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Capra RP, Lazzarotto-da-Silva G, Grezzana-Filho TJM, Viana GS, Prediger JE, Rabolini B, Silva RK, Prediger L, de Araujo A, Alvares-da-Silva MR, Feier FH, Chedid MF, Kruel CRP. Low hepatic artery resistive index on Doppler ultrasound performed on the first post-liver transplant day is associated both with hepatic artery thrombosis and decreased graft survival. Langenbecks Arch Surg 2023; 408:231. [PMID: 37306803 DOI: 10.1007/s00423-023-02971-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 06/06/2023] [Indexed: 06/13/2023]
Abstract
PURPOSE Although liver transplantation (LT) outcomes have improved significantly over the last decades, early vascular complications are still associated with elevated risks of graft failure. Doppler ultrasound (DUS) enables detection of vascular complications, provides hepatic artery Resistive Index (RI). The aim of our study was to evaluate the association of the RI parameters of DUS performed in the first post-transplant week with post-transplant outcomes. METHODS All consecutive patients undergoing a first LT between 2001 and 2019 at a single center were included. Patients were divided into two groups: RI < 0.55 and RI ≥ 0.55. Patients were also divided according to the presence or absence of hepatic artery thrombosis (HAT). Graft survival was compared between groups. RESULTS Overall, 338 patients were included. HAT occurred in 23 patients (6.8%), of which 7 were partial and 16, complete. Biliary complications were more common in patients with HAT (10 [43.5%]) vs. 38 [12.1%] [p < 0.001]). Graft survival was lower for patients with HAT (p = 0.047). Also, RI < 0.55 was associated with increased incidence of HAT (p < 0.001). Additionally, patients with RI < 0.55 on post-operative day 1 had decreased graft survival as compared to patients with RI > 0.55 (p = 0.041). RI on post-operative day 3 and 5 was not predictive of inferior graft outcomes. CONCLUSIONS Intensive use of DUS in the early post-LT period offers the possibility of early diagnosis of vascular complications, guiding medical and surgical management of HAT. Additionally, according to our data, low RI (< 0.55) on the first postoperative day also is a predictor of HAT and decreased graft-survival.
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Affiliation(s)
- Rodrigo P Capra
- Post-Graduate Program in Surgical Sciences, Medical School of UFRGS, Porto Alegre, Brazil
| | | | - Tomaz J M Grezzana-Filho
- Post-Graduate Program in Surgical Sciences, Medical School of UFRGS, Porto Alegre, Brazil
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 90035-903, Brazil
| | - Gabriel S Viana
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 90035-903, Brazil
| | - João E Prediger
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 90035-903, Brazil
| | - Bruno Rabolini
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 90035-903, Brazil
| | - Rafaela K Silva
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 90035-903, Brazil
| | - Lucas Prediger
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 90035-903, Brazil
| | - Alexandre de Araujo
- Gastroenterology and Hepatology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Mario R Alvares-da-Silva
- Gastroenterology and Hepatology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Flavia H Feier
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 90035-903, Brazil
| | - Marcio F Chedid
- Post-Graduate Program in Surgical Sciences, Medical School of UFRGS, Porto Alegre, Brazil.
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 90035-903, Brazil.
| | - Cleber R P Kruel
- Post-Graduate Program in Surgical Sciences, Medical School of UFRGS, Porto Alegre, Brazil
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Sixth Floor, Room 600, Porto Alegre, 90035-903, Brazil
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Caso Maestro O, Justo Alonso I, Marcacuzco Quinto A, Manrique Municio A, Calvo Pulido J, García‐Sesma A, Jiménez‐Romero C. Expanding donor age in liver transplantation using liver grafts from nonagenarian donors. Clin Transplant 2022; 36:e14684. [DOI: 10.1111/ctr.14684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/18/2022] [Accepted: 04/09/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Oscar Caso Maestro
- Unit of HPB Surgery and Abdominal Organ Transplantation `Doce de Octubre´ Hospital. Instituto de Investigación (imas12) Department of Surgery Faculty of Medicine Complutense University Madrid Spain
| | - Iago Justo Alonso
- Unit of HPB Surgery and Abdominal Organ Transplantation `Doce de Octubre´ Hospital. Instituto de Investigación (imas12) Department of Surgery Faculty of Medicine Complutense University Madrid Spain
| | - Alberto Marcacuzco Quinto
- Unit of HPB Surgery and Abdominal Organ Transplantation `Doce de Octubre´ Hospital. Instituto de Investigación (imas12) Department of Surgery Faculty of Medicine Complutense University Madrid Spain
| | - Alejandro Manrique Municio
- Unit of HPB Surgery and Abdominal Organ Transplantation `Doce de Octubre´ Hospital. Instituto de Investigación (imas12) Department of Surgery Faculty of Medicine Complutense University Madrid Spain
| | - Jorge Calvo Pulido
- Unit of HPB Surgery and Abdominal Organ Transplantation `Doce de Octubre´ Hospital. Instituto de Investigación (imas12) Department of Surgery Faculty of Medicine Complutense University Madrid Spain
| | - Alvaro García‐Sesma
- Unit of HPB Surgery and Abdominal Organ Transplantation `Doce de Octubre´ Hospital. Instituto de Investigación (imas12) Department of Surgery Faculty of Medicine Complutense University Madrid Spain
| | - Carlos Jiménez‐Romero
- Unit of HPB Surgery and Abdominal Organ Transplantation `Doce de Octubre´ Hospital. Instituto de Investigación (imas12) Department of Surgery Faculty of Medicine Complutense University Madrid Spain
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Safe use of livers from deceased donors older than 70 years in recipients with HCV cirrhosis treated with direct-action antivirals. Retrospective cohort study. Int J Surg 2021; 91:105981. [PMID: 34098075 DOI: 10.1016/j.ijsu.2021.105981] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/28/2021] [Accepted: 05/25/2021] [Indexed: 01/05/2023]
Abstract
INTRODUCTION There is controversy regarding the use of older grafts for liver transplantation (LT) in HCV-infected patients, but the introduction of direct-acting antivirals (DAA) can radically change that debate. METHODS The aim of this retrospective cohort study was to evaluate outcomes of the use of liver grafts from donors older than 70 years in recipients with HCV infection who underwent pre- or post-LT treatment with DAA. We compared two groups of patients who underwent LT using livers >70 years; the groups were defined according to antiviral therapy: non-DAA therapy group (n = 62; LT between May 1996 and December 2013), and DAA therapy group (n = 31; LT between January 2014 and December 2019). RESULTS Thirty (96.8%) patients of DAA therapy and nine (14.5%) of non-DAA therapy (21 patients underwent complete therapy with interferon-ribavirin) achieved sustained viral response (SVR). One, 3-, and 5-year patient survival were 83.9%, 67.7%, and 56.5% in the non-DAA group vs 93.5%, 88.4%, and 88.4% in the DAA group (P = 0.04); the 1-, 3-, and 5-year graft survival were 77.4%, 62.9%, and 51.6% in the non-DAA group vs. 88.6%, 83.7%, and 83.7% in the DAA group (P = 0.03). Multivariate analysis demonstrated donor female sex and DAA therapy as protective factors of graft survival. CONCLUSIONS Pre- or post-LT therapy with DAA in HCV-infected patients has achieved an almost overall SVR. The use of liver grafts >70 years in these patients treated with DAA was associated with significantly higher 5-year patient and graft survival in DAA group compared to non-DAA group. Thus, the introduction of DAA therapy has allowed the safe use of livers >70 years in HCV-positive recipients.
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Tian M, Wang B, Xue Z, Dong D, Liu X, Wu R, Yu L, Xiang J, Zhang X, Zhang X, Lv Y. Telemedicine for Follow-up Management of Patients After Liver Transplantation: Cohort Study. JMIR Med Inform 2021; 9:e27175. [PMID: 33999008 PMCID: PMC8167618 DOI: 10.2196/27175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/11/2021] [Accepted: 04/15/2021] [Indexed: 01/10/2023] Open
Abstract
Background Technical capabilities for performing liver transplantation have developed rapidly; however, the lack of available livers has prompted the utilization of edge donor grafts, including those donated after circulatory death, older donors, and hepatic steatosis, thereby rendering it difficult to define optimal clinical outcomes. Objective We aimed to investigate the efficacy of telemedicine for follow-up management after liver transplantation. Methods To determine the efficacy of telemedicine for follow-up after liver transplantation, we performed a clinical observation cohort study to evaluate the rate of recovery, readmission rate within 30 days after discharge, mortality, and morbidity. Patients (n=110) who underwent liver transplantation (with livers from organ donation after citizen's death) were randomly assigned to receive either telemedicine-based follow-up management for 2 weeks in addition to the usual care or usual care follow-up only. Patients in the telemedicine group were given a robot free-of-charge for 2 weeks of follow-up. Using the robot, patients interacted daily, for approximately 20 minutes, with transplant specialists who assessed respiratory rate, electrocardiogram, blood pressure, oxygen saturation, and blood glucose level; asked patients about immunosuppressant medication use, diet, sleep, gastrointestinal function, exercise, and T-tube drainage; and recommended rehabilitation exercises. Results No differences were detected between patients in the telemedicine group (n=52) and those in the usual care group (n=50) regarding age (P=.17), the model for end-stage liver disease score (MELD, P=.14), operation time (P=.51), blood loss (P=.07), and transfusion volume (P=.13). The length and expenses of the initial hospitalization (P=.03 and P=.049) were lower in the telemedicine group than they were in the usual care follow-up group. The number of patients with MELD score ≥30 before liver transplantation was greater in the usual care follow-up group than that in the telemedicine group. Furthermore, the readmission rate within 30 days after discharge was markedly lower in the telemedicine group than in the usual care follow-up group (P=.02). The postoperative survival rates at 12 months in the telemedicine group and the usual care follow-up group were 94.2% and 90.0% (P=.65), respectively. Warning signs of complications were detected early and treated in time in the telemedicine group. Furthermore, no significant difference was detected in the long-term visit cumulative survival rate between the two groups (P=.50). Conclusions Rapid recovery and markedly lower readmission rates within 30 days after discharge were evident for telemedicine follow-up management of patients post–liver transplantation, which might be due to high-efficiency in perioperative and follow-up management. Moreover, telemedicine follow-up management promotes the self-management and medication adherence, which improves patients’ health-related quality of life and facilitates achieving optimal clinical outcomes in post–liver transplantation.
