Adult Living Donor Versus Deceased Donor Liver Transplant (LDLT Versus DDLT) at a Single Center: Time to Change Our Paradigm for Liver Transplant

Hepatocellular Carcinoma and the Role of Liver Transplantation: An Update and Review

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death worldwide. Multiple treatment modalities are available for the management of HCC, depending on its stage as determined by the Barcelona Clinic Liver Cancer staging system. Because liver transplantation (LT) theoretically removes the cancer and replaces the organ at risk for future malignancy, LT is often considered the most definitive and one of the most efficacious treatment options for HCC. Nevertheless, the success and efficacy of liver transplantation depend on various tumor characteristics. As a result, multiple criteria have been developed to assess the appropriateness of a case of HCC for LT, with the pioneering Milan Criteria established in 1996. Over the past 20 to 30 years, these criteria have been critically evaluated, expanded, and often liberalized to make LT for patients with HCC a more universally applicable option. Furthermore, the development of other treatment modalities has enabled downstaging and bridging strategies for HCC prior to LT. In this narrative and comprehensive review, we provided an update on recent trends in the epidemiology of HCC, selection criteria for LT, implementation of LT across different regions, treatment modalities available as bridges, downstaging strategies, alternatives to LT, and, finally, post-LT surveillance.

Living Donor Liver Transplant Programs in the United States Need to Be Carefully Nurtured Amidst Expanding Use of Perfusion Technology

Living donor transplantation constitutes a small portion of total transplants in the United States as compared Southeast Asia and Middle East. Recent consensus meeting has identified reluctance on the part of transplant providers and donor financial concerns as the major hindrance in increasing the Living donor liver transplants in US. There is a need to carefully analyze the recent outcome data from across the globe and from large volume North American centers that clearly establishes the benefit of Living donor transplants for both adults and children and reducing wait list mortality. LDLT also provides an opportunity for expanding the indications to offer transplant for indications like colorectal metastasis and intrahepatic cholangiocarcinoma without reducing the number of livers available for traditional indications. Recent expansion of perfusion technology has demonstrated significant increase in utilization of Non heart beating donor livers over the last few years. However, with simultaneous increase in patients being added to the wait list, the wait list mortality and dropouts have been persistently high. In this opinion piece, the authors have looked at the transplant trends in the US in the last few years and advocate for adopting a complementary rather than a singular approach for expansion of LDLT along with new perfusion technologies for increasing the number of liver transplants in the US.

AI-Based 3D Liver Segmentation and Volumetric Analysis in Living Donor Data

This study investigated the application of deep learning for 3-dimensional (3D) liver segmentation and volumetric analysis in living donor liver transplantation. Using abdominal computed tomography data from 55 donors, this study aimed to evaluate the liver segmentation performance of various U-Net-based models, including 3D U-Net, RU-Net, DU-Net, and RDU-Net, before and after hepatectomy. Accurate liver volume measurement is critical in liver transplantation to ensure adequate functional recovery and minimize postoperative complications. The models were trained and validated using a fivefold cross-validation approach. Performance metrics such as Dice similarity coefficient (DSC), recall, specificity, precision, and accuracy were used to assess the segmentation results. The highest segmentation accuracy was achieved in preoperative images with a DSC of 95.73 ± 1.08%, while postoperative day 7 images showed the lowest performance with a DSC of 93.14 ± 2.10%. A volumetric analysis conducted to measure hepatic resection and regeneration rates revealed an average liver resection rate of 40.52 ± 8.89% and a regeneration rate of 13.50 ± 8.95% by postoperative day 63. A regression analysis was performed on the volumetric results of the artificial intelligence model's liver resection rate and regeneration rate, and all results were statistically significant at p < 0.0001. The results indicate high reliability and clinical applicability of deep learning models in accurately measuring liver volume and assessing regenerative capacity, thus enhancing the management and recovery of liver donors.

Optimization of surgical evaluation algorithms for living donor liver transplantation

BACKGROUND

Living donor liver transplantation (LDLT) is an established and endorsed alternative for deceased donor liver transplantation with better recipient outcomes. Nevertheless, while extensive evaluation of potential donors is crucial, evaluation algorithms differ between transplant centres and guidelines.

METHODS

We included 317 individuals evaluated for LDLT between 07/2007-07/2022 in a retrospective analysis. The evaluation process was analysed to identify the key reasons for declining 77 potential donors. Additionally, 146 donors that underwent LDLT were analysed regarding risk factors for complications.

