Living-donor liver transplantation for high-urgency situations

Current Status and Outcomes of Living Donor Liver Transplantation for Pediatric Acute Liver Failure: Results From a Multicenter Retrospective Study Over Two Decades

BACKGROUND

Although the outcomes of living donor liver transplantation (LDLT) for pediatric acute liver failure (PALF) have improved, patient survival remains lower than in patients with chronic liver disease. We investigated whether the poor outcomes of LDLT for PALF persisted in the contemporary transplant era.

METHODS

We analyzed 193 patients who underwent LDLT between December 2000 and December 2020. The outcomes of patients managed in 2000-2010 (era 1) and 2011-2020 (era 2) were compared.

RESULTS

The median age at the time of LDLT was 1.2 years both eras. An unknown etiology was the major cause in both groups. Patients in era 1 were more likely to have surgical complications, including hepatic artery and biliary complications (p = 0.001 and p = 0.013, respectively). The era had no impact on the infection rate after LDLT (cytomegalovirus, Epstein-Barr virus, and sepsis). The mortality rates of patients and grafts in era one were significantly higher (p = 0.03 and p = 0.047, respectively). The 1- and 5-year survival rates were 76.4% and 70.9%, respectively, in era 1, while they were 88.3% and 81.9% in era 2 (p = 0.042). Rejection was the most common cause of graft loss in both groups. In the multivariate analysis, sepsis during the 30 days after LDLT was independently associated with graft loss (p = 0.002).

CONCLUSIONS

The survival of patients with PALF has improved in the contemporary transplant era. The early detection and proper management of rejection in patients, while being cautious of sepsis, should be recommended to improve outcomes further.

A complete treatment of adult living donor liver transplantation: a review of surgical technique and current challenges to expand indication of patients

The growing disparity between the number of liver transplant candidates and the supply of deceased donor organs has motivated the development of living donor liver transplantation (LDLT). Over the last two decades, the operation has been markedly improved by innovations rendering modern results comparable with those of deceased donor liver transplantation (DDLT). However, there remains room for further innovation, particularly in adult living donor liver transplantation (ALDLT). Unlike whole-size DDLT and pediatric LDLT, size-mismatching between ALDLT graft and recipient body weight and changing dynamics of posttransplant allograft regeneration have remained major challenges. A better understanding of the complex surgical anatomy and physiologic differences of ALDLT helps avoid small-for-size graft syndrome, graft congestion from outflow obstruction and graft hypoperfusion from portal flow steal. ALDLT for high-urgency patients (Model for End-Stage Liver Disease score >30) can achieve results comparable to DDLT in high volume centers. Size limitations of partial grafts and donor safety issues can be overcome with dual grafts and modified right-lobe grafts that preserve the donor's middle hepatic vein trunk. Extended application of LDLT for unresectable hepatocellular carcinoma above Milan criteria is an optional strategy at the cost of slightly compromised survival. ABO-blood group incompatibility obstacles have been broken down by introducing a paired donor exchange program and refined peri-operative management of ABO-incompatible ALDLT. This review focuses on recent innovations of surgical techniques, safe donor selection, current strategies to expand ALDLT with broadened patient selection criteria and important aspects of teamwork required for success.

Paired donor interchange to avoid ABO-incompatible living donor liver transplantation

We report an emergency paired donor interchange living donor liver transplant performed on January 13, 2009. The 4 operations (2 liver transplants) were performed simultaneously. The aim was to avoid 2 ABO-incompatible liver transplants. One recipient in acute liver failure underwent transplantation in a high-urgency situation. The abdomen of the other recipient had severe adhesions from previous spontaneous bacterial peritonitis that rendered the recipient operation almost impossible. The ethical and logistical issues are discussed. Approaches adopted in anticipation of potential adverse outcomes are explained in view of the higher donor and recipient mortality and morbidity rates in comparison with kidney transplantation.

