Donors’ Quality of Life Evaluated by Short Form-36 Analysis After Living Donor Liver Transplantation in a Single-Center Experience N. Kawagishi, I. Takeda, S. Miyagi, K. Sato, and N. Ohuchi ABSTRACT Background and Purpose. The purpose of this study was to compare the quality of life of donors using the Short Form 36 (SF-36) analysis between the left and right graft periods of living donor liver transplantation. Patients and Methods. In the left graft period (July 1991 to July 2003), 68 donors were eligible for analysis and 76 were eligible in the right graft period (August 2003 to October 2010). Nine right lobe grafts were included in the left graft period, and 52 right lobe grafts were included in the right graft period. We investigated the risks of donation and evaluated the following: blood loss, operation time, postoperative liver function, and duration of hospitalization. We also assessed quality of life in donors, who were mailed a structured questionnaire and the SF-36. Results. Ten of the 68 donors in the left graft period and 12 of the 76 in the right graft period had postoperative complications. Most postoperative complications were treated without surgical procedures. There was no donor death in our series. Forty-eight donors in the left graft period and 36 in the right graft period responded to our investigation. Compared with published Japanese norms in SF-36, our donors scored similar or higher than the general population in both groups. Two donors in the left graft period and one in the right graft period regretted their decisions to donate. All donors returned to normalcy. Conclusions. These results suggested that the donors’ quality of life was guaranteed in terms of the SF-36 investigation regardless of the donation period in our series.
L
IVING DONOR LIVER TRANSPLANTATION (LDLT) has been performed mainly in the countries where the availability of deceased donors is quite limited, as in Japan. The most crucial point of this treatment is to obtain grafts from healthy individuals. A decisive factor in the donor evaluation is the protection of the donor from both physical and emotional harm. So this kind of transplantation has been accepted in terms of the donor safety and ethical issue. Although the short-term risks and safety of the donor’s operation have been guaranteed at present [1,2], their long-term safety and quality of life (QOL) based on social and emotional evaluation have not been elucidated. We already reported the risks and quality of donors’ life mainly in the 1990s [3]. But the social and transplantation backgrounds have been changed in the last two decades. Namely, in the 1990s most of the grafts were left lobes from parents, and in the next decade the most of the grafts were right lobes from various types of the relatives including
ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 675e677 (2014)
nephews and nieces. So the psychosocial consideration and the long-term follow-up became an important issue for the donor in recent years. The purpose of this study is to compare the quality of life of donors using Short Form 36 (SF-36) analysis between the left graft period and the right graft period of LDLT in our hospital. The unique point of this study was the investigation of the donor’s QOL by comparing 2 separate periods in the same institution. We investigated the changes in
From the Divisions of Transplantation, Reconstruction, and Endoscopic Surgery (N.K., I.T., S.M., K.S., N.O.) and Organ Transplantation (N.K.), Tohoku University Hospital, Sendai, Japan. Address reprint requests to Naoki Kawagishi, Division of Transplantation, Reconstruction, and Endoscopic Surgery, Tohoku University Hospital, Seiryou-machi, Aoba-ku, Sendai, 980-8574, Japan. E-mail: [email protected] 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.054 675
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KAWAGISHI, TAKEDA, MIYAGI ET AL
Fig 1. Short Form 36 scores in both periods. No significant difference was observed. Two donors whose recipients died regretted being a donor in the left graft period, but no one regretted it in the right graft period.
psychosocial background and the influence of the donor’s graft type. Moreover, the long-term analysis of donors demonstrated the justification of LDLT and protection of donors.
donation in the left graft period and of 1487 days in the right graft period. Informed consent was obtained from both donors and recipients. All procedures were reviewed and approved by the ethical committee of Tohoku University Hospital and have therefore been performed in accordance with the ethical statements of the Declaration of Helsinki and the Transplantation Society. All data were derived from research and clinical activities carried out in accordance with the principles of the Declaration of Istanbul. Values are given as mean standard deviation. Student t test and one-way analysis of variance were used to compare categorical data. The level of statistical significance was set at P < .05. All calculations were made with the StatView software package (SAS Institute, Cary, NC, United States).