RESULTS

The main reasons for donor refusal were liver volumetry (40.3 %) and metabolic factors including obesity or steatotic liver disease (20.8 %). Contrast-enhanced computed tomography (CECT) identified 63.6 % of all declined donors; CECT combined with assessment of medical history, physical examination, blood testing and ultrasonography, identified 87.0 % of declined potential donors. Associated with this selection, complication rates in donors were low (≥II in 17.1 %; none with ≥IVb). Notably, higher age was a risk factor for developing a complication ≥II after hemi-hepatectomy (p = 0.0373).

CONCLUSIONS

We propose a progressive 4-step evaluation algorithm that begins with a very basic assessment combined with up-front CECT. This early phase of testing is expected to identify nearly 90 % of ineligible donors, thereby conserving critical resources, time and money, as well as minimising burden for potential donors.

FUNDING

J.M.W. received funding by grant We-4675/6-1 from the Deutsche Forschungsgemeinschaft (DFG) in Bonn, Germany.

Comparison of Vascular Complications Between Living-donor and Deceased-donor Liver Transplantation - A Systematic Review and Meta-analysis

Background

Vascular complications commonly cause graft loss and morbidity after liver transplantation (LT). Comparative data on the risk of vascular complications are limited. Hence, the present meta-analysis was conducted to analyze the difference in vascular complications between living-donor LT (LDLT) and deceased-donor LT (DDLT).

Methods

A literature search of three databases was conducted for studies comparing the incidence of vascular complications with LDLT and DDLT. The event rates and odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model.

Results

A total of 20 studies were included in the final analysis. There was no difference in the incidence of overall vascular complications (9.3%, 95% CI: 6.6-12.0 vs. 8.5%, 95% CI: 5.6-11.4) between LDLT and DDLT with OR 0.94 (95% CI: 0.73-1.21) (15 studies).There was a higher incidence of vascular complications with LDLT in older studies (published before 2013) but not in new studies. When comparing the individual complications, LDLT was associated with a higher incidence of hepatic artery thrombosis (HAT) (3.8%, 95% CI: 2.4-5.2 vs. 1.6%, 95% CI: 1.1-2.2)with OR 2.20 (95% CI: 1.53-3.17) (14 studies)and a significantly lower incidence of intra-abdominal bleeding(4.8%, 95% CI: 3.3-6.2 vs. 7.9%, 95% CI: 5.0-10.7) with OR 0.64 (95% CI: 0.47-0.87) (11 studies). However, there was no difference in the incidence (2.1%, 95% CI: 0.5-3.8 vs. 1.0%, 95% CI: 0.1-1.9) of portal vein thrombosis between LDLT and DDLT with OR 1.85 (95% CI: 0.82-4.18) (6 studies).

Conclusion

Despite a comparable risk of vascular complications between LDLT and DDLT, LDLT was associated with a higher risk of HAT and a lower risk of intraprocedural bleeding. Further studies are required to analyze the effect of donor-recipient characteristics and surgical techniques on the risk of vascular complications.

Comparison of Clinical Outcomes Using Left and Right Liver Grafts in Adult-to-adult Living-donor Liver Transplantation: A Retrospective Cohort Study Using the Korean Organ Transplantation Registry

BACKGROUND

Living-donor liver transplantation has been widely performed as an alternative to the scarce liver grafts from deceased donors. More studies are reporting favorable outcomes of left liver graft (LLG). This study compared the clinical outcomes between living-donor liver transplantation using LLG and right liver graft (RLG) with similar graft-to-recipient body weight ratios.

METHODS

This study analyzed 4601 patients from a multicenter observational cohort using the Korean Organ Transplantation Registry between 2014 and 2021. After matching the Model for End-stage Liver Disease score and graft-to-recipient body weight ratios because of the extremely different number in each group, the LLG and RLG groups comprised 142 (25.1%) and 423 (74.9%) patients, respectively.

RESULTS

For donors, the median age was higher in the LLG group than in the RLG group (34 y [range, 16-62 y] versus 30 y [16-66 y] ; P  = 0.002). For recipients, the LLG group showed higher 90-d mortality than the RLG group (11 [7.7%] versus 9 [2.1%]; P  = 0.004). The long-term graft survival was significantly worse in the LLG group ( P  = 0.011). In multivariate Cox proportional hazards regression analysis for graft survival, LLG was not a significant risk factor (hazard ratio, 1.01 [0.54-1.87]; P  = 0.980). Otherwise, donor age (≥40 y; 2.18 y [1.35-3.52 y]; P  = 0.001) and recipients' body mass index (<18.5 kg/m 2 ; 2.98 kg/m 2 [1.52-5.84 kg/m 2 ]; P  = 0.002) were independent risk factors for graft survival.