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Affiliation(s)
- Min Tian
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Bo Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhao Xue
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Dinghui Dong
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xuemin Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Rongqian Wu
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Liang Yu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Junxi Xiang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaogang Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xufeng Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yi Lv
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Serum Factor V Is a Continuous Biomarker of Graft Dysfunction and a Predictor of Graft Loss After Liver Transplantation. Transplantation 2019; 103:944-951. [PMID: 30130328 DOI: 10.1097/tp.0000000000002429] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Factor V has never been compared to a validated early allograft dysfunction (EAD) definition. We aimed to assess factor V as a biomarker of EAD and a predictor of graft loss after liver transplantation (LT). METHODS We retrospectively assessed the serum factor V levels on postoperative day 1 after LT. Patients were divided according to their factor V levels into the ≤36.1 U/mL and > 36.1 U/mL groups. The primary outcome was graft loss within 1, 3, and 6 months. The secondary outcome was EAD, as defined by Olthoff et al. Predictors of outcomes were identified by multivariable logistic regression. RESULTS Two hundred twenty-seven patients were included in the study: 74 with factor V of 36.1 U/mL or less and 153 with factor V >36.1 U/mL. EAD was diagnosed in 41 (55.4%) of 74 patients with factor V of 36.1 U/mL or less and in 20/153 (13.1%) patients with factor V >36.1 U/mL (P < 0.001). According to the multivariable regression model, factor V was a continuous marker of EAD (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.94-0.98 per U/mL). Among the study groups, the 1-, 3-, and 6-month graft survival rates were 82%, 74%, and 74%, respectively, for patients with factor V of 36.1 U/mL or less and 98%, 95%, and 95%, respectively, for patients with factor V >36.1 U/mL (P = 0.001). Factor V was a continuous predictor for 3- and 6-month graft losses (OR, 0.96; 95% CI, 0.94-0.99 and OR, 0.97; 95% CI, 0.94-0.99 per U/mL), whereas EAD was not significant when adjusted for factor V. CONCLUSION Factor V is an early marker for EAD and is a continuous predictor of short-term graft loss after LT.
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Domagala P, Takagi K, Ijzermans JN, Polak WG. Grafts from selected deceased donors over 80 years old can safely expand the number of liver transplants: A systematic review and meta-analysis. Transplant Rev (Orlando) 2019; 33:209-218. [PMID: 31303351 DOI: 10.1016/j.trre.2019.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/23/2019] [Accepted: 06/28/2019] [Indexed: 12/20/2022]
Abstract
AIM The aim of this systematic review and meta-analysis was to present the outcome of deceased adult liver transplantation from octogenarian (≥80 years old) donors compared to younger grafts. METHODS A systematic search was performed on six databases to identify all available original papers that report the outcome of adult recipients who underwent liver transplantation from a deceased octogenarian donor. RESULTS Overall, 39,034 liver transplantations from 12 studies were reported with 789 (2.02%) cases receiving grafts from octogenarian donors. Eight studies were included in the meta-analysis. There was no difference regarding the one, three, and five-year graft and patient survival between the recipients of livers <80 years old and octogenarian grafts. There were significantly more episodes of biliary complications in the recipients of octogenarian grafts (34/459; 7.4%) in comparison to the recipients of livers <80 years old (372/37074; 1.0%) (OR 0.53; 95% CI = 0.35-0.81; P 0.004; I2 = 0%). The incidence of primary non-function, vascular complications and re-transplantation did not differ between groups. CONCLUSIONS The short- and medium-term graft and patient survival of octogenarian liver transplantation is not inferior compared to the liver transplantation with younger grafts, however with a higher rate of biliary complications.
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Affiliation(s)
- Piotr Domagala
- Erasmus MC, University Medical Centre Rotterdam, Department of Surgery, Division of HPB & Transplant Surgery, Dr. Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands; The Medical University of Warsaw, Department of General and Transplantation Surgery, Nowogrodzka 59 St, 02-006 Warsaw, Poland.
| | - Kosei Takagi
- Erasmus MC, University Medical Centre Rotterdam, Department of Surgery, Division of HPB & Transplant Surgery, Dr. Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands; Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Gastroenterological Surgery, 2-5-1 Shikatacho, Kita-ku, Okayama-shi, Okayama, Japan
| | - Jan N Ijzermans
- Erasmus MC, University Medical Centre Rotterdam, Department of Surgery, Division of HPB & Transplant Surgery, Dr. Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands.
| | - Wojciech G Polak
- Erasmus MC, University Medical Centre Rotterdam, Department of Surgery, Division of HPB & Transplant Surgery, Dr. Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands.
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Memeo R, de'Angelis N, Salloum C, Compagnon P, Laurent A, Feray C, Duvoux C, Azoulay D. Clinical outcomes of right-lobe split-liver versus orthotopic liver transplants from donors more than 70 years old. Prog Transplant 2018; 25:243-50. [PMID: 26308784 DOI: 10.7182/pit2015303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Context-The imbalance between the organ supply and the number of potential transplant recipients led to consideration of expanded-criteria liver donors. Objective-To compare right-lobe split-liver transplants (RL-SLTs) with orthotopic liver transplants (OLTs) from donors more than 70 years old (OLT-O) and OLTs from donors less than 55 years old (OLT-Y). Methods-Seventy-one patients who received an RL-SLT were matched for age, sex, and Model for End-stage Liver Disease score with 71 patients who underwent OLT-O and 142 patients who underwent OLT-Y. Clinical outcomes were compared between groups. Results-Longer operation time was associated with RL-SLT (P< .001) as well as more blood loss (P= .03) and transfusions (P= .05). Postoperative morbidity was less in the OLT-Y group, with a lower rate of grades III to IV Clavien-Dindo complication (30%), compared with values in OLT-O (52%) and RL-SLT (38%). Kaplan-Meier analysis demonstrated better 1-year and 3-year survival rates in the OLT-Y group (97% and 92%, respectively), compared with 92% and 86.3%, respectively, in the RL-SLT group; and 84.5% and 73%, respectively, in the OLT-O group (P = .03). Kaplan-Meier analysis also demonstrated differences between the groups in terms of 1-year and 3-year graft survival rates, which were 92% and 86%, respectively, in OLT-Y; 77% and 66%, respectively, in the OLT-O, and 84.2% and 76.6%, respectively, in the RL-SLT group (P= .01). Conclusion-Even if OLT-Y guarantees better patient and graft survival, both RL-SLT and OLT-O can be used safely to expand the pool of liver donors, showing acceptable clinical results and complications rates.
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Affiliation(s)
- Riccardo Memeo
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Nicola de'Angelis
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Chady Salloum
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Philipe Compagnon
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Alexis Laurent
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Cyrille Feray
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Cristoph Duvoux
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Daniel Azoulay
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
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Haddad L, Marciano S, Cleres M, Zerega A, Piñero F, Orozco F, Braslavsky G, Mendizabal M, Gondolesi G, Gil O, Silva M, Mastai R, Imventarza O, Descalzi V, Gadano A. Characteristics of Liver Transplantation in Argentina: A Multicenter Study. Transplant Proc 2018; 50:478-484. [PMID: 29579832 DOI: 10.1016/j.transproceed.2017.11.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 11/11/2017] [Indexed: 11/16/2022]
Abstract
INTRODUCTION There is a lack of information regarding outcomes after liver transplant in Latin America. OBJECTIVES This study sought to describe outcomes after liver transplant in adult patients from Argentina. METHODS We performed an ambispective cohort study of adult patients transplanted between June 2010 and October 2012 in 6 centers from Argentina. Only patients who survived after the first 48 hours postransplantation were included. Pretransplantation and posttransplantation data were collected. RESULTS A total of 200 patients were included in the study. Median age at time of transplant was 50 (interquartile range [IQR] 26 to 54) years. In total, 173 (86%) patients had cirrhosis, and the most frequent etiology in these patients was hepatitis C (32%). A total of 35 (17%) patients were transplanted with hepatocellular carcinoma. In patients with cirrhosis, the median Model for End-Stage Liver Disease (MELD) score at time of liver transplant was 25 (IQR 19 to 30). Median time on the waiting list for elective patients was 101 (IQR 27 to 295) days, and 3 (IQR 2 to 4) days for urgent patients. Almost 40% of the patients were readmitted during the first 6 months after liver transplant. Acute rejection occurred in 27% of the patients. Biliary and vascular complications were reported in 39 (19%) and 19 (9%) patients, respectively. Renal failure, diabetes, and dyslipidemia were present in 40 (26%), 87 (57%), and 77 (50%) at 2 years, respectively. CONCLUSIONS We believe the information contained in this article might be of value for reviewing current practices and developing local policies.