Alleviating the burden of small-for-size graft in right liver living donor liver transplantation through accumulation of experience

The issue of small-for-size graft (SFSG) containing the middle hepatic vein in right liver living donor liver transplantation from 1996 to 2008 (n = 320) was studied. Characteristics of donors, grafts and recipients were comparable between Era I (first 50 cases) and Era II (next 270 cases) except that the median model for end-stage liver disease (MELD) score was higher in Era I (29 vs. 24; p = 0.024). The median graft to standard liver volume ratio (G/SLV) in Era I was 49.0% (range, 32.8-86.2%), versus 49.3% (range, 28.4-89.4%) in Era II (p = 0.498). Hospital mortality rate, the study endpoint, dropped from 16.0% (8/50) in Era I to 2.2% (6/270) in Era II (p = 0.000). Univariate analysis showed that MELD score (p = 0.002), pretransplant hepatorenal syndrome (p = 0.000) and Era I (p = 0.000) were significant in hospital mortality. Logistic regression analysis showed that only Era I (relative risk 9.758; 95% confidence interval, 2.885-33.002; p = 0.000) was significant. In Era I, G/SLV<40% had a relative risk of 7.8 (95% confidence interval, 1.225-49.677; p = 0.030). The hospital mortality rates for G/SLV<40% were 50% (3/6) and 1.9% (1/52) in Era I and II respectively. In conclusion, through accumulation of experience, SFSG became less important as a factor in hospital mortality.

Pediatric acute liver failure with molecular adsorbent recirculating system treatment

BACKGROUND

The prognosis of pediatric acute liver failure (PALF) has been significantly improved by emergency orthotopic liver transplantation (OLT). Since 2004, the molecular adsorbent recirculating system (MARS) has been proposed as a bridging procedure. The aim of our study was to assess its efficacy in children with PALF.

PATIENTS AND METHODS

Since 1999 we performed treatment of 39 fulminant hepatic failure (FHF) cases with MARS. Since September 2004 we treated 6 pediatric patients with FHF who were of mean age 10.6 years (range, 3-15 years) including 4 females and 2 males. In 3 cases the cause of FHF was unknown; in 2 cases, it was induced by paracetamol overdose; and in 1, by acute hepatitis B virus. Inclusion criteria were: bilirubin >15 mg/dL; creatinine >or=2 mg/dL; encephalopathy grade >II; and International normalized ratio (INR) >2.5. Other estimated parameters were: AST and ALT serum levels, lactate, and urine volume. Neurological status was monitored using the Glasgow Coma Scale (GCS). Continuous MARS treatment was performed in all patients with a kit change every 8 hours. Intensive care unit (ICU) treatment was applied to optimize regeneration and to prevent cardiovascular complications.

RESULTS

We observed a significant improvement among levels of bilirubin (P< .009), ammonia (P< .005), creatinine (P< .02), GCS (P< .002), and predictive criteria and as Sequential Organ Failure Assessment (SOFA) and Pediatric End-Stage Liver Disease (PELD). Three children underwent OLT: 1 died after 5 days due to primary nonfunction and 2 children are alive after a median follow-up of 14 months. In 2 children the MARS treatment led to resolution of clinical status without liver transplantation. One child died before OLT due to sepsis and multiorgan failure.

CONCLUSIONS

We concluded that application of the MARS liver support device in combination with experienced ICU management contributed to improve the clinical status in children with PALF awaiting liver transplantation.

A decade of right liver adult-to-adult living donor liver transplantation: the recipient mid-term outcomes

OBJECTIVE

We analyzed a single center's experience over a decade of right liver living donor liver transplantation (RLDLT).

SUMMARY BACKGROUND DATA

To define the donor risk and recipient benefit ratio, midterm outcome of this life-saving treatment modality ought to be known.

METHODS

Consecutive patients from 9 May 1996 were included. Era I comprised the first 50 patients and Era II comprised the remaining 184 patients. Their midterm outcomes were compared with patients receiving deceased donor liver transplantation (DDLT) of the same period in the same center.

RESULTS

With a median follow-up of 48 months, the 1-, 3-, and 5-year overall survival rates were 93.2%, 85.7%, and 82.4%, respectively and were comparable with those of DDLT (n = 131) (90.1%, 87.7%, and 85.2%) (P = 0.876). Hospital mortality decreased from 16% in Era I to 2.2% in Era II (P = 0.000). Reduced hospital mortality improved the overall survival rates from Era I to Era II (78%, 74%, and 72% vs. 97.3%, 88.7%, and 85.1%, respectively) (P = 0.003). The 5-year survival rate of recipients with hepatocellular carcinoma (HCC) (n = 65) was 65.7%. Starting from Era II, excellent 5-year survival of recipients without HCC was achieved as compared with DDLT in the same period (93.4% vs. 88.2%) (P = 0.493). The 5-year survival rates of recipients with HCC within the Milan criteria of Era II and DDLT in the same period were 72.0% and 100%, respectively (P = 0.091). Multivariate analysis indicated that only Era I (relative risk = 2.606; P = 0.005) and pretransplant HCC (relative risk = 2.729; P = 0.002) adversely affected overall survival.

