two donors were readmitted for treatment of a partial small bowel obstruction that resolved with bowel rest and hydration. Pneumonia developed in two donors 2 months postsurgery and was treated with parenteral antibiotics. Pulmonary emboli occurred in two donors at 1 month early in our experience after they traveled a long distance to return home; there have been no additional cases of late pulmonary emboli since we extended our prophylactic anticoagulation regimen to a total of 6 postoperative weeks. One donor was readmitted for the treatment of a sinus tachycardia and had a negative ischemia work-up. Keloids developed in five donors, four of whom were treated with intralesional steroid injections with marked flattening of the keloid. One donor opted not to have their keloid treated. Although four donors suffered mental health disturbances, this did not lead to any readmissions.

Complications beyond 1 year:  We only experienced three complications beyond 12 months after surgery and these are listed in Table 5. One donor with a late keloid was referred to Plastic Surgery for treatment. One donor developed an incisional hernia after 1 year, which was surgically repaired. Another donor presented with a partial small bowel obstruction at 3.5 years postdonation, which resolved with hydration and bowel rest. We did not see any psychosocial problems beyond this period.

Psychosocial outcomes

Psychiatric complications:  Of the 202 donors, four female donors (2%) developed psychiatric complications. Two donors, without a predonation history of depression, developed a Major Depressive Episode, which was successfully treated with antidepressants and counseling by a psychiatrist. In both of these cases, their recipients had died. Two donors, with a known diagnosis of generalized anxiety disorder at the time of donation, experienced symptom exacerbation within the first postoperative month that resolved with the resumption of their usual anxiolytic medications.

Marital status pre- and postdonation:  At last follow-up, the majority of the donors were in a stable relationship (62%) (Table 1(B)). Three of the married donors (none of whom were married to their recipients) divorced following donation, and three were widowed after the spouse to whom they donated to died. Seven of the previously single donors married. Three previously divorced donors and one widowed donor remarried.

Donor employment status:  All donors were able to return to work following donation (Table 1(C)). The mean length of time for return to employment was 9.7 ± 3.6 weeks with a range from 2 to 52 weeks. One donor who was previously working retired and one was incarcerated. Four donors who had been receiving long-term disability pensions prior to donation, for reasons unrelated to donor surgery, were able to re-enter the work force postdonation. Four donors (two male, two female) were referred to our psychosocial team for counseling regarding job dissatisfaction, 3 within 6 months and 1 at 12 months postdonation (these four donors were not the same ones who had mental health problems).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Medical Complications
  8. Psychosocial and Psychiatric Complications
  9. Long-Term Follow-Up of Living Liver Donors
  10. Acknowledgment
  11. Conflict of Interest Statement
  12. References

This is the largest single center study to date assessing medical outcomes of living liver donors prospectively beyond 1 year after donor hepatectomy. Long-term medical and psychiatric complications were rare. Our single center design was advantageous due to consistency of data collection and our findings should be generalizable given that we used the principles and practices recommended by the Vancouver Forum on Live Donation (7,8) to guide our donor selection, surgery and follow-up care.

Results from numerous centers have shown that with careful donor selection and specialized care, low short-term morbidity and mortality rates are achievable (12,21,22). In a large retrospective observational series from the A2ALL consortium in the United States, Ghobrial et al. (16) reported the complications from all potential living donors assessed between 1998 and 2003. Out of the 393 donors who underwent donation, 62% did not experience complications. Out of the 38% of those donors that did experience postoperative problems, 21% had 1 and 10.2% had 2 complications. Overall, approximately half the complications seen were classified as Grade 1 and half as Grade 2 with few complications in the Grades 3 and 4 categories.

However, there are very few other reports of longer term morbidity and mortality and many of these studies are flawed by small sample size or retrospective data collection; hence the novelty of this report (6,12,14–18). In the LDLT program in Kyoto, Japan, complications of any kind were observed in 30% of donors (19). Yi et al. (5) reported an overall complication rate of 78.3% based upon their prospective evaluation of donor morbidity in 83 right lobe donors who were followed for 1 year. Similarly, Chan et al. (20) reported a 20.5% overall complication rate in 200 consecutive right lobe donors. Nonetheless, worldwide reports of late donor deaths and morbidity (18) support our belief that long-term follow-up and care of liver donors is desirable.