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Affiliation(s)
- L Haddad
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - S Marciano
- Departamento de Investigación, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M Cleres
- Unidad de hepatología y Trasplante Hepático, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - A Zerega
- Unidad de Trasplante Hepático, Sanatorio Allende, Córdoba, Argentina
| | - F Piñero
- Unidad de Hígado y Trasplante Hepático, Hospital Universitario Austral, Buenos Aires, Argentina
| | - F Orozco
- Unidad de Trasplante Hepático Hospital Alemán, Buenos Aires, Argentina
| | - G Braslavsky
- Unidad de Trasplante Hepático Hospital Dr. Cosme Argerich, Buenos Aires, Argentina
| | - M Mendizabal
- Unidad de Hígado y Trasplante Hepático, Hospital Universitario Austral, Buenos Aires, Argentina
| | - G Gondolesi
- Unidad de hepatología y Trasplante Hepático, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - O Gil
- Unidad de Trasplante Hepático, Sanatorio Allende, Córdoba, Argentina
| | - M Silva
- Unidad de Hígado y Trasplante Hepático, Hospital Universitario Austral, Buenos Aires, Argentina
| | - R Mastai
- Unidad de Trasplante Hepático Hospital Alemán, Buenos Aires, Argentina
| | - O Imventarza
- Unidad de Trasplante Hepático Hospital Dr. Cosme Argerich, Buenos Aires, Argentina
| | - V Descalzi
- Unidad de hepatología y Trasplante Hepático, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - A Gadano
- Sección Hepatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Halazun KJ, Rana AA, Fortune B, Quillin RC, Verna EC, Samstein B, Guarrera JV, Kato T, Griesemer AD, Fox A, Brown RS, Emond JC. No country for old livers? Examining and optimizing the utilization of elderly liver grafts. Am J Transplant 2018; 18:669-678. [PMID: 28960723 DOI: 10.1111/ajt.14518] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 08/21/2017] [Accepted: 09/18/2017] [Indexed: 01/25/2023]
Abstract
Of the 1.6 million patients >70 years of age who died of stroke since 2002, donor livers were retrieved from only 2402 (0.15% yield rate). Despite reports of successful liver transplantation (LT) with elderly grafts (EG), advanced donor age is considered a risk for poor outcomes. Centers for Medicare and Medicaid Services definitions of an "eligible death" for donation excludes patients >70 years of age, creating disincentives to donation. We investigated utilization and outcomes of recipients of donors >70 through analysis of a United Network for Organ Sharing Standard Transplant Analysis and Research-file of adult LTs from 2002 to 2014. Survival analysis was conducted using Kaplan-Meier curves, and Cox regression was used to identify factors influencing outcomes of EG recipients. Three thousand one hundred four livers from donors >70, ≈40% of which were used in 2 regions: 2 (520/3104) and 9 (666/3104). Unadjusted survival was significantly worse among recipients of EG compared to recipients of younger grafts (P < .0001). Eight independent negative predictors of survival in recipients of EG were identified on multivariable analysis. Survival of low-risk recipients who received EG was significantly better than survival of recipients of younger grafts (P = .04). Outcomes of recipients of EG can therefore be optimized to equal outcomes of younger grafts. Given the large number of stroke deaths in patients >70 years of age, the yield rate of EGs can be maximized and disincentives removed to help resolve the organ shortage crisis.
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Affiliation(s)
- K J Halazun
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medical College, New York, NY, USA.,Center for Liver Disease and Transplantation, Columbia University Medical Center, NY Presbyterian Hospital, New York, NY, USA
| | - A A Rana
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - B Fortune
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medical College, New York, NY, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - R C Quillin
- Center for Liver Disease and Transplantation, Columbia University Medical Center, NY Presbyterian Hospital, New York, NY, USA
| | - E C Verna
- Center for Liver Disease and Transplantation, Columbia University Medical Center, NY Presbyterian Hospital, New York, NY, USA
| | - B Samstein
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medical College, New York, NY, USA.,Center for Liver Disease and Transplantation, Columbia University Medical Center, NY Presbyterian Hospital, New York, NY, USA
| | - J V Guarrera
- Center for Liver Disease and Transplantation, Columbia University Medical Center, NY Presbyterian Hospital, New York, NY, USA
| | - T Kato
- Center for Liver Disease and Transplantation, Columbia University Medical Center, NY Presbyterian Hospital, New York, NY, USA
| | - A D Griesemer
- Center for Liver Disease and Transplantation, Columbia University Medical Center, NY Presbyterian Hospital, New York, NY, USA
| | - A Fox
- Center for Liver Disease and Transplantation, Columbia University Medical Center, NY Presbyterian Hospital, New York, NY, USA
| | - R S Brown
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medical College, New York, NY, USA.,Center for Liver Disease and Transplantation, Columbia University Medical Center, NY Presbyterian Hospital, New York, NY, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - J C Emond
- Center for Liver Disease and Transplantation, Columbia University Medical Center, NY Presbyterian Hospital, New York, NY, USA
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10
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The New Era of Transplant Oncology: Liver Transplantation for Nonresectable Colorectal Cancer Liver Metastases. Can J Gastroenterol Hepatol 2018; 2018:9531925. [PMID: 29623268 PMCID: PMC5829429 DOI: 10.1155/2018/9531925] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 12/31/2017] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is the third most incident cancer worldwide. Most of CRC patients will develop distant metastases, mainly to the liver, and liver resection is the only potential chance for cure. On the other hand, only a small proportion of patients with hepatic CRC metastasis are candidates for upfront liver resection. Liver transplantation (LT) is an attractive option for patients with nonresectable CRC liver metastases (NRCLM) without extrahepatic involvement. Initial experiences with LT for NRCLM achieved very poor outcomes, with a 5-year overall survival (OS) lower than 20%. However, these initial studies did not have a standardized patient selection or neoadjuvant or adjuvant therapies. With recent advances in the surgical and medical oncology fields, the landscape has changed. Recent studies from Norway have shown an encouraging 5-year OS of 50% when transplanting patients with NRCLM. Nevertheless, the main concern when expanding the indications for LT is organ shortage. To manage this organ shortage, strategies utilizing live donor liver transplantation are gaining favor. A few ongoing trials are assessing the impact of LT in NRCLM patient survival. Therefore, the aim of this paper is to review the current status of LT for NRCLM.
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11
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Short-term Results of Liver Transplantation With Octogenarian Donors. Transplant Proc 2018; 50:184-191. [DOI: 10.1016/j.transproceed.2017.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 12/04/2017] [Indexed: 02/06/2023]
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12
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Díaz Jaime F, Berenguer M. Pushing the donor limits: Deceased donor liver transplantation using organs from octogenarian donors. Liver Transpl 2017; 23:S22-S26. [PMID: 28779558 DOI: 10.1002/lt.24841] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 07/27/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Francia Díaz Jaime
- Hepatology and Liver Transplantation Unit, Department of Gastroenterology, La Fe University Hospital, Valencia, Spain
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit, Department of Gastroenterology, La Fe University Hospital, Valencia, Spain.,Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,Network Center for Biomedical Research in Hepatic and Digestive Diseases, Madrid, Spain.,Facultad de Medicina, Universidad de Valencia, Valencia, Spain
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13
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Peloso A, Oldani G. Enlarged selection criteria for hepatocellular cancer: is the upper limit needed? Transl Gastroenterol Hepatol 2017; 2:73. [PMID: 29034346 PMCID: PMC5639021 DOI: 10.21037/tgh.2017.09.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 08/28/2017] [Indexed: 12/12/2022] Open
Abstract
Liver transplantation (LT) for hepatocellular carcinoma (HCC) is strategically challenging because the very good mid-term outcomes of this treatment jar with the risk of cancer recurrence. Although Milan criteria (MC) tap the balance on the safe side, they tend to be considered too restrictive and new, enlarged criteria have been conceived in order to enlarge the pool of potential recipients. Some extended criteria are more audacious then others, but they seem to be well tailored on the local reality they are applied to. Being HCC epidemiology and organs availability very variable between regions, a universally valid 'upper limit' is yet to be determinable.
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Affiliation(s)
- Andrea Peloso
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of General Surgery, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Graziano Oldani
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- HPB Centre, Geneva University Hospitals, Geneva, Switzerland
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14
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Cepeda-Franco C, Bernal-Bellido C, Barrera-Pulido L, Álamo-Martínez JM, Ruiz-Matas JH, Suárez-Artacho G, Marín-Gómez LM, Tinoco-González J, Díaz-Aunión C, Padillo-Ruiz FJ, Gómez-Bravo MÁ. Survival Outcomes in Liver Transplantation With Elderly Donors: Analysis of Andalusian Transplant Register. Transplant Proc 2017; 48:2983-2986. [PMID: 27932125 DOI: 10.1016/j.transproceed.2016.09.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/16/2016] [Accepted: 09/01/2016] [Indexed: 02/08/2023]
Abstract
Recently, there has been a large discrepancy between the number of patients on the waiting list for a liver transplant and the availability of deceased donors, with an increase in annual wait list mortality rates. Elderly donor livers are thought to be marginal grafts; however, in recent years, their utilization has constantly increased. The aim of this study is to evaluate the utilization of elderly donors in Andalusia and post-transplant outcomes. This retrospective observational study of 2408 liver transplants, performed in Andalusia between 2000 and 2014, analyzes the outcomes from donors aged 70 plus (n = 423) in terms of survival rates of the graft and the recipient, the type of transplant, donor age, and D-MELD score (product of donor age and preoperative Model for End-stage Liver Disease score). The most frequent indications for transplant were alcoholic cirrhosis (49.2%), hepatitis C cirrhosis (13%), and hepatocellular carcinoma (12.5%). The overall survival at 5 years was 64%, with a significant fall in survival for recipients with a D-MELD greater than 1500 (57%; P = .045). In the 70-year-old-plus donor group, the overall patient survival was 58.4%. The retransplant rate increased proportionately with donor age. In the alcoholic cirrhosis recipient subgroup, the overall survival at 5 years was 67.6% (P < .05) compared with 33.5% in patients with hepatitis C. Use of elderly donors is a safe strategy to reduce the scarcity of donors, provided that a D-MELD score below 1500 is obtained. Retransplant rates increase progressively with donor age. It is necessary to carefully screen recipients of older organs, taking into account that the best results are obtained for alcoholic cirrhosis, negative viral load hepatitis C, and a D-MELD score below 1500.