CONCLUSIONS

High midterm survivals were achieved by reduction of hospital mortality through accumulation of experience and transplanting recipients with low chance of recurrence of HCC. RLDLT could be considered as a legitimate alternative to DDLT.

Adult living donor liver transplantation: body mass index and MELD score of recipients are independent risk factors for hospital mortality

BACKGROUND AND AIMS

Adult living donor liver transplantation (LDLT) has been established as elective procedure or urgent procedure to save the life of patients with terminal liver diseases. The outcome of LDLT varies between transplant centers. Here, we aim to evaluate the outcome of LDLT in our center and to identify the risk factors that are associated with hospital mortality of recipients.

PATIENTS AND METHODS

A cohort study with 32 consecutive cases of adult living donor liver transplantation was conducted in two cooperated medical centers. Perioperative data, incidence of postoperative complications, and hospital mortality were analyzed.

RESULTS

No major surgical complications and no hospital mortality were observed in all 32 donors. All donors were discharged with normal liver function with median intensive care unit (ICU) stay of 1 day and median hospital stay of 10 days. All recipients had normal liver function in early posttransplant period. Eighty-one percent of the recipient survived with normal liver function for more than 1 year. The pretransplant ICU stay, renal failure, international normalized ratio (>1.8), and Model for End-stage Liver Disease (MELD) score (>20) were independent risk factors for hospital mortality of recipients.

CONCLUSIONS

Adult living donor liver transplantation should be reserved to less "sick" patients in the era of organ allocation based on MELD score.

Live donors in liver transplantation

Living donor liver transplantation (LDLT) has been controversial since its inception. Begun in response to deceased donor organ shortage and waiting list mortality, LDLT was initiated in 1989 in children, grew rapidly after its first general application in adults in the United States in 1998, and has declined since 2001. There are significant risks to the living donor, including the risk of death and substantial morbidity, and 2 highly publicized donor deaths are thought to have contributed to decreased enthusiasm for LDLT. Significant improvements in outcomes have been seen over recent years, and data, including from the National Institutes of Health-funded Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL), have established a survival benefit from pursuing LDLT. Despite this, LDLT still composes less than 5% of adult liver transplants, significantly less than in kidney transplantation where living donors compose approximately 40% of all transplantations performed. The ethics, optimal utility, and application of LDLT remain to be defined. In addition, most studies to date have focused on posttransplantation outcomes and have not included the effect of the learning curve on outcome or the potential impact of LDLT on waiting list mortality. Further growth of LDLT will depend on defining the optimal recipient and donor characteristics for this procedure as well as broader acceptance and experience in the public and in transplant centers.

Historical perspective of living donor liver transplantation

Living donor liver transplantation (LDLT) has gone through its formative years and established as a legitimate treatment when a deceased donor liver graft is not timely or simply not available at all. Nevertheless, LDLT is characterized by its technical complexity and ethical controversy. These are the consequences of a single organ having to serve two subjects, the donor and the recipient, instantaneously. The transplant community has a common ground on assuring donor safety while achieving predictable recipient success. With this background, a reflection of the development of LDLT may be appropriate to direct future research and patient-care efforts on this life-saving treatment alternative.

Paediatric acute liver failure and transplantation: The University of Essen experience

To report our experience with 17 children who underwent a liver transplantation (LT) for acute liver failure (ALF). All LT procedures (deceased and living donor) were offered. Since 2003 Molecular Adsorbents Recycling System (MARS) was proposed as bridging procedure. We monitored the perioperative course and the short- and long-term outcomes. All children developed pretransplant hepatic encephalopathy (mostly grades II and III); six needed ventilator support and three haemodialysis. Median PELD/MELD score was 30. MARS was used in five children with poor pretransplant prognostic factors: all five survived the LT without sequelae. We performed 13 deceased donor LT (seven whole, five split and onr reduced) and four left lateral LDLT. Postoperative complications were observed in 10 children, requiring re-operation in seven. Two children developed irreversible neurological disorders. After a median follow up of 45 months, 16 children are still alive. About 1- and 5-year cumulative patient survival rates are 94% with a corresponding graft survival of 88% and 81%, respectively. The combination of experienced paediatric ICU management, the application of new liver support devices, and the capacity to offer both living and deceased donor transplant alternatives in a timely fashion represent the best formula to achieve optimal results in children with ALF.

