By asking whether we should perform deceased donor liver transplantation (DDLT) after living donor liver transplantation (LDLT) has failed, we appear to be questioning the generally accepted current practice of retransplantation for transplant failure. However, we will also consider in this analysis that LDLT may have been performed for patients whose tumors were beyond the local criteria for listing or increased priority on the deceased donor (DD) wait list (ie, the patients were not eligible for DDLT originally). To arrive at a recommendation, we will analyze the outcomes and ethical implications of retransplantation by considering the following 4 questions:
- Should we perform DDLT after the failure of DDLT? 2. Should we perform DDLT after the failure of LDLT in a patient without hepatocellular carcinoma (HCC)? 3. Should we perform DDLT after the failure of LDLT in a patient with HCC who fulfills the local criteria for listing and increased priority on the wait list? 4. Should we perform DDLT after the failure of LDLT in a patient with HCC who does not fulfill the local criteria for listing or increased priority on the wait list (ie, the patient failed to meet the criteria for DDLT originally)?
With questions 1 to 3, we will consider the ethical foundation for the current practice of retransplantation for graft failure, and this discussion will serve as the basis for question 4, which is more controversial.
Methods
Electronic literature searches were performed with the Ovid MEDLINE, Embase, and Cochrane databases in English, German, and French. The following key words were used in various combinations: liver transplant, live donor liver transplant, retransplant, rejection, loss, failure, survival, primary nonfunction, hepatic artery thrombosis, mortality, UNOS (ie, the United Network for Organ Sharing), and Eurotransplant. The MEDLINE search yielded 49 publications, the Embase search yielded 68, and the Cochrane search yielded 46. These were reviewed; the relevant studies were supplemented with additional studies, and they are referenced in the literature review.
The quality of the evidence is determined with the Oxford Centre for Evidence-Based Medicine levels of evidence for ranking evidence about the effectiveness of treatments or screening procedures 1 :
โข Level 1a. Systematic review with homogeneity of randomized controlled trials.