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Xiang Z, Li J, Zeng H, Xiang X, Gao F, Wang K, Wei X, Zheng S, Xu X. Current Understanding of Marginal Grafts in Liver Transplantation. Aging Dis 2024:AD.2024.0214. [PMID: 38607739 DOI: 10.14336/ad.2024.0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/14/2024] [Indexed: 04/14/2024] Open
Abstract
End-stage liver disease (ESLD), stemming from a spectrum of chronic liver pathologies including chronic liver failure, acute cirrhosis decompensation and hepatocellular carcinoma, imposes a significant global healthcare burden. Liver transplantation (LT) remains the only treatment for ESLD. However, the escalating mortality on transplant waitlists has prompted the utilization of marginal liver grafts in LT procedures. These grafts primarily encompass elderly livers, steatotic livers, livers from donation after circulatory death, split livers and those infected with the hepatitis virus. While the expansion of the donor pool offers promise, it also introduces concomitant risks. These encompass graft failure, biliary and cardiovascular complications, the recurrence of liver disease and reduced patient and graft survival. Consequently, various established strategies, ranging from improved donor-recipient matching to surgical interventions, have emerged to mitigate these risks. This article undertakes a comprehensive assessment of the current landscape, evaluating the viability of diverse marginal liver grafts. Additionally, it synthesizes approaches aimed at enhancing the quality of such marginal liver grafts. The overarching objective is to augment the donor pool and ameliorate the risk factors associated with the shortage of liver grafts.
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Affiliation(s)
- Ze Xiang
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Jiarui Li
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Huixuan Zeng
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Xiaonan Xiang
- Zhejiang University School of Medicine, Hangzhou 310058, China
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, Cambridgeshire, UK
| | - Fengqiang Gao
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Kai Wang
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Xuyong Wei
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
| | - Shusen Zheng
- Zhejiang University School of Medicine, Hangzhou 310058, China
- Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Xiao Xu
- Zhejiang University School of Medicine, Hangzhou 310058, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
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Stoltz DJ, Gallo AE, Lum G, Mendoza J, Esquivel CO, Bonham A. Technical Variant Liver Transplant Utilization for Pediatric Recipients: Equal Graft Survival to Whole Liver Transplants and Promotion of Timely Transplantation Only When Performed at High-volume Centers. Transplantation 2024; 108:703-712. [PMID: 37635278 DOI: 10.1097/tp.0000000000004772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Technical variant liver transplantation (TVLT) is a strategy to mitigate persistent pediatric waitlist mortality in the United States, although its implementation remains stagnant. This study investigated the relationship between TVLT utilization, transplant center volume, and graft survival. METHODS Pediatric liver transplant recipients from 2010 to 2020 (n = 5208) were analyzed using the Scientific Registry of Transplant Recipients database. Transplant centers were categorized according to the average number of pediatric liver transplants performed per year (high-volume, ≥5; low-volume, <5). Graft survival rates were compared using Kaplan-Meier curves and log-rank tests. Cox proportional hazards models were used to identify predictors of graft failure. RESULTS High-volume centers demonstrated equivalent whole liver transplant and TVLT graft survival ( P = 0.057) and significantly improved TVLT graft survival compared with low-volume centers ( P < 0.001). Transplantation at a low-volume center was significantly associated with graft failure (adjusted hazard ratio, 1.6; 95% confidence interval, 1.14-2.24; P = 0.007 in patients <12 y old and 1.8; 95% confidence interval, 1.13-2.87; P = 0.013 in patients ≥12 y old). A subset of high-volume centers with a significantly higher rate of TVLT use demonstrated a 23% reduction in waitlist mortality. CONCLUSIONS Prompt transplantation with increased TVLT utilization at high-volume centers may reduce pediatric waitlist mortality without compromising graft survival.
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Affiliation(s)
- Daniel J Stoltz
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Amy E Gallo
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Grant Lum
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Julianne Mendoza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Carlos O Esquivel
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Andrew Bonham
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
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Lauterio A, Cillo U, Spada M, Trapani S, De Carlis R, Bottino G, Bernasconi D, Scalamogna C, Pinelli D, Cintorino D, D'Amico FE, Spagnoletti G, Miggino M, Romagnoli R, Centonze L, Caccamo L, Baccarani U, Carraro A, Cescon M, Vivarelli M, Mazaferro V, Ettorre GM, Rossi M, Vennarecci G, De Simone P, Angelico R, Agnes S, Di Benedetto F, Lupo LG, Zamboni F, Zefelippo A, Patrono D, Diviacco P, Laureiro ZL, Gringeri E, Di Francesco F, Lucianetti A, Valsecchi MG, Gruttadauria S, De Feo T, Cardillo M, De Carlis L, Colledan M, Andorno E. Improving outcomes of in situ split liver transplantation in Italy over the last 25 years. J Hepatol 2023; 79:1459-1468. [PMID: 37516203 DOI: 10.1016/j.jhep.2023.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND & AIMS Split liver transplant(ation) (SLT) is still considered a challenging procedure that is by no means widely accepted. We aimed to present data on 25-year trends in SLT in Italy, and to investigate if, and to what extent, outcomes have improved nationwide during this time. METHODS The study included all consecutive SLTs performed from May 1993 to December 2019, divided into three consecutive periods: 1993-2005, 2006-2014, and 2015-2019, which match changes in national allocation policies. Primary outcomes were patient and graft survival, and the relative impact of each study period. RESULTS SLT accounted for 8.9% of all liver transplants performed in Italy. A total of 1,715 in situ split liver grafts were included in the analysis: 868 left lateral segments (LLSs) and 847 extended right grafts (ERGs). A significant improvement in patient and graft survival (p <0.001) was observed with ERGs over the three periods. Predictors of graft survival were cold ischaemia time (CIT) <6 h (p = 0.009), UNOS status 2b (p <0.001), UNOS status 3 (p = 0.009), and transplant centre volumes: 25-50 cases vs. <25 cases (p = 0.003). Patient survival was significantly higher with LLS grafts in period 2 vs. period 1 (p = 0.008). No significant improvement in graft survival was seen over the three periods, where predictors of graft survival were CIT <6 h (p = 0.007), CIT <6 h vs. ≥10 h (p = 0.019), UNOS status 2b (p = 0.038), and UNOS status 3 (p = 0.009). Retransplantation was a risk factor in split liver graft recipients, with significantly worse graft and patient survival for both types of graft (p <0.001). CONCLUSIONS Our analysis showed Italian SLT outcomes to have improved over the last 25 years. These results could help to dispel reservations regarding the use of this procedure. IMPACT AND IMPLICATIONS Split liver transplant(ation) (SLT) is still considered a challenging procedure and is by no means widely accepted. This study included all consecutive in situ SLTs performed in Italy from May 1993 to December 2019. With more than 1,700 cases, it is one of the largest series, examining long-term national trends in in situ SLT since its introduction. The data presented indicate that the outcomes of SLT improved during this 25-year period. Improvements are probably due to better recipient selection, refinements in surgical technique, conservative graft-to-recipient matching, and the continuous, yet carefully managed, expansion of donor selection criteria under a strict mandatory split liver allocation policy. These results could help to dispel reservations regarding the use of this procedure.
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Affiliation(s)
- Andrea Lauterio
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padova, Italy
| | - Marco Spada
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Silvia Trapani
- Italian National Transplant Center-Istituto Superiore Di Sanità, Rome, Italy
| | - Riccardo De Carlis
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; PhD Course in Clinical and Experimental Sciences, University of Padua, Padua, Italy
| | - Giuliano Bottino
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Davide Bernasconi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Centre-B4, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Chiara Scalamogna
- North Italy Transplant Program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Domenico Pinelli
- Department of Organ Failure and Transplantation, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Davide Cintorino
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | | | - Gionata Spagnoletti
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Marco Miggino
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Renato Romagnoli
- Liver Transplant Center, General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Leonardo Centonze
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Lucio Caccamo
- Division of General Surgery and Liver Transplantation, Fondazione Cà Granda IRCCS, Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Umberto Baccarani
- Department of Medicine, Liver Transplant Center, University of Udine, Italy
| | - Amedeo Carraro
- Liver Transplant Unit, University and Hospital Trust of Verona, Italy
| | - Matteo Cescon
- Hepatobiliary Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Vivarelli
- HPB Surgery and Transplantation Unit, United Hospital of Ancona, Department of Experimental and Clinical Medicine Polytechnic University of Marche, Ancona, Italy
| | - Vincenzo Mazaferro
- Department of Oncology and Onco-Hematology, University of Milan, Italy; Department of Surgery, Istituto Nazionale Tumori Fondazione IRCCS Milan, Italy
| | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Massimo Rossi
- General Surgery and Organ Transplantation, Sapienza University of Rome, Umberto I Polyclinic of Rome, Rome, Italy
| | - Giovanni Vennarecci
- Division of Hepatobiliary Surgery and Liver Transplant Center, AORN Cardarelli, Naples, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation AOU Pisana, Pisa, Italy
| | - Roberta Angelico
- Department of Surgical Sciences, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Salvatore Agnes
- Department of Surgery, Transplantation Service, Catholic University of the Sacred Heart, Foundation A. Gemelli Hospital, Rome, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit Azienda Ospedaliera Policlinico, University of Modena and Reggio Emilia Modena, Italy
| | - Luigi Giovanni Lupo
- General Surgery and Liver Transplantation Unit, University of Bari, Bari, Italy
| | - Fausto Zamboni
- Department of Surgery, General and Hepatic Transplantation Surgery Unit, A.O.B. Brotzu, Cagliari, Italy
| | - Arianna Zefelippo
- Division of General Surgery and Liver Transplantation, Fondazione Cà Granda IRCCS, Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Damiano Patrono
- Liver Transplant Center, General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Pietro Diviacco
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Zoe Larghi Laureiro
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padova, Italy
| | - Fabrizio Di Francesco
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Alessandro Lucianetti
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Maria Grazia Valsecchi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Centre-B4, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy; Department of Surgery and Medical and Surgical Specialties, University of Catania, 95124, Catania, Italy
| | - Tullia De Feo
- North Italy Transplant Program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cardillo
- Italian National Transplant Center-Istituto Superiore Di Sanità, Rome, Italy
| | - Luciano De Carlis
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Colledan
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Department of Organ Failure and Transplantation, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Enzo Andorno
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
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4
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Yu Z, Keskinocak P, Magliocca JF, Romero R, Sokol J. Split or whole liver transplantation? Utilization and posttransplant survival. Hepatol Commun 2023; 7:e0225. [PMID: 37655982 PMCID: PMC10476835 DOI: 10.1097/hc9.0000000000000225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 06/08/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Split liver transplantation (SLT), where a single donor liver is divided for transplantation to 2 recipients, has the potential to increase the availability of size-matched livers for pediatric candidates and expand the supply of donor organs available for adult candidates. Although SLT is a well-established technique, the number of SLTs has remained flat during the past 2 decades, partly due to concerns about the posttransplant survival of SLT recipients compared with whole liver transplantation (WLT) recipients. Prior work on SLT versus WLT survival analysis had limitations because, for pediatric recipients, it did not consider the correlations between donor age/weight and the allograft type, and for adult recipients, it may have included records where the donor livers did not meet the split liver criteria (splittable). METHODS Using the Organ Procurement and Transplantation Network's database (2003-2019), this study analyzes and compares (i) key characteristics of donors and recipients, (ii) donor-recipient match dynamics (organ offers and accept/decline decisions), and (iii) recipient posttransplant survival, for SLT and WLT. RESULTS AND CONCLUSIONS The results in this study show that the posttransplant survival of SLT and WLT recipients is similar (controlling for other confounding factors that may impact posttransplant survival), highlighting the importance of SLT for increasing the liver supply and potential benefits for both pediatric and adult candidates.
