Impact of elderly donors for liver transplantation: A single-center experience

Pretransplant Renal Dysfunction Negatively Affects Prognosis After Living Donor Liver Transplantation: A Single-Center Retrospective Study

BACKGROUND

To evaluate the influence of preoperative renal function on prognosis after living donor liver transplantation (LDLT).

METHODS

Living donor liver transplantation cases were categorized into 3 groups as follows: renal failure with hemodialysis (HD; n = 42), renal dysfunction (RD; n = 94) (glomerular filtration rate <60 mL/min/1.73 m2), and normal renal function (NF; n = 421). The study used no prisoners, and participants were neither coerced nor paid. The manuscript complies with the Helsinki Congress and the Declaration of Istanbul.

RESULTS

Five-year overall survival (OS) rates were 59.0%, 69.3%, and 80.0% in the HD, RD, and NF groups, respectively (P < .01). The frequency of bacteremia within 90 days after LDLT was 76.2%, 37.2%, and 34.7%, respectively (P < .01 in HD vs RD and HD vs NF). Patients with bacteremia showed a worse outcome than those without (1-year OS, 65.6% vs 93.3%), thus corroborating the poor prognosis in the HD group. The high frequency of bacteremia in the HD group was mainly attributable to health care-associated bacterium, such as coagulase-negative Staphylococci, Enterococcus spp., and Pseudomonas aeruginosa. In the HD group, HD was started within 50 days before LDLT for acute renal failure in 35 patients, of which 29 (82.9%) successfully withdrew from HD after LDLT and demonstrated better prognosis (1-year OS, 69.0% vs 16.7%) than those who continued HD.

CONCLUSIONS

Preoperative renal dysfunction is associated with poor prognosis after LDLT, possibly due to a high incidence of health care-associated bacteremia.

Utilization of elderly donors in liver transplantation for patients with hepatocellular carcinoma: A national retrospective cohort study of China

BACKGROUND

Profound organ shortages worldwide have led to the increased utilization of marginal organs from older individuals. However, the effectiveness of liver transplantation (LT) with organs from elderly donors for patients with hepatocellular carcinoma (HCC) remains controversial. The objective of the current study was to assess the overall survival (OS) and disease-free survival (DFS) of patients with HCC following LT using grafts from deceased donors over 60 years old.

MATERIAL AND METHODS

Patients with HCC who underwent LT between 2015 and 2018 were identified in the China Liver Transplant Registry database. The overall survival and disease-free survival of older liver donors (OLDs) were compared with those of younger liver donors (YLDs) after propensity score matching.

RESULTS

From January 2015 to December 2018, a total of 4971 HCC patients were enrolled in the study according to the screening criteria. The absolute and relative utilization of liver grafts from elderly patients over 60 years for HCC patients increased every year, from 65 (9.3%) in 2015 to 268 (14.5%) in 2018. Disease-free survival (DFS) was significantly lower in HCC patients with elderly donors (both P < 0.05) after propensity score matching. The OLD group had worse DFS than YLD group if patients had tumors beyond the Milan criteria (P < 0.05).

CONCLUSIONS

The use of older donors for LT has been growing quickly in the last few years in China. Grafts from older donors can be safely used in HCC recipients with similar OS and comparable perioperative complications. However, further investigation into whether older donor has an impact on recurrence is warranted, especially among those with tumors beyond the Milan criteria.

Intraoperative High Fraction of Inspiratory Oxygen is Independently Associated with Worse Outcome After Living-Donor Liver Transplantation: A Retrospective Study

Background

Ischemia and reperfusion injury is an important factor that determines graft function after liver transplantation, and oxygen plays a crucial role in this process. However, the relationship between the intraoperative high fraction of inspiratory oxygen (FiO₂) and living-donor-liver-transplantation (LDLT) outcome remains unclear.

Patients and Methods

A total of 199 primary adult-to-adult LDLT cases in Kyoto University Hospital between January 2010 and December 2017 were enrolled in this study. The intraoperative FiO₂ was averaged using the total amount of intraoperative oxygen and air and defined as the calculated FiO₂ (cFiO₂). The cutoff value of cFiO₂ was set at 0.5.

