Outcomes of living donor liver transplantation for acute liver failure: the adult-to-adult living donor liver transplantation cohort study

Adult living-related liver donation for acute liver failure: is it ethically appropriate?

Acute liver failure (ALF) results in the annual death of approximately 3.5 per million people in the United States. Unfortunately, given the marked shortage of cadaveric liver donations and the ethical questions that plague utilization of living donor liver transplantation (LDLT) for ALF, many patients with ALF die before a liver is allocated to them. In this review, we discuss how the consistent utilization of LDLT for ALF could decrease the mortality rate of ALF. Additionally, we examine a key underlying issue: is LDLT for ALF ethically appropriate?

Living Donor Liver Transplantation

A perception that living donor liver transplantation can be accomplished with an acceptable donor complication rate and recipient survival rate has led to the acceptance of living donor liver transplantation as a viable alternative to decreased deceased donor transplantation. Careful candidate evaluation and selection has been crucial to the success of this procedure. Advancements in the understanding of the lobar nature of the liver and of liver regeneration have advanced the surgical technique. Initial attempts at adult-to-adult donation utilized the left hepatic lobe, but now have evolved into use of the right hepatic lobe. Size matching is very important to successful graft function in the recipient. There is great concern regarding morbidity and mortality in donors. Biliary complications and infections continue to be among the most highly reported complications, although rates vary among centers and countries. Reports of single center complications have ranged from 9% to 67%. A survey of centers in the United States in 2003 reported complications of 10%. A series from our institution reported complications arising in 13 (33%) of 39 patients. A review focused on documenting donor deaths found 33 living liver donor deaths worldwide. The much publicized immediate postoperative mishap of 2002 that resulted in a donor’s death resulted in a drop in the utilization of living donor liver transplantation in the United States, from which this procedure has never fully recovered. The future development and expansion of living donor liver transplantation depends on open communication regarding donor complications and deaths. Close immediate postoperative monitoring and meticulous management will remain an essential aspect in limiting donor complications and deaths.

Improved outcomes in pediatric liver transplantation for acute liver failure

OLT is a life-saving option for ALF.

AIM

To evaluate our outcomes in pediatric OLT for ALF.

METHODS

Retrospective review of our data between 1992 and 2007.

RESULTS

Of 142 children with ALF, 126 were listed, of which 40 spontaneously improved, nine died, and 77 underwent OLT (median waiting time four days). Fifty-three children received deceased donor grafts (34 whole and 19 split grafts), and there were 24 living donor grafts. The one- and five-yr patient survival was 87% and 80%, and graft survival 83% and 79%, respectively. Thirteen patients died after OLT, and there were nine retransplants in seven patients. Patient weight, length of stay, creatinine, and infection were significantly associated with death; increased weight and black ethnicity were associated with graft loss on univariate analysis, but not on multivariate analysis. There were no significant differences in patient survival (one and five yr), graft loss, or other complications between the groups.

CONCLUSION

We report the largest single-center study of OLT in pediatric ALF, demonstrating no difference in outcomes between different graft types. Our liberal use of segmental grafts may allow earlier OLT in this high-risk cohort and contribute to our excellent outcomes.

Anesthesia and outcome after partial hepatectomy for adult-to-adult donor transplantation

PURPOSE OF REVIEW

The worldwide adoption of live liver donors as a source of donor organs for transplantation has been curtailed by the very real risk of complications in otherwise healthy people. Our objective in this review is to outline the perioperative management of the live liver donor for adult-to-adult transplantation.

RECENT FINDINGS

The incidence and severity of complications following live liver donation is extremely variable, and reporting needs to be standardized if we are to improve the perioperative management and outcomes. Agreed definitions would clarify the incidence and severity of postoperative complications, allow identification of areas in which management can be improved and suggest areas for future investigation. Such an effort will require the cooperation of centers around the world.

SUMMARY

Live liver donation is a valuable option for organ donation that can be conducted safely with a multidisciplinary perioperative approach. Future considerations should focus on the recovery period and how the intraoperative management can be optimized to minimize the impact of surgery on donors' quality of life.

Acute liver failure

Acute liver failure is a rare disorder with high mortality and resource cost. In the developing world, viral causes predominate, with hepatitis E infection recognised as a common cause in many countries. In the USA and much of western Europe, the incidence of virally induced disease has declined substantially in the past few years, with most cases now arising from drug-induced liver injury, often from paracetamol. However, a large proportion of cases are of unknown origin. Acute liver failure can be associated with rapidly progressive multiorgan failure and devastating complications; however, outcomes have been improved by use of emergency liver transplantation. An evidence base for practice is emerging for supportive care, and a better understanding of the pathophysiology of the disorder, especially in relation to hepatic encephalopathy, will probably soon lead to further improvements in survival rates.