Current trends in live liver donation

The introduction of living donor liver transplantation (LDLT) has been one of the most remarkable steps in the field of liver transplantation (LT), able to significantly expand the scarce donor pool in countries in which the growing demands of organs are not met by the shortage of available cadaveric grafts. Although the benefits of this procedure are enormous, the physical and psychological sacrifice of the donors is immense, and the expectations for a good outcome for themselves, as well as for the recipients, are high. We report a current overview of the latest trends in live liver donation in its different aspects (i.e. donor's selection, evaluation, operation, morbidity, mortality, ethics and psychology). This review is based on our center's personal experience with almost 200 LDLTs and a detailed analysis of the international literature of the last 7 years about this topic. Knowing in detail how to approach to the different aspects of living liver donation may be helpful in further improve donor's safety and even recipient's outcome.

Working up donors for high-urgency and elective adult-to-adult live donor liver transplantation

Donor workup for adult-to-adult live donor liver transplantation is done to ensure that the donor remains physically and psychologically healthy after saving or improving the life of the recipient. Even though two-thirds of the liver transplants in our center were from live donors, this life-saving procedure remains a mere treatment option, given the magnitude of the donor operation with the associated donor risks. Live donor liver transplantation was also adopted for high-urgency situations provided that the donor was suitable and the recipient considered salvageable. Donor workup in this setting had not been reported in the literature. In this cohort of 399 potential donors, 128 (32.1%) ultimately underwent donor surgery. Donors in the high-urgency situation had a lower operation rate of 28.4% (64/225) compared with that of 36.8% (64/174) of donors in the elective situation (P = 0.049). Dropouts from step 1 mainly because of ABO incompatibility, positive hepatitis serology, comorbidities, and voluntary donor withdrawal were 52.6% (210/399). Only 11.6% (22/189) of the potential donors who proceeded to subsequent steps of the workup dropped out (2 were psychologically unsuitable, 10 were anatomically prohibitive). The transplantation rate of potential recipients with 1 or more potential donors was also high. The rates were similar for the high-urgency (55%, 64/116) and the elective (51%, 64/125) situations. In a region with scarcity of deceased donor liver grafts, careful and expeditious initial donor workup minimizes dropouts from subsequent steps and allows timely transplantation in high-urgency situations.

Donor quality of life before and after adult-to-adult right liver live donor liver transplantation

Donor right hepatectomy for adult-to-adult live donor liver transplantation (ALDLT) is a major surgical operation for the benefit of the recipient. Justification of procedure mandates knowledge of the possible physical and psychological negative effects on the donor. We prospectively and longitudinally quantified donor quality of life using generic and condition-specific questionnaires up to 1 year. The generic questionnaires were the Karnofsky Performance Status scale and the Chinese (Hong Kong) version of the Medical Outcomes Study 36-Item Short-Form Survey, which measures 8 health concepts: 4 physical components and 4 mental components. Within 1 year, 30 consecutive donors were included. These 11 male and 19 female donors (36.7% and 63.3%, respectively) had a median age of 35 years (range, 21-56 years). There was no donor mortality or major complications. Donor quality-of-life worsening was most significant in the first 3 postoperative months, particularly among the physical components. The physical and mental components returned to the previous levels in 6 to 12 months' time, though the Karnofsky performance scores were slightly lower at 1 year (P = 0.011). Twenty-six (86.7%) donors declared that they would donate again if there were such a need and it were technically possible. It was noticed that older donors were more likely to express unwillingness to donate again. In conclusion, the temporary worsening of donor quality of life substantiates ALDLT as an acceptable treatment modality.

Asian contribution to living donor liver transplantation

Although the shortage of brain-dead donor organs is a worldwide problem, the situation is especially serious in Asia because of various cultural and social reasons, and cadaveric organ donation remains below 5 per million population per year. Living donor liver transplantation (LDLT) could provide an alternative for liver graft for patients with acute and chronic end-stage liver disease. This article introduces the important contributions to the development of LDLT by the leading Asian liver transplantation centers. The first successful adult LDLT using a left-lobe graft was reported by Makuuchi et al. from Japan in 1994. To overcome the barrier of graft-size matching for adult patients with use of a left-lobe graft, a trial of adult LDLT using a right-lobe graft with middle hepatic vein was reported with satisfactory outcome by Fan et al. from Hong Kong in 1997. Despite the impressive results of right-lobe LDLT, considerable debate persists concerning donor safety. Lee et al. from Korea initiated modified right-lobe liver grafting with interposition vein grafts to drain anterior segment and two left-lobe liver grafting to overcome graft-size insufficiency and to ensure donor safety in 1999 and 2000, respectively. In addition to technical innovations, indications for liver transplantation have been developed by Asian centers as LDLT activity has increased.