From 2000 to 2006, 90 day, 1 and 5 year recipient survival rates following transplant at our center were equivalent for LDLT and DDLT recipients. In addition, LDLT offered a 10% 1 year survival advantage compared with recipients who underwent DDLT or remained on the waiting list (23).

The ongoing success of LDLT relies upon the assumption that the donor operation is performed safely and does not compromise long-term health. This study adds to a small but growing literature examining the effects of donation beyond 1 year. Long-term medical and psychiatric complications among our donors were rare (1%), and quality of life in this cohort, as reported by Dubay et al. (24), does not appear to be adversely affected by the donation process. From its inception, our LDLT program has benefited from our surgical team's extensive experience with non-transplant hepatobiliary surgery and our institution's familiarity with the postoperative care of these patients. The medical care of donors is assigned primarily to a senior hepatologist and a family practitioner who assess prospective donors. In addition, all donors are assessed by our psychosocial team who are also available for postdonation psychological support. The nature of our donor follow-up does not follow a strictly surgical model but encompasses a more comprehensive approach engaging a full-time family practitioner. This has enabled us to monitor the effect of donation on donor overall physical, psychological and social well-being.

In order to give informed consent, donors must be fully aware of the potential risks of live donation and the incidence of all complications including death. Many studies have underreported minor complications (14,25) thus a precise risk of donor morbidity has been challenging to quantify. Beavers et al. (9) reported, in their review of 12 studies of right lobe living donors, a crude complication rate of 31%. At our center, all donor complications, both medical and psychiatric, have been recorded in a prospectively maintained database and with our close donor follow up, we believe that our findings reflect the actual risk of donor complications, both short- and long-term.

Medical Complications

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Medical Complications
  8. Psychosocial and Psychiatric Complications
  9. Long-Term Follow-Up of Living Liver Donors
  10. Acknowledgment
  11. Conflict of Interest Statement
  12. References

In living donors, the reported rate of infections, incisional hernias and small bowel obstruction, is 9–19% (26–29). In our cohort, wound complications were relatively common (8.4%). Five wound infections occurred within the first month and two within the second. The latter were likely local suture reactions however were recorded as infections as their cultures grew commensal flora. All but one incisional hernia occurred within the first year and all required surgical correction. After the first year, the only other abdominal complication was a small bowel obstruction at 3 years postdonation. This low rate of abdominal complications after 1 year is consistent with reports from other centers (2,30–32).

Pulmonary embolism, a well-recognized cause of donor mortality (12,33) occurred in four donors (2%). Recommendations to reduce the risk of thromboembolic events including smoking cessation and discontinuing of hormonal contraception are followed at our center. Unless donors indicate a family or personal history of thromboembolic disorders, an extensive hematologic workup, advocated by some groups (26) is not conducted. Based on recommendations from our hematology colleagues, all donors are treated with compression stockings and anticoagulation. Early in our experience two donors developed non life-threatening pulmonary embolism following a 6 hour automobile trip 1 month postdonation. Prophylaxis with low molecular weight heparin now continues for a period of six weeks, recognizing there is no level 1 evidence to support this practice. It is noteworthy that notwithstanding these aggressive preventative measures, two donors developed pulmonary emboli 2 days postsurgery and were subsequently anticoagulated for 6 months and have made a full recovery.

Bile leaks from the cut surface of the liver have been reported to occur in 5–10% of right lobe donors (15,27–28,34–36). To date bile leaks have occurred in five (3%) of our donors. Biliary structuring developed in one of our donors within the first year and resolved without therapeutic intervention. Significant bleeding requiring re-operation was experienced by five donors. In all, the bleeding occurred within the first postoperative day and was localized to the hilar plate. The decision to re-operate on these donors was based on our programmatic philosophy and experience that the risk of morbidity from a negative laparotomy is low and that the bleeding source is usually from small hilar plate vessels (10) that are not amenable to treatment by radiologic techniques.