Fulminant hepatic failure: when to transplant

Fulminant hepatic failure is a life-threatening condition that can lead to rapid deterioration and death if timely treatment is not instituted. Many patients recover with supportive care. Patients with deteriorating signs and laboratory parameters require prompt assessment and listing for liver transplantation. Outcome following transplantation is a function of severity of illness before transplantation, timeliness of liver transplantation and graft quality and function. With appropriate immunosuppression and close follow-up most patients can lead near normal lives following liver transplantation.

Gender-specific differences associated with living donor liver transplantation: a review study

Living donor liver transplantation (LDLT) has developed into an important therapeutic option for liver diseases. For living donor kidney transplantation (LDKT), gender-specific differences have been observed among both donors (two-thirds being women and one-third being men) and recipients (two-thirds being men and one-third being women). The aim of this study was to determine whether there is a gender disparity for LDLT. We contacted 89 national and international transplantation registries, single transplant centers, and coordinators. In addition, a sample of 274 articles dealing with LDLT and its outcomes was reviewed and compared with the registry data. The data included the gender of the donors and recipients, the country of transplantation, and the donor-recipient relationship. The investigation showed that overall there were slightly more men among the donors (53% male and 47% female). As for the recipients, 59% of the organs were distributed to males, and 41% were distributed to females. Differences in the gender distribution were observed with respect to individual countries. Worldwide, 80% of the donors were blood-related, 11% were not blood-related, and 9% were spouses. The data acquired from the publications were similar to the registry data. Our research has shown that there are hardly any registry data published, a lot of countries do not have national registries, or the access to these data is difficult. Even widely ranging published studies often do not give information on the gender distribution or the donor-recipient relationship. Further investigations are needed to understand the possible medical, psychosocial, or cultural reasons for gender distribution in LDLT and the differences in comparison with LDKT.

Emergency adult-to-adult living-donor liver transplantation for acute liver failure in a hepatitis B virus endemic area

The outcomes of patients with acute liver failure (ALF) vary greatly according to etiology. Emergency adult-to-adult living-donor liver transplantation (adult LDLT) would help address the shortage of available organs for patients with ALF, especially in hepatitis B virus (HBV)-endemic areas. We analyzed a prospective database of 110 consecutive adult patients with ALF. ALF was defined as sudden development of severe coagulopathy and encephalopathy within 26 weeks of onset of symptoms. In about 90% of patients, ALF was caused by etiologies that usually result in poor outcomes, including HBV infection (37%). Three cases (3%) were associated with acetaminophen overdose. Of the 99 patients listed for emergency liver transplantation, four (4%) underwent deceased-donor liver transplantation (DDLT), and 40 (40%) underwent adult LDLT. The 1-year survival rate of adult LDLT patients was 85%. Of the 55 patients listed but not transplanted, 45 (82%) died within a median of 7 days (range, 1-90 days). Multivariate analysis showed that adult LDLT (hazard ratio [HR] 0.10, P < 0.01) and DDLT (HR 0.12, P = 0.04) were associated with decreased mortality, whereas older age (HR 1.03, P = 0.01) and higher Model for End-stage Liver Disease (MELD) (HR 1.03, P = 0.04) was associated with increased mortality of patients. There was no living donor mortality. Eight (17.8%) and three (6.7%) living donors experienced grade 1 and 2 complications, respectively.

CONCLUSION

Emergency adult LDLT can be performed expeditiously and safely for patients with ALF, and greatly improves the survival rate. As the window during which transplantation is possible is limited, emergency adult LDLT should be considered one of the first-line treatment options in patients with ALF, especially in regions in which ALFs are caused by etiologies associated with poor outcome and the supply of organs is severely limited.