CONCLUSIONS

Although the short-term and long-term graft survival was worse in the LLG group, LLG was not an independent risk factor for graft survival in multivariate analysis. LLGs are still worth considering for selected donors and recipients regarding risk factors for graft survival.

Liver Retransplantation Using Living Donor Grafts: A Feasible Approach for Chronic Allograft Failure

BACKGROUND

The indication of living donor liver retransplantation (re-LDLT) for retransplant candidates with chronic allograft failure (CAF) is increasing because of the high mortality rate of patients on the waiting list. However, evidence supporting re-LDLT for CAF remains scarce because of technical difficulties. We aimed to examine the feasibility based on our significant case experience.

METHODS

A total of 95 retransplant cases (adult: 53, pediatric: 42) between 2000 and 2020 were retrospectively reviewed. Graft survival after re-LDLT and deceased donor liver retransplantation (re-DDLT) was compared among recipients with CAF and acute allograft failure (AAF).

RESULTS

Re-LDLTs for CAF were performed in 58 (61.1%) cases, re-DDLTs for CAF in 16 (16.8%) cases, re-LDLTs for AAF in 13 (13.7%) cases, and re-DDLTs for AAF in 8 (8.4%) cases. Re-DDLTs have become increasingly prevalent over time. Retransplantation for AAF results in lower graft survival than that for CAF in both adult and pediatric cases. All adult recipients who underwent re-LDLT for AAF died within 1 y after retransplantation. The 5-y graft survival between re-LDLT and re-DDLT for CAF was not significantly different (73.8% versus 75.0%, P  = 0.84). Operation time and blood loss were not significantly different.

CONCLUSIONS

The survival rate of re-LDLT for recipients with CAF is permissible. Re-LDLT may be another treatment option for recipients with CAF.

Risk factors for biliary strictures and leaks after living-donor liver transplantation: a systematic review and meta-analysis

BACKGROUND

Liver transplantation is the only curative treatment of end-stage liver disease. Unfortunately, a significant number of patients on the organ waitlist die waiting for an organ. Living-donor liver transplantation (LDLT) is an approach that has been used to expand organ availability. Although LDLT has excellent outcomes, biliary complications remain a significant drawback. This meta-analysis aimed to precisely assess the predictors of biliary stricture and leak after LDLT.

METHODS

PubMed, Embase, and Web of Science databases were searched from inception to January 2024. Only studies that used a multivariate model to assess risk factors for post-LDLT biliary stricture or leak in adult participants were included. Studies reporting unadjusted risk factors were excluded. Pooled adjusted odds ratios (ORs) and pooled hazard ratios (HRs) with 95% CIs for risk factors reported in ≥2 studies were obtained within a random-effects model.

RESULTS

Overall, 22 studies with 9442 patients who underwent LDLT were included. The post-LDLT biliary stricture rate was 22%, whereas the post-LDLT biliary leak rate was 14%. In addition, 13 unique risk factors were analyzed. Postoperative bile leak (OR, 4.10 [95% CI, 2.88-5.83]; HR, 3.88 [95% CI, 2.15-6.99]) was the most significant predictor of biliary stricture after LDLT. Other significant predictors of biliary stricture after LDLT were right lobe graft (OR, 2.56; 95% CI, 1.23-5.32), multiple ducts for anastomosis (OR, 1.62; 95% CI, 1.08-2.43), ductoplasty (OR, 2.07; 95% CI, 1.36-3.13), ABO incompatibility (OR, 1.45; 95% CI, 1.16-1.81), and acute cellular rejection (OR, 4.10; 95% CI, 2.88-5.83). Donor bile duct size (HR, 0.82; 95% CI, 0.74-0.91; P = .001, I2 = 0%) was found to be significantly associated with reduced risk of post-LDLT biliary stricture. Donor age, recipient age, recipient male sex, and duct-to-duct anastomosis were not associated with an increased risk of post-LDLT biliary strictures. Multiple ducts for anastomosis (OR, 1.86; 95% CI, 1.43-2.43) was a significant predictor of post-LDLT biliary leak. Recipient age, warm ischemia time, and duct-to-duct anastomosis were not associated with an increased risk of post-LDLT biliary leak.

