Columbia Presbyterian Study Shows Procedure Concentrated in a Few Major Centers More Experience Translates Into Better Patient Outcomes
Feb 27, 2003
The number of adult-to-adult living donor liver transplants in the United States is increasing and centers with the largest volume have the lowest complication rates, according to results from the first compilation of these procedures in the country.
The study, to be published in the February 27th issue of The New England Journal of Medicine, was done in response to the lack of comprehensive data or a centralized registry of donor and recipient morbidity and mortality that has led some experts to call for either limitations on which centers can perform the procedure or for government regulation.
The collected data constitute the first and most comprehensive state-of-the-state analysis of practice patterns and outcomes of living donor transplantation in this country, says Robert S. Brown Jr., M.D., MPH, the medical director of the Center for Liver Disease and Transplantation at NewYork-Presbyterian Hospital and associate professor of medicine at Columbia University College of Physicians Surgeons, and the study's author. It is the only multicenter analysis in the United States and includes more centers and patients than survey studies from other countries as well. Although living donor liver transplantation is standard practice in pediatric cases, its use in adults has been somewhat controversial, due to the lack of data on morbidity, mortality, and procedure frequency and indications. Such an analysis is of critical importance not only for centers that are contemplating doing adult-to-adult living donor transplantation, but also for potential donors and recipients so that they will be able to make informed choices, says Dr. Brown.
During the past decade, adults in need of a liver transplant have faced a critical shortage of cadaveric organs. During this time, the waiting period for a suitable cadaveric liver and the mortality for patients on transplantation waiting lists have increased markedly. The success of living donor pediatric liver transplantation spurred the development of adult-to-adult living donor liver transplantation in response to this dramatic lack of cadaveric livers.
In contrast to living donor pediatric liver transplants, which uses approximately 20 percent of the smaller left lobe of the liver, adult-to-adult liver transplantation utilizes between 55 percent and 60 percent of the larger right lobe of the liver. There is little doubt that this procedure will continue to grow in frequency-there just aren't enough cadaveric livers available for the patients who so urgently need them, explains Jean Emond, M.D.,Vice Chairman and Chief of Transplantation, NewYork-Presbyterian and Thomas S. Zimmer professor of reconstructive surgery, Columbia University College of Physicians Surgeons. There was only one such transplantation program in place in 1997, he adds, and by 2000 the number had increased to 38. Adult-to-adult living donor transplant now accounts for about 5 percent of all adult liver transplants.
The investigators sent a 24-item survey to all 122 transplant programs registered with United Network for Organ Sharing (UNOS) to report on transplants performed by the end of October 2000. Our goal was to assess the number of programs performing or planning to perform adult-to-adult living donor liver transplants, the volumes of these programs for adult and pediatric cadaveric and living donor transplants, donor evaluation and outcomes, and indications for recipient transplantation and outcomes, as well as the degree of institutional support, explains Dr. Brown. Responses were received from 84 (69 percent) of these centers; these 84 centers performed over 90 percent of all cadaveric liver transplants in the US in 1999. Forty-two of these programs (37 percent) performed at least one living donor liver transplant between 1997 and 2000, for a total of 449 cases. These cases accounted for virtually all of the adult-to-adult living donor liver transplants during this time period. Of the remaining 42 centers, 32 (76 percent) planned to start performing the procedure within the next 12 months. The number of adult-to-adult living donor liver transplants increased from one in 1997 to 266 in 2000. Fourteen centers had performed more than 10 such procedures over the three-year period, accounting for 362 (80 percent) of the total. The centers that performed the procedure were more likely to be larger volume centers and to have previously performed pediatric living donor liver transplantation. Just as there was a wide variation in the numbers of transplants done by centers, there was also a wide variation in the donor evaluation procedure, follow-up procedure, and morbidity, according to Dr. Brown. While almost all of the centers evaluated donors before surgery by a hepatologist (90 percent), social worker (95 percent), and psychiatrist or psychologist (86 percent), only 50 percent had the potential donor see a physician who was not part of the transplant team. In addition, only 17 percent of centers had the donor evaluated by an ethicist. Diagnostic evaluation of potential donors also varied, with most centers either not requiring or selective about performing invasive procedures like liver biopsy and arteriography.
Overall 65 of the 449 donors (14 percent) experienced one or more complications, centers in the highest quartile of donor complication rate had complications in more than 33 percent of donors. These centers performed fewer living donor liver transplants (average of 4) compared with the remaining programs (average of 14). The risk of death quoted by the transplant team to potential donors varied more than 10-fold, from less than 0.1 percent to greater than 1 percent, reflecting uncertainty in the magnitude of actual risk. The reported donor mortality rate was 1 of 449 procedures (0.2 percent).
The major strength of this study, according to Dr. Brown, was that it was broad-based and collected a wide range of donor evaluations and outcomes. However, we need clinical research studies to determine some critical constituents of transplant programs, such as the optimal evaluation process, informed consent components, the relation of donor and recipient characteristics to outcome, and the potential long-term adverse effects of living donation, Dr. Brown says. While this procedure is certainly life saving for many, many people, there is still a lack of donors. We truly need to identify and treat liver disease early and to do our utmost to prevent liver disease. That's the real long-term solution to liver problems, he concludes.
NewYork-Presbyterian Hospital is a 2,369-bed academic medical center created from the merger between The New York Hospital and The Presbyterian Hospital. It provides state-of-the-art inpatient, ambulatory, and preventive care in all areas of medicine at five major centers: NewYork Weill Cornell Medical Center, Columbia Presbyterian Medical Center, Children's Hospital of NewYork-Presbyterian, The Allen Pavilion, and the Westchester Division. One of the largest and most comprehensive health-care institutions in the world, the Hospital is committed to excellence in patient care, research, education, and community service. The NewYork-Presbyterian Healthcare System which includes acute-care and community hospitals, long-term care facilities, home-health agencies, ambulatory sites, and specialty institutions ensures high-quality, cost-effective, and conveniently accessible care to communities throughout the tri-state metropolitan region. The System serves over 20 percent of the patients in the New York Metropolitan area. The Hospital has academic affiliations with two of the country's leading medical colleges: Joan and Sanford I. Weill Medical College of Cornell University and Columbia University College of Physicians Surgeons.
Columbia University College of Physicians Surgeons
Established in 1767, Columbia's College of Physicians Surgeons was the first institution in the country to grant the M.D. degree. Among the most selective medical schools in the country, the school is also home to the largest medical research enterprise in New York State and one of the largest in the country. NewYork-Presbyterian Hospital is the primary teaching hospital for the Columbia University College of Physicians Surgeons, providing international leadership in biomedical research and patient care.