Results

Between the cFiO₂ <0.5 (n = 156) and ≥0.5 group (n = 43), preoperative recipients’ background, donor factors, and intraoperative parameters were almost comparable. Postoperatively, the cFiO₂ ≥0.5 group showed a higher early allograft dysfunction (EAD) rate (P = 0.049) and worse overall graft survival (P = 0.036) than the cFiO₂ <0.5 group. Although the cFiO₂ ≥0.5 was not an independent risk factor for EAD in multivariable analysis (OR 2.038, 95%CI 0.992–4.186, P = 0.053), it was an independent risk factor for overall graft survival after LDLT (HR 1.897, 95%CI 1.007–3.432, P = 0.048).

Conclusion

The results of this study suggest that intraoperative high FiO₂ may be associated with worse graft survival after LDLT. Avoiding higher intraoperative FiO₂ may be beneficial for LDLT recipients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06544-7.

Impact of Donor Age on the Outcome of Living-donor Liver Transplantation: Special Consideration to the Feasibility of Using Elderly Donors

BACKGROUND

The use of elderly donors (≥60 y) in living-donor liver transplantation (LDLT) remains controversial. In this study, we aimed to determine the safety of surgery for elderly donors and the impact of donor age on LDLT outcomes.

METHODS

We, retrospectively, reviewed 470 cases of LDLT at Kumamoto University Hospital from December 1998 to March 2017.

RESULTS

Donors were divided into 5 groups according to age: 20-29 (n = 109), 30-39 (n = 157), 40-49 (n = 87), 50-59 (n = 81), and ≥60 (n = 36). At our institution, elderly donor candidates required additional preoperative work-up. There were no significant differences in the incidence of postoperative complications and duration of postoperative hospital stay among the 5 donor groups. Regardless of graft type, elderly donors were comparable to younger donor groups (<30 y) in postoperative recovery of liver function. Risk-adjusted overall survival rates of recipients among donor groups were not significantly different. Additionally, donor age was not significantly associated with 6-month graft survival of adult and pediatric recipients.

CONCLUSIONS

Elderly candidates ≥60 years of age can safely be selected as LDLT donors after meticulous preoperative work-up.

The combination of a male donor's high muscle mass and quality is an independent protective factor for graft loss after living donor liver transplantation

We evaluated the hypothesis that grafts from donors with high muscle mass and quality may have a better outcome after living-donor-liver-transplantation (LDLT) than those from usual donors. A total of 376 primary adult-to-adult LDLT cases were enrolled in this study. Donor skeletal muscle mass index (SMI) and intramuscular adipose tissue content (IMAC) were used as markers of muscle mass and quality. In male donor cases (n = 198), those with higher SMI and lower IMAC than age-adjusted values were defined as the "high muscularity donors" (n = 38) and the others were defined as the "control" (n = 160). The high muscularity donor showed better 1-year (97% vs 82%, P = .020) and overall graft survival rate (88% vs 67%, P = .024) than the control group after LDLT. Contrastingly, the influence of the muscularity was not observed in female donor cases. Multivariable analysis including donor age confirmed that a high muscularity donor was an independent protective factor for overall graft survival after LDLT (hazard ratio, 0.337; 95% CI: 0.101-0.838; P = .017). Our study first confirmed that high muscle mass and quality of a male donor is a protective factor of allograft loss after LDLT, independently from donor age.

Update on liver transplantation-newer aspects

Liver transplantation (LT) remains the only therapeutic option offering gold standard treatment for end-stage liver disease (ESLD) and acute liver failure (ALF), as well as for certain early-stage liver tumors. Currently, the greatest challenge facing LT is the simple fact that there are not enough adequate livers for all the potential patients that could benefit from LT. Despite efforts to expand the donor pool to include living and deceased donors, organ shortage is still a major problem in many countries. To solve this problem, the use of marginal liver grafts has become an inevitable choice. Although the definition of marginal grafts or criteria for expanded donor selection has not been clarified yet, they are usually defined as grafts that may potentially cause primary nonfunction, impaired function, or late loss of function. These include steatotic livers, older donors, donors with positive viral serology, split livers, and donation after cardiac death (DCD). Therefore, to get the best outcome from these liver grafts, donor-recipient selection should be vigilant. Alcohol- related liver disease (ALD) is one of the most common indications for LT in Europe and North America. Traditionally, LT for alcoholic liver disease was kept limited for patients who have achieved 6 months of abstinence, in part due to social and ethical concerns regarding the use of a limited resource. However, the majority of patients with severe alcoholic hepatitis who fail medical therapy will not live long enough to meet this requirement. Besides, the initial results of early liver transplantation (ELT) without waiting for 6 months of abstinence period are satisfactory in severe alcoholic hepatitis (SAH). It will be important to take care of these patients from a newer perspective.