CONCLUSION

In this meta-analysis, 7 unique risk factors were shown to be predictive of post-LDLT biliary stricture, one of which was associated with both post-LDLT biliary stricture and leak. Donor bile duct size was found to be protective against post-LDLT biliary strictures. Identifying reliable predictors is crucial for recognizing high-risk patients. This approach can facilitate the implementation of preventive measures, surveillance protocols, and targeted interventions to reduce the incidence of biliary strictures after LDLT.

Interplay of Donor-Recipient Relationship and Donor Race in Living Liver Donation in the United States

INTRODUCTION

Living liver donation improves survival of end-stage liver disease (ESLD) patients. Yet, it continues to represent a small proportion of United States (U.S.) liver transplantation with existing racial disparities. We investigated the interplay of donor-recipient relationship and donor race to understand donor subgroups with no significant increase.

METHODS

We studied 4407 living liver donors in the U.S. from January 1, 2012, to December 31, 2022 (median age = 36 years, and 59% were biologically related to the recipient). We quantified the change in the number of donors per 3-year increment using negative binomial regression (incidence rate ratio [IRR]), stratified by donor-recipient relationship and race/ethnicity.

RESULTS

Among biologically related donors, the observed annual number of White donors increased from 146 to 253, Hispanic donors from 18 to 53, and Black donors decreased from 11 to 10. Among unrelated donors, White donors increased from 65 to 221, Hispanic donors from 4 to 25, and Black donors from 3 to 11. For the IRR of biologically related donors aged <40 and ≥40 years, White donors increased by 18% and 22%; Hispanic donors increased by 25% and 54%; and Black donors did not change. Likewise, the IRR of unrelated donors aged <40 and ≥40 years, White donors increased by 48% and 55%; Hispanic donors increased by 52% and 65%; and Black donors did not change.

CONCLUSIONS

While biologically related donors represent the majority of donors, unrelated donors have substantially risen in recent years, primarily driven by White donors. Although the rate of unrelated donations increased among Hispanic donors, the absolute number remains very small (≤25 donors/year). Interventions are needed to increase education among Hispanic and Black communities to grow unrelated living liver donations across race/ethnicity.

Financial toxicity in living donor liver transplantation: A call to action for financial neutrality

After 2 decades of limited growth, living donor liver transplant (LDLT) has been increasingly accepted as a promising solution to the growing organ shortage in the US. With experience, LDLT offers superior graft and patient survival with low rates of rejection. However, not all waitlisted patients have equal access to LDLT, with financial toxicity representing a substantial barrier. Potential living liver donors face indirect, direct, and opportunity costs associated with donation as well as insurance-based discrimination and variable employer leave policies. There are multiple potential national, local, and patient-centered solutions to address some of the cost-related issues associated with living LDLT. These include standardization of employer leave policies, creation of federal and state-led tax relief programs, optimization of National Living Donor Assistance Center use, engagement of independent living donor advocates, creation of financial toolkits, and encouragement of recipient or donor-led fundraising. In this piece, members of the North American Living Liver Donation Group, a consortium of 37 LDLT programs, explore these financial challenges and discuss solutions to achieve financial neutrality, where individuals can donate free from financial constraints or gains. As a community, it is imperative that we confront factors driving financial toxicity to improve equity and access to LDLT.

The rising cost of liver transplantation in the United States

Liver transplantation (LT) is the only curative treatment for end-stage liver disease and significantly improves patient outcomes. However, LT is resource-intensive and costly, with expenditures rising dramatically in recent years. Factors contributing to this increase in cost include expanded transplant criteria, utilization of marginal organs, and broader organ distribution, resulting in significant logistical expenses. Advanced technologies like organ perfusion devices, while promising better outcomes, further inflate costs due to their high price and market monopolization. Moreover, living donor liver transplant and utilization of donation after cardiac death organs introduce higher initial expenditures yet potential long-term savings. Despite rising costs, reimbursement has remained largely stagnant, putting financial strain on transplant programs, and threatening their sustainability. This review examines the multifaceted drivers of rising costs in LT, focusing on recent policy changes, the role of organ procurement organizations, and the impact of new technologies. We also propose comprehensive solutions at national, organ procurement organization, and local levels, including optimizing resource allocation, leveraging regional collaborations, and advocating for revised reimbursement models to curb escalating costs. Addressing these challenges is critical to ensuring the continued viability of LT programs and maintaining patient access to this life-saving intervention.