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Affiliation(s)
- C Cepeda-Franco
- Liver Transplant Unit, Virgen del Rocío University Hospital, Seville, Spain.
| | - C Bernal-Bellido
- Liver Transplant Unit, Virgen del Rocío University Hospital, Seville, Spain
| | - L Barrera-Pulido
- Liver Transplant Unit, Virgen del Rocío University Hospital, Seville, Spain
| | - J M Álamo-Martínez
- Liver Transplant Unit, Virgen del Rocío University Hospital, Seville, Spain
| | | | - G Suárez-Artacho
- Liver Transplant Unit, Virgen del Rocío University Hospital, Seville, Spain
| | - L M Marín-Gómez
- Liver Transplant Unit, Virgen del Rocío University Hospital, Seville, Spain
| | - J Tinoco-González
- Liver Transplant Unit, Virgen del Rocío University Hospital, Seville, Spain
| | | | - F J Padillo-Ruiz
- Liver Transplant Unit, Virgen del Rocío University Hospital, Seville, Spain
| | - M Á Gómez-Bravo
- Liver Transplant Unit, Virgen del Rocío University Hospital, Seville, Spain
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15
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Jiménez-Romero C, Cambra F, Caso O, Manrique A, Calvo J, Marcacuzco A, Rioja P, Lora D, Justo I. Octogenarian liver grafts: Is their use for transplant currently justified? World J Gastroenterol 2017; 23:3099-3110. [PMID: 28533667 PMCID: PMC5423047 DOI: 10.3748/wjg.v23.i17.3099] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/12/2017] [Accepted: 03/20/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To analyse the impact of octogenarian donors in liver transplantation.
METHODS We present a retrospective single-center study, performed between November 1996 and March 2015, that comprises a sample of 153 liver transplants. Recipients were divided into two groups according to liver donor age: recipients of donors ≤ 65 years (group A; n = 102), and recipients of donors ≥ 80 years (group B; n = 51). A comparative analysis between the groups was performed. Quantitative variables were expressed as mean values and SD, and qualitative variables as percentages. Differences in properties between qualitative variables were assessed by χ2 test. Comparison of quantitative variables was made by t-test. Graft and patient survivals were estimated using the Kaplan-Meier method.
RESULTS One, 3 and 5-year overall patient survival was 87.3%, 84% and 75.2%, respectively, in recipients of younger grafts vs 88.2%, 84.1% and 66.4%, respectively, in recipients of octogenarian grafts (P = 0.748). One, 3 and 5-year overall graft survival was 84.3%, 83.1% and 74.2%, respectively, in recipients of younger grafts vs 84.3%, 79.4% and 64.2%, respectively, in recipients of octogenarian grafts (P = 0.524). After excluding the patients with hepatitis C virus cirrhosis (16 in group A and 10 in group B), the 1, 3 and 5-year patient (P = 0.657) and graft (P = 0.419) survivals were practically the same in both groups. Multivariate Cox regression analysis demonstrated that overall patient survival was adversely affected by cerebrovascular donor death, hepatocarcinoma, and recipient preoperative bilirubin, and overall graft survival was adversely influenced by cerebrovascular donor death, and recipient preoperative bilirubin.
CONCLUSION The standard criteria for utilization of octogenarian liver grafts are: normal gross appearance and consistency, normal or almost normal liver tests, hemodynamic stability with use of < 10 μg/kg per minute of vasopressors before procurement, intensive care unit stay < 3 d, CIT < 9 h, absence of atherosclerosis in the hepatic and gastroduodenal arteries, and no relevant histological alterations in the pre-transplant biopsy, such as fibrosis, hepatitis, cholestasis or macrosteatosis > 30%.
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16
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Abstract
The process of ageing has an impact on the entire human body including the organ systems. In transplantation, professionals are daily faced with risk assessment of suitable donor offers , whether to accept a liver graft for a specific recipient. In this context, livers from elderly donors are more frequently accepted for transplantation, to increase the donor pool and compensate the high waiting list mortality. In the current practice it is not unusual to accept 60-year old donor livers for transplantation, as the donor demographics have significantly changed over the years. However, controversy exists regarding the use of livers from donors above 70 or 80 years, particular in combination with other risk factors, e.g. liver steatosis, warm ischaemia or long cold storage. This review focuses first on the impact of ageing on liver morphology and function. Second, we will highlight outcome after transplantation from elderly donors. Finally, we describe further risk factors and donor-recipient selection under the scope of old donor organs and include our institutional experience and policy.
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17
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Liver transplantation for hepatocellular carcinoma: outcomes and novel surgical approaches. Nat Rev Gastroenterol Hepatol 2017; 14:203-217. [PMID: 28053342 DOI: 10.1038/nrgastro.2016.193] [Citation(s) in RCA: 277] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Liver transplantation for hepatocellular carcinoma (HCC) is the best treatment option for patients with early-stage tumours and accounts for ∼20-40% of all liver transplantations performed at most centres worldwide. The Milan criteria are the most common criteria to select patients with HCC for transplantation but they can be seen as too restrictive. Several proposals have been made for a moderate expansion of the criteria, which result in good outcomes but with an increase in the risk of tumour recurrence. In this Review, we provide a comprehensive overview of the outcomes after liver transplantation for HCC, focusing on tumour recurrence in terms of surveillance, prevention and treatment. Additionally, novel surgical techniques have been developed to increase the available pool of organs for liver transplantation (such as living donor liver transplantation, donation after circulatory death and split livers), but the effect of these techniques on patients with HCC is still under debate. Thus, we will describe these techniques and expose the benefits and disadvantages of each surgical approach. Finally, we will comment on the limitations of the current priority policies for liver transplantation and the need to further refine them to better serve the population.
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18
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Toniutto P, Zanetto A, Ferrarese A, Burra P. Current challenges and future directions for liver transplantation. Liver Int 2017; 37:317-327. [PMID: 27634369 DOI: 10.1111/liv.13255] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 09/08/2016] [Indexed: 12/14/2022]
Abstract
Liver transplantation is an effective and widely used therapy for several patients with acute and chronic liver diseases. The discrepancy between the number of patients on the waiting list and available donors remains the key issue and is responsible for the high rate of waiting list mortality. The recent news is that the majority of patients with hepatitis C virus related liver disease will be cured by new antivirals therefore we should expect soon a reduction in the need of liver transplantation for these recipients. This review aims to highlight, in two different sections, the main open issues of liver transplantation concerning the current and future strategies to the best use of limited number of organs. The first section cover the strategies to increase the donor pool, discussing the use of older donors, split grafts, living donation and donation after cardiac death and mechanical perfusion systems to improve the preservation of organs before liver transplantation. Challenges in immunosuppressive therapy and operational tolerance induction will be evaluated as potential tools to increase the survival in liver transplant recipients and to reducing the need of re-transplantation. The second section is devoted to the evaluation of possible new indications to liver transplantation, where the availability of organs by implementing the strategies mentioned in the first section and the reduction in the number of waiting transplants for HCV disease is realized. Among these new potential indications for transplantation, the expansion of the Milan criteria for hepatocellular cancer is certainly the most open to question.
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Affiliation(s)
- Pierluigi Toniutto
- Department of Clinical Sciences Experimental and Clinical, Medical Liver Transplant Section, University of Udine, Udine, Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padova, Italy
| | - Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padova, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padova, Italy
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19
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Echeverri J, Selzner M. "In 10 years" debate: Con-machine perfusion will be limited to specific situations (Steatotic, donation after circulatory death). Liver Transpl 2016; 22:29-32. [PMID: 27588758 DOI: 10.1002/lt.24622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 08/30/2016] [Indexed: 12/31/2022]
Affiliation(s)
- Juan Echeverri
- Department of Surgery, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - Markus Selzner
- Department of Surgery, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada.
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20
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León Díaz F, Fernández Aguilar J, Sánchez Pérez B, Montiel Casado C, Aranda Narváez J, Pérez Daga J, Suárez Muñoz M, Santoyo Santoyo J. Results of Liver Transplantation With Donors Older than 75 Years: A Case-Control Study. Transplant Proc 2016; 48:2499-2502. [DOI: 10.1016/j.transproceed.2016.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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21
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Lué A, Solanas E, Baptista P, Lorente S, Araiz JJ, Garcia-Gil A, Serrano MT. How important is donor age in liver transplantation? World J Gastroenterol 2016; 22:4966-4976. [PMID: 27275089 PMCID: PMC4886372 DOI: 10.3748/wjg.v22.i21.4966] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 04/15/2016] [Accepted: 05/04/2016] [Indexed: 02/06/2023] Open
Abstract
The age of liver donors has been increasing in the past several years because of a donor shortage. In the United States, 33% of donors are age 50 years or older, as are more than 50% in some European countries. The impact of donor age on liver transplantation (LT) has been analyzed in several studies with contradictory conclusions. Nevertheless, recent analyses of the largest databases demonstrate that having an older donor is a risk factor for graft failure. Donor age is included as a risk factor in the more relevant graft survival scores, such as the Donor Risk Index, donor age and Model for End-stage Liver Disease, Survival Outcomes Following Liver Transplantation, and the Balance of Risk. The use of old donors is related to an increased rate of biliary complications and hepatitis C virus-related graft failure. Although liver function does not seem to be significantly affected by age, the incidence of several liver diseases increases with age, and the capacity of the liver to manage or overcome liver diseases or external injuries decreases. In this paper, the importance of age in LT outcomes, the role of donor age as a risk factor, and the influence of aging on liver regeneration are reviewed.
