Should we perform deceased donor liver transplantation after living donor liver transplantation has failed?

Abstract

By asking whether we should perform deceased donor liver transplantation (DDLT) after living donor liver transplantation (LDLT) has failed, we appear to be questioning the generally accepted current practice of retransplantation for transplant failure. However, we will also consider in this analysis that LDLT may have been performed for patients whose tumors were beyond the local criteria for listing or increased priority on the deceased donor (DD) wait list (ie, the patients were not eligible for DDLT originally). To arrive at a recommendation, we will analyze the outcomes and ethical implications of retransplantation by considering the following 4 questions:1. Should we perform DDLT after the failure of DDLT? 2. Should we perform DDLT after the failure of LDLT in a patient without hepatocellular carcinoma (HCC)? 3. Should we perform DDLT after the failure of LDLT in a patient with HCC who fulfills the local criteria for listing and increased priority on the wait list? 4. Should we perform DDLT after the failure of LDLT in a patient with HCC who does not fulfill the local criteria for listing or increased priority on the wait list (ie, the patient failed to meet the criteria for DDLT originally)?With questions 1 to 3, we will consider the ethical foundation for the current practice of retransplantation for graft failure, and this discussion will serve as the basis for question 4, which is more controversial. MATERIALS AND METHODSElectronic literature searches were performed with the Ovid MEDLINE, Embase, and Cochrane databases in English, German, and French. The following key words were used in various combinations: liver transplant, live donor liver transplant, retransplant, rejection, loss, failure, survival, primary nonfunction, hepatic artery thrombosis, mortality, UNOS (ie, the United Network for Organ Sharing), and Eurotransplant. The MEDLINE search yielded 49 publications, the Embase search yielded 68, and the Cochrane search yielded 46. These were reviewed; the relevant studies were supplemented with additional studies, and they are referenced in the literature review.

Retransplantation using living‐donor right‐liver grafts

“…It has also demonstrated that with creative techniques for graft revascularization, excellent long‐term survival can be achieved, although with a price of considerable short‐term morbidity and re‐intervention. Right‐lobe liver retransplantation is justifiable not only because it saves lives; it lightens the bitter demand for deceased‐donor grafts and prevents retransplant candidates slipping from the elective surgery category into the urgent surgery category . Without doubt, liver transplant surgeons have to balance between fulfilling responsibilities to patients requiring retransplants and bringing risks to living graft donors.…”

Surgical Treatment Strategies and Prognosis of Hepatocellular Carcinoma

“…In patients transplanted for HCC from a living donor within regionally accepted criteria, re-transplantation for graft failure using a cadaveric liver is also possible and accepted by the scientific community. If the transplant from a living donor had been done over the criteria, re-transplant from a cadaver is not recommended [94][95][96][97][98].…”

2010 International consensus conference on liver transplantation for hepatocellular carcinoma: Texts of experts

“…[22][23][24] They discussed ethical concerns with the double equipoise describing the balance between the recipient's survival benefit with or without LDLT and the risks of morbidity and mortality for the donor. Five years after the publication of the findings of the Vancouver forum, 25 it is well accepted that patients with HCC within the Milan criteria should be offered LDLT as a treatment option.…”