American perspectives for LDLT in 2024

Living donor liver transplantation (LDLT) was first performed in the US in 1989, primarily benefiting pediatric patients. Its adoption for adults faced setbacks after a donor death in 2001, causing widespread risk aversion. Despite ethical justification and demonstrated safety, LDLT remains underutilized, with fewer than 10% of liver transplants being LDLT. Recent trends indicate improved access to deceased donor liver transplantation (DDLT) due to increased organ donation and technological advances like Normothermic Regional Perfusion (NRP). However, LDLT remains critical, especially for pediatric patients and specific adult populations who benefit significantly from it. Barriers to LDLT include public and clinician apprehensions about donor risks, despite studies showing low-complication rates. Non-directed donations and broader social media engagement have increased donor pools, though the volume of LDLT in the US remains lower than in Asia due to limited training and experience. The A2ALL consortium has been pivotal in studying LDLT safety and outcomes. Currently, around 40 US centers perform LDLT, with high-volume centers leading by example. Training paradigms for LDLT are evolving, with initiatives like the ASTS LDLT master class aiming to enhance surgical expertise. While LDLT is embedded in US liver-transplant practices, its expansion is hampered by risk aversion and the availability of DDLT. Nonetheless, LDLT is essential for addressing the supply-demand mismatch in liver transplantation.

An updated analysis of retransplantation following living donor liver transplantation in the United States: Insights from the latest UNOS database

There is no recent update on the clinical course of retransplantation (re-LT) after living donor liver transplantation (LDLT) in the US using recent national data. The UNOS database (2002-2023) was used to explore patient characteristics in initial LT, comparing deceased donor liver transplantation (DDLT) and LDLT for graft survival (GS), reasons for graft failure, and GS after re-LT. It assesses waitlist dropout and re-LT likelihood, categorizing re-LT cohort based on time to re-listing as acute or chronic (≤ or > 1 mo). Of 132,323 DDLT and 5955 LDLT initial transplants, 3848 DDLT and 302 LDLT recipients underwent re-LT. Of the 302 re-LT following LDLT, 156 were acute and 146 chronic. Primary nonfunction (PNF) was more common in DDLT, although the difference was not statistically significant (17.4% vs. 14.8% for LDLT; p = 0.52). Vascular complications were significantly higher in LDLT (12.5% vs. 8.3% for DDLT; p < 0.01). Acute re-LT showed a larger difference in primary nonfunction between DDLT and LDLT (49.7% vs. 32.0%; p < 0.01). Status 1 patients were more common in DDLT (51.3% vs. 34.0% in LDLT; p < 0.01). In the acute cohort, Kaplan-Meier curves indicated superior GS after re-LT for initial LDLT recipients in both short-term and long-term ( p = 0.02 and < 0.01, respectively), with no significant difference in the chronic cohort. No significant differences in waitlist dropout were observed, but the initial LDLT group had a higher re-LT likelihood in the acute cohort (sHR 1.40, p < 0.01). A sensitivity analysis focusing on the most recent 10-year cohort revealed trends consistent with the overall study findings. LDLT recipients had better GS in re-LT than DDLT. Despite a higher severity of illness, the DDLT cohort was less likely to undergo re-LT.

Comparison of Biliary Complications Between Living and Deceased Donor Liver Transplantations: A Systematic Review and Meta-analysis

To understand if the risk of biliary complications is higher with living donor liver transplantation (LDLT) compared to deceased donor liver transplantation (DDLT), the present meta-analysis was conducted to analyze the differences between these two types of liver transplantations. Three databases were searched from inception to September 2023 for comparative studies reporting biliary complications with LDLT and DDLT. Odds ratios (OR) with 95% confidence intervals were calculated for all the dichotomous outcomes. Twenty-eight studies were included in the final analysis. LDLT was associated with a significantly higher incidence of biliary complications than DDLT (OR 1.96, 95% CI: 1.56-2.47). However, on subgroup analysis, only studies published in or before 2014 reported a higher incidence of biliary complications with LDLT, but not with studies published after 2014. An analysis of individual adverse events showed that LDLT was associated with a higher incidence of both bile leak (OR 3.38, 95% CI: 2.52-4.53) and biliary stricture (OR 1.75, 95% CI: 1.20-2.55). LDLT was associated with a higher incidence of overall biliary complications, including bile leak and biliary stricture. With advances in surgical techniques, there has been a reduction in the risk of biliary complications.