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22
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Abstract
BACKGROUND The availability of donor organs limits the number of patients in need who are offered liver transplantation. Measures to expand the donor pool are crucial to prevent on-list mortality. The aim of this study was to evaluate the use of livers from deceased donors who were older than 75 years. METHODS Fifty-four patients who received a first liver transplant (D75 group) from 2001 to 2011 were included. Donor and recipient data were collected from the Nordic Liver Transplant Registry and medical records. The outcome was compared with a control group of 54 patients who received a liver graft from donors aged 20 to 49 years (D20-49 group). Median donor age was 77 years (range, 75-86 years) in the D75 group and 41 years (range, 20-49 years) in the D20-49 group. Median recipient age was 59 years (range, 31-73 years) in the D75 group and 58 years (range, 31-74 years) in the D20-49 group. RESULTS The 1-, 3-, and 5-year patient/graft survival values were 87/87%, 81/81%, and 71/67% for the D75 group and 88/87%, 75/73%, and 75/73% for the D20-49 group, respectively. Patient (P = 0.89) and graft (P = 0.79) survival did not differ between groups. The frequency of biliary complications was higher in the D75 group (29.6/13%, P = 0.03). CONCLUSIONS Selected livers from donors over age 75 years should not be excluded based on age, which does not compromise patient or graft survival despite a higher frequency of biliary complications.
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23
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Mils K, Lladó L, Fabregat J, Baliellas C, Ramos E, Secanella L, Busquets J, Pelaez N. Resultados del trasplante hepático con donantes de más de 70 años. Cir Esp 2015; 93:516-21. [DOI: 10.1016/j.ciresp.2015.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 04/20/2015] [Accepted: 04/24/2015] [Indexed: 01/26/2023]
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Westerkamp AC, Korkmaz KS, Bottema JT, Ringers J, Polak WG, van den Berg A, van Hoek B, Metselaar HJ, Porte RJ. Elderly donor liver grafts are not associated with a higher incidence of biliary complications after liver transplantation: results of a national multicenter study. Clin Transplant 2015; 29:636-43. [PMID: 25997000 DOI: 10.1111/ctr.12569] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Liver transplantation with livers grafts from elderly donors has been associated with a higher risk of biliary complications. The aim of this study was to examine whether our national protocol could contribute to a lower incidence of biliary complications. METHODS All adult recipients in the Netherlands transplanted with a liver from an elderly donor (≥ 65 yrs; n = 68) in the period January 2000-July 2011 were matched with recipients of a liver from a donor <65 yr (n = 136). Outcome parameters were 90-d, one-yr, and three-yr patient/graft survival rates, biliary complications (non-anastomotic stricture, anastomotic stricture, biliary leakage, and post-transplant cholangitis), and postoperative hepatic ischemic injury serum markers (AST/ALT). RESULTS The median cold ischemia time (CIT) was 7:25 (h:min) in the group recipients of an elderly donor liver graft. Ninety-day, one-yr, and three-yr patient/graft survival rates were similar between the group with an elderly donor liver and their younger controls. Moreover, no differences were found in the incidence of biliary complications and postoperative levels of AST/ALT between the two groups. CONCLUSION Transplantation of livers from elderly donors (≥ 65 yr) is not associated with a higher incidence of biliary complications, in a national policy wherein the CIT is kept short.
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Affiliation(s)
- Andrie C Westerkamp
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kerem S Korkmaz
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan T Bottema
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Ringers
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Wojciech G Polak
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Aad van den Berg
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Bakr MA, Nagib AM, Donia AF. Induction immunosuppressive therapy in kidney transplantation. EXP CLIN TRANSPLANT 2014; 12 Suppl 1:60-9. [PMID: 24635795 DOI: 10.6002/ect.25liver.l58] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Induction therapy after kidney transplantation is intensive immunosuppression in the initial days after transplant when the immune system of the recipient has the first contact with donor antigens. Initial intensive immunosuppression may be required to prevent acute rejection and graft loss, and subsequent immunosuppression may be decreased to minimize adverse events associated with immunosuppressive drugs. Induction agents include lymphocyte-depleting antibodies such as rabbit antithymocyte globulin, alemtuzumab, muromonab-CD3, rituximab, and bortezomib; lymphocyte-nondepleting antibodies such as interleukin 2 receptor antibodies; and other discontinued or investigational agents such as efalizumab and alefacept. Induction therapy may be adjusted for special situations such as living-donor kidney transplant, pediatric transplant, hepatitis C virus-seropositive recipients, recipients who require desensitization, patients who are at risk for developing delayed graft function, and old donors. The optimal immunosuppressive regimen may vary, and clinical practice guidelines are available.
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Chedid MF, Rosen CB, Nyberg SL, Heimbach JK. Excellent long-term patient and graft survival are possible with appropriate use of livers from deceased septuagenarian and octogenarian donors. HPB (Oxford) 2014; 16:852-8. [PMID: 24467292 PMCID: PMC4159459 DOI: 10.1111/hpb.12221] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 12/17/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although increasing donor age adversely affects survival after liver transplantation, livers have been used from selected deceased donors older than 70 years. Although there are reports of excellent short-term results, long-term results are unknown. Our experience was reviewed with septuagenarian and octogenarian deceased donors to determine long-term outcomes. METHODS All primary deceased donor liver transplants performed at our institution between July 1998 and December 2010 were reviewed. Recipients of livers procured after circulatory arrest, split and reduced-size livers and multiple organ transplants were excluded from the study. Patient and graft survival were calculated using the Kaplan-Meier method, and survival comparisons were made with the log-rank test. RESULTS In total, 780 patients met inclusion criteria, and 109 patients received livers from donors older than 70 years (range = 70-86). There were no differences in long-term patient (P = 0.67) or graft (P = 0.42) survival between hepatitis C negative recipients of livers from older compared with younger donors. In contrast, 7-year survival for HCV-positive recipients of older donor livers was less than half that of HCV-negative recipients. DISCUSSION Transplantation of livers from septua- and octogenarian donors can achieve excellent long-term patient and graft survival for selected HCV-negative patients.
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Affiliation(s)
| | - Charles B Rosen
- Correspondence, Charles B. Rosen, Division of Transplantation Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Tel: +1 507 266 6640. Fax: +1 507 266 2810. E-mail:
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27
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Jiménez-Romero C, Caso Maestro O, Cambra Molero F, Justo Alonso I, Alegre Torrado C, Manrique Municio A, Calvo Pulido J, Loinaz Segurola C, Moreno González E. Using old liver grafts for liver transplantation: Where are the limits? World J Gastroenterol 2014; 20:10691-10702. [PMID: 25152573 PMCID: PMC4138450 DOI: 10.3748/wjg.v20.i31.10691] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 12/16/2013] [Accepted: 04/03/2014] [Indexed: 02/06/2023] Open
Abstract
The scarcity of ideal liver grafts for orthotopic liver transplantation (OLT) has led transplant teams to investigate other sources of grafts in order to augment the donor liver pool. One way to get more liver grafts is to use marginal donors, a not well-defined group which includes mainly donors > 60 years, donors with hypernatremia or macrosteatosis > 30%, donors with hepatitis C virus or hepatitis B virus positive serologies, cold ischemia time > 12 h, non-heart-beating donors, and grafts from split-livers or living-related donations. Perhaps the most practical and frequent measure to increase the liver pool, and thus to reduce waiting list mortality, is to use older livers. In the past years the results of OLT with old livers have improved, mainly due to better selection and maintenance of donors, improvements in surgical techniques in donors and recipients, and intra- and post-OLT management. At the present time, sexagenarian livers are generally accepted, but there still exists some controversy regarding the use of septuagenarian and octogenarian liver grafts. The aim of this paper is to briefly review the aging process of the liver and reported experiences using old livers for OLT. Fundamentally, the series of septuagenarian and octogenarian livers will be addressed to see if there is a limit to using these aged grafts.
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Alamo JM, Olivares C, Jiménez G, Bernal C, Marín LM, Tinoco J, Suárez G, Serrano J, Padillo J, Gómez MÁ. Donor characteristics that are associated with survival in liver transplant recipients older than 70 years with grafts. Transplant Proc 2014; 45:3633-6. [PMID: 24314980 DOI: 10.1016/j.transproceed.2013.10.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The use of grafts from donors older than 70 years of age is increasing due to the decrease in the number of donors and the increase in waiting list patients. MATERIAL AND METHODS We undertook a univariate and multivariate analysis of 980 adult recipients of whole liver grafts, 129 of them from donors aged 70 years or older. RESULTS No differences were found in patient survival compared with recipients of younger grafts. There were no higher rates of rejection, vascular or biliary complications, postoperative bleeding, or infections, but older grafts were associated with graft dysfunction (P = .01) and a higher frequency of postoperative refractory ascites (P = .007), but without a greater need for retransplantation. As graft-associated factors, the joint presence in the donor of diabetes (P = .00; confidence interval [CI] = 0.04-0.117), hypertension (P = .00; CI = 0.22-0.39), and weight of more than 90 kg (P = .031; CI = 0.05-0.104) were suggestive of poor prognostic factors in recipient survival. Survival in hepatitis C virus (HCV) recipients or recipients aged older than 60 years was worse with donors aged older than 70 years, although not significantly so. With grafts from donors aged older than 80 years (n = 15), although patient survival rate was good (70% at 10 years), there was a higher rate of retransplantation (20%) and the early mortality rate was 13.3%. CONCLUSIONS Use of grafts from donors aged older than 70 years is safe, with similar survival to patients with younger grafts. The appearance of initial dysfunction with prolonged ascites may be due to a delay in reaching a correct functionality, but was not associated with increased mortality, complications, or need for retransplantation. It should also be avoided in recipients older than 60 years or with HCV. Grafts older than 80 years were associated with a good long-term patient survival but at the expense of a higher rate of retransplantation. However, it helps to reduce the time on the waiting list and, thus, mortality. We noted decreased survival associated with donor hypertension, diabetes, and obesity, so these donors should be selected more rigorously.