PATIENTS AND METHODS From July 1991 to October 2010, 142 LDLTs were performed in pediatric and adult patients with end-stage liver disease in the Division of Transplantation, Reconstruction, and Endoscopic Surgery of Tohoku University Hospital. This program was approved by the ethics committee of Tohoku University Hospital, and the patients gave their informed consent for all procedures and therapies. Donors were selected among parents, brothers, sisters, and spouses on the basis of liver function tests, serological markers of hepatitis, ABO blood group, grafterecipient size matching, lymphocyte crossmatching and HLA typing. The right lobe, left lobe, or the left lateral segment of the liver was transplanted. Sixty-eight donors were eligible for analysis in the left graft period (July 1991eJuly 2003), and 76 donors were eligible in the right graft period (August 2003eOctober 2010). Nine right lobe grafts were included in the left graft period, and 52 right lobe grafts were included in the right graft period. We investigated the risks of donation and evaluated the following: blood loss, operation time, postoperative liver function, and duration of hospitalization. To evaluate donors’ QOL, a structured questionnaire and the SF-36 were mailed to them. The self-administered SF-36 survey assesses 8 health domains: (1) physical functioning, (2) role limitations due to physical health, (3) role limitations due to emotional problems, (4) vitality, (5) pain, (6) mental health, (7) social function, and (8) general health. We investigated QOL at the mean of 1665 days after
RESULTS
Ten (14.7%) of the 68 donors in the left graft period and 13 (17.6%) of the 76 in the right graft period had postoperative complications. Most postoperative complications were treated without surgical procedures. One donor in the left graft period who suffered from sepsis and respiratory distress secondary to an intra-abdominal abscess was subjected to surgical drainage and was discharged from hospital after 64 days. In addition, 1 donor in the right graft period had pulmonary embolism; fortunately he was cured by the anticoagulation therapy. There was no donor death in our series. Forty-eight donors in the left graft period and 36 in the right graft period responded to our investigation. Compared with published Japanese norms in SF-36, our donors scored similar or higher than the general population
Table 1. Short Form 36 Scores With or Without Complications During Left Graft Era Mental Health Role (Emotional) Social Function Vitality Function
All donors No recipient complications Recipients with complications No donor complications Donors with complications *P < .05.
86.4 88.5 74.3 87.1 82.3
15.4 14.1 18.0* 14.4 21.3
84.7 85.4 81.0 85.4 81.0
26.6 27.9 17.8 26.9 26.2
93.7 93.9 92.9 93.6 94.6
13.1 13.7 9.8 13.7 9.8
82.5 83.0 79.3 82.9 80.0
16.4 15.7 20.9 15.7 21.0
Physical
95.8 96.5 92.1 96.5 92.1
5.7 5.6 4.9 5.6 4.9
Role (Physical)
86.5 88.4 75.0 87.2 82.1
18.6 18.6 14.4 18.6 18.9
Bodily Pain
86.2 86.9 82.1 87.3 79.7
16.6 16.9 15.8 16.9 14.1
General Health
81.6 86.8 68.6 82.4 77.3
17.6 11.6 26.9* 16.2 25.2
DONORS’ QUALITY OF LIFE EVALUATED BY SF-36 ANALYSIS
677
Table 2. Short Form-36 Scores With or Without Complications During Right Graft Era Mental Health Role (Emotional) Social Function Vitality Function
All donors No recipient complications Recipients with complications No donor complications Donors with complications
77.9 77.3 78.9 76.5 85
16.8 15.1 19.7 15.9 20.7
94.2 96.6 90.4 94.2 94.4
15.3 9.2 21.6 15.8 13.6
93.4 93.8 92.9 92.5 97.9
15.7 12.6 20 16.9 5.1
in both groups (Fig 1). Two donors in the left graft period and 1 donor in the right graft period regretted their decisions to donate. All donors returned to normalcy. SF-36 scores were compared in terms of the complications. In the left graft period, mental health and general health in the recipient complication group was inferior to the no recipient complication group (Table 1). In the right graft period, there were no differences between the 2 groups (Table 2). DISCUSSION
In this study, we retrospectively reviewed the safety of the donor operation and donor QOL based on the results of the SF-36 analysis. Donor safety is the top priority in LDLT, but it is impossible to eliminate the complications. It is most important thing to continue to refine surgical innovations as well as to improve preoperative and postoperative management of donor safety. It was reported that the postoperative complications in the right lobe graft donors were significantly more severe and frequent than those in left lobe graft donors [4]. In our series, donors in the right graft period had complications more frequently than those in the left graft period, but all of the complications resolved and patients returned to normalcy. As for other aspects of the donor safety, the long-term QOL is also important. It was reported that psychological complications presented later postdonation and they also tended to take longer to resolve [5]. We investigated the donors more than 4 years after the operation, and they scored similar or higher than the general population in both groups. It should be noted that mental health and general health in the recipient complication group was inferior to the group without recipient complication in the left graft period. We should also mention that not all the donors responded to this SF-36 survey. We cannot
