Living donation for the very ill patient with type I hepatorenal syndrome: Are we ready?

See Article on Page 779 HRS, hepatorenal syndrome. As defined by the International Ascites Club, type I hepatorenal syndrome (HRS) has a very high mortality rate of 22% to 41%.1-3 A single-center experience with liver transplantation in HRS patients who received deceased donor liver transplants reported acceptable survival (13 of 17 patients). Previous dialysis was a significant risk factor for mortality.4 Sanyal et al.5 analyzed the use of terlipressin for HRS in a randomized trial in 2008. The study was not designed to provide data on survival after liver transplantation; however, in a reanalysis of the data by Boyer et al.,6 all 18 patients who were enrolled in the terlipressin arm and underwent transplantation were alive 6 months after transplantation. This suggests that good outcomes can be obtained for HRS patients. It has long been known that the pretransplant renal function has a significant impact on posttransplant survival, but according to the aforementioned studies, HRS apparently does not significantly affect outcomes after deceased donor liver transplantation.7-9 HRS is a marker of the degree of illness of the patient, and living donor liver transplantation for the very sick patient may be associated with poorer outcomes. Conventional wisdom and practice in the United States dictate that living donor liver transplantation generally should not be performed for these patients because of (1) concerns about the outcomes of living donor liver transplantation and (2) the possibility of increased availability of deceased donor transplants (due to the high Model for End-Stage Liver Disease scores of patients with significant renal dysfunction). The provocative article by Chok et al.10 in this issue of Liver Transplantation deals with a very ill cohort of HRS patients treated with living donor liver transplantation, and it suggests changes in practice at least in areas in which deceased donation may be limited. In this retrospective study,10 approximately one-third of the patients had type I HRS, and they were compared to a control group without HRS. The overall majority of the recipients suffered from hepatitis B, and many of the patients may have had acute-on-chronic liver disease. The average Model for End-Stage Liver Disease score of these patients was 43. As may have been predicted, the overall morbidity (eg, the length of stay and the dialysis and transfusion requirements) was worse in the HRS group. The 1-year survival rate for these patients was approximately 85%; this exceeds the overall expected US survival rate for recipients of deceased donor transplants. Chok et al.10 have demonstrated an excellent survival rate that is comparable to the rate of a high Model for End-Stage Liver Disease score population undergoing deceased donor transplantation in the United States. The results reported by Chok et al.10 appear to fall within the zone of ethical acceptability. There is no balancing act of double equipoise if the survival rate exceeds the rate with deceased donor transplants in the United States. Also, the availability of deceased donor organs in Hong Kong is much lower than the availability in the United States.11 The Vancouver conference addresses the expectations regarding the outcomes of living donation: if living donation can yield an acceptable recipient outcome at an acceptable donor risk, it should be considered.12 Although there have been multiple donor deaths in the United States and throughout the world, the risks of living donation appear to be justified by the relative recipient benefit and donor risk. Chok et al.10 have pushed the recipient envelope in an environment in which there is limited access to deceased donor transplantation. Living donation is more commonly performed in regions of the United States with a severe donor shortage and long waiting times.13 Donation service areas with limited access to donor organs may not have the luxury of treating HRS/fulminant failure with only deceased donor transplantation and may need to consider the use of living donor transplantation in this situation. If the donor is protected12 and the early recipient mortality rate is not prohibitive (as demonstrated by the Hong Kong group), we should proceed with living donor transplantation. One potential issue is that providing living donation to this group of patients with acute decompensation may mean expedited donor evaluations. The psychological risk for an expedited donor may be increased, although the mortality of the donor is unlikely to be affected. If we can ethically and morally accept this risk, living donation should be considered.

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