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Affiliation(s)
- Zhuoting Yu
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Pinar Keskinocak
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Joseph F. Magliocca
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rene Romero
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joel Sokol
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
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Ding L, Yu X, Zhang R, Qian J, Zhang W, Wu Q, Zhou L, Yang Z, Zheng S. Full-Right Full-Left Split Liver Transplantation for Two Adult Recipients: A Single-Center Experience in China. J Clin Med 2023; 12:3782. [PMID: 37297977 PMCID: PMC10253538 DOI: 10.3390/jcm12113782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/03/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND The most effective treatment for end-stage liver diseases is liver transplantation, which is impeded by the shortage of donor livers. Split liver transplantation (SLT) is important for addressing the donor liver shortage. However, full-right full-left SLT for two adult recipients is globally rarely conducted. This study aimed to investigate the clinical outcomes of this technique. METHODS We retrospectively analyzed the clinical data of 22 recipients who underwent full-right full-left SLT at Shulan (Hangzhou) Hospital between January, 2021 and September, 2022. The graft-to-recipient weight ratio (GRWR), cold ischemia time, operation time, length of the anhepatic phase, intraoperative blood loss, and red blood cell transfusion amount were all analyzed. The differences in liver function recovery after transplantation were compared between the left and right hemiliver groups. The postoperative complications and prognosis of the recipients were also analyzed. RESULTS The livers of 11 donors were transplanted into 22 adult recipients. The GRWR ranged from 1.16-1.65%, the cold ischemia time was 282.86 ± 134.87 min, the operation time was 371.32 ± 75.36 min, the anhepatic phase lasted 60.73 ± 19.00 min, the intraoperative blood loss was 759.09 ± 316.84 mL, and the red blood cell transfusion amount was 695.45 ± 393.67 mL. No significant difference in the levels of liver function markers, total bilirubin, aspartate aminotransferase, or alanine aminotransferase between left and right hemiliver groups at 1, 3, 5, 7, 14, and 28 d postoperatively was observed (both p > 0.05). One recipient developed bile leakage 10 d after transplantation, which improved with endoscopic retrograde cholangiopancreatography-guided nasobiliary drainage and stent placement. Another developed portal vein thrombosis 12 d after transplantation and underwent portal vein thrombectomy and stenting to restore portal vein blood flow. A color Doppler ultrasound performed 2 d after transplantation revealed hepatic artery thrombosis in one patient, and thrombolytic therapy was administered to restore hepatic artery blood flow. The liver function of other patients recovered quickly after transplantation. CONCLUSIONS Full-right full-left SLT for two adult patients is an efficient way to increase the donor pool. It is safe and feasible with careful donor and recipient selection. Transplant hospitals with highly experienced surgeons in SLT are recommended to promote using full-right full-left SLT for two adult recipients.
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Affiliation(s)
- Limin Ding
- Division of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (L.D.); (X.Y.); (J.Q.); (Q.W.)
- NHFPC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou 310003, China;
- Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou 310003, China
- Key Laboratory of Organ Transplantation, Hangzhou 310003, China
| | - Xizhi Yu
- Division of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (L.D.); (X.Y.); (J.Q.); (Q.W.)
- NHFPC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou 310003, China;
- Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou 310003, China
- Key Laboratory of Organ Transplantation, Hangzhou 310003, China
| | - Rui Zhang
- Fuzhou Medical College, Nanchang University, Fuzhou 344000, China;
| | - Junjie Qian
- Division of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (L.D.); (X.Y.); (J.Q.); (Q.W.)
- NHFPC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou 310003, China;
- Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou 310003, China
- Key Laboratory of Organ Transplantation, Hangzhou 310003, China
| | - Wu Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310022, China;
| | - Qinchuan Wu
- Division of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (L.D.); (X.Y.); (J.Q.); (Q.W.)
- NHFPC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou 310003, China;
- Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou 310003, China
- Key Laboratory of Organ Transplantation, Hangzhou 310003, China
| | - Lin Zhou
- NHFPC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou 310003, China;
- Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou 310003, China
- Key Laboratory of Organ Transplantation, Hangzhou 310003, China
- Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Hangzhou 310003, China
| | - Zhe Yang
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310022, China;
| | - Shusen Zheng
- Division of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (L.D.); (X.Y.); (J.Q.); (Q.W.)
- NHFPC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou 310003, China;
- Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou 310003, China
- Key Laboratory of Organ Transplantation, Hangzhou 310003, China
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310022, China;
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6
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Xu M, Dong C, Sun C, Wang K, Zhang W, Qin H, Han C, Yang Y, Zhang F, Wang Z, Zheng W, Wei X, Gao W, Shen Z. Impact of donor age on short-term outcomes after pediatric split liver transplantation. Front Pediatr 2023; 11:1131629. [PMID: 37114006 PMCID: PMC10126406 DOI: 10.3389/fped.2023.1131629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 03/28/2023] [Indexed: 04/29/2023] Open
Abstract
Background Donor shortage is an important limitation of liver transplantation (LT). Split liver transplantation (SLT) may increase the sources of donors and reduce the problem of organ shortage. However, there are no standard criteria of the selection of SLT donor, especially regarding the donor age. Methods We retrospectively analyzed the clinical data of children who received initial SLT between January 2015 and December 2021. Based on the age of donors, the patients were divided into groups A (1-10 years old; n = 26), B (10-45 years old; n = 87), and C (45-55 years old; n = 27). The short-term (<1 year after SLT) outcomes of the recipients were analyzed. Results A total of 140 patients received SLT from 122 donors. The 1-, 3- and 12-month patient survival rates in group A were 100.0%, and the graft survival rates were 92.3%. The 1-, 3- and 12-month survival rates of patient and graft in group B were 97.7%, 96.6%, and 95.0%, respectively, and in group C were 85.2%, 85.2%, and 81.1%, respectively. The patient survival rate was significantly lower in group C than in groups A and B (p = 0.0082). There was no significant difference in graft survival between the three groups (p = 0.0545). Conclusions Similar results were obtained for pediatric SLT with donors <10 years old and 10-45 years old. Pediatric SLT can be performed with older donors (45-55 years) after strict donor selection and selection of appropriate recipients.
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Affiliation(s)
- Min Xu
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Chong Dong
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Chao Sun
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Kai Wang
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Wei Zhang
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Hong Qin
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Chao Han
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Yang Yang
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Fubo Zhang
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Zhen Wang
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Weiping Zheng
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Xinzhe Wei
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Wei Gao
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
- Correspondence: Wei Gao
| | - Zhongyang Shen
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
- Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
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7
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Vargas PA, Cullen JM, Dalzell C, DiPaola F, Pelletier S, Soltys KA, Mazariegos GV, Oberholzer J, Goldaracena N. Increased use of split liver grafts in adult recipients following implementation of a pediatric liver transplant program. Pediatr Transplant 2022; 26:e14159. [PMID: 34687473 DOI: 10.1111/petr.14159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/23/2021] [Accepted: 09/26/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Split liver transplantation (SLT) is a strategy to address organ shortage, but is a technically more demanding procedure than whole graft liver transplantation (LT). We aimed to determine the outcomes following SLT in adult recipients as well as to highlight the impact that having a pediatric LT program has on SLT implementation. METHODS All SLTs conducted at a single-center from 2010 to 2019 were identified. Patient data was obtained through retrospective review of the electronic medical record. Kaplan-Meier analysis assessed primary outcomes of 1-,3-, and 5-year graft and patient survival. RESULTS We identified 37 SLTs performed at our institution from 2010 to 2019. Twenty-four donated livers resulted in 21 extended right lobes and 16 left lateral segments for adults and pediatrics recipients, respectively. Eighty-one percent (30/37) of the SLTs were performed after introduction of the combined pediatric program in 2016. 13/24 donor livers were split with both grafts allocated and used at our institution and 92% occurred after introduction of the pediatric program. Graft survival rates at 1-, 3-, and 5-years were 94% in adult recipients and 100% for all time periods in pediatric recipients. Actuarial post-transplant patient survival was 100% at 1-, 3-, and 5-years in both. CONCLUSIONS The introduction of a pediatric liver transplantation program resulted in more than a fourfold increase in the number of SLTs performed at our center. Increase in allocation and use of both grafts at our institution was also seen.
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Affiliation(s)
- Paola Andrea Vargas
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jonathan Michael Cullen
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Christina Dalzell
- School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Frank DiPaola
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | - Shawn Pelletier
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Kyle A Soltys
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.,Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - George Vincent Mazariegos
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.,Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jose Oberholzer
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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8
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Vargas PA, Dalzell C, Robinson T, Cunningham M, Henry Z, Stotts MJ, Su F, Argo C, Pelletier S, Oberholzer J, Goldaracena N. Split liver transplantation with extended right grafts on adult recipients: A propensity score matching analysis. Clin Transplant 2022; 36:e14801. [PMID: 35997030 DOI: 10.1111/ctr.14801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/24/2022] [Accepted: 08/14/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Split liver transplantation (SLT) emerged due to its potential to contribute to the organ pool and reduce organ shortage. However, SLT is technically challenging and has been associated with higher rates of postoperative complications leading to concerns about graft and patient survival. Moreover, there are few studies on matched-pair adult recipients of SLT and whole-liver transplant (WLT), with conflicting results. METHODS This retrospective study analyze outcomes among adults who underwent SLT at our institution from 2010 to 2019. A 1:1 propensity score matching analysis was performed based on important donor and recipient variables. Baseline characteristics and postoperative outcomes were analyzed and compared between groups. Actuarial graft and patient survival were analyzed by KM curves. RESULTS Out of 592 adults receiving a LT in our institution, 21 SLT adult recipients were identified and matched with 21 adults undergoing WLT. As expected donor age was significantly lower in SLT recipients (16 (15-22) vs. 32 (17-47), P = .012). Additional donor characteristics, including anthropometrics, and ischemic times were similar between groups. Baseline recipient characteristics and postoperative outcomes, including length of stay, vascular complications, biliary complications, and re-transplantation were comparable between SLT and WLT recipients. Graft (95/95/95 vs. 100/94/94, P = .98) and patient (100/100/100 vs. 100/94/94, P = .30) survival at 1-, 3-, 5-years, were similar between the SLT- and WLT group, respectively. CONCLUSION Split liver transplantation has the potential to increase the availability of organs for adult recipients without compromising individual outcomes.
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Affiliation(s)
- Paola A Vargas
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Christina Dalzell
- School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Todd Robinson
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michaela Cunningham
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Zachary Henry
- Department of Medicine, Division of Gastroenterology, University of Virginia, Charlottesville, Virginia, USA
| | - Matthew J Stotts
- Department of Medicine, Division of Gastroenterology, University of Virginia, Charlottesville, Virginia, USA
| | - Feng Su
- Department of Medicine, Division of Gastroenterology, University of Virginia, Charlottesville, Virginia, USA
| | - Curtis Argo
- Department of Medicine, Division of Gastroenterology, University of Virginia, Charlottesville, Virginia, USA
| | - Shawn Pelletier
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jose Oberholzer
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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9
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Wang D, Fan N, Wang X, Sun Y, Guan G, Wang J, Zhu X, Zang Y, Cai J, Guo Y. IV segment portal vein reconstruction in split-liver transplantation with extended right grafts. BMC Surg 2022; 22:311. [PMID: 35953816 PMCID: PMC9367133 DOI: 10.1186/s12893-022-01761-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Liver transplantation is one of the most effective treatments for end-stage liver disease. Split liver transplantation (SLT) can effectively improve the utilization efficiency of grafts. However, split liver transplantation still faces shortcomings and is not widely used in surgery. How to improve the effective transplantation volume of split liver transplantation and promote the postoperative recovery of patients has important clinical significance. Methods In our study, the donor’s liver was split into the extended right graft and left lateral sector, and the IV segment occur ischemia. To guarantee the functional graft size, and avoid complications, we reconstructed the IV segment portal vein and left portal vein. And we analyzed the operation time, intraoperative bleeding, liver function, and postoperative complications. Results In our research, 14 patients underwent IV segment portal vein reconstruction, and 8 patients did not undergo vascular reconstruction. We found that the ischemic area of the IV segment decreased significantly after IV segment portal vein reconstruction. We found that there was no significant difference in operation time and postoperative complications between the patients of the groups. There were significant differences in ALT on the 1st day and albumin on the 6th day after the operation. Conclusion It indicates that IV segment reconstruction in SLT surgery can alleviate the graft ischemic and promote the recovery of liver function after the operation. And, IV segment reconstruction as a novel operating procedure may be widely used in SLT.
