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Consensus, Dilemmas, and Challenges in Living Donor Liver Transplantation in Latin America

Salvalaggio, Paolo R. MD, PhD; Seda Neto, João MD, PhD; Alves, Jefferson Andre MD; Fonseca, Eduardo A. MD, PhD; Carneiro de Albuquerque, Luiz MD, PhD; Andraus, Wellington MD, PhD; Massarollo, Paulo B. MD, PhD; Duro Garcia, Valter MD, PhD; Maurette, Rafael J. MD; Ruf, Andrés E. MD; Pacheco-Moreira, Lucio F. MD, PhD; Caicedo Rusca, Luis A. MD; Osorio, Veronica Botero MD; Matamoros, Maria Amalia MD; Varela-Fascinetto, Gustavo MD; Jarufe, Nicolas P. MD

Author Information
doi: 10.1097/TP.0000000000001180
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Abstract

Access to transplantation in Latin America is limited.1 To expand access, some programs from the region perform living donor liver transplantation (LDLT). We aimed to review the history, volume, outcomes, unique characteristics, and challenges of LDLT in Latin America. We used data from the Latin American and Caribbean Transplant Society, transplant societies and opinions from local experts.

History, Current Status and Challenges of LDLT in Latin America

Two pediatric LDLTs were described in Brazil in the late 1990s.2 Both donors were discharged shortly after operation and had uneventful recoveries. Recipients had postoperative complications and infections and died within the first year after surgery.2,3 With improving outcomes, there was increasing interest for adult-to-adult right lobe LDLT, particularly in Brazil and Argentina.4-6

The number of effective deceased donors per million population (pmp) almost doubled in the region over the past decade. The largest countries of the region now use the model for end-stage liver disease (MELD) system for liver allocation. The MELD awards exception points to patients who were previously served by LDLT, or those with hepatocellular carcinoma. Thus, better donation rates and allocation systems that favor patients in need decrease the utilization of living donors. Living donor liver transplantation went from 20.2% of the total number of liver transplants in 2005 to 8.5% in 2014.1

Today, LDLT in Latin America is mainly restricted to pediatric patients, particularly to small recipients who face a major restriction for deceased donors under 10 kg. In 2014, LDLT was responsible for 35% to 60% of the number of pediatric liver transplants, representing the main source of grafts for toddlers in Brazil and in the region (Figure 1).

FIGURE 1
FIGURE 1:
Pediatric liver transplantation activity in Brazil, stratified by age and type of transplant. LDLT, living donor liver transplant; DDLT, deceased donor liver transplant.

Split liver transplantation is also underdeveloped in Latin America. There are few policies that can allow broad utilization of split techniques. Alliances of large transplant centers and the determination of the proper technique for each side of the split graft, and how they will be allocated can foster the development of these techniques, reducing the need for living donors for small children.7

Currently, there are more than 160 teams performing liver transplants in Latin America, but we identified only 30 transplant centers involved with LDLT in the past 2 years. In 2014, 226 LDLTs were performed in the region (8.5% of liver transplants, Figure 2).

FIGURE 2
FIGURE 2:
Evolution of the number of Living Donor Liver Transplants in Latin America from 2009 through 2014.

Most countries have specific requirements for living donation and require that LDLT come from altruistic donors. In few countries, there are specific requirements of a family relationship between donor and recipient to proceed with LDLT. Most countries do not impose specific protocols for donor work-up, allowing the transplant units to assess the ethics involved in each procedure. Organ trade is illegal in Latin America, and all countries prohibit organ trafficking.1

We have previously described the difficulties in obtaining data and interpreting transplant outcomes in Latin America. Data collection is not mandatory in most countries and is not transparent for the general population and the transplant community.1 Experienced teams have LDLT outcomes comparable to international expert centers, but donor and recipient morbidity might be underreported. At least 3 donor deaths have been reported in Brazil.5,6 Argentina has the most complete database. Liver transplant activity is registered online in real-time fashion (www.sintra.incucai.gov.ar). Online submission of standardized and complete data regarding the transplant procedure is mandatory in Argentina. This database contains 253 LDLTs from 2000 to 2010. One-year, 5-year, and 10-year patient and graft survival rates were 86%, 84%, 74%, and 82%, 77%, 68%, respectively.

Latin America had multiple attempts to form transplant databases, including donor data. These initiatives probably failed due to the inappropriate funding and to the difficulties in enforcing data reporting. A Brazilian living donor liver registry started in 2005. Data were collected from 554 donors (only 26% of all LDLT). According to this registry, biliary complications were observed in 5.7% and other surgeries due to complications in 5.9%. Moving forward, the liver transplant community should invest major efforts into obtaining adequate data to permit better comparisons among centers and to nurture collaborations around the globe. An initial step could involve the participation of key LDLT centers in a new research consortium that will use the previous experiences of The Adult-to-Adult Living Donor Liver Transplantation Cohort Study in the United States. This Latin American research initiative could initially collect retrospective data from the largest LDLT participating centers. The initial data set will serve as a backbone for a second phase of data collection. In this second phase, other centers involved with LDLT in the region could opt in to join the consortium, and data will be collected prospectively. Funding for investment in technology and human resources for the database could be obtained from donations for research from individuals or private companies. An alternative model would involve mandatory data collection from all transplant activities funded and enforced by the regulators of the transplant national systems of each country.