Recent evolution of living donor liver transplantation at Kyoto University: How to achieve a one-year overall survival rate of 99%?

Previously, living donor liver transplantation was considered as a "high-risk, high-return" medical treatment due to the relatively high short-term mortality. It is our task to change "high-risk, high-return" into a "low-risk, high-return" situation. In this review article, the recent evolutions in living donor liver transplantation for both donors and recipients at Kyoto University such as portal vein pressure modulation, hybrid donor operation, and perioperative management considering sarcopenia, focusing on improvement of short-term outcomes are described. Under a paradigm of "marketing and innovation", various innovations and efforts have been made over the last decade aiming at improving the short-term outcomes of both donors and recipients. By doing so, excellent short-term results after living donor liver transplantation have been achieved, along with a potentially epoch-making discoveries.

Small-for-size syndrome in liver transplantation: Definition, pathophysiology and management

BACKGROUND

Since the first success in an adult patient, living donor liver transplantation (LDLT) has become an universally used procedure. Small-for-size syndrome (SFSS) is a well-known complication after partial LT, especially in cases of adult-to-adult LDLT. The definition of SFSS slightly varies among transplant physicians. The use of a partial liver graft has risks of SFSS development. Persistent portal vein (PV) hypertension and PV hyper-perfusion after LT were identified as the main factors. Hence, various approaches were explored to modulate PV flow and decrease PV pressure in order to alleviate this syndrome. Herein, the definition, clinical symptoms, pathophysiology, basic research, as well as preventive and treatment strategies for SFSS are reviewed based on an extensive review of the literature and on our own experiences.

DATA SOURCES

The articles were collected through PubMed using search terms "liver transplantation", "living donor liver transplantation", "living liver donation", "partial graft", "small-for-size graft", "small-for-size syndrome", "graft volume", "remnant liver", "standard liver volume", "graft to recipient body weight ratio", "sarcopenia", "porcine", "swine", and "rat". English publications published before March 31, 2020 were included in this review.

RESULTS

Many transplant surgeons performed PV flow modulation, including portocaval shunt, splenic artery ligation and splenectomy. With these techniques, patient outcome has been improved even when using a "small" graft. Other factors, such as preoperative recipients' nutritional and skeletal muscle status, graft congestion, and donor factors, were also identified as risk factors which all have been addressed using various strategies.

CONCLUSIONS

The surgical approach controlling PV flow and pressure could help to prevent SFSS especially in severely ill recipients. In the absence of efficacious medications to resolve SFSS, conservative treatments, including aggressive fluid balance correction for massive ascites, anti-microbiological therapy to prevent or control sepsis and intensive nutritional therapy, are all required if SFSS could not be prevented.

Preoperative abnormal body composition is closely related to bacteremia after living donor liver transplantation

OBJECTIVE

Infection is the most critical cause of early death after liver transplantation (LT). However, the effect of preoperative body composition on bacteremia after LT is unclear. The aim of this study was to examine the effects of preoperative body composition on bacteremia after living donor LT (LDLT).

METHODS

The study comprised 277 patients who underwent LDLT at Kyoto University, Kyoto, Japan, between January 2008 and June 2016. We evaluated body composition parameters including skeletal muscle mass index (SMI), intramuscular adipose tissue content (IMAC), and visceral-to-subcutaneous adipose tissue area ratio (VSR) using preoperative plain computed tomography at the L3 level. We compared the incidence of bacteremia, species, period of antibiotic administration, mortality due to bacteremia, and survival rates according to the number of abnormal body composition factors (low SMI, high IMAC, and high VSR). Moreover, risk factors for post-transplant bacteremia were examined.

RESULTS

Incidence of bacteremia was significantly higher in patients with three abnormal factors (47.1%), two factors (42%), or a single factor (37%) than in patients with no factors (22.5%; P = 0.027). Species of bacteremia did not differ significantly among the four groups. The period of antibiotic administration was significantly shorter (P = 0.039) and mortality of patients with bacteremia and survival rates were significantly better (P < 0.001, each) in patients with no factors. Multivariate analysis identified ABO incompatibility (P = 0.002) and low SMI (P = 0.045) as independent risk factors for bacteremia after LT.

CONCLUSION

Preoperative abnormal body composition was closely related to bacteremia after LDLT.

[High donor age for liver transplantation : Tackling organ scarcity in Germany]

BACKGROUND

Liver transplantation is the only curative treatment option for patients with end-stage liver disease; however, the 40% decline of available organ donors in recent years in Germany necessitates the optimization of available resources and possibly extending the criteria to older donors.

