2021/01/21 by Gabriel E. Gondolesi, Gabriel Gondolesi
Medicine · #Organ Transplantation Techniques and Outcomes #Organ Donation and Transplantation #Liver Disease and Transplantation
paper · doi:10.1097/tp.0000000000003611
The Japanese Liver Transplantation Society (JLTS), in this issue, has analyzed 3347 pediatric liver transplants performed in Japan at 51 centers from 1989 to 2018.1 The analysis highlights the importance of having a national, multicenter, and prospective database. It provides an example to be followed by the transplant community in many nations. This manuscript brings to transplant specialists globally the possibility of learning from a system that differs from the Western model of care2 but that has allowed pediatric liver transplantation to successfully evolve over the years. The study provides an insight into what has been achieved in a country with limited deceased donation activity which, despite the Japanese Ministry of Health encouragement since 1997, has only been able to provide for 2.3% of the total demand for pediatric liver transplants between 1989 and 2018. There has been a slight increase over those 3 decades, rising from 0.34% to 0.81% and 4.8%, respectively. Although this increase represents some progress, deceased donation in Japan clearly needs further investment, development, and the legal frameworks to emulate the level of success seen in other regions of the world.3-5 To provide sufficient liver transplants for their children in need, the Japanese Organ Transplant Network could evaluate the possibility not only of performing domino liver transplants but also stimulating the use of ex vivo or in situ split liver donations, which has become a major source of pediatric deceased liver donation in countries with far fewer resources than Japan, highly recognized for having extremely well-developed surgical technics and skills.6,7 Splitting the liver brings additional advantages through optimizing the use of a single donor for 2 recipients, reducing the need for ABO-incompatible transplants, and avoiding the need for a living donor. The disadvantage of the practice of splitting deceased donor livers is that it requires the commitment of the surgical team to provide senior experienced surgeons for the procedure both to reduce operating times and improve results for both transplant recipients. The registry of the JLTS was established in 1980, as a cooperative research consortium, aiming to characterize and follow the trends in patients’ characteristics and graft survival outcomes from all liver transplant centers in Japan. The current report presents the superb results for graft survival in pediatric recipients of 75.4% at 30 y, which must be considered as an exemplar for others to follow. But, like most registries, the constant review is needed to ensure continued relevance over time and to avoid obsolescence. Without such revision, significant limitations in the data set can be observed. Examples in the JLTS registry are recognized by the authors, including the lack of information on pediatric end stage liver disease scores, modern immunosuppressive protocols, surgical complications, and definition of causes of death. The current report reveals parents were the donors in 95.2% of the cases (mothers in 52.3%) with the left lateral segment the commonest graft. No early living donor mortality was observed, despite higher donor age and BMI in some cases. If there is any concern to be raised about registries such as this one, it would be the lack of data about long-term living donor follow-up. This is a critical issue for the transplant community, especially in countries where 97.7% of liver donors are living. A recent study from Asia, highlighted in the discussion, has demonstrated that live liver donors have increased long-term mortality risk compared with similar healthy controls.8 Further reports are needed to better understand if that finding is reproduced in other countries and if so what the dominant causes might be for higher long-term living donor death rates. Finally, it is important to note the issue of the unique listing criteria for pediatric liver transplantation in Japan. Although physicians consent patients/families after evaluation for living or deceased donor transplants, patients are listed for deceased donors only if the family has agreed to donation. This provides a contrast to many national regulations, which recommend that every patient evaluated for any transplant should be included in a national waiting list, whether or not they are scheduled to receive a living donor liver. In some countries, living donor liver transplants cannot be performed unless the recipient has been listed for deceased donation for at least for 48 h before the living donor transplant.9 A unique registry for patients included in the waiting list also helps to fulfill regulatory compliance and requirements to avoid concerns about organ and tissue trafficking and transplant tourism, which is important in some nations.10 The JLTS Registry highlights the very long-term commitment by Japanese transplant programs to measuring important outcomes of pediatric liver donation, which many nations should strive to emulate.