68.8 69.3 67.9 67.5 75
20.5 17.5 25.2 18.7 29.3
Physical
94.6 97.1 90.7 95.8 88.3
Role (Physical)
Bodily Pain
10.2 93.6 14.7 84.3 3.7 97 6.6 88.5 15.2 88.8 21.7 77.5 9.3 94 15 84.5 12.9 90.6 14.7 83.2
20.2 15.1 25.5 19.2 26.7
General Health
73.4 75.3 69.7 73.7 71.7
14.8 15.8 12.5 14.7 16.5
discard the possibility that those donors might be less satisfied with their experiences. Some reports said the evaluation of the preoperative donor’s mental burden was important for the postoperative care from the psychological point of view [6,7]. In our hospital no preoperative quantitative evaluation of psychological status has been performed so far, thus we should address this aspect in the future. In Japan LDLT is still necessary to save patients with endstage liver disease. Although complete exclusion of surgical risks and psychological dissatisfaction cannot be ruled out, we should make efforts to minimize them. In conclusion, these results suggest that the donors’ QOL was guaranteed in terms of the SF-36 investigation regardless of the donation period in our series. REFERENCES [1] Kawagishi N, Ohkohchi N, Fujimori K, et al. Safety of the donor operation in living-related liver transplantation: analysis of 22 donors. Transplant Proc 1998;30:3279e80. [2] Shoji M, Ohkohchi N, Fujimori K, et al. The safety of the donor operation in living-donor liver transplantation: an analysis of 45 donors. Transpl Int 2003;16:461e4. [3] Miyagi S, Kawagishi N, Fujimori K, et al. Risks of donation and quality of donors’ life after living donor liver transplantation. Transpl Int 2005;18:47e51. [4] Iida T, Ogura Y, Oike F, et al. Surgery-related morbidity in living donors for liver transplantation. Transplantation 2010;89: 1276e82. [5] Abecassis MM, Fisher RA, Olthoff KM, et al. Complications of living donor hepatic lobectomyda comprehensive report. Am J Transplant 2012;12:1208e17. [6] Erim Y, Beckmann M, Kroencke S, et al. Influence of kinship on donors’ mental burden in living donor liver transplantation. Liver Transpl 2012;18:901e6. [7] Simpson MA, Kendrick J, Verbesey JE, et al. Ambivalence in living liver donors. Liver Transpl 2011;17:1226e33.
L
IVING DONOR LIVER TRANSPLANTATION (LDLT) has been performed mainly in the countries where the availability of deceased donors is quite limited, as in Japan. The most crucial point of this treatment is to obtain grafts from healthy individuals. A decisive factor in the donor evaluation is the protection of the donor from both physical and emotional harm. So this kind of transplantation has been accepted in terms of the donor safety and ethical issue. Although the short-term risks and safety of the donor’s operation have been guaranteed at present [1,2], their long-term safety and quality of life (QOL) based on social and emotional evaluation have not been elucidated. We already reported the risks and quality of donors’ life mainly in the 1990s [3]. But the social and transplantation backgrounds have been changed in the last two decades. Namely, in the 1990s most of the grafts were left lobes from parents, and in the next decade the most of the grafts were right lobes from various types of the relatives including
ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 675e677 (2014)
nephews and nieces. So the psychosocial consideration and the long-term follow-up became an important issue for the donor in recent years. The purpose of this study is to compare the quality of life of donors using Short Form 36 (SF-36) analysis between the left graft period and the right graft period of LDLT in our hospital. The unique point of this study was the investigation of the donor’s QOL by comparing 2 separate periods in the same institution. We investigated the changes in
From the Divisions of Transplantation, Reconstruction, and Endoscopic Surgery (N.K., I.T., S.M., K.S., N.O.) and Organ Transplantation (N.K.), Tohoku University Hospital, Sendai, Japan. Address reprint requests to Naoki Kawagishi, Division of Transplantation, Reconstruction, and Endoscopic Surgery, Tohoku University Hospital, Seiryou-machi, Aoba-ku, Sendai, 980-8574, Japan. E-mail: [email protected] 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.054 675
676
KAWAGISHI, TAKEDA, MIYAGI ET AL
Fig 1. Short Form 36 scores in both periods. No significant difference was observed. Two donors whose recipients died regretted being a donor in the left graft period, but no one regretted it in the right graft period.
