A Report of the Vancouver Forum on the Care of the Live Organ Donor: Lung, Liver, Pancreas, and Intestine Data and Medical Guidelines

An international conference of transplant physicians, surgeons, and allied health professionals was held in Vancouver, Canada, on September 15 and 16, 2005 to address the care of the live lung, liver, pancreas, and intestine organ donor. The Vancouver Forum was convened under the auspices of the Ethics Committee of The Transplantation Society. Forum participants included over 100 leaders in organ transplantation, representing many countries from around the world, including participants from the following continents: Africa, Asia, Australia, Europe, North and South America. The objective of the Vancouver Forum was to develop an international standard of care for the live lung, liver, pancreas and intestinal organ donor. This Vancouver Forum followed a conference convened in Amsterdam on the care of the live kidney donor (1, 2). There were four organ specific work groups at the Vancouver Forum: lung, liver, pancreas and intestine. Each organ work group addressed the following topics in concert and reported their findings in a plenary presentation to all participants: The evaluation of the potential live donor Criteria of live donor medical suitability Operative events, donor morbidity and mortality Responsibility and duration of donor follow up. The Vancouver Forum also provided an opportunity for the Ethics Committee of The Transplantation Society to address issues of informed consent, the responsibilities of the transplant team, live donor selection, autonomy and satisfaction, and procedural safeguards. An ethics statement of the Vancouver Forum pertaining to these issues will be published separately by the Ethics Committee of The Transplantation Society. The transplant community has a responsibility for the care of the live organ donor. The death of a live donor is a tragedy of immeasurable proportion that brings an ethical dimension distinct from the complications that might be experienced in a recipient. Report from the Thoracic Group Live donor lung transplantation generally involves three simultaneous operations: two donor lobectomies and a recipient bilateral pneumonectomy and lobar implantation. The use of live donors is occurring in cases in which the potential recipient mortality is high while awaiting for lung allografts from a deceased donor. With increasing experience however, the practice may expand to include elective patients (3, 4). I. Donor Evaluation The goals of donor selection are to identify donors with excellent health, adequate pulmonary reserve for lobar donation and a willingness to accept the risks of donation without coercion (5, 6). A preference is given for family members or unrelated individuals with emotional attachment to recipient and/or family. A preference is also given for a spouse or donor with “significant other” relationship to the potential recipient. The necessity of two live lung donors for a single recipient also brings a consideration of both parents as donors for the potential recipient. An element of coercion can always exist between any potential donor and the recipient and/or the recipient's other siblings. “Stranger” or “Good Samaritan” donation remains controversial with caution required in the screening process to exclude active or uncontrolled psychiatric disorders or inappropriate motivation, and ensure the altruistic nature of the donation. The donor evaluation is a multi-phased process that begins with the potential recipient and family providing the names of potential donors with basic health information and height, weight, age, relationship, and smoking history. A preliminary psychosocial evaluation of selected donors is performed to assess the desire to donate. This evaluation includes a determination of the donor motivation, pain tolerance, feelings regarding the possible death of the potential recipient (and the donor) and the ability of the potential donor to be separated from family responsibilities and career obligations. Consultation with appropriate authorities regarding postlobectomy employability and insurability (life, disability insurance) is required. Prospective donors should be informed of the morbidity associated with lobectomy and the potential for mortality, as well as for potential negative recipient outcomes in regard to life expectancy and quality of life after transplantation. II. Criteria of Live Donor Medical Suitability The following are the eligibility criteria for living lobar lung donation: Age 18–60 years and able to give informed consent No active tobacco smoking or a significant smoking history No active lung disease/previous ipsilateral thoracic surgery No identifiable risk for familial lung disease (i.e. familial forms of idiopathic lung disease or pulmonary artery hypertension) No cachexia (BMI <18 kg/m2) or obesity (BMI ≥30 kg/m2) ABO blood type compatibility with recipient Donor lobe size compatible with recipient hemithorax Normal pulmonary function and arterial blood gas results No conditions that significantly increase the risk of general anesthesia, surgery, and postoperative recovery No psychosocial, ethical issues, or concerns about donor motivation Not pregnant No active malignancy No active significant infection (HIV, hepatitis, acute CMV) III. Operative Events, Donor Morbidity and Mortality The standard operative live donor lung transplant procedure is for the recipient to undergo a bilateral pneumonectomy and for two live lung donors to provide the left lower lobe and the right lower lobe simultaneously to the recipient (7, 8). Approximately 550 live lung donors constitute 98% of the global experience. The mean age was 38±10 years (range 18–60 years). Sixty percent of the live lung donors have been male, 76% have been related to the recipient and 24% were unrelated. Of the related donors, 40% were parents, 29% siblings, and 15% uncle/aunt. The remainder were cousins 9%, 5% son/daughter, 1% nephew/niece, <1% grandparent, and 1% miscellaneous. Of the live donors that were unrelated to the recipients 74% were friends, 20% spouses, and 6% strangers. To date there has been no reported peri-operative mortality of a lung donor. There have been life-threatening complications in 3 donors (0.5%) with an intra-operative ventricular fibrillation