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Affiliation(s)
- Dong Wang
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Ning Fan
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Xin Wang
- Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Yandong Sun
- Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Ge Guan
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Jianhong Wang
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.,Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Xiaodan Zhu
- Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Yunjin Zang
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.,Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Jinzhen Cai
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China. .,Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.
| | - Yuan Guo
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China. .,Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.
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10
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Ge J, Kim WR, Lai JC, Kwong AJ. "Beyond MELD" - Emerging strategies and technologies for improving mortality prediction, organ allocation and outcomes in liver transplantation. J Hepatol 2022; 76:1318-1329. [PMID: 35589253 DOI: 10.1016/j.jhep.2022.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/24/2022] [Accepted: 03/04/2022] [Indexed: 02/06/2023]
Abstract
In this review article, we discuss the model for end-stage liver disease (MELD) score and its dual purpose in general and transplant hepatology. As the landscape of liver disease and transplantation has evolved considerably since the advent of the MELD score, we summarise emerging concepts, methodologies, and technologies that may improve mortality prognostication in the future. Finally, we explore how these novel concepts and technologies may be incorporated into clinical practice.
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Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California - San Francisco, San Francisco, CA, USA
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California - San Francisco, San Francisco, CA, USA
| | - Allison J Kwong
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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11
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Dalzell C, Vargas PA, Soltys K, Dipaola F, Mazariegos G, Oberholzer J, Goldaracena N. Living Donor Liver Transplantation vs. Split Liver Transplantation Using Left Lateral Segment Grafts in Pediatric Recipients: An Analysis of the UNOS Database. Transpl Int 2022; 36:10437. [PMID: 35391900 PMCID: PMC8980223 DOI: 10.3389/ti.2022.10437] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/03/2022] [Indexed: 12/12/2022]
Abstract
Split and LDLT in pediatric patients have the potential to decrease wait times and waitlist mortality. Using UNOS-STAR data, we compared outcomes of pediatric patients undergoing LDLT and SLT using LLS grafts. The baseline characteristics and post-operative outcomes were compared between groups. Actuarial graft and patient survival were analyzed with Kaplan-Meier curves. Between 2010 and 2019, 911 pediatric LT were included in the analysis (LD graft group, n = 508, split graft group, n = 403). LD graft recipients spent more time on the waitlist vs. the split graft group (60 (22–138) days vs. 46 (16–108) days; p = 0.007). LD recipients had a lower rate of graft failure, found in 9.8% of patients compared with 14.6% in the split graft group (p = 0.02). HAT was the most common graft failure cause, with similar rates. Graft and patient survival at 1-, 3-, and 5-years was comparable between LDLT and SLT. In subgroup analyses, patients with biliary atresia, those ≤10 kg or ≤10 years old receiving an LD graft showed improved graft survival. In conclusion, LDLT is associated with a lower rate of graft failure in pediatric patients. The use of LLS regardless of the type of donor is a safe way to facilitate access to transplantation to pediatric patients with acceptable short and long-term outcomes.
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Affiliation(s)
- Christina Dalzell
- School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Paola A Vargas
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Kyle Soltys
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States.,Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Frank Dipaola
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Virginia, Charlottesville, VA, United States
| | - George Mazariegos
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States.,Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jose Oberholzer
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States
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12
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Lau NS, Liu K, McCaughan G, Crawford M, Pulitano C. Are split liver grafts a suitable option in high-risk liver transplant recipients? Curr Opin Organ Transplant 2021; 26:675-680. [PMID: 34653087 DOI: 10.1097/mot.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To assess the outcomes of split liver transplantation (SLT) in adults and children and evaluate its role in high-risk recipients with a high model for end-stage liver disease (MELD) score, an urgent indication or requiring retransplantation. RECENT FINDINGS Split liver grafts in general have equivalent long-term survival outcomes to whole grafts despite an increase in biliary complications. Recent success and technical advances have encouraged use of these grafts in high-risk recipients. Split liver grafts can be used successfully in recipients with a high MELD score if there is adequate weight-matching. There are mixed results in urgent indication recipients and for retransplantation such that use in this group of patients remains controversial. SUMMARY SLT addresses donor shortages by facilitating the transplant of two recipients from the same donor liver. By using careful donor and recipient selection criteria, SLT can achieve equivalent long-term outcomes to whole grafts. These grafts have been used successfully in recipients with a high MELD score, but should be used selectively in urgent indication recipients and for retransplantation.
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Affiliation(s)
- Ngee-Soon Lau
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ken Liu
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Geoffrey McCaughan
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael Crawford
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital
| | - Carlo Pulitano
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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13
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14
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Kong L, Lv T, Jiang L, Yang J, Yang J. Outcomes of hemi- versus whole liver transplantation in patients from mainland china with high model for end-stage liver disease scores: a matched analysis. BMC Surg 2020; 20:290. [PMID: 33218334 PMCID: PMC7677100 DOI: 10.1186/s12893-020-00965-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 11/15/2020] [Indexed: 02/08/2023] Open
Abstract
Background Adult hemiliver transplantation (AHLT) is an important approach given the current shortage of donor livers. However, the suitability of AHLT versus adult whole liver transplantation (AWLT) for recipients with high Model for End-Stage Liver Disease (MELD) scores remains controversial. Methods We divided patients undergoing AHLT and AWLT into subgroups according to their MELD scores (≥ 30: AHLT, n = 35; AWLT, n = 88; and < 30: AHLT, n = 323; AWLT, n = 323). Patients were matched by demographic data and perioperative conditions according to propensity scores. A cut-off value of 30 for MELD scores was determined by comparing the overall survival data of 735 cases of nontumor liver transplantation. Results Among patients with an MELD score ≥ 30 and < 30, AHLT was found to be associated with increased warm ischemia time, operative time, hospitalization time, and intraoperative blood loss compared with AWLT (P < 0.05). In the MELD ≥ 30 group, although the 5-year survival rate was significantly higher for AWLT than for AHLT (P = 0.037), there was no significant difference between AWLT and AHLT in the MELD < 30 group (P = 0.832); however, we did not observe a significant increase in specific complications following AHLT among patients with a high MELD score (≥ 30). Among these patients, the incidence of complications classified as Clavien-Dindo grade III or above was significantly higher in patients undergoing AHLT than in those undergoing AWLT (25.7% vs. 11.4%, P = 0.047). For the MELD < 30 group, there was no significant difference in the incidence of complications classified as Clavien-Dindo grade III or above for patients undergoing AHLT or AWLT. Conclusion In patients with an MELD score < 30, AHLT can achieve rates of mortality and overall survival comparable to AWLT. In those with an MELD score ≥ 30, the prognosis and incidence of complications classified as Clavien-Dindo III or above are significantly worse for AHLT than for AWLT; therefore, we may need to be more cautious regarding the conclusion that patients with a high MELD score can safely undergo AHLT.
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Affiliation(s)
- LingXiang Kong
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Tao Lv
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Li Jiang
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jian Yang
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jiayin Yang
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
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15
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Ge J, Perito ER, Bucuvalas J, Gilroy R, Hsu EK, Roberts JP, Lai JC. Split liver transplantation is utilized infrequently and concentrated at few transplant centers in the United States. Am J Transplant 2020; 20:1116-1124. [PMID: 31705730 PMCID: PMC7103556 DOI: 10.1111/ajt.15696] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/19/2019] [Accepted: 11/01/2019] [Indexed: 01/25/2023]
Abstract
Split liver transplantation (SLT) is 1 strategy for maximizing the number of deceased donor liver transplants. Recent reports suggest that utilization of SLT in the United States remains low. We examined deceased donor offers that were ultimately split between 2010 and 2014. SLTs were categorized as "primary" and "secondary" transplants. We analyzed allocation patterns and used logistic regression to evaluate factors associated with secondary split discard. Four hundred eighteen livers were split: 54% from adult, 46% from pediatric donors. Of the 227 adult donor livers split, 61% met United Network for Organ Sharing "optimal" split criteria. A total of 770 recipients (418 primary and 352 secondary) were transplanted, indicating 16% discard. Ninety-two percent of the 418 primary recipients were children, and 47% were accepted on the first offer. Eighty-seven percent of the 352 secondary recipients were adults, and 7% were accepted on the first offer. Of the 352 pairs, 99% were transplanted in the same region, 36% at the same center. In logistic regression, shorter donor height was associated with secondary discard (odds ratio 0.97 per cm, 95% CI 0.94-1.00, P = .02). SLT volume by center was not predictive of secondary discard. Current policy proposals that incentivize SLT in the United States could increase the number of transplants to children and adults.
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Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | - Emily R. Perito
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of California – San Francisco, San Francisco, CA
| | - John Bucuvalas
- Mount Sinai Kravis Children’s Hospital and Recanati/Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Richard Gilroy
- Liver Transplant Program, Intermountain Medical Center, Murray, UT
| | - Evelyn K. Hsu
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital, Seattle, WA
| | - John P. Roberts
- Division of Transplant Surgery, Department of Surgery, University of California – San Francisco, San Francisco, CA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
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16
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Valentino PL, Emre S, Geliang G, Li L, Deng Y, Mulligan D, Rodriguez-Davalos MI. Frequency of whole-organ in lieu of split-liver transplantation over the last decade: Children experienced increased wait time and death. Am J Transplant 2019; 19:3114-3123. [PMID: 31152483 DOI: 10.1111/ajt.15481] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 04/05/2019] [Accepted: 05/05/2019] [Indexed: 01/25/2023]
Abstract
Organ shortage is a barrier to liver transplantation (LT). Split LT (SLT) increases organ utilization, saving 2 recipients. A simulation of Organ Procurement and Transplantation Network/United Network for Organ Sharing data (2007-2017) was performed to identify whole-organ LT grafts (WLT) that met the criteria for being splittable to 2 recipients. Waitlist consequences presented. Deceased donor (DD) livers transplanted as whole organs were evaluated for suitability to split. Of these DD organs, we identified the adolescent and adult recipients of WLT who were suitable for SLT. Pediatric candidates suitable to share the SLT were ascertained from DD match-run lists, and 1342 splittable DD organs were identified; 438 WLT recipients met the criteria for accepting a SLT. Review of the 438 DD match-run lists identified 420 children next on the list suitable for SLT. Three hundred thirty-three children (79%) underwent LT, but had longer wait-times compared to 591 actual pediatric SLT recipients (median 147 days vs 44 days, P < 0.001). Thirty-three of 420 children died on waitlist after a mean 206 days (standard deviation 317). Sharing organs suitable for splitting increases the number of LT, saving more lives. With careful patient selection, SLT will not be a disadvantage to the adult recipients. With a children-first allocation scheme, SLT will naturally increase the number of allografts because adult organs are too large for small children.