Outcomes of liver transplantation for hepatocelluler carcinoma from living donor versus deceased donor within University of Southern California San Francisco criteria: a report from Turkey

Background

Hepatocellular cancer (HCC) is the most common primary liver cancer with increasing incidence. Liver transplantation (LT) has been accepted as main curative liver cancer treatment. The effectiveness of LDLT as opposed to Deceased Donor Liver Transplant (DDLT) for patients with HCC is still controversial. There is limited data comparing the long-term outcomes of patients undergoing LDLT or DDLT for HCCs that do not meet the Milan criteria.

Methods

We aimed to compare the perioperative and survival outcomes of LDLT with DDLT in HCC patients.Patients underwent LT between January 2012 and December 2020 were retrospectively analyzed. There were 137 patients who met the UCSF criteria. Of these, 75 patients received LDLT and 62 patients DDLT.The primary end points in the present study were oncologic outcomes such as the recurrence rate, disease-free survival (DFS) and overall survival (OS) of LDLT and DDLT in patients with HCC.

Results

PET-CT SUVmax value, the amount of erythrocyte solution (ES) as blood transfusion of red cells given and the tumor recurrence rate were significantly higher among the deceased patients recurrence, ES, PET-CT SUVmax value and tumor differentiation had significant effects on survival. In the multivariate reduced model, cox regression analysis showed significant effects of recurrence, ES, locoregional treatment response and PET-CT on survival.Albeit not significant, the one-year recurrence rate in the LDLT was similar to that in the DDLT, three- and five-year recurrence rates were higher in DDLT compared to LDLT.

Conclusion

There is less chance of cold ischemia time and better-quality grafts with minimal fatty changes, lower recurrence rates and similar survival rates can be achieved in LDLT compared to DDLT.

The Trends in Health Care Utilization and Costs Associated With Primary Liver Cancer: An Analysis of United States Hospitals Between 2016 and 2019

BACKGROUND

Primary liver cancer (PLC) has placed an increasing economic and resource burden on the health care system of the United States. We attempted to quantify its epidemiology and associated costs using a national inpatient database.

METHODS

Hospital discharge and insurance claims data from the National Inpatient Sample were used to conduct this analysis. Patients diagnosed with PLC (hepatocellular carcinoma or cholangiocarcinoma) were included in the study population, which was then stratified using patient demographics, comorbidities, degree of cancer spread, liver disease complications, and other descriptors. Trends were analyzed via regression curves for each of these strata from the years 2016 to 2019, with special attention to patterns in hospitalization incidence, inpatient mortality rate, total costs, and average per-capita costs. The resulting curves were evaluated using goodness-of-fit statistics and P -values.

RESULTS

Aggregate hospitalization incidence, inpatient mortality rates, and total costs were found to significantly increase throughout the study period ( P =0.002, 0.002, and 0.02, respectively). Relative to their demographic counterparts, males, White Americans, and those older than 65 years of age contributed the largest proportions of total costs. These population segments also experienced significant increases in total expenditure ( P =0.04, 0.03, and 0.02, respectively). Admissions deemed to have multiple comorbidities were associated with progressively higher total costs throughout the study period ( P =0.01). Of the categorized underlying liver diseases, only admissions diagnosed with alcoholic liver disease or nonalcoholic fatty liver disease saw significantly increasing total costs ( P =0.006 and 0.01), although hepatitis C was found to be the largest contributor to total expenses.

CONCLUSIONS

From 2016 to 2019, total costs, admission incidence, and inpatient mortality rates associated with PLC hospitalization increased. Strata-specific findings may be reflective of demographic shifts in the PLC patient populations, as well as changes in underlying chronic liver disease etiologies.

Early Conversion to Everolimus Within 180 Days of Living Donor Liver Transplantation

BACKGROUND

Early conversion to Everolimus (EVR) post deceased donor liver transplant has been associated with improved renal function but increased rejection. Early EVR conversion has not been evaluated after living donor liver transplant (LDLT). A retrospective cohort study was conducted to compare the rate of rejection and renal function in patients converted to EVR early post-LDLT to patients on calcineurin inhibitors (CNIs).

