On May 4, 2003, the first donor death after living-related liver transplantation (LRLT) occurred in Kyoto, Japan. The donor who died was a mother in her late forties who in August 2002 donated the right lobe of her liver to her adolescent daughter with liver cirrhosis caused by congenital biliary atresia. The mother’s liver function had deteriorated progressively after the donation. In January 2003, the mother finally fell into liver failure after an unsuccessful domino liver transplant from a donor with a metabolic disease. She died 4 months later without regaining consciousness.
The daughter, who has recovered well, had initially received a liver from her father in 1994. Because of graft rejection, however, the daughter’s condition eventually deteriorated and she became critically ill before her second LRLT. The only potential living donor was her mother, who unfortunately had mild hypertension (systolic blood pressure, 150–160 mm Hg) and a slight fatty liver diagnosed by preoperative computed tomographic (CT) scan and echogram. After intense discussion, the transplant team reached the decision to undertake emergent LRLT surgery. When the donor later developed liver failure and died, the university hospital opened the case to the media and invited external inspection by the Japanese Liver Transplant Society. Histologic examination of the donor liver revealed that she had nonalcoholic steatohepatitis (NASH), a rare disease with a poor prognosis that is capable of progressing to liver cirrhosis or cancer (1). The transplant team initially planned to perform a right lobectomy without the middle hepatic vein, leaving an estimated residual liver volume by CT volumetry of 37%. During the operation, however, the team judged it better to perform a right lobectomy with the middle hepatic vein. The donor’s residual liver volume by CT volumetry was 28%, lower than the suggested safe range of 30%.
LRLT has the potential to reduce the shortage of organs for transplantation worldwide (2). Although the pros and cons of living donation have been widely discussed (3), the ultimate priority is undoubtedly the safety of the donor. This is the first donor death that has occurred in some 2,300 LRLT undertaken in Japan. At Kyoto University, where approximately 900 cases have been undertaken, an institutional ethics committee evaluates each case and ensures adequate informed consent (4). In spite of these precautions and a procession of successful cases, the Japanese medical community has now experienced the ultimate tragedy inherent in living-related organ transplantation—the loss of a donor’s life.
The Japanese transplant professionals now intend to (1) include testing for NASH (by biopsy) in the criteria for selecting donors at potential risk; (2) establish safer standards for preoperative CT volumetric analysis; (3) increase the required education team for selecting donors; and (4) amend the process of informed consent by including disclosure of unpredictable risk of rare complications including NASH. We hope that Japan’s experience of a death after LRLT and the procedural modifications learned from this misfortune will help contribute to the future sound development of LRLT worldwide.
Akira Akabayashi
Brian T. Slingsby
Misao Fujita
REFERENCES
1. Angulo P. Nonalcoholic fatty liver disease. N Engl J Med 2002; 346: 1221–1231.
2. Trotter JF, Wachs M, Everson GT, et al. Adult-to-adult transplantation of the right hepatic lobe from a living donor. N Engl J Med 2002; 346: 1074–1082.
3. Cronin DC II, Millis JM, Siegler M. Transplantation of liver grafts from living donors into adults: Too much, too soon. N Engl J Med 2001; 344: 1633–1637.
4. Akabayashi A, Nishimori M, Fujita M, et al. Living related liver transplantation: A Japanese experience and development of a checklist for donor’s informed consent. Gut 2003; 52: 152.
