The current understanding of the psychiatric problems experienced by living liver donors is very limited. There are only a few published reports regarding the frequency and nature of psychiatric complications in this group of patients. Walter et al. (7
) assessed psychosocial stress in 46 donors 6 months after donation. They reported that 11% of the donors had an “enhanced perception of stress.” Goldman reported outcomes in 20 living liver donors to pediatric recipients and found two marital dissolutions and one adjustment disorder in this cohort (8
). In Japan, psychiatric problems were described in 31 LDLT donors in whom major depressive disorder occurred in three patients (10%) (9
). There are reports of depression and completed suicides in cases of living donor kidney transplantation. Johnson et al. (10
) analyzed outcomes in 524 living kidney donors in which 23% of respondents experienced self-reported depression after surgery and 15% reported depression within one month before the survey. In addition, three suicides have been reported in living kidney donors (11
The major focus of complications in living liver donors has been directed toward surgical complications occurring in the immediate postoperative period. However, psychiatric complications may occur long after surgery. During this phase of postoperative recovery, assessment of donors at most centers may be very limited or nonexistent. Beavers et al. (13
) reported practice patterns of long-term follow-up in LDLT donors in the United States. At 1 year after the donor surgery, only 25% of centers had scheduled clinic visits with the donor, only 14% required blood chemistries, and only one program administered a follow-up survey of the donors. Without careful donor monitoring during the late phase of postoperative recovery, physicians at LDLT centers are unlikely to recognize important psychiatric problems in their donors. Consequently, transplant physicians are advised to consider long-term follow-up of their donors. By doing so, the full extent of post-transplantation psychiatric problems could be identified, and those individuals could be treated. In addition, risk factors for psychiatric or psychological complications may be identified so that methods to reduce or avoid these problems could be implemented in future donors.
Our data do not explain whether living liver donors are inherently more prone to psychiatric problems or whether the stress of the evaluation and hepatectomy may increase this risk. The donor cohort is likely more physically and psychologically healthy than the general population because of the careful screening and evaluation of donor candidates. Potential donors with significant psychiatric problems identified during the evaluation routinely are rejected for donation. Many centers would have rejected donor 1 as a candidate based on the previous history of psychiatric problems. Furthermore, many centers include a psychiatric assessment of each donor during the evaluation. In addition, previous studies have shown that the donors scored as high or significantly higher than the general population in objective measures of quality-of-life (SF-36) (14
). Finally, Surman et al. (15
) have suggested that donors may be so driven to donate that they may attempt to conceal underlying psychopathology. Despite these relevant factors, which would suggest a higher level of mental health in liver donors, some patients experienced severe psychiatric complications, including suicide after donation. We cannot directly attribute the donor surgery to the suicides, attempted suicides, or other less-severe psychiatric complications noted in the retrospective study, since these problems may have existed to some degree prior to donation. The national suicide rate is approximately 1/10,000. The relatively small number of patients in our cohort makes estimates of suicide rate problematic. However, two successful suicides in this small cohort are two orders of magnitude higher than the national rate, and is cause for concern.
In summary, we have shown that severe psychiatric complications occur in a small segment of living donors after donor surgery. Careful preoperative assessment and postoperative monitoring of these patients may help to understand and prevent such tragic events. Our study also highlights the need for continual clinical follow-up for living liver donors. It is our hope that future data coming from the A2ALL prospective study will continue to shed light on this issue and perhaps assist clinicians in identifying factors that may place prospective donors at increased risk for future psychological complications.