Differences in Attitude Toward Living and Postmortal Liver Donation in the United States, Germany, and Japan

Living liver donation is a possible immediate option for decreasing the shortage of liver allografts worldwide. Risks related to the donation make this procedure ethically controversial. Study groups of medical students (N= 330) from three different nations were analyzed with a complex questionnaire, and data were subjected to multiparameter analysis. The readiness for living liver donation was dependent upon the cultural background of the study groups. It was higher in the U.S. than in Germany and Japan, with a higher donation readiness for children as recipients than adults. Major differences among distinct sociodemographic groups need to be carefully addressed when setting up consensus guidelines for the clinical practice of living donation.

Progress in living donor liver transplantation

Living donor liver transplantation (LDLT) has the capacity to reduce the current discrepancy between the number of patients on the transplant waiting list and the number of available organ donors. For pediatric patients, LDLT has clearly reduced the number of waiting list deaths, providing compelling evidence for an increase in LDLT programs. This review discusses many of the recent advances in LDLT.

Experience after the evaluation of 700 potential donors for living donor liver transplantation in a single center

Adequate selection of donors is a major prerequisite for living donor liver transplantation (LDLT). Few centers report on the entire number of potential donors considered or rejected for living donation. From April 1998 to July 2003, a total of 111 living donor liver transplantations were performed at our institution, with 622 potential donors for 297 adult recipients and 78 potential donors for 52 pediatric recipients evaluated. In the adult group, only 89 (14%) potential donors were considered suitable, with a total of 533 (86%) potential donors rejected. Of these, 67% were excluded either at initial screening or during the first and second steps of the evaluation procedure. In 31% of all cases, the evaluation of donors was canceled because of recipient issues. In the pediatric group, 22 (28%) donors were selected, with the other 56 (72%) rejected. Costs of the complete evaluation process accounted for 4,589 Euro (Euro) per donor. The evaluation of a potential living donor is a complex and expensive process. We present the results on the evaluation of the largest group of potential donors for adults reported in the literature. Only 14% of potential donors in our series were considered suitable candidates. It has not yet been established who should cover the expenses of the evaluation of all rejected donors. In conclusion, all efforts should be made in order to develop an effective screening protocol for the evaluation of donors with the aim of saving time and resources for a liver transplantation program.

Epidemiology and results of liver transplantation for acute liver failure in Chile

Acute liver failure (ALF) is a severe, life-threatening condition associated with a high mortality rate. The objective of this study is to present the experience of a Chilean liver transplant program with orthotopic liver transplantation (OLT) for ALF. All patients with the diagnosis of ALF evaluated in our program between January 1995 and May 2003 were included in the analyses of etiology and outcomes. Candidates for OLT activated on a national waiting list were transplanted with cadaveric or living-related donor (LRD) organs. Twenty-seven patients age 1 to 19 years (median, 7.4 years) were transplanted at a median weight of 30.7 kg including 17 cadaveric and 10 with LRD livers. Most frequent etiologies were hepatitis A in 10 cases (37%) and unknown in 12 (48.1%). One donor experienced superficial phlebitis. Four patients were retransplanted (14.8%). Twenty patients are alive with 1- and 5-year survival rates of 74.1% At a median follow up of 34 months (range = 2 to 120). Seven patients died due to sepsis, multiorganic failure, graft primary nonfunction, intracranial hemorrhage, and intraoperative cardiac arrest. This experience revealed results comparable to international reports, allowing survival of patients destined to die.

Living-donor liver transplantation: 12 years of experience in Asia

Living-donor liver transplantation has provided a solution to the severe lack of cadaveric grafts for the replacement of livers afflicted with end-stage cirrhosis, fulminant disease, or inborn errors of metabolism. The pioneering experience in Japan in the early 1990s helped open wide the avenues of a new branch of science that is technically demanding and whose benefits are clearly dramatic. The need for alternative sources of liver grafts was common to the entire Asian region and, fortunately, the option of obtaining partial liver grafts from live donors had already become tenable. By the second half of the past decade, living-donor liver transplant programs had been successfully established in Hong Kong, Taiwan, and Korea. More than 1,500 cases have been performed over a 12-year period. This report describes the cumulative experience in living-donor liver transplantation in Asia on the basis of data from five major liver transplant centers.