METHODS

This was a single center retrospective cohort study of adult LDLT recipients between January 2012 and July 2019. Patients converted to EVR within 180 days of transplant were compared to patients on CNIs. The primary endpoint was biopsy proven acute rejection (BPAR) at 24 months posttransplant. Key secondary endpoints included eGFR at 24 months, change in eGFR, adverse events, and all-cause mortality.

RESULTS

From a total of 173 patients involved in the study: 58 were included in the EVR group and 115 in the CNI group. Median conversion to EVR was 26 days post-LDLT. At 24 months, there was no difference in BPAR (22.7% EVR vs. 19.1% CNI, p = 0.63). Median eGFR at 24 months posttransplant was not significantly different (68.6 [24.8 to 112.4] mL/min EVR vs. 75.9 [35.6-116.2] mL/min CNI, p = 0.103). Change in eGFR from baseline was worse in the EVR group (-13.0 [-39.9 to 13.9] mL/min EVR vs. -5.0 [-31.2 to 21.2] mL/min CNI, p = 0.047). Median change from conversion to 24 months posttransplant (EVR group only) was -3.43 mL/min/1.73 m2 (-21.0 to 9.6).

CONCLUSIONS

Early EVR conversion was not associated with increased risk of rejection among LDLT recipients. Renal function was not impacted. EVR may be considered as an alternative after LDLT in patients intolerant of CNIs.

Advances in Immunotherapy for Transplant Oncology

The increasing incidence of global cancer rates has created an entirely new demand for curative treatment modalities to improve patient outcomes [...].

Survival after live donor versus deceased donor liver transplantation: propensity score-matched study

BACKGROUND

For individuals with advanced liver disease, equipoise in outcomes between live donor liver transplant (LDLT) and deceased donor liver transplant (DDLT) is uncertain.

METHODS

A retrospective cohort study was performed using data extracted from the Scientific Registry of Transplant Recipients. Adults who underwent first-time DDLT or LTDL in the United States between 2002 and 2020 were paired using propensity-score matching with 1:10 ratio without replacement. Patient and graft survival were compared using the model for end-stage liver disease (MELD) score for stratification.

RESULTS

After propensity-score matching, 31 522 DDLT and 3854 LDLT recipients were included. For recipients with MELD scores ≤15, LDLT was associated with superior patient survival (HR = 0.92; 95% c.i. 0.76 to 0.96; P = 0.013). No significant differences in patient survival were observed for MELD scores between 16 and 30. Conversely, for patients with MELD scores >30, LDLT was associated with higher mortality (HR 2.57; 95% c.i. 1.35 to 4.62; P = 0.003). Graft survival was comparable between the two groups for MELD ≤15 and for MELD between 21 and 30. However, for MELD between 16 and 20 (HR = 1.15; 95% c.i. 1.00 to 1.33; P = 0.04) and MELD > 30 (HR = 2.85; 95% c.i. 1.65 to 4.91; P = 0.001), graft survival was considerably shorter after LDLT. Regardless of MELD scores, re-transplantation rate within the first year was significantly higher after LDLT.

CONCLUSIONS

In this large propensity score-matched study using national data, comparable patient survival was found between LDLT and DDLT in recipients with MELD scores between 16 and 30. Conversely, for patients with MELD > 30, LDLT was associated with worse outcomes. These findings underscore the importance of transplant selection for patients with high MELD scores.

Liver Transplantation in Chronic Liver Disease and Acute on Chronic Liver Failure- Indication, Timing and Practices

Liver transplantation (LT) is the second most common solid organ transplantation worldwide. LT is considered the best and most definitive therapeutic option for patients with decompensated chronic liver disease (CLD), hepatocellular carcinoma (HCC), acute liver failure (ALF), and acute-on-chronic liver failure (ACLF). The etiology of CLD shows wide geographical variation, with viral hepatitis being the major etiology in the east and alcohol-related liver disease (ALD) in the west. Non-alcoholic fatty liver disease (NAFLD) is on an increasing trend and is expected to be the most common etiology on a global scale. Since the first successful LT, there have been radical changes in the indications for LT. In many circumstances, not just the liver disease itself but factors such as extra-hepatic organ dysfunction or failures necessitate LT. ACLF is a dynamic syndrome that has extremely high short-term mortality. Currently, there is no single approved therapy for ACLF, and LT seems to be the only feasible therapeutic option for selected patients at high risk of mortality. Early identification of ACLF, stratification of patients according to disease severity, aggressive organ support, and etiology-specific treatment approaches have a significant impact on post-transplant outcomes. This review briefly describes the indications, timing, and referral practices for LT in patients with CLD and ACLF.

