Live liver donors' risk thresholds: risking a life to save a life

Abstract

Background: There is still some controversy regarding the ethical issues involved in live donor liver transplantation (LDLT) and there is uncertainty on the range of perioperative morbidity and mortality risks that donors will consider acceptable.

Methods: This study analysed donors' inclinations towards LDLT using decision analysis techniques based on the probability trade-off (PTO) method. Adult individuals with an emotional or biological relationship with a patient affected by end-stage liver disease were enrolled. Of 122 potential candidates, 100 were included in this study.

Results: The vast majority of participants (93%) supported LDLT. The most important factor influencing participants' decisions was their wish to improve the recipient's chance of living a longer life. Participants chose to become donors if the recipient was required to wait longer than a mean ± standard deviation (SD) of 6 ± 5 months for a cadaveric graft, if the mean ± SD probability of survival was at least 46 ± 30% at 1 month and at least 36 ± 29% at 1 year, and if the recipient's life could be prolonged for a mean ± SD of at least 11 ± 22 months.

Conclusions: Potential donors were risk takers and were willing to donate when given the opportunity. They accepted significant risks, especially if they had a close emotional relationship with the recipient.

Figure 1

A pie chart used as a visual aid to illustrate to participants in this study the likelihood of expected outcomes in living donor liver transplantation

Figure 2

Representation of how probability trade-off technique works. The participant was given an initial scenario (left-hand bar) in which the risk for perioperative mortality following living donor liver transplantation was 5%. During the interview, the risk for perioperative mortality was increased by increments of 1% until it reached 15% (right-hand bar). At this level of risk, the participant changed his or her mind and declined to become a live liver donor. In this example, this participant's threshold for perioperative mortality risk was 15% and the maximum risk increment tolerable (threshold value minus initial value) was 10%

Figure 3

Preferences of participants asked if they were willing to undergo partial hepatectomy to donate part of their liver to a potential recipient waiting for a liver transplant (P = 0.0001)

Figure 4

Percentages of participants willing to donate part of their liver in living donor liver transplantation based on the recipient–donor relationship (P = 0.0001)

Figure 5

Percentages of participants willing to donate part of their liver in living donor liver transplantation based on the primary cause of the liver disease affecting the recipient, the probability that liver failure might reoccur because of the nature of the original disease or self-inflicted hepatotoxicity and the age of the recipient (P = 0.001). HCV, hepatitis C virus; PSC, primary sclerosing cholangitis

Figure 6

Importance attributed to some of the variables influencing participant decisions. Values were measured using a visual analogue scale (VAS; 0 = non-important, 10 = extremely important) in 93 participants who were willing to donate. The number of participants who were ambivalent or against donation was too small to allow any meaningful analysis. Error bars show 95% confidence intervals

Figure 7

Donors’ inclination to undergo hepatectomy in relation to: (a) operative risks for complications and death; (b) the time required to make a full recovery after surgery; (c) the likelihood of requiring blood transfusions; (d) the length of time spent by the recipient on the waiting list; (e) the recipient's survival benefit; (f) the recipient's age, and (g) the transplant team's surgical expertise