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Affiliation(s)
- Pamela L Valentino
- Department of Pediatrics, Section of Gastroenterology and Hepatology, Yale University School of Medicine, New Haven, Connecticut
| | - Sukru Emre
- Department of Surgery, Transplantation and Immunology, Yale University School of Medicine, New Haven, Connecticut
| | - Gan Geliang
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, Connecticut
| | - Luhang Li
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, Connecticut
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, Connecticut
| | - David Mulligan
- Department of Surgery, Transplantation and Immunology, Yale University School of Medicine, New Haven, Connecticut
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17
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Bobbert M, Primc N, Schäfer RN. Is there an ethical obligation to split every donor liver? Scarce resources, medical factors, and ethical reasoning. Pediatr Transplant 2019; 23:e13534. [PMID: 31297945 DOI: 10.1111/petr.13534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 06/07/2019] [Accepted: 06/07/2019] [Indexed: 12/21/2022]
Abstract
SLT has the potential to counter the worldwide shortage of donor organs. Although the preferred recipients of SLT are usually pediatric patients, a more stringent ethical argument than the fundamental prioritization of children is to demonstrate that SLT of deceased donor organs could increase access to this potentially lifesaving resource for all patients, including children. Several empirical studies show that SLT also makes it possible to achieve similar outcomes to WLT in adults if several factors are observed. In general, it can be regarded as ethically permissible to insist on splitting a donor liver if, in an individual case, SLT is expected to have a similar outcome to that of WLT. The question is therefore no longer whether, but under what conditions SLT is able to achieve similar results to WLT. One of the main challenges of the current debate is the restricted comparability of the available data. We therefore have an ethical obligation to improve the available empirical data by implementing prospective clinical studies, SLT programs, and national registries. The introduction of 2 modes of allocation-one for patients willing to accept both SLT and WLT, and a second for patients only willing to accept WLT-would help to resolve the issue of patient autonomy in the case of mandatory splitting policy.
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Affiliation(s)
- Monika Bobbert
- Seminary of Moral Theology, Department of Theology, University of Münster, Munster, Germany
| | - Nadia Primc
- Institute of History and Ethics of Medicine, Heidelberg University, Heidelberg, Germany
| | - Rebecca N Schäfer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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18
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Sasaki K, Firl DJ, McVey JC, Schold JD, Iuppa G, Diago Uso T, Fujiki M, Aucejo FN, Quintini C, Eghetsad B, Miller CM, Hashimoto K. Elevated Risk of Split-Liver grafts in adult liver Transplantation: Statistical Artifact or Nature of the Beast? Liver Transpl 2019; 25:741-751. [PMID: 30615254 DOI: 10.1002/lt.25409] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/26/2018] [Indexed: 02/07/2023]
Abstract
A recent study using US national registry data reported, using Cox proportional hazards (PH) models, that split-liver transplantation (SLT) has improved over time and is no more hazardous than whole-liver transplantation (WLT). However, the study methods violated the PH assumption, which is the fundamental assumption of Cox modeling. As a result, the reported hazard ratios (HRs) are biased and unreliable. This study aimed to investigate whether the risk of graft survival (GS) in SLT has really improved over time, ensuring attention to the PH assumption. This study included 80,998 adult deceased donor liver transplantation (LT) (1998-2015) from the Scientific Registry Transplant Recipient. The study period was divided into 3 time periods: era 1 (January 1998 to February 2002), era 2 (March 2002 to December 2008), and era 3 (January 2009 to December 2015). The PH assumption was tested using Schoenfeld's test, and where the HR of SLT violated the assumption, changes in risk for SLT over time from transplant were assessed. SLT was performed in 1098 (1.4%) patients, whereas WLT was used in 79,900 patients. In the Cox PH analysis, the P values of Schoenfeld's global tests were <0.05 in all eras, which is consistent with deviation from proportionality. Assessing HRs of SLT with a time-varying effect, multiple Cox models were conducted for post-LT intervals. The HR curves plotted according to time from transplant were higher in the early period and then decreased at approximately 1 year and continued to decrease in all eras. For 1-year GS, the HRs of SLT were 1.92 in era 1, 1.52 in era 2, and 1.47 in era 3 (all P < 0.05). In conclusion, the risk of SLT has a time-varying effect and is highest in the early post-LT period. The risk of SLT is underestimated if it is evaluated by overall GS. SLT was still hazardous if the PH assumption was considered, although it became safer over time.
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Affiliation(s)
- Kazunari Sasaki
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Daniel J Firl
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - John C McVey
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Giuseppe Iuppa
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago Uso
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Masato Fujiki
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Federico N Aucejo
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Cristiano Quintini
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Bijan Eghetsad
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Charles M Miller
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Koji Hashimoto
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
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19
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Ge J, Lai JC. Split-Liver Allocation: An Underused Opportunity to Expand Access to Liver Transplantation. Liver Transpl 2019; 25:690-691. [PMID: 30920162 DOI: 10.1002/lt.25458] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 03/25/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
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20
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Zhu B, Wang J, Li H, Chen X, Zeng Y. Living or deceased organ donors in liver transplantation for hepatocellular carcinoma: a systematic review and meta-analysis. HPB (Oxford) 2019; 21:133-147. [PMID: 30503300 DOI: 10.1016/j.hpb.2018.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/18/2018] [Accepted: 11/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The outcomes of living donor liver transplantation (LDLT) versus deceased donor liver transplantation (DDLT) for HCC patients were not well defined and it was necessary to reassess. METHODS A comprehensive literature search was conducted in PubMed, Embase, Cochrane Library, Google Scholar and WanFang database for eligible studies. Perioperative and survival outcomes of HCC patients underwent LDLT were pooled and compared to those underwent DDLT. RESULTS Twenty-nine studies with 5376 HCC patients were included. For HCC patients underwent LDLT and DDLT, there were comparable rates of overall survival (OS) (1-year, RR = 1.04, 95%CI = 1.00-1.09, P = 0.03; 3-year, RR = 1.03, 95%CI = 0.96-1.11, P = 0.39; 5-year, RR = 1.04, 95%CI = 0.95-1.13, P = 0.43), disease free survival (DFS) (1-year, RR = 1.00, 95%CI = 0.95-1.05, P = 0.99; 3-year, RR = 1.00, 95%CI = 0.94-1.08, P = 0.89; 5-year, RR = 1.01, 95%CI = 0.93-1.09, P = 0.85), recurrence (1-year, RR = 1.41, 95%CI = 0.72-2.77, P = 0.32; 3-year, RR = 0.89, 95%CI = 0.57-1.39, P = 0.60; and 5-year, RR = 0.85, 95%CI = 0.56-1.31, P = 0.47), perioperative mortality within 3 months (RR = 0.89, 95%CI = 0.50-1.59, p = 0.70) and postoperative complication (RR = 0.99, 95%CI = 0.70-1.39, P = 0.94). LDLT was associated with better 5-year intention-to-treat patient survival (ITT-OS) than DDLT (RR = 1.11, 95% CI = 1.01-1.22, P = 0.04). CONCLUSION This meta-analysis suggested that LDLT was not inferior to DDLT in consideration of comparable perioperative and survival outcomes. However, in terms of 5-year ITT-OS, LDLT was a possibly better choice for HCC patients.
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Affiliation(s)
- Bo Zhu
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, 610041, China; Laboratory of Liver Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jinju Wang
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, 610041, China; Laboratory of Liver Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hui Li
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, 610041, China; Laboratory of Liver Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xing Chen
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, 610041, China; Laboratory of Liver Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yong Zeng
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, 610041, China; Laboratory of Liver Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
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21
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Mogul DB, Luo X, Garonzik-Wang J, Bowring MG, Massie AB, Schwarz KB, Cameron AM, Bridges JFP, Segev DL. Expansion of the Liver Donor Supply Through Greater Use of Split-Liver Transplantation: Identifying Optimal Recipients. Liver Transpl 2019; 25:119-127. [PMID: 30230191 PMCID: PMC6320274 DOI: 10.1002/lt.25340] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/28/2018] [Indexed: 12/13/2022]
Abstract
The increased use of split-liver transplantation (SLT) represents a strategy to increase the supply of organs. Although outcomes after SLT and whole liver transplantation (WLT) are similar on average among pediatric recipients, we hypothesized that the relationship between graft type and outcomes may vary depending on patient, donor, and surgical characteristics. We evaluated graft survival among pediatric (<18 years) deceased donor, liver-only transplant recipients from March 2002 until December 2015 using data from the Scientific Registry of Transplant Recipients. Graft survival was assessed in a Cox proportional hazards model, with and without effect modification between graft type and donor, recipient, and surgical characteristics, to identify conditions where the risk of graft loss for SLT and WLT were similar. In a traditional multivariable model, characteristics associated with graft loss included donor age >50 years, recipient weight <10 kg, acute hepatic necrosis, autoimmune diseases, tumor, public insurance, and cold ischemia time (CIT) >8 hours. In an analysis that explored whether these characteristics modified the relationship between graft type and graft loss, many characteristics associated with loss actually had similar outcomes regardless of graft type, including weight <10 kg, acute hepatic necrosis, autoimmune diseases, and tumor. In contrast, several subgroups had worse outcomes when SLT was used, including recipient weight 10-35 kg, non-biliary atresia cholestasis, and metabolic disease. Allocation score, share type, or CIT did not modify risk of graft type and graft failure. Although one might anticipate that individuals with higher rates of graft loss would be worse candidates for SLT, data suggest that these patients actually have similar rates of graft loss. These findings can guide surgical decision making and may support policy changes that promote the increased use of SLT for specific pediatric recipients.
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Affiliation(s)
- Douglas B. Mogul
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Kathleen B. Schwarz
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew M. Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John F. P. Bridges
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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22
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Hackl C, Schmidt KM, Süsal C, Döhler B, Zidek M, Schlitt HJ. Split liver transplantation: Current developments. World J Gastroenterol 2018; 24:5312-5321. [PMID: 30598576 PMCID: PMC6305537 DOI: 10.3748/wjg.v24.i47.5312] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/09/2018] [Accepted: 10/21/2018] [Indexed: 02/06/2023] Open
Abstract
In 1988, Rudolf Pichlmayr pioneered split liver transplantation (SLT), enabling the transplantation of one donor liver into two recipients - one pediatric and one adult patient. In the same year, Henri Bismuth and colleagues performed the first full right/full left split procedure with two adult recipients. Both splitting techniques were rapidly adopted within the transplant community. However, a SLT is technically demanding, may cause increased perioperative complications, and may potentially transform an excellent deceased donor organ into two marginal quality grafts. Thus, crucial evaluation of donor organs suitable for splitting and careful screening of potential SLT recipients is warranted. Furthermore, the logistic background of the splitting procedure as well as the organ allocation policy must be adapted to further increase the number and the safety of SLT. Under defined circumstances, in selected patients and at experienced transplant centers, SLT outcomes can be similar to those obtained in full organ LT. Thus, SLT is an important tool to reduce the donor organ shortage and waitlist mortality, especially for pediatric patients and small adults. The present review gives an overview of technical aspects, current developments, and clinical outcomes of SLT.