arrest (1) and two with a postoperative pulmonary artery thrombosis. The mean length of the initial hospitalization following the lung lobectomy has been 8.5 days (range 3–36). Approximately 4% of live lung donors have experienced an intraoperative complication that included ventricular fibrillation arrest (1), the necessity of a right middle lobe sacrifice 7 (1.3%), the necessity of a right middle lobe re-implantation 6 (1.1%), the necessity of a non-autologous transfusion PRBC's 5 (0.9%) and a permanent phrenic nerve injury (1). Approximately 5% (27) of donors experienced complications requiring surgical or bronchoscopic intervention. These complications included bleeding (6), bronchopleural fistula (5), pleural effusion (5), empyema (2) bronchial stricture (2), pericarditis requiring pericardiectomy (2), arrhythmias requiring ablation (2) and a chylothorax (1). There were 14 (2.6%) live lung donors that were readmitted to the hospital because of a pneumothorax, an arrhythmia, empyema, pericarditis, dyspnea, pleural effusion, bronchial stricture, bronchopleural fistula, pneumonia, hemoptysis, and dehydration. The long term (> one year) donor complaints of live lung donors include chronic incisional pain, dyspnea, pericarditis, and non-productive cough. IV. Responsibility and Duration of Donor Follow Up A constant awareness of the risk to the living donors must be maintained with any live donor organ transplantation program, and comprehensive short term follow-up should be mandatory. The Vancouver Forum Lung Group recommended that long term follow-up be strongly encouraged and funded by government/insurance the outcomes are well in the recipient of live donor lobectomy have to long term follow-up include from the transplant willingness of donors to work to the transplant and a general that are donors live from the transplant and are to for follow-up The death of the recipient all donors have to their of living without is Responsibility for the care of the donor complications the the Lung Group on and to the postoperative surgical recommended follow-up by the transplant or the medical in general from one between 3 to one to as as three and generally to 3 in the follow-up also and included pulmonary function quality of life and psychiatric Report from the Group A potential recipient should be to be a for transplantation to the of the potential donor. A of practice was for live donor transplantation these also be appropriate for organ from lung, pancreas and intestine of Live Live donation should be performed the risk to the donor is by the of an in the recipient. The and of a live donor transplant should the for a recipient with the disease a deceased donor The for live donor transplantation should be the as for deceased donor transplantation with the of that live donor transplantation to transplantation from a deceased donor. Live donor transplantation should an to the recipient to for an deceased donor organ to for transplantation. The to with a live donor transplant should be after a of the recipient risk to as to of quality of life and for a deceased donor. The risk of mortality and morbidity associated with live donor right is and the risk to the donor is live donor transplantation should and that that donor mortality and morbidity is a recipient of a live donor the and should be to the for a recipient of the disease a deceased donor for Live Donor Transplantation disease were addressed that have been infection and the criteria as a single 5 or 3 or no 3 is an for live donor transplantation are on and follow the for live donor transplantation in patients with the criteria should be the as that for deceased donor transplantation. is an for live donor transplantation. transplantation for with a live donor or deceased donor may be because of the risk of disease and the appropriate for transplantation in a may be from a live donor. is an for live donor transplantation. live donor transplantation for should have the to the donor evaluation and The ability to a evaluation of the potential donor including blood pulmonary function of the liver, and evaluation by the ethical in a to is I. Donor Evaluation The donor evaluation should be in a that includes an donor and a of the recipient as a for a The of the donor evaluation should screening of potential donors history and and No psychosocial, ethical issues, or concerns about the of the donor. No active or uncontrolled psychiatric donor A history and including and should be to exclude that significantly increase the donor donor evaluation should blood a comprehensive and of The donor should be for that may have a on the donor (and the and The evaluation should be by a health care as a or should be to assess and may be or the of the surgical Donor A donor remains controversial The use of the as a of and the for a donor is of as a to donation may be by and The of the Vancouver Forum participants was to that a donor be performed blood are and or other are on A may be the or in potential donors related to a potential recipient with hepatitis, or II. Criteria of Live Donor Medical Suitability The following are the eligibility criteria for live donation: Age There is to the age for living donation. reported general surgery and a of years has been live donor transplantation has been performed with donors age is by ability to give reported that transplantation living donors to be or of recipients or have emotional with This and the of any for donation are by an ethical The Ethics in is of the hospital evaluation A process in and reported that an must be to the by the potential donor the donor is related to the recipient (i.e. friends, is a spouse of or the donor is related without of (i.e. or to that many of Vancouver participants a is an of suitability an emotional the use of a donor to the potential recipient in live donor kidney was reported to be an of live donation. surgical experience that a high kg/m2) may increase the risk of surgical a of may quality and is an to live donation. may the by Donor a of at of the with Vancouver Forum participants that in the of recipient an to recipient of should be ABO ABO blood type is however, ABO blood type live donor may be in as of age without the of and in no deceased donor is that findings that should living donation or for right and is recommended for donors with A should be after