• Vol. 38 No. 4, 315–321
  • 15 April 2009

Expanding the Donor Pool for Liver Transplantation in the Setting of an “Opt-out” Scheme – 3 years after New Legislation



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Introduction: The revised Human Organ Transplant Act (HOTA) was implemented in Singapore in July 2004. We aim to evaluate expanding the potential donor pool for liver transplant in Singapore with the inclusion of marginal donors. Materials and Methods: All donor referrals between July 2004 and June 2007 were studied. All potential deceased liver donors were heart-beating. After being reviewed by the transplant coordinator, potential donors were assessed by a transplant hepatologist and a transplant surgeon for suitability of organ donation strictly based on the programme’s donor assessment protocol. Reasons for rejection as potential donors were documented. The clinical characteristics of all donor referrals were retrospectively reviewed, and an independent decision was made as to whether liver retrieval in each rejected case might have been possible. Results: Among the 128 potential donor referrals, 20 donors (15.6%) underwent liver retrieval. Of the 20 livers retrieved, 16 were implanted and 4 were not implanted (3 unfit recipients, and 1 donor liver with 40% steatosis). Another 10 donor livers were assessed intraoperatively and were rejected because of varying levels of steatosis. Of these livers assessed, 5 donor livers had steatosis <40% and 5 had steatosis >40%. Of the remaining potential donors, 45 were deemed not possible because of prolonged hypotension (9), on-going or unresolved sepsis (13), high-risk behaviour (4), non-actualisation (8), or pre-existing medical conditions (11). Another 53 donors may potentially have been suitable donors but were rejected because of possible sepsis (13), no suitable recipients (12), transient hypotension (10), transient abnormal liver function test (6), history of alcohol ingestion (5), non-actualisation because of consent (4) and other reasons (3). Overall, it was deemed that 61 donors (47.7%) might potentially have been suitable liver donors. Conclusions: Despite new legislation (HOTA) in Singapore, the utilisation of cadaveric donor livers showed no increase in the last 3 years. By expanding our donor criteria to include marginal donors, we could potentially increase the availability of deceased donor livers to meet our waiting list demands.

Presently, liver transplantation has become routine management for an expanding group of patients with endstage liver disease and hepatocellular carcinoma. However, organ availability limits the application of liver transplantation. As a result, there is a large increase in the liver transplant waiting list in the US and a significant increase in deaths while on the waiting list.1 While the shortage of donor organs is a worldwide problem, the situation appears more critical in Asia where cadaveric organ donation remains below 5 per million population (pmp).2 Several strategies employed in increasing the availability of organs include using living-related liver donors,3-5 acceptance of marginal donors6,7 and legislation of deceased donor transplantation.

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