The price tag of living donor liver transplantation

Abstract

Liver transplantation is an effective, life-saving treatment for children with end-stage liver disease, acute liver failure, certain metabolic liver diseases, and hepatic malignancies. In fact, pediatric liver transplants have the highest graft survival of any solid organ transplant at any age! Despite this great success, there remains a growing shortage of donor organs because of the disproportionate increase in the number of potential recipients compared with the stagnant number of cadaver organ donors. Thus, a variety of surgical techniques have been developed over the past decade to allow children to receive part of a donor liver from a larger child or an adult. These techniques include reduced size grafts, split liver grafts (two recipients for one donor organ) and living donor grafts. Outcome from all three of these technical variants is excellent; however, little is known about the comparative true health care costs of these procedures. In this issue of The Journal, Cole et al provide a first look into the economic impact of living donor liver transplantation in a midwest Children's Hospital. The authors point out that one advantage of living donor transplantation is that the child can be transplanted earlier in the course of illness—before major medical complications develop and when optimal neurodevelopmental outcome may be preserved. However, the living donor recipients had a higher mean cost of care in the first year after transplantation compared with those receiving cadaver donor livers; this was primarily due to a higher prevalence of biliary complications in the former. The report by Cole et al balances the potential advantages with the reality of increased direct costs after the transplantation. Further analyses of the total health care costs (direct and indirect) both before and after liver transplantation are now needed to better understand the comparative costs, as well as the potential benefits, of this important surgical technique. In addition, a careful comparison of costs and outcome of living donor transplants to the increasingly frequent split liver donor transplantation will be necessary to assess the two most promising means of providing new livers to children in desperate need. Liver transplantation is an effective, life-saving treatment for children with end-stage liver disease, acute liver failure, certain metabolic liver diseases, and hepatic malignancies. In fact, pediatric liver transplants have the highest graft survival of any solid organ transplant at any age! Despite this great success, there remains a growing shortage of donor organs because of the disproportionate increase in the number of potential recipients compared with the stagnant number of cadaver organ donors. Thus, a variety of surgical techniques have been developed over the past decade to allow children to receive part of a donor liver from a larger child or an adult. These techniques include reduced size grafts, split liver grafts (two recipients for one donor organ) and living donor grafts. Outcome from all three of these technical variants is excellent; however, little is known about the comparative true health care costs of these procedures. In this issue of The Journal, Cole et al provide a first look into the economic impact of living donor liver transplantation in a midwest Children's Hospital. The authors point out that one advantage of living donor transplantation is that the child can be transplanted earlier in the course of illness—before major medical complications develop and when optimal neurodevelopmental outcome may be preserved. However, the living donor recipients had a higher mean cost of care in the first year after transplantation compared with those receiving cadaver donor livers; this was primarily due to a higher prevalence of biliary complications in the former. The report by Cole et al balances the potential advantages with the reality of increased direct costs after the transplantation. Further analyses of the total health care costs (direct and indirect) both before and after liver transplantation are now needed to better understand the comparative costs, as well as the potential benefits, of this important surgical technique. In addition, a careful comparison of costs and outcome of living donor transplants to the increasingly frequent split liver donor transplantation will be necessary to assess the two most promising means of providing new livers to children in desperate need.