In 2005, Shah et al. (10) demonstrated that, despite a preexisting large case volume of major hepatobiliary resections and deceased donor liver transplantations, we experienced a learning curve with LDLT and that our morbidity rate decreased over time from the inception of our LDLT program. Similar reductions in complication rates over time have also been shown by surgical groups in Chicago and Hamburg (37). This suggests that volume alone is not the sole determinant of outcome and other factors such as careful donor selection and comprehensive long-term follow-up are also important.

Psychosocial and Psychiatric Complications

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Medical Complications
  8. Psychosocial and Psychiatric Complications
  9. Long-Term Follow-Up of Living Liver Donors
  10. Acknowledgment
  11. Conflict of Interest Statement
  12. References

In our cohort, donors did not appear to have significant psychosocial or psychiatric difficulties postdonation. This is consistent with other reports which have made similar conclusions (2,30). The time to return to work or study was similar to other centers.

In contrast with some other living donor transplant programs; a previous psychiatric diagnosis is not an absolute contraindication to donation at our center. Potential donors with a history of depression, anxiety or substance abuse underwent an extensive psychiatric and social evaluation to assess whether the potential psychological benefits of donation were likely to outweigh any potential psychological harm. These donors were also required to demonstrate prior compliance with regular follow-up with mental health care workers. To our knowledge, no donor with a history of depression has reported another depressive episode and those with chronically depressed mood at the time of donation have remained stable. No donors with a history of substance abuse have experienced a relapse and all remain compliant with regular attendance at support programs.

Our psychiatric complication rate of 2% is somewhat lower than rates previously reported for living liver donors (4–14%), (38,39). One possible explanation for this discrepancy is that our pre-donation psychiatric assessment allowed us to distinguish between (a) donors who developed a new psychiatric disorder (that was not present prior to donation) and (b) donors who already had psychiatric issues prior to donating. It is unclear whether previous studies have accounted for pre-donation psychiatric disorders that remained present, but relatively unchanged, postdonation. However, given that we did not employ a standardized psychiatric assessment at follow-up visits, and that appointments were on an annual basis after the first year, we acknowledge that we may have underestimated the actual rate of psychiatric complications. Nonetheless, our experience suggests that, provided the appropriate supports are in place and that with close follow-up, individuals with a past history of depression, anxiety and substance abuse can cope well with living liver donation and do not appear to be negatively affected psychologically by the experience.

In our experience, compliance with follow-up has been excellent, which enables us to state with confidence the rate of early and late complications (28% <1 month, 11% 1–12 months, 1% >12 months). Universal health care in our country facilitates our ability to follow donors long-term. The majority of our donors prefer to continue follow-up at our center for the first year although after this time period, donors who live a significant distance away often opt to have their annual testing conducted locally. These donors remain in direct contact with our donor team and provide updates regarding any changes in their health. Of the ten donors lost to follow-up, none were lost during the first year, none experienced complications after the third month and all were in good health at their last follow-up. Two donors declined further follow-up after 2 years both citing that they did not feel it was necessary.

Long-Term Follow-Up of Living Liver Donors

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Medical Complications
  8. Psychosocial and Psychiatric Complications
  9. Long-Term Follow-Up of Living Liver Donors
  10. Acknowledgment
  11. Conflict of Interest Statement
  12. References

Donors are informed at the commencement of their assessment of our intention to conduct follow-up for a minimum of 10 years postdonation. A dedicated team including a nurse assessment coordinator and a family physician employed full time by the program follow all donors from their first entry into the assessment process, perioperatively and postoperatively. We believe this approach is necessary to assure prospective donors that they will not suffer any long-term medical or psychological complications.

In conclusion, we have found that adult right lobe liver donation, in experienced hands, is relatively safe. Serious long-term medical and psychiatric complications are relatively rare and a formal infrastructure and adoption of a holistic approach may enhance donor compliance with long-term follow-up.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Medical Complications
  8. Psychosocial and Psychiatric Complications
  9. Long-Term Follow-Up of Living Liver Donors
  10. Acknowledgment
  11. Conflict of Interest Statement
  12. References