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Affiliation(s)
- J-M Alamo
- Liver Transplant Unit, Virgen del Rocío Hospital, Seville, Spain.
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Angelico M, Nardi A, Romagnoli R, Marianelli T, Corradini SG, Tandoi F, Gavrila C, Salizzoni M, Pinna AD, Cillo U, Gridelli B, De Carlis LG, Colledan M, Gerunda GE, Costa AN, Strazzabosco M, Cillo U, Fagiuoli S, Strazzabosco M, Caraceni P, Toniutto P, Nanni Costa A, Salizzoni TM, Romagnoli R, Bertolotti G, Patrono D, De Carlis L, Slim A, Mangoni J, Rossi G, Caccamo L, Antonelli B, Mazzaferro V, Regalia E, Sposito C, Colledan M, Corno V, Tagliabue F, Marin S, Cillo U, Vitale A, Gringeri E, Donataccio M, Donataccio D, Baccarani U, Lorenzin D, Bitetto D, Valente U, Gelli M, Cupo P, Gerunda G, Rompianesi G, Pinna A, Grazi G, Cucchetti A, Zanfi C, Risaliti A, Faraci M, Tisone G, Anselmo A, Lenci I, Sforza D, Agnes S, Di Mugno M, Avolio A, Ettorre G, Miglioresi L, Vennarecci G, Berloco P, Rossi M, Ginanni Corradini S, Molinaro A, Calise F, Scuderi V, Cuomo O, Migliaccio C, Lupo L, Notarnicola G, Gridelli B, Volpes R, Li Petri S, Zamboni F, Carbotta G, Dedola S, Nardi A, Marianelli T, Gavrila C, Ricci A, Vespasiano F. A Bayesian methodology to improve prediction of early graft loss after liver transplantation derived from the liver match study. Dig Liver Dis 2014; 46:340-7. [PMID: 24411484 DOI: 10.1016/j.dld.2013.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 11/07/2013] [Accepted: 11/10/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND To generate a robust predictive model of Early (3 months) Graft Loss after liver transplantation, we used a Bayesian approach to combine evidence from a prospective European cohort (Liver-Match) and the United Network for Organ Sharing registry. METHODS Liver-Match included 1480 consecutive primary liver transplants performed from 2007 to 2009 and the United Network for Organ Sharing a time-matched series of 9740 transplants. There were 173 and 706 Early Graft Loss, respectively. Multivariate analysis identified as significant predictors of Early Graft Loss: donor age, donation after cardiac death, cold ischaemia time, donor body mass index and height, recipient creatinine, bilirubin, disease aetiology, prior upper abdominal surgery and portal thrombosis. RESULTS A Bayesian Cox model was fitted to Liver-Match data using the United Network for Organ Sharing findings as prior information, allowing to generate an Early Graft Loss-Donor Risk Index and an Early Graft Loss-Recipient Risk Index. A Donor-Recipient Allocation Model, obtained by adding Early Graft Loss-Donor Risk Index to Early Graft Loss-Recipient Risk Index, was then validated in a distinct United Network for Organ Sharing (year 2010) cohort including 2964 transplants. Donor-Recipient Allocation Model updating using the independent Turin Transplant Centre dataset, allowed to predict Early Graft Loss with good accuracy (c-statistic: 0.76). CONCLUSION Donor-Recipient Allocation Model allows a reliable donor and recipient-based Early Graft Loss prediction. The Bayesian approach permits to adapt the original Donor-Recipient Allocation Model by incorporating evidence from other cohorts, resulting in significantly improved predictive capability.
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Affiliation(s)
- Mario Angelico
- Liver Unit, Tor Vergata University, Rome, Italy; Italian Association for the Study of the Liver (AISF), Italian National Transplant Centre (CNT) and Italian Liver Transplant Centres, Italy
| | | | - Renato Romagnoli
- Liver Transplant Unit, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy; Italian Association for the Study of the Liver (AISF), Italian National Transplant Centre (CNT) and Italian Liver Transplant Centres, Italy.
| | - Tania Marianelli
- Liver Unit, Tor Vergata University, Rome, Italy; Italian Association for the Study of the Liver (AISF), Italian National Transplant Centre (CNT) and Italian Liver Transplant Centres, Italy
| | - Stefano Ginanni Corradini
- Gastroenterology Unit, La Sapienza University, Rome, Italy; Italian Association for the Study of the Liver (AISF), Italian National Transplant Centre (CNT) and Italian Liver Transplant Centres, Italy
| | - Francesco Tandoi
- Liver Transplant Unit, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy
| | - Caius Gavrila
- Department of Mathematics, Tor Vergata University, Rome, Italy
| | - Mauro Salizzoni
- Liver Transplant Unit, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy
| | | | - Umberto Cillo
- Liver Transplant Unit, Università of Padua, Italy; Italian Association for the Study of the Liver (AISF), Italian National Transplant Centre (CNT) and Italian Liver Transplant Centres, Italy
| | | | | | | | | | | | - Mario Strazzabosco
- Digestive Disease Section, University of Milan Bicocca, Milan, Italy; Yale University Liver Centre, New Haven, USA; Italian Association for the Study of the Liver (AISF), Italian National Transplant Centre (CNT) and Italian Liver Transplant Centres, Italy
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Results of Liver Transplants From Donors Aged 70 Plus: Analysis of Andalusian Transplant Register. Transplant Proc 2013; 45:3647-9. [DOI: 10.1016/j.transproceed.2013.10.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Mossdorf A, Kalverkamp S, Langenbrinck L, Ulmer TF, Temizel I, Neumann U, Heidenhain C. Allocation procedure has no impact on patient and graft outcome after liver transplantation. Transpl Int 2013; 26:886-92. [DOI: 10.1111/tri.12144] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 04/07/2013] [Accepted: 06/10/2013] [Indexed: 01/15/2023]
Affiliation(s)
- Anne Mossdorf
- Department of General, Visceral and Transplantation Surgery; Uniklinik RWTH Aachen; Aachen; Germany
| | - Sebastian Kalverkamp
- Department of General, Visceral and Transplantation Surgery; Uniklinik RWTH Aachen; Aachen; Germany
| | - Luise Langenbrinck
- Department of General, Visceral and Transplantation Surgery; Uniklinik RWTH Aachen; Aachen; Germany
| | - Tom Florian Ulmer
- Department of General, Visceral and Transplantation Surgery; Uniklinik RWTH Aachen; Aachen; Germany
| | - Ilknur Temizel
- Department of Internal Medicine III; Uniklinik RWTH Aachen; Aachen; Germany
| | - Ulf Neumann
- Department of General, Visceral and Transplantation Surgery; Uniklinik RWTH Aachen; Aachen; Germany
| | - Christoph Heidenhain
- Department of General, Visceral and Transplantation Surgery; Uniklinik RWTH Aachen; Aachen; Germany
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Stey A, Doucette J, Florman S, Emre S. Donor and Recipient Factors Predicting Time to Graft Failure Following Orthotopic Liver Transplantation: A Transplant Risk Index. Transplant Proc 2013; 45:2077-82. [DOI: 10.1016/j.transproceed.2013.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Darius T, Monbaliu D, Jochmans I, Meurisse N, Desschans B, Coosemans W, Komuta M, Roskams T, Cassiman D, van der Merwe S, Van Steenbergen W, Verslype C, Laleman W, Aerts R, Nevens F, Pirenne J. Septuagenarian and octogenarian donors provide excellent liver grafts for transplantation. Transplant Proc 2013; 44:2861-7. [PMID: 23146543 DOI: 10.1016/j.transproceed.2012.09.076] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Wider utilization of liver grafts from donors ≥ 70 years old could substantially expand the organ pool, but their use remains limited by fear of poorer outcomes. We examined the results at our center of liver transplantation (OLT) using livers from donors ≥ 70 years old. METHODS From February 2003 to August 2010, we performed 450 OLT including 58 (13%) using donors ≥ 70 whose outcomes were compared with those using donors <70 years old. RESULTS Cerebrovascular causes of death predominated among donors ≥ 70 (85% vs 47% in donors <70; P < .001). In contrast, traumatic causes of death predominated among donors <70 (36% vs 14% in donors ≥ 70; P = .002). Unlike grafts from donors <70 years old, grafts from older individuals had no additional risk factors (steatosis, high sodium, or hemodynamic instability). Both groups were comparable for cold and warm ischemia times. No difference was noted in posttransplant peak transaminases, incidence of primary nonfunction, hepatic artery thrombosis, biliary strictures, or retransplantation rates between groups. The 1- and 5-year patient survivals were 88% and 82% in recipients of livers <70 versus 90% and 84% in those from ≥ 70 years old (P = .705). Recipients of older grafts, who were 6 years older than recipients of younger grafts (P < .001), tended to have a lower laboratory Model for End-Stage Liver Disease score (P = .074). CONCLUSIONS Short and mid-term survival following OLT using donors ≥ 70 yo can be excellent provided that there is adequate donor and recipient selection. Septuagenarians and octogenarians with cerebrovascular ischemic and bleeding accidents represent a large pool of potential donors whose wider use could substantially reduce mortality on the OLT waiting list.