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Affiliation(s)
- Christina Hackl
- Department of Surgery, University Hospital Regensburg, Regensburg 93053, Germany
| | - Katharina M Schmidt
- Department of Surgery, University Hospital Regensburg, Regensburg 93053, Germany
| | - Caner Süsal
- Collaborative Transplant Study (CTS), Institute of Immunology, Heidelberg University, Heidelberg 69120, Germany
| | - Bernd Döhler
- Collaborative Transplant Study (CTS), Institute of Immunology, Heidelberg University, Heidelberg 69120, Germany
| | - Martin Zidek
- Department of Surgery, University Hospital Regensburg, Regensburg 93053, Germany
| | - Hans J Schlitt
- Department of Surgery, University Hospital Regensburg, Regensburg 93053, Germany
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23
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Gavriilidis P, Roberts KJ, Azoulay D. Right lobe split liver graft versus whole liver transplantation: A systematic review by updated traditional and cumulative meta-analysis. Dig Liver Dis 2018; 50:1274-1282. [PMID: 30236766 DOI: 10.1016/j.dld.2018.08.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 08/20/2018] [Accepted: 08/22/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Advancements in surgical techniques and experience of donor-recipient pairing has led to a wider use of right split liver grafts in adults. An update meta-analysis was conducted to compare right split liver graft (RSLG) and whole liver transplantation (WLT) using traditional and cumulative approaches. METHODS Databases were searched for relevant articles over the previous 20 years (MEDLINE, Embase, Cochrane Library, and Google Scholar). Meta-analyses were performed using both fixed and random effects models. Patient and graft survival were obtained using the inverse variance hazard ratio method. RESULTS Donors were significantly younger in the RSLG group than in the WLT group (MD = -12.06 [-16.29 to -7.83]; P < .001). In addition, the model for end-stage liver disease (MELD) score was significantly lower in the RSLG group than in the WLT group (MD = -2.45 [-4.61 to -.28]; P = .03). However, cold ischaemia time was significantly longer by 1 h in the RSLG group than in the WLT group (MD = 57 [20.63-92.73]; P = .002). Overall biliary, vascular, and outflow tract complications and hepatic artery thrombosis were significantly lower in the WLT group than in the RSLG group (odds ratio [OR] = 1.75 [1.35-2.27], P < .001; OR = 1.91 [1.37-2.65], P = .006; Peto OR = 1.83 [1.19-2.82], P = .006; and Peto OR = 2.07 [1.39-3.10], P = .004, respectively). However, no difference in patient and graft survival was noted between the two cohorts. CONCLUSIONS Although the RSLG group had a higher postoperative complication rate than the WLT group, equal patient and graft survival benefits were observed.
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Affiliation(s)
- Paschalis Gavriilidis
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, UK; Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor University Hospital, Créteil, France.
| | - Keith J Roberts
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, UK
| | - Daniel Azoulay
- Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor University Hospital, Créteil, France
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24
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Trapero-Marugán M, Little EC, Berenguer M. Stretching the boundaries for liver transplant in the 21st century. Lancet Gastroenterol Hepatol 2018; 3:803-811. [DOI: 10.1016/s2468-1253(18)30213-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 06/20/2018] [Accepted: 06/22/2018] [Indexed: 12/12/2022]
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25
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Chul Yoon K, Song S, Jwa EK, Lee S, Man Kim J, Kim OK, Kyun Hong S, Yi NJ, Lee KW, Soo Kim M, Hwang S, Suh KS, Lee SK. Survival Outcomes in Split Compared With Whole Liver Transplantation. Liver Transpl 2018; 24:1411-1424. [PMID: 29747216 DOI: 10.1002/lt.25196] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/20/2018] [Accepted: 05/03/2018] [Indexed: 12/11/2022]
Abstract
Split-liver transplantation (SLT) should be cautiously considered because the right trisection (RTS) graft can be a marginal graft in adult recipients. Herein, we analyzed the outcomes of RTS-SLT in Korea, where >75% of adult liver transplantations are performed with living donor liver transplantation. Among 2462 patients who underwent deceased donor liver transplantations (DDLTs) from 2005 to 2014, we retrospectively reviewed 86 (3.5%) adult patients who received a RTS graft (RTS-SLT group). The outcomes of the RTS-SLT group were compared with those of 303 recipients of whole liver (WL; WL-DDLT group). Recipient age, laboratory Model for End-Stage-Liver Disease (L-MELD) score, ischemia time, and donor-to-recipient weight ratio (DRWR) were not different between the 2 groups (P > 0.05). However, malignancy was uncommon (4.7% versus 36.3%), and the donor was younger (25.2 versus 42.7 years) in the RST-SLT group than in the WL-DDLT group (P < 0.05). The technical complication rates and the 5-year graft survival rates (89.0% versus 92.8%) were not different between the 2 groups (P > 0.05). The 5-year overall survival (OS) rate (63.1%) and graft-failure-free survival rate (63.1%) of the RTS-SLT group were worse than that of the WL-DDLT group (79.3% and 79.3%; P < 0.05). The factors affecting graft survival rates were not definite. However, the factors affecting OS in the RTS-SLT group were L-MELD score >30 and DRWR ≤1.0. In the subgroup analysis, OS was not different between the 2 groups if the DRWR was >1.0, regardless of the L-MELD score (P > 0.05). In conclusion, a sufficient volume of the graft estimated from DRWR-matching could lead to better outcomes of adult SLTs with a RTS graft, even in patients with high L-MELD scores.
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Affiliation(s)
- Kyung Chul Yoon
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Sanghee Song
- Transplantation Center, Seoul National University Hospital, Seoul, South Korea
| | - Eun-Kyoung Jwa
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ok-Kyoung Kim
- Transplantation Center, Seoul National University Hospital, Seoul, South Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Myoung Soo Kim
- Department of Surgery and The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Suk-Koo Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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26
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Mogul DB, Luo X, Bowring MG, Chow EK, Massie AB, Schwarz KB, Cameron AM, Bridges JFP, Segev DL. Fifteen-Year Trends in Pediatric Liver Transplants: Split, Whole Deceased, and Living Donor Grafts. J Pediatr 2018; 196:148-153.e2. [PMID: 29307689 PMCID: PMC5924625 DOI: 10.1016/j.jpeds.2017.11.015] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/10/2017] [Accepted: 11/03/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate changes in patient and graft survival for pediatric liver transplant recipients since 2002, and to determine if these outcomes vary by graft type (whole liver transplant, split liver transplant [SLT], and living donor liver transplant [LDLT]). STUDY DESIGN We evaluated patient and graft survival among pediatric liver-only transplant recipients the PELD/MELD system was implemented using the Scientific Registry of Transplant Recipients. RESULTS From 2002-2009 to 2010-2015, survival for SLT at 30 days improved (94% vs 98%; P < .001), and at 1 year improved for SLT (89% to 95%; P <.001) and LDLT (93% to 98%; P = .002). There was no change in survival for whole liver transplant at either 30 days (98% in both; P = .7) or 1 year (94% vs 95%; P = .2). The risk of early death with SLT was 2.14-fold higher in 2002-2009 (adjusted hazard ratio [aHR] vs whole liver transplant, 1.472.143.12), but this risk disappeared in 2010-2015 (aHR, 0.651.131.96), representing a significant improvement (P = .04). Risk of late death after SLT was similar in both time periods (aHR 2002-2009, 0.871.141.48; aHR 2010-2015, 0.560.881.37). LDLT had similar risk of early death (aHR 2002-2009, 0.491.032.14; aHR 2010-2015, 0.260.742.10) and late death (aHR 2002-2009, 0.520.831.32; aHR 2010-2015, 0.170.441.11). Graft loss was similar for SLT (aHR, 0.931.091.28) and was actually lower for LDLT (aHR, 0.530.710.95). CONCLUSIONS In recent years, outcomes after the use of technical variant grafts are comparable with whole grafts, and may be superior for LDLT. Greater use of technical variant grafts might provide an opportunity to increase organ supply without compromising post-transplant outcomes.
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Affiliation(s)
- Douglas B Mogul
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mary G Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric K Chow
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Kathleen B Schwarz
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew M Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John F P Bridges
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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27
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Kim HB, Vakili K. To Split or Not to Split? That is No Longer the Question. J Pediatr 2018; 196:12-13. [PMID: 29395183 DOI: 10.1016/j.jpeds.2017.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/06/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Heung Bae Kim
- Pediatric Transplant Center Department of Surgery Boston Children's Hospital Boston, Massachusetts.
| | - Khashayar Vakili
- Pediatric Transplant Center Department of Surgery Boston Children's Hospital Boston, Massachusetts
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28
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Zamora-Valdes D, Leal-Leyte P, Kim P, Testa G. Fighting Mortality in the Waiting List: Liver Transplantation in North America, Europe, and Asia. Ann Hepatol 2018; 16:480-486. [PMID: 28612751 DOI: 10.5604/01.3001.0010.0271] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Liver disease is a major cause of mortality worldwide. Liver transplantation (LT) is the most effective treatment for end stage liver disease. Available resources and social circumstances have led to different ways of implementing LT around the world. The experience with pediatric LT corroborates the hypothesis that a combination of surgical strategies can be beneficial. The goal of this manuscript is to describe the strategies used by LT centers in North America, Europe and Asia and how these strategies can be applied to reduce waitlist mortality and increase access to LT.
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Affiliation(s)
- Daniel Zamora-Valdes
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Pilar Leal-Leyte
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Peter Kim
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Giuliano Testa
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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29
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Angelico R, Nardi A, Adam R, Nadalin S, Polak WG, Karam V, Troisi RI, Muiesan P. Outcomes of left split graft transplantation in Europe: report from the European Liver Transplant Registry. Transpl Int 2018; 31:739-750. [PMID: 29505674 DOI: 10.1111/tri.13147] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/19/2017] [Accepted: 02/27/2018] [Indexed: 02/07/2023]
Abstract
Split liver transplantation (SLT) has been widely adopted across Europe, resulting in remarkable reduction in the paediatric waiting-list mortality. Left split graft (LSG) is commonly used for paediatric recipients; however, deceased donor criteria selection are not universal. The aim of this study was to analyse the LSG outcome from the European Liver Transplant Registry and to identify risk factors for graft failure. Data from 1500 children transplanted in 2006-2014 with LSG from deceased donors were retrospectively analysed. Overall, graft losses were 343(22.9%) after 5 years from transplantation, 240(70.0%) occurred within the first 3 months. Estimated patient survival was 89.1% at 3 months and 82.9% at 5 years from SLT. Re-transplantation rate was 11.5%. At multivariable analysis, significant risk factors for graft failure at 3 months included the following: urgent SLT (HR = 1.73, P = 0.0012), recipient body weight ≤6 kg (HR = 1.91, P = 0.0029), donor age >50 years (HR = 1.87, P = 0.0039), and cold ischaemic time (CIT) [HR = 1.07 per hour, P = 0.0227]. LSG has good outcomes and SLT is excellent option for paediatric recipients in the current organ shortage era. We identified practical guidelines for LSG donor and recipient selection criteria: donor age may be safely extended up to 50 years in the absence of additional risk factors; thus, children <6 kg and urgent transplantation need CIT <6 h and appropriate graft/recipient size-matching to achieve good outcomes.
