Liver Transplantation in Singapore: Challenges and Strategies of Low- to Mid-volume Centers

Abstract

LEGISLATION FOR ORGAN TRANSPLANTATION Singapore, located in Southeast Asia, has a developed economy, a multiethnic population of 5.7 million, and spends 2.1% of its gross domestic product on health care. The Medical Therapy, Education and Research Act passed in 1972 allows people to pledge their organs for transplant, research, or education upon death. A low sign-up rate despite an extensive campaign led to the Human Organ Transplant Act in 1987, essentially an opt-out system that presumes consent to procure organs for transplantation upon death. Initially, Human Organ Transplant Act applied only to traumatic causes of death among Singapore permanent residents and citizens (21–60 y), non-Muslims, restricted to the procurement kidneys. This Act was amended in 2004 to include all causes of death and retrieval of heart, liver, cornea while also covering the regulation of living donor transplants. The amendment in 2008 included Muslims, and in 2009, the upper age limit was removed and paired matching was permitted.1 OVERALL LIVER TRANSPLANT ACTIVITY The first deceased donor liver transplantation (DDLT) in Singapore was performed in 1990 and the first living donor liver transplant (LDLT) in 1996 at the National University Hospital (NUH) Singapore. Since then, >500 LDLT and DDLT have been completed in Singapore. At present, there are 4 liver transplantation centers in Singapore, with 2 centers in the public sector—National University Centre for Organ Transplantation at NUH and the SingHealth Transplant Center at the Singapore General Hospital that was commissioned for liver transplants in 2005; 2 additional centers are in the private sector. National University Centre for Organ Transplantation accounted for the majority of liver transplants in Singapore. Figure 1 shows the timelines of key events including liver transplant volume, number of actualized deceased solid donors (defined as those referred for donation after conformation of brain death), liver procured from deceased donors (defined as percent of actualized donors), and removal from liver transplant waitlist (defined as percent of patients removed from the waitlist because death or disease progression). Despite efforts in revising legislations, donation rates have been relatively static, whereas utilization rate has improved dramatically.FIGURE 1.: Liver transplantation in Singapore. DDLT, deceased donor liver transplantation; HOTA, Human Organ Transplant Act; LDLT, living donor liver transplantation.LDLT TO SUPPORT SHORTAGE OF DECEASED DONORS—WAYS TO ADDRESS THE LOW-VOLUME CHALLENGE Singapore remains to have very low deceased donation rates at around 6 per million population per year, with "only" 2.4% of the population listed in the Objector's Register as being opposed to organ donation. Possible reasons for the low donation rate in Singapore may be linked to not moving ahead with terminating life support on the basis of poor prognosis if there are concerns on family objection2; a large discrepancy in donor referral and actualization among hospitals,3 an insufficient awareness of organ donation, in addition to conflicting cultural and religious beliefs may represent additional reasons. An organ procurement case in 2007, during which organs were retrieved from a brain-dead donor, despite strong objections from the next of kin, not only made national news but also captured international attention. Such publicity is counterproductive with a detrimental impact on donation rates in addition to supporting pushback of intensive care unit and other medical personnel in supporting organ donation.4 Of note, those opposed to organ donation listed in the "Objector's Register" increased from 2526 in 2006 to 9326 in 2007 and 34 494 in 2008 and only started dropping thereafter with 1778 individuals listed in 2019. LDLT continues to play a major role in overcoming the deceased donor shortage in Singapore. Although discussions on LDLT are usually initiated early in the evaluation process,