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Affiliation(s)
- T Darius
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
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Long-Term Results Using Old Liver Grafts for Transplantation: Sexagenerian Versus Liver Donors Older than 70 Years. World J Surg 2013; 37:2211-21. [DOI: 10.1007/s00268-013-2085-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Freeman RB. Deceased donor risk factors influencing liver transplant outcome. Transpl Int 2013; 26:463-70. [PMID: 23414069 DOI: 10.1111/tri.12071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 11/27/2012] [Accepted: 01/07/2013] [Indexed: 12/14/2022]
Abstract
As the pressure for providing liver transplantation to more and more candidates increases, transplant programs have begun to consider deceased donor characteristics that were previously considered unacceptable. With this trend, attention has focused on better defining those donor factors that can impact the outcome of liver transplantation. This review examines deceased donor factors that have been associated with patient or graft survival as well as delayed graft function and other liver transplant results.
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Affiliation(s)
- Richard B Freeman
- Department of Surgery, Dartmouth Hitchcock Medical Center, Geisel School of Medicine a Dartmouth, 1 Medical Center Drive, Lebanon, NH 03756, USA.
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Reich DJ, Guy SR. Donation After Cardiac Death in Abdominal Organ Transplantation. ACTA ACUST UNITED AC 2012; 79:365-75. [DOI: 10.1002/msj.21309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Abstract
Several criteria are used to differentiate between standard and extended allograft donors. These criteria include deceased after cardiac death, advanced donor age, steatosis, previous malignancy in the donor, hepatitis C virus-positive allografts, human T-cell lymphotropic virus-positive allografts, active infections in the donor, high-risk donors, split liver transplantations, and living donor liver transplantations. Review of the literature can lead each practitioner to incorporate extended criteria donors into their transplant program, thereby individualizing the use of these allografts, increasing the donor pool, and decreasing overall waitlist mortality.
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Affiliation(s)
- Theresa R Harring
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
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Abstract
Over the past decade, use of ECD organs for OLT has allowed many transplant programs to afford patients access to an otherwise scarce resource and to maintain center volume. Although overall posttransplant outcomes are inferior to results with optimal, whole-liver grafts, aggressive utilization of ECD and DCD organs significantly lowers median wait-times for OLT, MELD score at OLT, and death while awaiting transplantation. It is incumbent on the transplant community to provide continued scrutiny of the many factors involved in ECD organ utilization, evaluate the degree of risk and benefit such allografts may impart on particular recipients, and thereby provide suitable “matching” to maximize favorable outcomes. Transplant caregivers need to provide patients with evidence-based care decisions, be good stewards of a scarce resource, and maintain threshold survival results for their programs. This requires balancing the urgency with which a transplant is needed and the utility of such a transplant. There is a clear necessity to pursue additional donor research to improve use of these marginal grafts and assess interventions that enhance the safety of ECD livers.
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Cascales Campos P, Ramírez P, Gonzalez R, Domingo J, Martínez Frutos I, Sánchez Bueno F, Robles R, Miras M, Pons JA, Parrilla P. Results of liver transplantation from donors over 75 years: case control study. Transplant Proc 2011; 43:683-6. [PMID: 21486573 DOI: 10.1016/j.transproceed.2011.01.087] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The use of elderly donors can increase the pool of organs available for transplant. The aim of this study was to analyze the outcomes of grafts from donors older than 75 years. PATIENTS AND METHODS We selected 29 patients transplanted from January 2003 to January 2010 with livers from donors older than 75 years for comparison with a control group (58 patients), selected among patients transplanted immediately before or after each study case. Data analyzed using SPSS 15.0 were considered statistically significant at P < .05. RESULTS Statistically significant differences were evident in the mean age of donors (78.3 ± 2.9 vs 50.4 ± 17.8 years, P < .001), levels of aspartate aminotransferase alanine aminotransferase (30.8 ± 18.13/24.9 ± 14.4 vs 53.81 ± 68.4/39.37 ± 39.94 U/L, P < .05), and waiting list time of (122.4 ± 94.3 vs 169.2 ± 135.5 days, P = .034) of elderly donor versus control graft cohorts. The median follow-up was 32 months (range: 4-88.0) No differences were observed at 1 and 3 years after transplantation: graft survival was 78% and 61% in the older donor group and 83% and 71% in the younger donor group, respectively. CONCLUSION The use of expanded donors from elderly subjects can increase the donor pool with good results.
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Affiliation(s)
- P Cascales Campos
- Department of Surgery, Liver Transplant Unit, Virgen de la Arrixaca University Hospital, Murcia, Spain.
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40
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Álamo J, Barrera L, Marín LM, Bernal C, Suárez G, Serrano J, Gómez M, Padillo F. Results of Liver Transplantation With Donors Older Than 70 Years: A Case-Control Study. Transplant Proc 2011; 43:2227-9. [DOI: 10.1016/j.transproceed.2011.05.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Serrano MT, Garcia-Gil A, Arenas J, Ber Y, Cortes L, Valiente C, Araiz JJ. Outcome of liver transplantation using donors older than 60 years of age. Clin Transplant 2011; 24:543-9. [PMID: 19925474 DOI: 10.1111/j.1399-0012.2009.01135.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
UNLABELLED The impact of donor age on liver transplantation has been analyzed in several studies with contradictory results. Our aim was to evaluate graft survival and complications in the first year after liver transplantations with livers from older donors. METHODS Prospective analysis of 149 consecutive primary liver transplantations performed between 2000 and 2005. Transplantations were divided into two groups according to donor age: group A, <60 yr old (n=102); and group B, ≥60 yr old (n=47). RESULTS Chronic and acute rejection, vascular complications, and infections were not statistically different between the groups. Anastomotic biliary strictures were similar in the two groups, but non-anastomotic biliary strictures (NABS) were clearly more frequent in the older donor group (17% vs. 4.9%; OR 3.9; p=0.025). NABS with no arterial complication was diagnosed in 10.6% of cases in group B vs. 1% in group A (OR=12; p=0.012). Graft survival in the first year was 86.67% in the younger group of donors and 71.43% in the older group (p<0.05), but patient survival was not different. CONCLUSIONS The use of grafts from donors≥60 yr decreased graft survival after liver transplantation and was related to a higher frequency of non-anastomotic biliary strictures.
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Affiliation(s)
- Maria Trinidad Serrano
- Department of Gastroenterology, Liver Unit, Clinic University Hospital Lozano Blesa, Aragon Health Sciences Institute, Zaragoza, Spain.
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Ballarin R, Spaggiari M, Di Benedetto F, Montalti R, De Ruvo N, Cautero N, Losi L, Bagni A, D'Errico A, Gerunda GE, Gerunda GE. No age limit for liver transplant donors. J Am Geriatr Soc 2010; 58:1816-8. [PMID: 20863355 DOI: 10.1111/j.1532-5415.2010.03039.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mota SM, Gasperin G, Cerski CT, Oliveira JRD, Álvares-da-Silva MR. Aging and its impact onthe quality of grafts: an experimental study in rats livers. ARQUIVOS DE GASTROENTEROLOGIA 2010; 47:297-300. [DOI: 10.1590/s0004-28032010000300016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2008] [Accepted: 08/12/2009] [Indexed: 01/03/2023]
Abstract
CONTEXT: There are consistent clues of worse results with grafts from older donors, especially in hepatitis C. University of Wisconsin (UW) solution is adopted for liver preservation, but other solutions are being studied, as fructose-1,6-bisphosphate (FBP). OBJECTIVE: To determinate the impact of aging of the donor on the cold ischemia injury in rat livers and compare UW and FBP. METHODS: Twenty male Wistar rats were studied - 10, aging 20 weeks: 5 to preservation with UW (C-UW) and 5, FBP (C-FBP); and other 10, aging 50 weeks: 5 to UW (E-UW) and 5 to FBP (E-FBP). Rats were anesthesized, submitted to hepatectomy, and graft was kept under 2-4ºC for 8 hours. Liquid samples were taken at 2, 4, 6, and 8 hours, to determine AST and LDH. At the end, in the liver tissue thiobarbituric acid reactive substances and catalase were determined. RESULTS: Average liver weight was similar between controls and the others (12.5 g ± 1.8 and 13.4 g ± 2.0). AST and LDH levels were higher in C-UW group (P<0.05). In the older group, there was a difference between UW and FBP preserved livers related to LDH, but not to AST. Thiobarbituric acid reactive substances were superior in control group than in the older one (P = 0.001). Catalase activity was similar between these groups (P = 0.11), but it was superior in UW preserved animals (P = 0.02). CONCLUSION: Livers from older rats were similar to the controls regarding cold ischemia injury in FBP group. Surprisingly, with UW solution there was less cold ischemia injury in the elderly group. When comparing both solutions, FBP provided significantly more protection than UW in the controls. There was a trend to FBP to being better than UW in the elderly group. Further studies with liver from older donors and ischemia and reperfusion are needed.
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Spitzer AL, Lao OB, Dick AAS, Bakthavatsalam R, Halldorson JB, Yeh MM, Upton MP, Reyes JD, Perkins JD. The biopsied donor liver: incorporating macrosteatosis into high-risk donor assessment. Liver Transpl 2010; 16:874-84. [PMID: 20583086 DOI: 10.1002/lt.22085] [Citation(s) in RCA: 239] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
To expand the donor liver pool, ways are sought to better define the limits of marginally transplantable organs. The Donor Risk Index (DRI) lists 7 donor characteristics, together with cold ischemia time and location of the donor, as risk factors for graft failure. We hypothesized that donor hepatic steatosis is an additional independent risk factor. We analyzed the Scientific Registry of Transplant Recipients for all adult liver transplants performed from October 1, 2003, through February 6, 2008, with grafts from deceased donors to identify donor characteristics and procurement logistics parameters predictive of decreased graft survival. A proportional hazard model of donor variables, including percent steatosis from higher-risk donors, was created with graft survival as the primary outcome. Of 21,777 transplants, 5051 donors had percent macrovesicular steatosis recorded on donor liver biopsy. Compared to the 16,726 donors with no recorded liver biopsy, the donors with biopsied livers had a higher DRI, were older and more obese, and a higher percentage died from anoxia or stroke than from head trauma. The donors whose livers were biopsied became our study group. Factors most strongly associated with graft failure at 1 year after transplantation with livers from this high-risk donor group were donor age, donor liver macrovesicular steatosis, cold ischemia time, and donation after cardiac death status. In conclusion, in a high-risk donor group, macrovesicular steatosis is an independent risk factor for graft survival, along with other factors of the DRI including donor age, donor race, donation after cardiac death status, and cold ischemia time.
