TThe liver is one of the few organs that does not need to be transplanted in its entirety. It can also be divided into parts, with one part going to the person who needs a new liver and the other part going to another liver. Removing barriers to this procedure, known as split liver transplantation, could reduce the number of deaths from liver failure.
Here is the actual illustration (names have been changed to protect privacy): Jacob was born with a rare disease that damaged his liver and required a transplant at about 6 months old. At age 5, he needed a second transplant, but his mother was told it was unlikely that the child's liver would be of suitable size in time. About six months later, on Halloween night in 2016, a young Rhode Island man died of a drug overdose. Two days later, Jacob harvested 40% of the man's liver at Boston Children's Hospital. Miranda, a woman in her 50s with acute liver failure, received the remaining 60%. Today, Jacob is a healthy and energetic 13-year-old. Miranda is also fine.
This best-case scenario may become the rule rather than the exception with the expansion of split liver transplantation.
Every year, approx. 2,400 Americans People eligible for liver transplants either die on the waiting list or are removed from the list for reasons such as: too sick to receive a transplant.
Because of the liver's unique ability to regenerate, approximately 10% of deceased donor livers can be split. Two recipients experienced long-term outcomes similar to those who received whole liver transplants. But only about 1% of deceased donor livers are actually split in the US. This means, by conservative estimates, that more than 600 additional lives could be saved each year if the introduction of split liver transplantation were widespread.
of Current overhaul The Organ Procurement and Transplant Network (OPTN) organization offers a unique opportunity to support split liver transplantation and its lifesaving potential. a 2022 report Researchers at the National Academies of Sciences, Engineering, and Medicine have announced plans to reduce the number of unused organs donated in the United States, including by requiring transplant centers to ensure that surgical staff is ready whenever an organ becomes available. identified opportunities to gradually reduce and President Biden signed bipartisan bill It goes into effect in September 2023 to make the federally overseen organ allocation system more efficient and accountable.
Discussion of life years lost typically focuses on organs (particularly kidneys) that for some reason remained viable and were not transplanted. However, the liver is a special case. The proportion of organs discarded does not fully capture the full utilization of livers, as a successfully transplanted liver could have saved the lives of two people on the waiting list instead of one. yeah.
The potential for split liver transplantation to save more lives has been recognized and promoted in countries such as Italy, the United Kingdom, and South Korea, which have mandated split liver transplantation within clearly defined limits. Masu. other countries, e.g. australia and new zealandhas a policy of splitting selected livers whenever possible. but as explained According to Case Western Reserve University's Health Matrix: The Journal of Law-Medicine, the United States' organ allocation infrastructure unnecessarily discourages liver division.
There are three main barriers to increasing split liver transplantation in the United States, each of which can be overcome with practical and prudent changes to the current legal landscape.
first, Unified network for organ sharing The nonprofit organization (UNOS) that administers OPTN under a contract with the federal government has historically set several criteria for dividing livers donated to individual patient transplant programs. The actual decision to split is made by the organ recipient's transplant surgeon. Physicians have a fiduciary responsibility to their patients and must focus on the best outcome for the liver transplant patient, not the best outcome for the liver transplant patient as a whole.
Split liver transplants carry a higher risk of complications than whole liver transplants, so transplant surgeons rarely choose the former unless the whole liver is too large for the patient. In rare cases where doctors agree to split, the secondary graft is assigned to a size-matched recipient, usually a smaller individual or child.
Second, performing a split liver transplant may jeopardize a transplant center's outcome data and thus its future. Transplant centers and associated staff undoubtedly earn money, prestige, and career opportunities by performing successful surgeries. A worse-than-expected surgical outcome can have negative consequences, such as regulatory action or negative publicity.
Although wider use of split liver transplantation may improve overall survival for patients with end-stage liver disease, its technical complexity may result in additional complications for recipients during and after surgery. This is an innovative surgery with evolving outcomes, and its appeal lies not in maximizing immediate results for a few lucky patients, but in the potential to maximize the number of lives saved, so split liver Programs that implement transplants risk being penalized as low performers. This is because the incidence of complications is higher.
Third, the concept of prioritization of transplant systems is another barrier to wider adoption of split liver transplantation. The limited number of livers from deceased donors available for transplantation are usually allocated to critically ill patients who urgently need a new liver. However, the sickest people often cannot receive a split liver and require a whole liver instead. Taking a portion of the liver from the normal distribution process and using it for split liver transplantation could reduce access to liver transplantation for the sickest patients.
To overcome these hurdles, OPTN will need to adopt forced partition policies similar to those already adopted in other countries. This policy requires that deceased donor livers suitable for splitting be presented to transplant programs only as split grafts. This not only saves more lives, but also emphasizes the transplant surgeon's fiduciary responsibility to the individual patient at the moment of organ donation and the transplant surgeon's desire to benefit other patients in similar situations. The inherent contradiction between them will also be resolved. If division is mandatory, the surgeon will have to choose whether to divide or not. The revised role will be to advise patients on whether to accept a split graft.
Mandatory splitting policies must be flexible so that split liver grafts can be allocated to those who will benefit the most from surgery, rather than the sickest patients, but may not be mandatory in truly urgent cases of fulminant liver disease. exceptions to such divisions should be allowed. Failure. Concern for people who are seriously ill is understandable, but must always be kept in perspective. Since only about 1 in 10 livers are suitable for splitting, the collateral impact on the sickest patients will be limited, and the sooner we can get more people off the waiting list, the more likely we will eventually be able to split a whole liver. It may reduce the number of people who need a transplant.
To encourage transplant centers to perform split liver transplants, data on surgical success should be collected and reported separately from whole liver transplants. This approach will give transplant specialists confidence in accepting split liver transplants by ensuring that potential complications associated with this innovative procedure will not disadvantage them and the transplant center.
Jacob and Miranda text every holiday and are sometimes together. Jacob considers Miranda a special aunt, someone who understands what he's been through and someone with whom he has something special to share. Jacob's mother and Miranda have also been in contact with the donor families, and hope that some of their son will survive among the two recipients of livers and five recipients of other organs. He was told that if he continued, he would find peace.
Reasonable changes to the current transplant allocation system could lead to more success stories like Jacob and Miranda.
Evelyn M. Tenenbaum is Professor of Law at Albany Law School and Professor of Bioethics at Albany Medical College. Jed Adam Gross is a bioethicist in the Department of Clinical and Organizational Ethics at the University Health Network in Toronto and an assistant professor at the Dalla Lana School of Public Health at the University of Toronto.