Uniqueness of LDLT in Latin America in Comparisons to Other Regions of the Globe

Volume, outcomes, and organization of LDLT in Latin America cannot be compared with South Korea, Hong Kong, and Japan that minimally perform deceased donor liver transplant (DDLT) and have different religious cultures.8 The transplant environment in Latin America cannot be compared with India, Pakistan, and Turkey. In these countries, private hospitals created centers of excellence in LDLT. These centers deliver transplant care to multiple countries through local alliances between the hospitals and/or government agreements with neighboring countries.9,10 Local technical expertise on these specialized facilities relies heavily on well-trained doctors and a multidisciplinary dedicated LDLT team. With the investment of private hospitals, appropriate human capital and well-coordinated commercial partnerships, LDLT developed faster and/or before DDLT in these countries.

In Brazil and Argentina, the contribution of living donation to the donor pool is similar to North America, which has a higher number of deceased donors pmp. At the same time, the contribution of LDLT is much smaller than that in Europe. Therefore, it seems that Latin America still lags behind in terms of the number of LDLT and the rate of living donor utilization in comparison with other regions with similar donation rates pmp.

The status of LDLT in Latin America reflects different levels of healthcare systems, variations in access to DDLT, reimbursement, availability of local facilities, and trained teams.1 We believe that this diversity of DDLT volume, outcomes, legislation, finances, and organization of transplant systems among the countries of the region makes LDLT unique in Latin America, therefore, demanding different strategies for different parts of the region to better use and develop LDLT.

Consensus, Dilemmas and the Need for International Partnerships

The consensus is that there is a large need for utilization of pediatric LDLT in the region. Split liver transplantation is still underdeveloped; there are not enough pediatric deceased donors, and even with the adoption of the modified pediatric end-stage liver disease score in Brazil, the waiting list mortality for children is still 20%.7

The current dilemma for the liver transplant community in Brazil and Argentina might be the lack of proper identification of adults who have not been well served by MELD and who have potential donors for a LDLT. Balancing donor risk, recipient waiting list mortality, posttransplant outcomes, and financial sustainability of LDLT programs is certainly challenging and will continue to evolve as the donor shortage extends and healthcare costs escalate.

Other countries in Latin America that do not have mature DDLT systems could expand access with the development of specialized LDLT units or partnering with teams that are experienced in LDLT in neighboring regions or countries, using a model that has worked in private hospitals in India, Pakistan, and Turkey. Investment in technology and forming a multidisciplinary LDLT team around well-trained doctors is the first step. Another action that would benefit LDLT in Latin America would involve mentoring of the local transplant teams by mature LDLT centers around the globe. Mentoring would facilitate the training of healthcare professionals, the acquisition of new technology, and the learning from previous experiences of large LDLT centers. This initiative has previously worked in South Asia (by the mentoring of large Indian LDLT centers to remote areas in the Everest area) and was also successfully implemented by the groups from San Jose; Costa Rica; and Kyoto, Japan. Transplant societies, such as the International Liver Transplant Society, could facilitate the contact of transplant leaders. It is possible that this model might not be needed for every single country of the region, but once local centers gain expertise in LDLT, government alliances and partnerships among healthcare institutions might allow LDLT to be offered to patients in need in the entire region and who do not have access to DDLT. We could therefore have specialized centers in Argentina or in the Southeast region of Brazil receiving patients from Uruguay and Paraguay. Patients from the Andes region could go to Chile. Patients from the Amazon region could then use Colombia as their local expert center. We might need to develop a transplant center in the Brazilian Northeast to serve as the local reference for LDLT in that area. Central America and Caribbean countries could form an alliance using the local expertise in San Jose and/or Mexico City. These possibilities could turn into realities and create liver transplant solutions that are beyond what Latin America has at the present moment.

Summary

Living donor liver transplantation activities are underused and undeveloped in Latin America in comparison to other regions of the globe. The diverse development of healthcare systems and different numbers of DDLT in each country make the region unique and justify different strategies for LDLT. Living donor liver transplantation fills the gap of grafts for the pediatric population not well served by DDLT or the current utilization of split livers. Identification of adult candidates who are not well served by the MELD system would be a second goal for the largest countries of the region. Countries and regions that do not have current DDLT programs or have extremely low organ donation rates could use LDLT through the development of local partnerships with the major LDLT programs in Latin America.

ACKNOWLEDGMENTS

The authors thank the Latin American and Caribbean Transplant Society, Associação Brasileira de Transplante de Órgãos, Sistema Nacional de Información de Procuración y Trasplante de la República Argentina and Sistema Nacional de Trasplante de México for providing the data.

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