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Letters to the Editor

Offspring to Parent LDLT: Narrowing the Gap Between Theory and Evidence

Choudhury, Rashikh Ahmed MD1; Yoeli, Dor MD1; Dagan, Amir MD1; Yaffe, Hillary MD1; Moore, Hunter B. MD, PhD1; Conzen, Kendra D. MD1; Adams, Megan MD1; Wachs, Michael MD1; Pomposelli, James J. MD, PhD1; Pomfret, Elizabeth A. MD, PhD1 and; Nydam, Trevor L. MD1

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doi: 10.1097/TP.0000000000003352
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To the Editor,

We are encouraged by the renewed interest in regard to the topic of offspring donation in the setting of living donor liver transplantation (LDLT). We reviewed the comments from Ho et al with great interest. Their comments demonstrate the need for validation of the findings of Dagan et al across a broad range of demographic groups.1 Of note, Ho et al reviewed their institution’s (National Taiwan University Hospital) LDLT experience and found no significant difference in long-term patient survival between recipients who received their grafts from offspring or nonoffspring donors. And furthermore, the gender of the donor also did not seem to influence survival.

As suggested by Cohen et al, fetal alloimmunity during pregnancy may create an immune environment, which leads to suboptimal graft function in the setting of offspring organ donation.2 In our study, of the organ procurement and transplantation network/scientific registry of transplant recipients (OPTN/SRTR) database from 1998 to 2018, offspring donation was only found to be inferior to nonoffspring donation in a subgroup analysis of recipient gender, when the recipient was female (mother), with male offspring paradoxically associated with inferior outcomes. No difference was observed with male recipients or in aggregate (male and female). As pregnancy would be the precipitating event to induce alloimmunity, only maternal recipients would be expected to experience inferior outcomes following offspring donation. This result was significant even after adjustment for relevant covariates, including donor age, graft type, so on.

It would be interesting to observe whether this phenomenon is also present in Ho et al’s patient cohort after an adjusted analysis with particular focus of the outcomes of the offspring to female parent recipient subgroup. As Dagan et al utilized OPTN/SRTR, several database-related constraints (missingness, lack of vascular anatomy detail of grafts, postop immunosuppression dosages, etc.) were placed on the study, which now requires validation in broader, more granular datasets like that of The National University. The implications of the findings of Dagan et al have wide-ranging impacts on the future of donor selection and management in the setting of LDLT (ie, counseling and the need to crossmatch). As such, we encourage continued debate and free inquiry into the matter.

Sincerely,

REFERENCES

1. Dagan A, Choudhury RA, Yaffe H, et al. Offspring versus nonoffspring to parent living donor liver transplantation: does donor relationship matter? Transplantation. 2020; 104:996–1002
2. Cohen JB, Shults J, Goldberg DS, et al. Kidney transplant outcomes: position in the match-run does not seem to matter beyond other donor risk factors. Am J Transplant. 2018; 18:1577–1578
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