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Affiliation(s)
- Austin L Spitzer
- Kaiser Permanente, Oakland Medical Center, Department of Surgery, Oakland, CA, USA
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Selzner M, Kashfi A, Selzner N, McCluskey S, Greig PD, Cattral MS, Levy GA, Lilly L, Renner EL, Therapondos G, Adcock LE, Grant DR, McGilvray ID. Recipient age affects long-term outcome and hepatitis C recurrence in old donor livers following transplantation. Liver Transpl 2009; 15:1288-95. [PMID: 19790152 DOI: 10.1002/lt.21828] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
We studied the role of donor and recipient age in transplantation/ischemia-reperfusion injury (TIRI) and short- and long-term graft and patient survival. Eight hundred twenty-two patients underwent deceased donor liver transplantation, with 197 donors being > or = 60 years old. We evaluated markers of reperfusion injury, graft function, and clinical outcomes as well as short- and long-term graft and patient survival. Increased donor age was associated with more severe TIRI and decreased 3- and 5-year graft survival (73% versus 85% and 72% versus 81%, P < 0.001) and patient survival (77% versus 88% and 77% versus 82%, P < 0.003). Hepatitis C virus (HCV) infection and recipient age were the only independent risk factors for graft and patient survival in patients receiving an older graft. In the HCV(+) cohort (297 patients), patients > or = 50 years old who were transplanted with an older graft versus a younger graft had significantly decreased 3- and 5-year graft survival (68% versus 83% and 64% versus 83%, P < 0.009). In contrast, HCV(+) patients < 50 years old had similar 3- and 5-year graft survival if transplanted with either a young graft or an old graft (81% versus 82% and 81% versus 82%, P = 0.9). In conclusion, recipient age and HCV status affect the graft and patient survival of older livers. Combining older grafts with older recipients should be avoided, particularly in HCV(+) patients, whereas the effects of donor age can be minimized in younger recipients.
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Affiliation(s)
- Markus Selzner
- Division of Multiorgan Transplantation, Department of General Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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Yoshizumi T, Ikeda Y, Kaneda Y, Sueishi K. Ex vivo transfer of nuclear factor-kappaB decoy ameliorates hepatic cold ischemia/reperfusion injury. Transplant Proc 2009; 41:1504-7. [PMID: 19545666 DOI: 10.1016/j.transproceed.2008.10.101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Accepted: 10/06/2008] [Indexed: 11/17/2022]
Abstract
Cold ischemia/reperfusion injury of the hepatic graft has been attributed to the release of various inflammatory cytokines. Specific inhibition of these cytokines may improve viability of the hepatic graft upon reperfusion. Herein we have assessed the efficacy of cis element decoy against nuclear factor-kappaB binding site delivery to the hepatic tissue in a rodent liver transplantation model. At 8 hours after reperfusion of the liver, significant reduction was noted in the livers treated with decoy in the release of cytosolic enzymes from the hepatocytes and in serum tumor necrosis factor alpha (P < .05). The neutrophilic infiltration into the hepatic grafts was significantly suppressed in the livers treated with decoy oligodeoxynucleotides (ODNs). Decoy ODNs against nuclear factor-kappaB binding site delivery improved the viability of the hepatic graft against cold ischemia/reperfusion injury in the rodent liver transplantation model.
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Affiliation(s)
- T Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Gordon Burroughs S, Busuttil RW. Optimal utilization of extended hepatic grafts. Surg Today 2009; 39:746-51. [PMID: 19779769 DOI: 10.1007/s00595-008-4022-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 07/09/2008] [Indexed: 12/22/2022]
Abstract
Orthotopic liver transplantation has emerged as the standard treatment for end-stage liver disease. In the United States, the number of listed patients has tripled in the last two decades. Organ availability during the same period has plateaued at approximately 6000 grafts annually, resulting in a fivefold increase in wait-list mortality. The problem is not specific to the United States; European and Asian registries report similar shortages. Donor pool expansion strategies such as the use of living donors, cadaveric split livers, and "extended criteria donors"; (ECD) are being pursued. Used judiciously, ECD grafts provide an opportunity for addressing the shortage. Although there is no universally accepted definition of ECD, the term generally refers to donor factors predisposing recipients to poor initial graft function and/or increased long-term risk. These factors include advanced donor age, hypernatremia, prolonged warm ischemic time, pressor requirement, and donation after cardiac death. The transplant community is scrutinizing all factors to evaluate the degree of risk they impart on the recipient and the extent to which grafts can be "matched"; to maintain acceptable outcomes. We review the importance of selected factors and the impact of a "matching"; strategy to minimize recipient risk while optimizing graft use.
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Affiliation(s)
- Sherilyn Gordon Burroughs
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA 90095-7054, USA
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Ikegami T, Shimada M, Imura S, Arakawa Y, Nii A, Morine Y, Kanemura H. Current concept of small-for-size grafts in living donor liver transplantation. Surg Today 2008; 38:971-82. [PMID: 18958553 DOI: 10.1007/s00595-008-3771-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2007] [Accepted: 02/18/2008] [Indexed: 12/16/2022]
Abstract
The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching called "small-for-size (SFS) graft syndrome." The initial trials to resolve this problem involved increasing the procured graft size, from left to right, and even extension to include a right lobe graft. Clinical cases of living right lobe donations have been reported since then, drawing attention to the risks of increasing the liver volume procured from a living donor. However, not only other modes of increasing graft volume such as auxiliary or dual liver transplantation, but also control of the increased portal pressure caused by an SFS graft, such as a portosystemic shunt or splenectomy, have been trialed with some positive results. To establish an effective strategy for transplanting SFS grafts and preventing SFS graft syndrome, it is essential to have precise knowledge and tactics to evaluate graft quality and graft volume, when performing these LDLTs with portal pressure control. We reviewed the updated literature on the pathogenesis of and strategies for using SFS grafts.
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Affiliation(s)
- Toru Ikegami
- Department of Surgery, University of Tokushima, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
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Petridis I, Gruttadauria S, Nadalin S, Viganò J, di Francesco F, Pietrosi G, Fili' D, Montalbano M, D'Antoni A, Volpes R, Arcadipane A, Vizzini G, Gridelli B. Liver transplantation using donors older than 80 years: a single-center experience. Transplant Proc 2008; 40:1976-8. [PMID: 18675105 DOI: 10.1016/j.transproceed.2008.05.063] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
AIM The shortage of organs for orthotopic liver transplantation (OLT) has forced transplantation centers to expand the donor pool by using donors traditionally labeled as "extended criteria donors." One such example is OLT using a donor with advanced age. MATERIALS AND METHODS We retrospectively evaluated 10 patients who received a liver graft from cadaveric donors older than 80 years. We analyzed pretransplantation donor and recipient characteristics, as well as the evolution of the recipients. RESULTS All 10 donors were older than 80 years (median age, 83.5; range, 80-93). No steatosis (>30%) was accepted in the older donor group. Medium follow-up was 19.5 months. The most frequent cause for OLT was hepatitis C virus (HCV) cirrhosis (8/10 patients). We had 1 case of primary nonfunction, 1 patient died immediately after surgery because of extrahepatic complications (cardiac arrest), and 2 other patients had a severe HCV recurrence and died after 1 and 2 years from OLT, respectively. Five patients had HCV recurrence and biliary complications were present in 60% of the patients. No cases of acute or chronic rejection were described. Overall survival rates after 1 and 3 years were 80% and 40%, respectively. CONCLUSIONS Old donor age is not an absolute contraindication to OLT. Liver grafts from donors older than 80 years can be used knowing that there is a high risk of postoperative complications. Furthermore, the increased risk of developing severe HCV recurrence, related to older donor age, suggests that such livers should be used in HCV-negative recipients.
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Affiliation(s)
- I Petridis
- Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
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Ikegami T, Taketomi A, Ohta R, Soejima Y, Yoshizumi T, Shimada M, Maehara Y. Donor age in living donor liver transplantation. Transplant Proc 2008; 40:1471-5. [PMID: 18589131 DOI: 10.1016/j.transproceed.2008.02.084] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 02/26/2008] [Indexed: 12/18/2022]
Abstract
BACKGROUND We sought to elucidate the influence of donor age in living donor liver transplantation (LDLT) using either left lobe (LL) or right lobe (RL) grafts. METHODS Recipients (n = 232) were categorized as: group O/LL (LL, donor age >50, n = 20); group Y/LL (LL, donor age < or =50, n = 140); Group O/RL (RL, donor age >50, n = 12); and group Y/RL (RL, donor age < or =50, n = 61). We compared post-LDLT graft functions. RESULTS Among LL LDLT, the incidence of small-for-size syndrome was significantly greater for group O/LL compared with group Y/LL (60.0% vs 16.3%, P < .01). However, the cumulative 5-year graft survivals were 73.8% in group O and 76.7% in group Y without substantial difference. In RL LDLT, the post-LDLT morbidity and mortality were similar for group O/RL and group Y/RL. CONCLUSION Partial liver grafts, even though LL grafts, from older donors can be used safely with caution in LDLT.
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Affiliation(s)
- T Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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