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Affiliation(s)
- Roberta Angelico
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | - Alessandra Nardi
- Department of Mathematics, University of Rome Tor Vergata, Rome, Italy
| | - René Adam
- Department of Hepatobiliary Surgery, Cancer and Transplantation, AP-HP AT, Hôpital Universitaire Paul Brousse, Université Paris-Sud, Villejuif, France
| | - Silvio Nadalin
- Department of General, Vascular and Transplant Surgery, University of Tuebingen, Tubingen, Germany
| | - Wojciech G Polak
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Vincent Karam
- Department of Hepatobiliary Surgery, Cancer and Transplantation, AP-HP AT, Hôpital Universitaire Paul Brousse, Université Paris-Sud, Villejuif, France
| | - Roberto I Troisi
- Department of General Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital Medical School, Ghent, Belgium
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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30
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Andrassy J, Wolf S, Lauseker M, Angele M, van Rosmalen MD, Samuel U, Rogiers X, Werner J, Guba M. Higher retransplantation rate following extended right split-liver transplantation: An analysis from the eurotransplant liver follow-up registry. Liver Transpl 2018; 24:26-34. [PMID: 29144580 DOI: 10.1002/lt.24980] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/19/2017] [Accepted: 10/11/2017] [Indexed: 12/13/2022]
Abstract
Split-liver transplantation has been perceived as an important strategy to increase the supply of liver grafts by creating 2 transplants from 1 allograft. The Eurotransplant Liver Allocation System (ELAS) envisages that the extended right lobes (ERLs) after splitting (usually in the pediatric center) are almost exclusively shipped to a second center. Whether the ELAS policy impacts the graft and patient survival of extended right lobe transplantation (ERLT) in comparison to whole liver transplantation (WLT) recipients remains unclear. Data on all liver transplantations performed between 2007 and 2013 were retrieved from the Eurotransplant Liver Follow-up Registry (n = 5351). Of these, 5013 (269 ERL, 4744 whole liver) could be included. The impact of the transplant type on patient and graft survival was evaluated using univariate and multivariate proportional hazard models adjusting for demographics of donors and recipients. Cold ischemia times were significantly prolonged for ERLTs (P < 0.001). Patient survival was not different between ERLT and WLT. In the univariate analysis, ERLT had a significantly higher risk for retransplantation (P = 0.02). For WLT, the risk for death gradually and significantly increased with laboratory Model for End-Stage Liver Disease (MELD) scores of >20. For ERLT, this effect was seen already with laboratory MELD scores of >14. These results mandate a discussion on how to refine the splitting policy to avoid excess retransplant rates in ERL recipients and to further improve transplant outcomes of these otherwise optimal donor organs. Liver Transplantation 24 26-34 2018 AASLD.
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Affiliation(s)
- Joachim Andrassy
- Department of Surgery, Ludwig-Maximilian University, Munich, Germany
| | - Sebastian Wolf
- Department of Surgery, Ludwig-Maximilian University, Munich, Germany
| | - Michael Lauseker
- Institute for Biometrics and Epidemiology, Ludwig-Maximilian University, Munich, Germany
| | - Martin Angele
- Department of Surgery, Ludwig-Maximilian University, Munich, Germany
| | | | - Undine Samuel
- Eurotransplant International Foundation, Leiden, the Netherlands
| | - Xavier Rogiers
- Eurotransplant International Foundation, Leiden, the Netherlands
| | - Jens Werner
- Department of Surgery, Ludwig-Maximilian University, Munich, Germany
| | - Markus Guba
- Department of Surgery, Ludwig-Maximilian University, Munich, Germany
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31
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Ross MW, Cescon M, Angelico R, Andorno E, Rossi G, Pinna A, De Carlis L, Baccarani U, Cillo U, Colledan M, Mazzaferro V, Tisone G, Rossi M, Tuzzolino F, Pagano D, Gruttadauria S, Mazariegos G, Gridelli B, Spada M. A matched pair analysis of multicenter longterm follow-up after split-liver transplantation with extended right grafts. Liver Transpl 2017. [PMID: 28650108 DOI: 10.1002/lt.24808] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Split-liver transplantation has been proposed as an alternative to whole liver (WL) transplantation to expand the donor pool, but studies comparing adult longterm outcomes between the 2 methods are conflicting and limited. This is the first Italian multicenter study that retrospectively analyzed 119 matched-pair recipients of whole and extended right grafts (ERGs) for longterm survival outcomes. In the overall population, WL recipients showed higher patient survival at 1 (93% versus 73%), 5 (87% versus 65%), and 10 years (83% versus 60%) after transplantation compared with split-liver recipients (P < 0.001); graft survivals of WL recipients were also superior at 1 (90% versus 76%), 5 (84% versus 57%), and 10 years (81% versus 52%) posttransplant (P < 0.001). However, among the 81 matched pairs that survived the first posttransplant year, 5- and 10-year patient survivals were 90% and 81% for split recipients and 99% and 96% for whole recipients, respectively (P = 0.34). The 5- and 10-year graft survivals were also comparable: 87% and 77% for split recipients, and 86% and 82% for whole recipients (P = 0.86). Cox regression analysis identified donor age >50, donor-to-recipient weight ratio < 1, retransplantation status, and United Network for Organ Sharing I-IIA status as risk factors for partial graft use. There were no significant differences in 5-year outcomes based on center volume. In conclusion, we demonstrate that adult liver transplantation with ERGs can achieve longterm success comparable with that of whole grafts in appropriate patients but should be selectively used in patients with risk factors. Liver Transplantation 23 1384-1395 2017 AASLD.
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Affiliation(s)
- Michael W Ross
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Matteo Cescon
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberta Angelico
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù, Children's Research Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Enzo Andorno
- Department of Transplant Surgery, San Martino Hospital, University of Genoa, Genoa, Italy
| | - Giorgio Rossi
- Division of Liver Transplantation, Ca' Granda Maggiore Hospital, Milan, Italy
| | - Antonio Pinna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Luciano De Carlis
- Department of Multi-Disciplinary Surgery, Division of General, HBP and Transplantation Surgery, Niguarda Transplant Center, Niguarda Hospital, Milano-Bicocca University, Milan, Italy
| | - Umberto Baccarani
- Division of Liver Transplant, Department of Medical and Biological Sciences, University Hospital of Udine, Udine, Italy
| | - Umberto Cillo
- Division of Hepatobiliary Surgery and Liver Transplantation, University of Padua, Padua, Italy
| | - Michele Colledan
- Division of Liver and Small Bowel Transplantation, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Vincenzo Mazzaferro
- Division of Gastrointestinal Surgery and Liver Transplantation, Istituto Nazionale Tumori of Milano, Istituto di Ricovero e Cura a Carattere Scientifico Foundation, University of Milan, Milan, Italy
| | - Giuseppe Tisone
- Division of Organ Transplantation, Tor Vergata University, Rome, Italy
| | - Massimo Rossi
- Department of General Surgery and Organ Transplantation, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Fabio Tuzzolino
- Information Technology Department, Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy
| | - Duilio Pagano
- Department for the Study of Abdominal Diseases and Abdominal Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico-Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy
| | - Salvatore Gruttadauria
- Department for the Study of Abdominal Diseases and Abdominal Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico-Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy
| | - George Mazariegos
- Division of Pediatric Transplantation, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Bruno Gridelli
- Department for the Study of Abdominal Diseases and Abdominal Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico-Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù, Children's Research Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
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33
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Alexopoulos SP, Nekrasov V, Cao S, Groshen S, Kaur N, Genyk YS, Matsuoka L. Effects of recipient size and allograft type on pediatric liver transplantation for biliary atresia. Liver Transpl 2017; 23:221-233. [PMID: 27862929 DOI: 10.1002/lt.24675] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 10/18/2016] [Indexed: 12/13/2022]
Abstract
The majority of pediatric patients with end-stage liver disease receive a transplant with a whole liver (WL) allograft. However, smaller recipients with biliary atresia (BA) may have improved outcomes with deceased donor partial liver (DDPL) or living donor allografts. This study compares the national outcomes for liver transplantation in BA, with attention to the interaction between liver allograft type and recipient size. From January 2, 2002 to December 30, 2014, 2123 pediatric patients underwent a primary liver transplant for BA. The majority of transplants (53%) were performed with a WL allograft. Utilization of a WL allograft increased from 42% of recipients weighing ≤ 7 kg to 74% of recipients weighing > 14 kg. The 1-, 5-, and 10-year graft survival in recipients weighing ≤7 kg was significantly superior for living donor liver transplantation (LDLT) (91%, 88%, 84%) and DDPL allografts (90%, 84%, 77%) compared with WL allografts (79%, 75%, 74%; P = 0.005). The 1-, 5-, and 10-year graft survival in recipients weighing >14 kg trended toward being inferior in recipients of DDPL allografts (85%, 85%, 71%) compared with WL allografts (96%, 91%, 86%; P = 0.06). Furthermore, the incidence of vascular thrombosis was highest in WL (13%) compared with LDLT (6%) and DDPL (5%) recipients ≤ 7 kg (P = 0.002). Liver retransplantation was also highest in WL (16%) compared with LDLT (9%) and DDPL (9%) recipients ≤ 7 kg (P = 0.02). In conclusion, strong consideration should be given to the use of technical variant allografts in small recipients with BA requiring liver transplantation. Liver Transplantation 23 221-233 2017 AASLD.
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Affiliation(s)
- Sophoclis P Alexopoulos
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Victor Nekrasov
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Shu Cao
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Susan Groshen
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Navpreet Kaur
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Yuri S Genyk
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Lea Matsuoka
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Hsu EK, Mazariegos GV. Global lessons in graft type and pediatric liver allocation: A path toward improving outcomes and eliminating wait-list mortality. Liver Transpl 2017; 23:86-95. [PMID: 27706890 PMCID: PMC6767049 DOI: 10.1002/lt.24646] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 09/24/2016] [Indexed: 12/11/2022]
Abstract
Current literature and policy in pediatric liver allocation and organ procurement are reviewed here in narrative fashion, highlighting historical context, ethical framework, technical/procurement considerations, and support for a logical way forward to an equitable pediatric liver allocation system that will improve pediatric wait-list and posttransplant outcomes without adversely affecting adults. Where available, varying examples of successful international pediatric liver allocation and split-liver policy will be compared to current US policy to highlight potential strategies that can be considered globally. Liver Transplantation 23:86-95 2017 AASLD.
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Affiliation(s)
- Evelyn K. Hsu
- University of Washington School of Medicine, Seattle Children's HospitalSeattleWA
| | - George V. Mazariegos
- Pediatric Transplant Surgery, Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMCPittsburghPA
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Sundaram SS, Mack CL, Feldman AG, Sokol RJ. Biliary atresia: Indications and timing of liver transplantation and optimization of pretransplant care. Liver Transpl 2017; 23:96-109. [PMID: 27650268 PMCID: PMC5177506 DOI: 10.1002/lt.24640] [Citation(s) in RCA: 142] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 09/10/2016] [Indexed: 12/12/2022]
Abstract
Biliary atresia (BA) is a progressive, fibro-obliterative disorder of the intrahepatic and extrahepatic bile ducts in infancy. The majority of affected children will eventually develop end-stage liver disease and require liver transplantation (LT). Indications for LT in BA include failed Kasai portoenterostomy, significant and recalcitrant malnutrition, recurrent cholangitis, and the progressive manifestations of portal hypertension. Extrahepatic complications of this disease, such as hepatopulmonary syndrome and portopulmonary hypertension, are also indications for LT. Optimal pretransplant management of these potentially life-threatening complications and maximizing nutrition and growth require the expertise of a multidisciplinary team with experience caring for BA. The timing of transplant for BA requires careful consideration of the potential risk of transplant versus the survival benefit at any given stage of disease. Children with BA often experience long wait times for transplant unless exception points are granted to reflect severity of disease. Family preparedness for this arduous process is therefore critical. Liver Transplantation 23:96-109 2017 AASLD.
