Liver Paired Exchange: Ready for Prime Time in North America?

An editorial in the November 2019 Liver Transplantation considers, among other things, how liver exchange might be more coercive than live liver donation, because real or imagined incompatibilities might no longer serve to excuse an ambivalent donor from going through with the donation. (I recall discussions like this at the outset of kidney exchange, and my sense is that, in those days, the doctors thought that they could still excuse ambivalent donors by indicating that they weren't healthy enough to donate...)

Liver Paired Exchange: Ready for Prime Time in North America?
Talia B. Baker M.D

"The evolution of kidney paired exchange (KPE) in the United States has expanded transplant options for ABO‐incompatible and human leukocyte antigen–incompatible living donor pairs.1 The success of KPE has prompted consideration of liver paired exchange (LPE). Although the idea seems promising, its application has been limited to a handful of centers in Asia.2-4
...
"In the United States, approximately 3,000 patients are removed from the liver waiting list each year because they become too ill or die prior to transplant.7 Although living donor liver transplantation (LDLT) is established as the primary source of donor allografts in many parts of Asia, it constitutes approximately only 4% of liver transplants in the United States.7 The potential number of living donor and recipient pairs that might be suitable for LPE in the United States is unknown and largely unexplored.
...
"The indications for LPE are more complex than in KPE where immunological factors drive the process. In LPE, anatomical factors, such as hepatic mass (ie, graft‐to‐recipient weight ratio and percent of future liver remnant), and anatomical considerations, such as arterial and biliary variants, will also importantly be considered.
...
"coercion, which remains one of the greatest ethical concerns for the evaluation of any living donor, will have to be considered in a more robust manner. Concerns about coercion may be exacerbated by indirect exchanges, such as in LPE, because a reluctant or hesitant donor may no longer be able to invoke ABO incompatibility, size, or anatomical incompatibility as a reasonable and accepted way to withdraw from consideration as a living donor.9 ...
"Often, transplant centers are able to select the most willing donors based on their commitment to step forward, expressing unwavering interest and determination to donate. This system inherently allows willing, but ambivalent, donors to be excused based on objective medical measures (most commonly ABO incompatibility or anatomical issues) without having to admit their ambivalence. In contrast, LPE may remove or limit this potential by offering alternative options for exchanges, thereby inadvertently exposing or subjugating ambivalent donors. "