results that donor infection with or are a for living donation. for is recommended in donors with with or without for a should be performed the potential donor has a history of thrombosis. III. Operative Events, Donor Morbidity and Mortality following live donor transplantation is strongly the of any postoperative a to exclude pulmonary of blood is by in the of right lobe donation. has in donor blood The following of a complication was by the Vancouver Forum work group for a live The of a procedure performed on the donor A from the in of patients surgical or recovery from the The of complications associated with live donation a of a complication has been The Vancouver Forum participants recommended the international use of the to and live donor complications by as to assess morbidity of donor and recipient transplantation a of a to was which may also to the of live donors of surgical complications for live of donor complications reported in the and is in lobe donation is associated with an morbidity from and complications that associated with left lobectomy or left of donor of complications in the reported Live Donor is provided in 3 the of the Vancouver donor have been to with the of a live donor There were for live donation donor or recipient A of complications in the Live Donor Operative Donor Mortality To live donor have been performed for the of transplantation and the of complications is to be 4). There have been 14 live donor donors have transplantation to operative complications from right lobe donation and donor is in a after donation. Mortality for the right lobe donor in to for left lobe operative donor Responsibility and Duration of Donor Follow Up Live donors should be followed for at after the follow-up may be may be always because the of the donor is to the transplant Donor health may the of follow up. The Vancouver Forum participants recommended that a of live donor complications be and that donor be reported to that the the and that is by the for has a live donor death or the necessity of a transplant following a donor a to the live donor transplantation are the of donation on the health and quality of from a to all individuals live donation in was at the Vancouver Forum by the Transplantation Society. Of the live donors, the with of the donors recovery by of donors reported recovery with of individuals to work or of donors their recovery to be A significant of donors regarding their This was of the of left donors were with right lobe recipient mortality in was Of the recipients that of their were to The participants of the Vancouver Forum that the transplantation community must to the health and of the live donor. to donation and the ability to and health and life must to be The participants also an that living donors for the of donation to be Report from The Group with type are appropriate for pancreas transplantation may be simultaneously for living pancreas donors may undergo pancreas donation or or simultaneous pancreas and kidney donation potential donors will be to a and psychosocial ABO and compatibility is mandatory. A donor can also be for and I. Donor Evaluation An initial will exclude donor with a history of active or chronic or a between the potential donor and recipient is a psychosocial evaluation follow in the of a screening by a with follow-up with a is required in the screening process to exclude active or uncontrolled psychiatric and ensure the altruistic nature of the donation. is by a and a surgical by a donor medical screening includes a history and and the following blood blood function and and a donor includes and and after the and an to assess the of the pancreas and specific for the live pancreas donor include screening of the live donor the to A is given for 3 days to the and a to is smoking is a in of is given over The of the is of and is performed at the following and A is given for 3 days to the and a to is smoking is the is between and A of is given over 3 and 15 The of the is and are at the following and to is as the mean of the and 5 following the with the is as the of the of between and after is as of at and 3 the of the 5 of is given over is at the of the of and is performed at the following and to is as the mean of the three between and 5 following the with the of after the blood in the a at is an The is maintained for 5 of is given over The of the is of and is performed at the following 7 and at is as the mean of the three between and 5 with the by with and with in by in and and with is by in a a on the history and in with the screening the following criteria will have to be in to be a potential live pancreas donor. II. Criteria of Live Donor Medical Suitability Criteria and pancreas donor should be between the of and donors years of age be in The regarding the age in countries may be because of the of deceased donor The potential donor should be to provide informed be and be able to with the and postoperative Donor must be without coercion and without The donor must also the nature of the procedure and the risks to or must also be of the risks of disease in the Criteria any of the following criteria should be as a pancreas Age with type or type the potential years from the recipient's age at the of of recipient is as at age donor must be at years with active or uncontrolled psychiatric disorders of or or or by group criteria blood A <1% to or of of of III. Operative Events, Donor Morbidity and Mortality Donor can be or With increasing however, the may have operative as is required to the and Donor A may have to be performed in to 15% of donors in of blood or that all donors and to and or fistula The of complications is postoperative complications These include bleeding for pneumonia, incisional and The of general postoperative complications is A complication is the of intestinal bleeding to hypertension) from in patients in the was left A is required and is of all criteria as by the are the risk of the donor is in Live Donor the of there have been live donor pancreas performed between and The of these was as 40% pancreas transplant pancreas after kidney and simultaneous live donor pancreas and kidney There are and live donor between and years following transplantation. There are 3 living donor with function the of simultaneous kidney and pancreas were performed between and of pancreas and all the kidney have been for