psychosocial background and the influence of the donor’s graft type. Moreover, the long-term analysis of donors demonstrated the justification of LDLT and protection of donors.
donation in the left graft period and of 1487 days in the right graft period. Informed consent was obtained from both donors and recipients. All procedures were reviewed and approved by the ethical committee of Tohoku University Hospital and have therefore been performed in accordance with the ethical statements of the Declaration of Helsinki and the Transplantation Society. All data were derived from research and clinical activities carried out in accordance with the principles of the Declaration of Istanbul. Values are given as mean standard deviation. Student t test and one-way analysis of variance were used to compare categorical data. The level of statistical significance was set at P < .05. All calculations were made with the StatView software package (SAS Institute, Cary, NC, United States).
PATIENTS AND METHODS From July 1991 to October 2010, 142 LDLTs were performed in pediatric and adult patients with end-stage liver disease in the Division of Transplantation, Reconstruction, and Endoscopic Surgery of Tohoku University Hospital. This program was approved by the ethics committee of Tohoku University Hospital, and the patients gave their informed consent for all procedures and therapies. Donors were selected among parents, brothers, sisters, and spouses on the basis of liver function tests, serological markers of hepatitis, ABO blood group, grafterecipient size matching, lymphocyte crossmatching and HLA typing. The right lobe, left lobe, or the left lateral segment of the liver was transplanted. Sixty-eight donors were eligible for analysis in the left graft period (July 1991eJuly 2003), and 76 donors were eligible in the right graft period (August 2003eOctober 2010). Nine right lobe grafts were included in the left graft period, and 52 right lobe grafts were included in the right graft period. We investigated the risks of donation and evaluated the following: blood loss, operation time, postoperative liver function, and duration of hospitalization. To evaluate donors’ QOL, a structured questionnaire and the SF-36 were mailed to them. The self-administered SF-36 survey assesses 8 health domains: (1) physical functioning, (2) role limitations due to physical health, (3) role limitations due to emotional problems, (4) vitality, (5) pain, (6) mental health, (7) social function, and (8) general health. We investigated QOL at the mean of 1665 days after
RESULTS
Ten (14.7%) of the 68 donors in the left graft period and 13 (17.6%) of the 76 in the right graft period had postoperative complications. Most postoperative complications were treated without surgical procedures. One donor in the left graft period who suffered from sepsis and respiratory distress secondary to an intra-abdominal abscess was subjected to surgical drainage and was discharged from hospital after 64 days. In addition, 1 donor in the right graft period had pulmonary embolism; fortunately he was cured by the anticoagulation therapy. There was no donor death in our series. Forty-eight donors in the left graft period and 36 in the right graft period responded to our investigation. Compared with published Japanese norms in SF-36, our donors scored similar or higher than the general population
Table 1. Short Form 36 Scores With or Without Complications During Left Graft Era Mental Health Role (Emotional) Social Function Vitality Function
All donors No recipient complications Recipients with complications No donor complications Donors with complications *P < .05.