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Affiliation(s)
- Shikha S. Sundaram
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Cara L. Mack
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Amy G. Feldman
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Ronald J. Sokol
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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36
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Reichman TW, Fiorello B, Carmody I, Bohorquez H, Cohen A, Seal J, Bruce D, Loss GE. Using on-site liver 3-D reconstruction and volumetric calculations in split liver transplantation. Hepatobiliary Pancreat Dis Int 2016; 15:587-592. [PMID: 27919847 DOI: 10.1016/s1499-3872(16)60155-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Split liver transplantation increases the number of grafts available for transplantation. Pre-recovery assessment of liver graft volume is essential for selecting suitable recipients. The purpose of this study was to determine the ability and feasibility of constructing a 3-D model to aid in surgical planning and to predict graft weight prior to an in situ division of the donor liver. METHODS Over 11 months, 3-D volumetric reconstruction of 4 deceased donors was performed using Pathfinder Scout© liver volumetric software. Demographic, laboratory, operative, perioperative and survival data for these patients along with donor demographic data were collected prospectively and analyzed retrospectively. RESULTS The average predicted weight of the grafts from the adult donors obtained from an in situ split procedure were 1130 g (930-1458 g) for the extended right lobe donors and 312 g (222-396 g) for left lateral segment grafts. Actual adult graft weight was 92% of the predicted weight for both the extended right grafts and the left lateral segment grafts. The predicted and actual graft weights for the pediatric donors were 176 g and 210 g for the left lateral segment grafts and 308 g and 280 g for the extended right lobe grafts, respectively. All grafts were transplanted except for the right lobe from the pediatric donors due to the small graft weight. CONCLUSIONS On-site volumetric assessment of donors provides useful information for the planning of an in situ split and for selection of recipients. This information may expand the donor pool to recipients previously felt to be unsuitable due to donor and/or recipient weight.
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Affiliation(s)
- Trevor W Reichman
- Ochsner Multi-Organ Transplant Institute, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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37
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Kimura K, Yoshizumi T, Itoh S, Harimoto N, Motomura T, Harada N, Nagatsu A, Ikegami T, Ninomiya M, Soejima Y, Maehara Y. Efficacy of recombinant thrombomodulin for DIC after deceased donor liver transplantation: a case report. Surg Case Rep 2016; 2:81. [PMID: 27495993 PMCID: PMC4975734 DOI: 10.1186/s40792-016-0208-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 07/28/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) after liver transplantation (LT) is a difficult complication. We report a case of disseminated intravascular coagulation after deceased donor liver transplantation (DDLT) treated with recombinant thrombomodulin (rTM). CASE PRESENTATION A 30-year-old woman underwent right tri-segment split graft DDLT for acute liver failure. She developed disseminated intravascular coagulation on post-operative day 5 with fever. Computed tomography revealed necrosis of hepatic segment IV, and her acute-phase disseminated intravascular coagulation score was seven points. She was given rTM, and the inflammation, liver function, and coagulation disorders immediately improved. However, pleural effusion drainage from the chest tube became bloody on post-operative day 11, and rTM was discontinued. She progressed well and was discharged from the hospital on post-operative day 28. rTM is an effective treatment for disseminated intravascular coagulation; however, rTM for cases with coagulation disorders, which can occur after liver transplantation, has both risks and benefits. CONCLUSIONS We report a case of DIC after LT, in which rTM was potentially effective. Further studies are needed to determine the appropriate dosages, duration, and additional considerations for rTM therapy in liver transplantation patients.
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Affiliation(s)
- Koichi Kimura
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan.
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Norifumi Harimoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Takashi Motomura
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Noboru Harada
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Akihisa Nagatsu
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Mizuki Ninomiya
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Yuji Soejima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
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38
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Nemes B, Gámán G, Polak WG, Gelley F, Hara T, Ono S, Baimakhanov Z, Piros L, Eguchi S. Extended-criteria donors in liver transplantation Part II: reviewing the impact of extended-criteria donors on the complications and outcomes of liver transplantation. Expert Rev Gastroenterol Hepatol 2016; 10:841-59. [PMID: 26831547 DOI: 10.1586/17474124.2016.1149062] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Extended-criteria donors (ECDs) have an impact on early allograft dysfunction (EAD), biliary complications, relapse of hepatitis C virus (HCV), and survivals. Early allograft dysfunction was frequently seen in grafts with moderate and severe steatosis. Donors after cardiac death (DCD) have been associated with higher rates of graft failure and biliary complications compared to donors after brain death. Extended warm ischemia, reperfusion injury and endothelial activation trigger a cascade, leading to microvascular thrombosis, resulting in biliary necrosis, cholangitis, and graft failure. The risk of HCV recurrence increased by donor age, and associated with using moderately and severely steatotic grafts. With the administration of protease inhibitors sustained virological response was achieved in majority of the patients. Donor risk index and EC donor scores (DS) are reported to be useful, to assess the outcome. The 1-year survival rates were 87% and 40% respectively, for donors with a DS of 0 and 3. Graft survival was excellent up to a DS of 2, however a DS >2 should be avoided in higher-risk recipients. The 1, 3 and 5-year survival of DCD recipients was comparable to optimal donors. However ECDs had minor survival means of 85%, 78.6%, and 72.3%. The graft survival of split liver transplantation (SLT) was comparable to that of whole liver orthotopic liver transplantation. SLT was not regarded as an ECD factor in the MELD era any more. Full-right-full-left split liver transplantation has a significant advantage to extend the high quality donor pool. Hypothermic oxygenated machine perfusion can be applied clinically in DCD liver grafts. Feasibility and safety were confirmed. Reperfusion injury was also rare in machine perfused DCD livers.
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Affiliation(s)
- Balázs Nemes
- a Department of Organ Transplantation, Faculty of Medicine, Institute of Surgery , University of Debrecen , Debrecen , Hungary
| | - György Gámán
- b Clinic of Transplantation and Surgery , Semmelweis University , Budapest , Hungary
| | - Wojciech G Polak
- c Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC , University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Fanni Gelley
- d Dept of Internal medicine and Gastroenterology , Polyclinic of Hospitallers Brothers of St. John of God , Budapest , Hungary
| | - Takanobu Hara
- e Department of Surgery , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Shinichiro Ono
- e Department of Surgery , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Zhassulan Baimakhanov
- e Department of Surgery , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Laszlo Piros
- b Clinic of Transplantation and Surgery , Semmelweis University , Budapest , Hungary
| | - Susumu Eguchi
- e Department of Surgery , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
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39
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Halac E, Dip M, Quiñonez E, Alvarez F, Espinoza JL, Romero P, Nievas F, Maurette R, Luque C, Matus D, Surraco P, Fauda M, McCormack L, Mattera FJ, Gondolesi G, Imventarza O. Split liver transplantation: Report of right and left graft outcomes from a multicenter Argentinean group. Liver Transpl 2016; 22:63-70. [PMID: 26369269 DOI: 10.1002/lt.24338] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/18/2015] [Accepted: 08/27/2015] [Indexed: 02/07/2023]
Abstract
Grafts from split livers (SLs) constitute an accepted approach to expand the donor pool. Over the last 5 years, most Argentinean centers have shown significant interest in increasing the use of this technique. The purpose of this article is to describe and analyze the outcomes of right-side grafts (RSGs) and left-side grafts (LSGs) from a multicenter study. The multicenter retrospective study included data from 111 recipients of SL grafts from between January 1, 2009 and December 31, 2013. Incidence of surgical complications, patient and graft survival, and factors that affected RSG and LSG survival were analyzed. Grafts types were 57 LSG and 54 RSG. Median follow-up times for LSG and RSG were 46 and 42 months, respectively. The 36-month patient and graft survivals for LSG were 83% and 79%, respectively, and for RSG were 78% and 69%, respectively. Retransplantation rates for LSG and RSG were 3.5% and 11%, respectively. Arterial complications were the most common cause of early retransplantation (less than 12 months). Cold ischemia time (CIT) longer than 10 hours and the use of high-risk donors (age ≥ 40 years or body mass index ≥ 30 kg/m2 or ≥ 5 days intensive care unit stay) were independent factors for diminished graft survival in RSG. None of the analyzed variables were associated with worse graft survival in LSG. Biliary complications were the most frequent complications in both groups (57% in LSG and 33% in RSG). Partial grafts obtained from liver splitting are an excellent option for patients in need of liver transplantation and have the potential to alleviate the organ shortage. Adequate donor selection and reducing CIT are crucial for optimizing results.
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Affiliation(s)
- Esteban Halac
- Servicio de Trasplante Hepático, Hospital Nacional de Pediatría Juan P. Garrahan, Buenos Aires, Argentina.,Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Marcelo Dip
- Servicio de Trasplante Hepático, Hospital Nacional de Pediatría Juan P. Garrahan, Buenos Aires, Argentina.,Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Emilio Quiñonez
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Fernando Alvarez
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Johana Leiva Espinoza
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Pablo Romero
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Franco Nievas
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Rafael Maurette
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Carlos Luque
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Daniel Matus
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Paz Surraco
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Martin Fauda
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Lucas McCormack
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Francisco J Mattera
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Gabriel Gondolesi
- Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
| | - Oscar Imventarza
- Servicio de Trasplante Hepático, Hospital Nacional de Pediatría Juan P. Garrahan, Buenos Aires, Argentina.,Argentinian Chapter, International Hepato-Pancreato-Biliary Association, Buenos Aires, Argentina
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40
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Zimmerman A, Flahive JM, Hertl M, Cosimi AB, Saidi RF. Outcomes of Full-Right-Full-Left Split Liver Transplantation in Adults in the USA: A Propensity-Score Matched Analysis. Int J Organ Transplant Med 2016; 7:69-76. [PMID: 28435638 PMCID: PMC5396054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Splitting a liver for utilization in adult/pediatric recipients has been shown to decrease mortality on the wait list without increasing the overall risk of long-term graft failure compared to a whole graft. However, splitting a single donor organ for two adult recipients, full-right-full-left split liver transplantation (FRFLSLT), to overcome organ shortage is still considered controversial. OBJECTIVE This study assessed the outcome of FRFLSLT comparing full-right (FR) and full-left (FL) with whole liver (WL) allografts in adults (1998-2010) using UNOS standard transplant analysis and research (STAR) file. Methods: Unadjusted allograft and patient survival were estimated using Kaplan-Meier survival curves. Adjusted analyses of survival were conducted controlling for propensity for WL allograft. RESULTS There were 83,313 cases of WL, 651 FR and 117 FL. Significant differences were evident in the unadjusted cohort between recipients who received FR and FL including donor, cold ischemic time, and days on transplant waiting list. Use of FL allograft resulted in a trend toward lower graft and patient survival compared to WL and FR, which was not statistically significant (p=0.07). In the matched cohort, FL hemiliver allograft had no detrimental effect on the allograft or patient survival after split liver transplantation when compared to FR and WL. CONCLUSION After adjusting for donor and recipient characteristics, there was no difference in allograft or patient survival with the use of FL, FR, or WL after liver transplantation in adults. FRFLSLT is a valuable and safe option to expand the donor pool.
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Affiliation(s)
- A. Zimmerman
- Division of Organ Transplantation, Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA
| | - J. M. Flahive
- Center for Outcomes Research, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - M. Hertl
- Division of Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - A. B. Cosimi
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - R. F. Saidi
- Division of Organ Transplantation, Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA,Correspondence: Reza F. Saidi, MD, FICS, FACS, Assistant Professor of Surgery, Division of Organ Transplantation, Department of Surgery, Alpert Medical School of Brown University, 593 Eddy Street, APC 921, Providence, RI 02903, USA ,Tel: +1-401-444-4861, Fax: +1-401-444-3283, E-mail:
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Lauterio A, Di Sandro S, Concone G, De Carlis R, Giacomoni A, De Carlis L. Current status and perspectives in split liver transplantation. World J Gastroenterol 2015; 21:11003-15. [PMID: 26494957 PMCID: PMC4607900 DOI: 10.3748/wjg.v21.i39.11003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/27/2015] [Accepted: 08/30/2015] [Indexed: 02/06/2023] Open
Abstract
Growing experience with the liver splitting technique and favorable results equivalent to those of whole liver transplant have led to wider application of split liver transplantation (SLT) for adult and pediatric recipients in the last decade. Conversely, SLT for two adult recipients remains a challenging surgical procedure and outcomes have yet to improve. Differences in organ shortages together with religious and ethical issues related to cadaveric organ donation have had an impact on the worldwide distribution of SLT. Despite technical refinements and a better understanding of the complex liver anatomy, SLT remains a technically and logistically demanding surgical procedure. This article reviews the surgical and clinical advances in this field of liver transplantation focusing on the role of SLT and the issues that may lead a further expansion of this complex surgical procedure.