one to years following transplantation. There was no of a donor There have been 5 live donor performed in in and in of live donor transplantation in and live donor performed in the of there been live donor after kidney transplantation in the experience IV. Responsibility and Duration of Donor Follow Up Follow Up The donor will have and blood hospitalization The and should be should be and these will the donor is in the and in of should be the will also of and for The donor will generally have a postoperative hospitalization of about 5 to 7 care of the donor is to that of any A is left in function are as well as and and may a or or left pain should be with and a to assess the of the the a should be are encouraged to their of with groups the should be The Vancouver Forum participants recommended the of a pancreas donor and for no donor have been reported after a should all cases Report from the Group Live donor intestinal transplantation has been the of two groups to provide a of surgical The of and experienced and in live donor intestinal transplantation in in 2005 at the The Vancouver Forum was the under the auspices of The Transplantation Society. transplantation is for the of patients with life complications of intestinal The life complication of intestinal is the years the results of intestinal transplantation have the of a of including in surgical and experience Live donor intestinal are procedure should be as an and an of the nature of the Vancouver Forum participants recommended that live donor intestinal transplantation should their for ethical and outcomes to an international The of deceased donors and the for long term are the to a recipient of a live donor intestinal from live donors may have in have a high mortality on the There are also in the of or are is and I. Donor Evaluation Live intestinal donation should be without The potential donor should be in health with no chronic medical that increase the operative There should be no history of intestinal donors must be for potential recipients have a or familial intestinal is required in the screening process to exclude active or uncontrolled psychiatric and ensure the altruistic nature of the donation. are with an ABO blood type determination and in with as by should be there are potential donors, ABO blood group and may donor selection, in the of a for a negative donor might be of these initial the that is for the live donor evaluation is as and psychosocial and for and disease and and and and artery no to donation are the are of the are performed to any or and is with a or To the or is a is performed patients must be informed of the II. Criteria of Live Donor Medical Suitability Age There is to the age for living intestine donation. reported general surgery a of years has been age is by ability to give donors should be or of recipients or should have emotional with This and the of any for donation are by a from the transplant There should be no psychosocial, ethical issues, or concerns about the of the donor or active or uncontrolled psychiatric surgical experience that a high kg/m2) may increase the risk of surgical a of may quality and is an to live donation. ABO ABO blood type is A comprehensive should be results that donor infection with or are a for living intestine donation. III. Operative Events, Donor and Mortality The of the donor is to provide adequate length of intestine to the recipient to ensure autonomy while length in the donor. the to donation there is to The donor is performed a the use of the live donor have been also the procedure is the of surgery the is and the of the is to the donor the of the artery the must be With the use of of the and/or the of the artery is The of the is the is and the of the is from of the for about the artery can be to the of the right The artery may have in the donor The of the the is to the artery and is also for The is The standard procedure includes of of is to at of the length in the donor. The of donor is The of the is the blood are and the of of is to the is with are of There was one of of and which of a donor of the and with a of the the donor of and The procedure specific risk for the live intestinal donor is given in The risk of death is to the risk of general anesthesia, be that following a about 3 to 5% of donors will develop a the mortality for patients with is about This risk will exist for the of the or are is and risk for the live intestinal of the Vancouver Forum Responsibility and Duration of Donor Follow Up The experience with live intestine donation is to the intestinal transplant as of transplant have performed intestinal that there were a living donor was the of the This was performed in a of transplant and there are of these living donor intestinal There were no donor or long term complications of intestinal donors reported at the Vancouver The of all intestine performed to date include live and and There are and was between live donor and deceased donor autonomy and of and death were between both The the donor procedure has a responsibility to ensure long term medical care of any The recommended follow includes a postoperative at and There are that can in the as and should be followed all have been The donor to be of a can be performed with at 6 and for 3 The long term risk of donation involves of in the of 1% to With the of a there is to mortality The intestinal group the following and of a donor in with the international intestinal transplant to of organ and results with Report and with intestine transplant the on death for patients for intestine The of the Vancouver Forum is to an international for the well of the live organ donor and to a of care by an group of The to with live donor transplantation should be after a of the recipient risk to as to of quality of morbidity and mortality on the This will also be by the and quality of any potential deceased donor The Vancouver Forum participants the of living have provided a life organ for a transplant recipient. The Forum participants also the that live organ donors have by the for transplantation of from deceased The Vancouver Forum was convened by the Ethics Committee of The Transplantation Society. to of for the that the Vancouver Forum to be also to and of The Transplantation for their The also to and for their in their of the

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