86.4 88.5 74.3 87.1 82.3
15.4 14.1 18.0* 14.4 21.3
84.7 85.4 81.0 85.4 81.0
26.6 27.9 17.8 26.9 26.2
93.7 93.9 92.9 93.6 94.6
13.1 13.7 9.8 13.7 9.8
82.5 83.0 79.3 82.9 80.0
16.4 15.7 20.9 15.7 21.0
Physical
95.8 96.5 92.1 96.5 92.1
5.7 5.6 4.9 5.6 4.9
Role (Physical)
86.5 88.4 75.0 87.2 82.1
18.6 18.6 14.4 18.6 18.9
Bodily Pain
86.2 86.9 82.1 87.3 79.7
16.6 16.9 15.8 16.9 14.1
General Health
81.6 86.8 68.6 82.4 77.3
17.6 11.6 26.9* 16.2 25.2
DONORS’ QUALITY OF LIFE EVALUATED BY SF-36 ANALYSIS
677
Table 2. Short Form-36 Scores With or Without Complications During Right Graft Era Mental Health Role (Emotional) Social Function Vitality Function
All donors No recipient complications Recipients with complications No donor complications Donors with complications
77.9 77.3 78.9 76.5 85
16.8 15.1 19.7 15.9 20.7
94.2 96.6 90.4 94.2 94.4
15.3 9.2 21.6 15.8 13.6
93.4 93.8 92.9 92.5 97.9
15.7 12.6 20 16.9 5.1
in both groups (Fig 1). Two donors in the left graft period and 1 donor in the right graft period regretted their decisions to donate. All donors returned to normalcy. SF-36 scores were compared in terms of the complications. In the left graft period, mental health and general health in the recipient complication group was inferior to the no recipient complication group (Table 1). In the right graft period, there were no differences between the 2 groups (Table 2). DISCUSSION
In this study, we retrospectively reviewed the safety of the donor operation and donor QOL based on the results of the SF-36 analysis. Donor safety is the top priority in LDLT, but it is impossible to eliminate the complications. It is most important thing to continue to refine surgical innovations as well as to improve preoperative and postoperative management of donor safety. It was reported that the postoperative complications in the right lobe graft donors were significantly more severe and frequent than those in left lobe graft donors [4]. In our series, donors in the right graft period had complications more frequently than those in the left graft period, but all of the complications resolved and patients returned to normalcy. As for other aspects of the donor safety, the long-term QOL is also important. It was reported that psychological complications presented later postdonation and they also tended to take longer to resolve [5]. We investigated the donors more than 4 years after the operation, and they scored similar or higher than the general population in both groups. It should be noted that mental health and general health in the recipient complication group was inferior to the group without recipient complication in the left graft period. We should also mention that not all the donors responded to this SF-36 survey. We cannot
68.8 69.3 67.9 67.5 75
20.5 17.5 25.2 18.7 29.3
Physical
94.6 97.1 90.7 95.8 88.3
Role (Physical)
Bodily Pain
10.2 93.6 14.7 84.3 3.7 97 6.6 88.5 15.2 88.8 21.7 77.5 9.3 94 15 84.5 12.9 90.6 14.7 83.2
20.2 15.1 25.5 19.2 26.7
General Health
73.4 75.3 69.7 73.7 71.7
14.8 15.8 12.5 14.7 16.5
discard the possibility that those donors might be less satisfied with their experiences. Some reports said the evaluation of the preoperative donor’s mental burden was important for the postoperative care from the psychological point of view [6,7]. In our hospital no preoperative quantitative evaluation of psychological status has been performed so far, thus we should address this aspect in the future. In Japan LDLT is still necessary to save patients with endstage liver disease. Although complete exclusion of surgical risks and psychological dissatisfaction cannot be ruled out, we should make efforts to minimize them. In conclusion, these results suggest that the donors’ QOL was guaranteed in terms of the SF-36 investigation regardless of the donation period in our series. REFERENCES [1] Kawagishi N, Ohkohchi N, Fujimori K, et al. Safety of the donor operation in living-related liver transplantation: analysis of 22 donors. Transplant Proc 1998;30:3279e80. [2] Shoji M, Ohkohchi N, Fujimori K, et al. The safety of the donor operation in living-donor liver transplantation: an analysis of 45 donors. Transpl Int 2003;16:461e4. [3] Miyagi S, Kawagishi N, Fujimori K, et al. Risks of donation and quality of donors’ life after living donor liver transplantation. Transpl Int 2005;18:47e51. [4] Iida T, Ogura Y, Oike F, et al. Surgery-related morbidity in living donors for liver transplantation. Transplantation 2010;89: 1276e82. [5] Abecassis MM, Fisher RA, Olthoff KM, et al. Complications of living donor hepatic lobectomyda comprehensive report. Am J Transplant 2012;12:1208e17. [6] Erim Y, Beckmann M, Kroencke S, et al. Influence of kinship on donors’ mental burden in living donor liver transplantation. Liver Transpl 2012;18:901e6. [7] Simpson MA, Kendrick J, Verbesey JE, et al. Ambivalence in living liver donors. Liver Transpl 2011;17:1226e33.