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42
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Dalal AR. Split liver transplantation: What’s unique? World J Transplant 2015; 5:89-94. [PMID: 26421261 PMCID: PMC4580931 DOI: 10.5500/wjt.v5.i3.89] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 12/26/2014] [Accepted: 06/19/2015] [Indexed: 02/05/2023] Open
Abstract
The intraoperative management of split liver transplantation (SLT) has some unique features as compared to routine whole liver transplantations. Only the liver has this special ability to regenerate that confers benefits in survival and quality of life for two instead of one by splitting livers. Primary graft dysfunction may result from small for size syndrome. Graft weight to recipient body weight ratio is significant for both trisegmental and hemiliver grafts. Intraoperative surgical techniques aim to reduce portal hyperperfusion and decrease venous portal pressure. Ischemic preconditioning can be instituted to protect against ischemic reperfusion injury which impacts graft regeneration. Advancement of the technique of SLT is essential as use of split cadaveric grafts expands the donor pool and potentially has an excellent future.
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43
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Moorlock G, Neuberger J, Draper H. Split liver transplantation: Papering over the cracks of the organ shortage. CLINICAL ETHICS 2015; 10:83-89. [DOI: 10.1177/1477750915599703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
Splitting livers allows two people (usually an adult and a child) to receive a liver transplant from one donated adult liver, but the risks to the adult recipient are greater than if they had received the equivalent whole liver. It has been suggested, therefore, that splitting livers harms adult recipients. Without liver splitting, however, there would be few livers available for children, and paediatric waiting time and waiting list mortality would significantly increase. In this paper, we argue that although splitting livers makes adults worse off, this should be considered sub-optimal benefit rather than harm. We explore justifications for sub-optimally benefitting adults in this way and consider alternatives to the current approach. We argue that splitting livers masks the more fundamental problem of low paediatric donation rates and that increasing the number of paediatric donations would improve the situation for both adult and paediatric liver patients.
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Affiliation(s)
- Greg Moorlock
- Institute of Applied Health Research, University of Birmingham, UK
| | | | - Heather Draper
- Institute of Applied Health Research, University of Birmingham, UK
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Wan P, Li Q, Zhang J, Xia Q. Right lobe split liver transplantation versus whole liver transplantation in adult recipients: A systematic review and meta-analysis. Liver Transpl 2015; 21:928-43. [PMID: 25832308 DOI: 10.1002/lt.24135] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/24/2015] [Accepted: 03/29/2015] [Indexed: 02/06/2023]
Abstract
Split liver transplantation (SLT) has proven to be an effective technique to reduce the mortality of children on the waiting list, but whether creating 2 split grafts from 1 standard-criteria whole liver would compromise outcomes of adult recipients remains uncertain. We conducted this meta-analysis to compare outcomes of right lobe SLT and whole liver transplantation (WLT) in adult patients. PubMed, Embase, and the Cochrane Library were searched for relevant articles published before December 2014. Outcomes assessed were patient survival (PS), graft survival (GS), and major surgical complications after transplantation. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to synthesize the results. Seventeen studies with a total of 48,457 patients met the full inclusion criteria. PS and GS rates were all found to be equivalent between SLT and WLT recipients. However, SLT was associated with higher rates of overall biliary complications (OR = 1.66; 95% CI = 1.29-2.15; P < 0.001), bile leaks (OR = 4.30; 95% CI = 2.97-6.23; P < 0.001), overall vascular complications (OR = 1.81; 95% CI = 1.29-2.53; P < 0.001), hepatic artery thromboses (OR = 1.71; 95% CI = 1.17-2.50; P = 0.005), and outflow tract obstructions (OR = 4.17; 95% CI = 1.75-9.94; P = 0.001). No significant difference was observed in incidences of biliary stricture, portal vein complications, postoperative bleeding requiring surgical treatments, primary nonfunction, and retransplantations. In subgroup analyses, biliary and vascular complications only increased after ex vivo SLT rather than in situ SLT, and SLT recipients had more retransplantations if they matched with WLT recipients in terms of urgent status. In conclusion, adult right lobe SLT was associated with increased biliary and vascular complications compared with WLT, but it did not show significant inferiority in PSs and GSs.
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Affiliation(s)
- Ping Wan
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qigen Li
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jianjun Zhang
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Maggi U, De Feo TM, Andorno E, Cillo U, De Carlis L, Colledan M, Burra P, De Fazio N, Rossi G. Fifteen years and 382 extended right grafts from in situ split livers in a multicenter study: Are these still extended criteria liver grafts? Liver Transpl 2015; 21:500-11. [PMID: 25545700 DOI: 10.1002/lt.24070] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 11/02/2014] [Accepted: 12/14/2014] [Indexed: 12/13/2022]
Abstract
In situ split liver extended right grafts (SL-ERGs) are still considered marginal grafts. Our aim was to verify this statement at the present time. From 1997 to 2011, a multicenter, retrospective study based on a prospective database was performed at 9 liver transplantation (LT) centers in northern Italy; it included 382 in situ SL-ERG transplants in adults. There were 358 primary LTs and 24 retransplantations (RETXs). The 1-, 3-, and 5-year overall graft survival rate for LT with in situ SL-ERGs were 73.5%, 63.3%, and 60.7%, respectively, from 1997 to 2004 and 83.5%, 80.3%, and 80.3%, respectively, thereafter (P=0.0001). A shorter total ischemia time and fewer RETX grafts were the main differences between the characteristics of the 2 periods. From 1997 to 2011, the 1-, 3-, and 5-year graft survival rates showed a significant difference between the 358 primary LT in situ SL-ERGs and the 24 RETX in situ SL-ERGs (P<0.001). In a multivariate analysis, the main prognostic factor for 60-day graft survival was a total ischemia time<8 hours for the 358 primary in situ SL-ERGs. From 2005 to 2011, in 2473 LTs, the 5-year graft survival for 184 in situ SL-ERGs and 2289 whole grafts was 75% and 80% (P=0.3), respectively. Univariate and multivariate studies alike failed to indicate that the type of graft was a prognostic factor for graft survival. A donor age>60 years, RETX grafts, and urgency were the main prognostic factors for failure for all of the grafts. Although caution should be taken regarding the choice of appropriate donors, in situ SL-ERGs should no longer be considered marginal grafts for experienced LT centers. SL-ERGs should not be used in RETX settings, and when SL-ERGs are used as primary grafts, the total ischemia time should be less than 8 hours.
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Affiliation(s)
- Umberto Maggi
- UO Chirurgia Generale e Trapianti di Fegato, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy; Department of Digestive and Hepatobiliary Surgery, AP-HP, U.F.R. de Médecine de l'Université Paris XII-Créteil, Paris, France
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Abstract
Liver transplantation has become the treatment of choice for nearly all causes of end-stage liver disease, fulminant liver failure, and selected primary hepatic malignancies. The demand for liver transplantation has persistently outmatched the availability of donor organs leading to the development of novel strategies to expand the donor pool. The authors review the process of liver transplant evaluation, methods used to address the donor shortage, and disease-specific outcomes and challenges and discuss posttransplant care.
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Affiliation(s)
- Ming-Ming Xu
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians & Surgeons, 622 West 168th Street, PH14, New York, NY 10032, USA
| | - Robert S Brown
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians & Surgeons, 622 West 168th Street, PH14, New York, NY 10032, USA.
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Mabrouk Mourad M, Liossis C, Kumar S, Gunson BK, Mergental H, Isaac J, Bramhall SR, Muiesan P, Mirza DF, Thamara P R Perera M. Vasculobiliary complications following adult right lobe split liver transplantation from the perspective of reconstruction techniques. Liver Transpl 2015; 21:63-71. [PMID: 25302412 DOI: 10.1002/lt.24015] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 09/25/2014] [Accepted: 09/29/2014] [Indexed: 12/11/2022]
Abstract
Split liver transplantation (SLT) compensates for the organ shortage and provides an alternative solution for recipients disadvantaged by a smaller body size. Variations in the hepatic arterial anatomy and reconstructive techniques may lead to more technical complications, and we sought to analyze the incidence and risk factors of vasculobiliary complications with respect to reconstructive techniques. We identified 171 adult right lobe SLT procedures and 1412 whole liver transplantation (WLT) procedures between January 2000 and June 2012 and compared the results of these 2 groups. In the SLT group, arterial reconstruction techniques were classified into 4 subgroups (I-IV), and biliary reconstruction was classified into 2 groups [duct-to-duct (DD) anastomosis and Roux-en-Y hepaticojejunostomy (RH)]. Specific surgical complications were analyzed against reconstruction techniques. The overall incidence of vascular and biliary complications in the SLT group was greater than that in the WLT group (P = 0.009 and P = 0.001, respectively). There was no difference in hepatic artery thrombosis (HAT), but we saw a tendency toward early HAT in the presence of multiple hepatic arteries supplying the right lobe graft (group IV; 20%) in comparison with the other arterial reconstruction groups (P = 0.052). No difference was noticed in the overall incidence of biliary complications in either DD or RH recipients across 4 arterial reconstruction groups. When the arterial reconstruction involved a right hepatic artery (groups II and III) combined with a DD biliary anastomosis, there was a significant preponderance of biliary complications (P = 0.04 and P = 0.01, respectively). There was no survival difference between SLT and WLT grafts. In conclusion, the complications of SLT are directly related to arterial and biliary reconstruction techniques, and this classification helps to identify high-risk reconstructive techniques.
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49
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Tessier MEM, Harpavat S, Shepherd RW, Hiremath GS, Brandt ML, Fisher A, Goss JA. Beyond the Pediatric end-stage liver disease system: Solutions for infants with biliary atresia requiring liver transplant. World J Gastroenterol 2014; 20:11062-11068. [PMID: 25170195 PMCID: PMC4145749 DOI: 10.3748/wjg.v20.i32.11062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 05/13/2014] [Accepted: 06/23/2014] [Indexed: 02/06/2023] Open
Abstract
Biliary atresia (BA), a chronic progressive cholestatic disease of infants, is the leading cause for liver transplant in children, especially in patients under two years of age. BA can be successfully treated with the Kasai portoenterostomy; however most patients still require a liver transplant, with up to one half of BA children needing a transplant by age two. In the current pediatric end-stage liver disease system, children with BA face the risk of not receiving a liver in a safe and timely manner. In this review, we discuss a number of possible solutions to help these children. We focus on two general approaches: (1) preventing/delaying need for transplantation, by optimizing the success of the Kasai operation; and (2) expediting transplantation when needed, by performing techniques other than the standard deceased-donor, whole, ABO-matched organ transplant.
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50
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Abstract
Liver transplantation is the best therapy in end-stage liver disease. Donor organ shortage and efforts to expand the donor organ pool are permanent issues given that advances in perioperative management and immunosuppressive therapy have brought the procedure into widespread clinical use. The management of organ procurement, including donor preconditioning and adequate organ storage, has a key role in transplantation. However, the organ procurement process can differ substantially between transplant centres, depending on local and national preferences. Advances in the field have come from experimental and clinical research on dynamic storage systems, such as machine perfusion devices, as an alternative to static cold storage. Determination of the clinical significance of these new systems is a topic worthy of future investigations.
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