Emergent right lobe adult-to-adult living-donor liver transplantation for high model for end-stage liver disease score severe hepatitis

The aim of this study was to explore the feasibility of emergency right lobe adult-to-adult living-donor liver transplantation (LDLT) for high model for end-stage liver disease (MELD) score severe hepatitis. Consecutive 10 high MELD score severe hepatitis patients underwent emergency right lobe adult-to-adult LDLT in our hospital from April to December 2007. The MELD score was 34.50 +/- 2.088. The outcomes of these recipients were retrospectively analyzed. Among them, eight cases of ABO blood group were identical and two cases compatible, one case was Rh negative. Two recipients died and the rest of the recipients and all donors are safe; perioperative and 2-year survival rate was 80%. The mean graft-recipient weight ratio (GRWR) was 1.27% +/- 0.25%, and graft volume to recipient standard liver volume ratio (GV/ESLVR) was 56.7% +/- 6.75%. Of the 10 patients, three received right lobe grafts with middle hepatic vein (MHV), four without MHV, three without MHV but followed by V and VIII hepatic vein outflow reconstruction. An encouraging outcome was achieved in this group: elevated serum creatinine, serum endotoxin, decreased serum prothrombin activity, and Tbil returned to normal on postoperative days 3, 7, 14, and 28, respectively. One-year survival rate was 80%. Outcomes of emergency right lobe adult-to-adult LDLT for high MELD score severe hepatitis were fairly encouraging and acceptable. Emergency right lobe adult-to-adult LDLT is an effective and life-saving modality for high MELD score acute liver failure patients following severe hepatitis.

Review article: the current management of acute liver failure

BACKGROUND

Acute liver failure is a devastating clinical syndrome with a persistently high mortality rate despite critical care advances. Orthotopic liver transplantation (OLT) is a life-saving treatment in selected cases, but effective use of this limited resource requires accurate prognostication because of surgical risks and the requirement for subsequent life-long immunosuppression.

AIM

To review the aetiology of acute liver failure, discuss the evidence behind critical care management strategies and examine potential treatment alternatives to OLT.

METHODS

Literature review using Ovid, PubMed and recent conference abstracts.

RESULTS

Paracetamol remains the most common aetiology of acute liver failure in developed countries, whereas acute viral aetiologies predominate elsewhere. Cerebral oedema is a major cause of death, and its prevention and prompt recognition are vital components of critical care support, which strives to provide multiorgan support and 'buy time' to permit either organ regeneration or psychological and physical assessment prior to acquisition of a donor organ. Artificial liver support systems do not improve mortality in acute liver failure, whilst most other interventions have limited evidence bases to support their use.

CONCLUSION

Acute liver failure remains a truly challenging condition to manage, and requires early recognition and transfer of patients to specialist centres providing intensive, multidisciplinary input and, in some cases, OLT.

Recent advances in liver transplantation for the practicing gastroenterologist

Liver transplantation is the definitive therapy for end-stage liver disease of various etiologies as well as acute liver failure and early-stage hepatocellular carcinoma. The Model for End-Stage Liver Disease (MELD) score is essential for organ allocation in the United States. Addition of the serum sodium level to the MELD score is a recent development that helps prognosticate cirrhotic patients with hyponatremia, a commonly seen manifestation of end-stage liver disease. The currently used Milan criteria for hepatocellular carcinoma have been expanded with some success at certain transplant centers, and tumor downstaging prior to transplant is being used more frequently. The tremendous shortage of donor organs continues to be the major limitation of this life-saving therapy. This has led to the use of extended-criteria donors, donation after cardiac death, split liver grafts, and live donor liver transplants. Renal dysfunction following liver transplant requires close monitoring and dose adjustments of immunosuppressive medications. Although most liver transplants in the United States are for chronic hepatitis C infection and its sequelae, hepatitis C virus recurrence is a common problem that is challenging to treat in the post-transplant population.

Liver and intestine transplantation in the United States 1998-2007

Liver transplantation numbers in the United States remained constant from 2004 to 2007, while the number of waiting list candidates has trended down. In 2007, the waiting list was at its smallest since 1999, with adults > or =50 years representing the majority of candidates. Noncholestatic cirrhosis was most commonly diagnosed. Most age groups had decreased waiting list death rates; however, children <1 year had the highest death rate. Use of liver allografts from donation after cardiac death (DCD) donors increased in 2007. Model for end-stage liver disease (MELD)/pediatric model for end-stage liver disease (PELD) scores have changed very little since 2002, with MELD/PELD <15 accounting for 75% of the waiting list. Over the same period, the number of transplants for MELD/PELD <15 decreased from 16.4% to 9.8%. Hepatocellular carcinoma exceptions increased slightly. The intestine transplantation waiting list decreased from 2006, with the majority of candidates being children <5 years old. Death rates improved, but remain unacceptably high. Policy changes have been implemented to improve allocation and recovery of intestine grafts to positively impact mortality. In addition to evaluating trends in liver and intestine transplantation, we review in depth, issues related to organ acceptance rates, DCD, living donor transplantation and MELD/PELD exceptions.