Living-related Liver Transplantation for Acute Liver Failure

Acute liver failure is a rare medical emergency in children. Without liver transplantation the majority of affected children will die. The shortage and unpredictability of donor organ availability compounds the risk. The clinical team may feel compelled to proceed to transplantation even when a suboptimal graft organ is offered. Unsurprisingly, the outcome of transplantation for acute liver failure is inferior to that of chronic liver disease.

Living-related liver transplantation (LRLT) in contrast provides a predictably timed, high-quality graft with a short ischaemic time. In addition, it allows parents to contribute to achieving their primary aim, the survival of their child. So what's to choose?

For many, however, there is an instinctive unease as to whether genuine informed consent can be achieved given the intensity of the situation and the short time available to complete an assessment. The transplant team assume an enormous responsibility when accepting a parent as a donor in this situation. They must ensure there is no overt coercion and that the donor risk is known and small. The outcome of LRLT should be at least as good as that of cadaveric transplantation done locally and should be comparable with international standards.

In practice in Western societies with mature cadaveric transplant programmes there is little experience with LRLT for acute liver failure ^(1,2). The team from Schneider Children's Medical Centre in Israel report their experience in this month's issue ⁽³⁾.

The Schneider team have demonstrated that it is feasible to counsel and assess families in the time available and that LRLT can be done with little physical risk to the donor. They achieved an outcome comparable with international experience for cadaveric transplant for acute liver failure in children. They also report that the donors believed that their consent was freely given and they did not regret this decision even if their child died.

Some of the problems are honestly presented. There was a disappointing incidence of hepatic artery thrombosis, but a successful strategy for preventing this was developed. This experience does raise the question about how best to introduce innovations in complex surgery, and in transplantation in particular. Centres introducing LRLT would be well advised to liaise and collaborate with centres that have established experience in this area.

The long-term outcome from LRLT in children appears encouraging. The physical risk to donors is low, they and their family relationships benefit from the experience, and the long-term outcome is superior to cadaveric transplantation ⁽⁴⁾. Interestingly, in retrospect, parents who had donated electively believed that their situation was urgent at the time and the decision to donate was immediate ⁽⁵⁾. Importantly, they did not regret that decision irrespective of the eventual outcome. Hence, our concerns as professionals about the particular intensity and urgency of the decision in acute liver failure may not be reflected in how affected families perceive this. It should be an important goal to determine the long-term physical and emotional outcomes for those donors who had to make their decision rapidly at a vulnerable time. I would hope that centres such as the Schneider and others would eventually be able to report such data.

For the rest of us, this experience demonstrates that with suitable infrastructure LRLT can be humane, successful, and appropriate in acute liver failure. Given the current organ donor situation, I believe we are likely to need this option in the United Kingdom.