MATERIAL AND METHODS

All 2652 livers made available to the Charité Universitätsmedizin Berlin from 2010 to 2016 were retrospectively analyzed and the clinical outcome of 526 liver transplantations during this time frame were evaluated.

RESULTS

The median age of donors of transplanted organs increased from 49.3 years in 2010 to 57.3 years in 2016 (p = 0.02). Organs from donors ≥65 years were more frequently discarded than organs from younger donors (n = 344, 18.4% vs. n = 220, 28.1%; p = 0.005). Moreover, the older donors had higher rates of diabetes mellitus and hepatic steatosis. Organs from older donors had a higher donor risk index (2.8 vs. 2.2; p < 0.001) and were transplanted more often in patients with preserved liver function and hepatocellular carcinoma and liver cirrhosis (n = 121, 74.7% of indications). The 3‑year survival after liver transplantation from donors ≥65 and ≥80 years old was not significantly reduced in comparison to younger donors; however, there was an increased retransplantation rate (28.6%; p = 0.005) after transplantation of organs from donors ≥80 years old.

CONCLUSION

Despite conservative organ acceptance there were higher rates of retransplantation after transplantation from very old donors. In the light of an increasing scarcity of suitable organs this mandates caution and highlights the need for adequate assessment instruments for marginal donor organs before transplantation.

Older Donor Age Is a Risk Factor for Negative Outcomes After Adult Living Donor Liver Transplantation Using Small-for-Size Grafts

Adult-to-adult living donor liver transplantation (ALDLT) using small-for-size grafts (SFSGs), ie, a graft with a graft-to-recipient weight ratio (GRWR) <0.8%, has been a challenge that should be carefully dealt with, and risk factors in this category are unclear. Therefore, we aimed to examine the risk factors and outcomes of ALDLT using SFSGs over a 13-year period in 121 patients who had undergone their first ALDLT using SFSGs. Small-for-size syndrome (SFSS), early graft loss, and 1-year mortality were encountered in 21.6%, 14.9%, and 18.4% of patients, respectively. By multivariate analysis, older donor age (≥45 years) was an independent risk factor for SFSS (odds ratio [OR], 4.46; P = 0.004), early graft loss (OR, 4.11; P = 0.02), and 1-year mortality (OR, 3.76; P = 0.02). Child-Pugh C class recipients were associated with a higher risk of SFSS development (P = 0.013; OR, 7.44). Despite no significant difference between GRWR categories in the multivariate outcome analysis of the whole population, in the survival analysis of the 2 donor age groups, GRWR <0.6% was associated with significantly lower 1-year survival than the other GRWR categories in the younger donor group. Moreover, in the high final portal venous pressure (PVP) group (>15 mm Hg), younger ABO-compatible donors showed 100% 1-year survival with a significant difference from the group of other donors. Older donor age was an independent risk factor for SFSS, early graft loss, and 1-year mortality after ALDLT using SFSGs. GRWR should not be <0.6%, and PVP modulation is indicated when grafts from older or ABO-incompatible donors are used.

Association between CXCL9/10 polymorphisms and acute rejection of liver allograft

While increased serum concentrations of CXCL9/10 are associated with acute cellular rejection (ACR) occurrence, the association between CXCL9/10 single nucleotide polymorphisms (SNPs) and ACR after liver transplantation (LT) remains unknown.In the present case-control study, polymorphisms of CXCL9 (rs10336) and CXCL10 (rs3921) were determined by polymerase chain reaction in 215 liver transplant recipients. ACR was defined as biopsy proven within 6 months after LT. As selected SNPs were in 3'-UTR region, their possible association with protein synthesis was assessed by measuring the plasma concentration of CXCL9/10 in a cohort of 40 new transplant patients using ELISA.There was no association between CXCL9/10 genotypes and overall incidence of ACR. However, patients with CXCL9 genotype AA developed ACR earlier than patients with GG genotype (P = .003), with similar results for CXCL10 gene (CC vs GG; P = .005). There was no statistically significant difference in plasma concentrations of CXCL9/10 between the rejectors and the non-rejectors. Of note, patients with AA CXCL9 genotype had significantly higher CXCL9 plasma concentrations than patients with AG (P = .01) or GG genotype (P = .045).In conclusion, the SNPs of CXCL9 (rs10336) and CXCL10 (rs3921) are not associated with the incidence of ACR. However, patients with CXCL9 genotype AA developed ACR earlier and the same genotype was associated with greater plasma concentrations suggesting the involvement of CXCL9 mediated processes in ACR development.

Feasibility of using marginal liver grafts in living donor liver transplantation

Liver transplantation (LT) is one of the most effective treatments for end-stage liver disease caused by related risk factors when liver resection is contraindicated. Additionally, despite the decrease in the prevalence of hepatitis B virus (HBV) over the past two decades, the absolute number of HBsAg-positive people has increased, leading to an increase in HBV-related liver cirrhosis and hepatocellular carcinoma. Consequently, a large demand exists for LT. While the wait time for patients on the donor list is, to some degree, shorter due to the development of living donor liver transplantation (LDLT), there is still a shortage of liver grafts. Furthermore, recipients often suffer from emergent conditions, such as liver dysfunction or even hepatic encephalopathy, which can lead to a limited choice in grafts. To expand the pool of available liver grafts, one option is the use of organs that were previously considered “unusable” by many, which are often labeled “marginal” organs. Many previous studies have reported on the possibilities of using marginal grafts in orthotopic LT; however, there is still a lack of discussion on this topic, especially regarding the feasibility of using marginal grafts in LDLT. Therefore, the present review aimed to summarize the feasibility of using marginal liver grafts for LDLT and discuss the possibility of expanding the application of these grafts.

Chronic pancreatitis in patients with liver cirrhosis negatively affects graft survival after liver transplantation

BACKGROUND

Limited data exists concerning the coincidence of chronic pancreatitis (CP) and liver cirrhosis with respect to the patient outcome after liver transplantation (LT). The aim of the study was to identify risk factors for graft loss after liver transplantation and to evaluate the impact of CP on graft survival.

METHODS

We analyzed the data of 421 cirrhotic patients who underwent evaluation for primary liver transplantation from January 2007 to January 2014. Diagnosis of CP based on morphologic findings which were graded according to the Cambridge and Manchester classification. (Graft) survival after LT was analyzed by Cox regression analysis. Recipient- and donor-related risk factors for graft loss were evaluated using univariate and multivariate analysis.

RESULTS

40/421 cirrhotic patients suffered from CP (9.5%). 250/421 (59.4%) patients underwent LT between January 2007 and January 2014. In total, 89 patients died or were in need of a re-transplantation during follow-up until August 2017. Patients with CP (N = 26) were at increased risk for graft loss after LT (hazard ratio = 2.183; 95% confidence interval = 1.232-3.868). CP (P = 0.001), a MELD score ≥24 (P = 0.021), absence of esophageal or gastrical varices (P = 0.018), the age of the donor (P = 0.008) and infections after transplantation (P = 0.030) were independent risk factors for organ loss after transplantation in the multivariate Cox regression analysis.

CONCLUSION

Patients with chronic pancreatitis are at increased risk for graft loss after LT. A high MELD score, the absence of esophageal or gastrical varices, an advanced donor age and post-transplant infections negatively affect graft survival, too.

Graft selection strategy in adult-to-adult living donor liver transplantation: When both hemiliver grafts meet volumetric criteria

To ensure donor safety in living donor liver transplantation (LDLT), the left and caudate lobe (LL) is the preferred graft choice. However, patient prognosis may still be poor even if graft volume (GV) selection criteria are met. Our aim was to evaluate the effects of right lobe (RL) donation when the LL graft selection criteria are met. Consecutive donors (n = 135) with preoperative LL graft volumetric GV/standard liver volume (SLV) of ≥35% and RL remnant of ≥35% were retrospectively studied. Patients were divided into 2 groups: LL graft and RL graft. Recipient's body surface area (BSA), Model for End-Stage Liver Disease (MELD) score, and the donor's age were higher in the RL group. The donor's BSA and preoperative volumetric GV/SLV of the LL graft were smaller in the RL group. The predicted score (calculated using data for graft size, donor age, MELD score, and the presence of portosystemic shunt, which correlated well with graft function and with 6-month graft survival) of the RL group, was significantly lower if the LL graft were used, but using the actual RL graft improved the score equal to that of the LL group. Six-month and 12-month graft survival rates did not differ between the 2 groups. In patients with a poor prognosis, a larger RL graft improved the predicted score and survival was equal to that of patients who received LL grafts. In conclusion, graft selection by GV, donor age, and recipient MELD score improves outcomes in LDLT. Liver Transplantation 22 914-922 2016 AASLD.