Risk Factors for Non-Adherence to Medication for Liver Transplant Patients: An Umbrella Review

Background/Objectives: Liver Transplantation (LT) is the second most common solid organ transplantation. Medication adherence on LT patients is key to avoiding graft failure, mortality, and important quality of life losses. The aim of this study is to identify risk-factors for non-adherence to treatment of liver transplant patients according to reliable published evidence. Methods: An umbrella review within the context of adherence to immunosuppressant medication of LT patients, was conducted. The review was performed in accordance with the principles of the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Results: A total of 11 articles were finally included for the review. Non-adherence factors were identified and allocated using the WHO classification of factors for non-adherence. Each of these groups contains a subset of factors that have been shown to influence adherence to medication, directly or indirectly, according to literature findings. Conclusions: The results of the review indicate that sociodemographic factors, factors related to the patient, factors related to the treatment, condition-related and health system-related factors are good categories of predictors for both adherence and non-adherence to immunosuppressive medication in LT patients. This list of factors may help physicians in the treating and recognizing of patients with a potential risk of non-adherence and it could help in the designing of new tools to better understand non-adherence after LT and targeted interventions to promote adherence of LT patients.

Usefulness of Diffusion-Weighted Imaging in Evaluating Acute Cellular Rejection and Monitoring Treatment Response in Liver Transplant Recipients

Acute cellular rejection (ACR) is a significant immune issue among recipients following liver transplantation. Although diffusion-weighted magnetic resonance imaging (DWI) is widely used for diagnosing liver disease, it has not yet been utilized for monitoring ACR in patients after liver transplantation. Therefore, the aim of this study was to evaluate the efficacy of DWI in monitoring treatment response among recipients with ACR. This study enrolled 25 recipients with highly suspected ACR rejection, and all subjects underwent both biochemistry and DWI scans before and after treatment. A pathological biopsy was performed 4 to 24 h after the first MRI examination to confirm ACR and degree of rejection. All patients were followed up and underwent a repeated MRI scan when their liver function returned to the normal range. After data acquisition, the DWI data were post-processed to obtain the apparent diffusion coefficient (ADC) map on a voxel-by-voxel basis. Five regions of interest were identified on the liver parenchyma to measure the mean ADC values from each patient. Finally, the mean ADC values and biochemical markers were statistically compared between ACR and non-ACR groups. A receiver operating characteristic (ROC) curve was constructed to evaluate the performance of the ADC and biochemical data in detecting ACR, and correlation analysis was used to understand the relationship between the ADC values, biochemical markers, and the degree of rejection. The histopathologic results revealed that 20 recipients had ACR, including 10 mild, 9 moderate, and 1 severe rejection. The results demonstrated that the ACR patients had significantly lower hepatic ADC values than those in patients without ACR. After treatment, the hepatic ADC values in ACR patients significantly increased to levels similar to those in non-ACR patients with treatment. The ROC analysis showed that the sensitivity and specificity for detecting ACR were 80% and 95%, respectively. Furthermore, the correlation analysis revealed that the mean ADC value and alanine aminotransferase level had strong and moderate negative correlation with the degree of rejection, respectively (r = -0.72 and -0.47). The ADC values were useful for detecting hepatic ACR and monitoring treatment response after immunosuppressive therapy.

Approach to Liver Transplantation: Is There a Difference between East and West?

Liver transplantation (LT) remains the only curative treatment for end-stage liver disease as well as acute liver failure. With the exponential increase in organ demand due to the increasing incidence and prevalence of liver diseases, the need to overcome the supply and demand mismatch has arisen. In this review, we discuss the current universal status of LT, emphasizing various LT practices worldwide.

Living Donor Liver Transplantation for Adults With High Model for End-stage Liver Disease Score: The US Experience

BACKGROUND

Outcomes after living-donor liver transplantation (LDLT) at high Model for End-stage Liver Disease (MELD) scores are not well characterized in the United States.

METHODS

This was a retrospective cohort study using Organ Procurement and Transplantation Network data in adults listed for their first liver transplant alone between 2002 and 2021. Cox proportional hazards models evaluated the association of MELD score (<20, 20-24, 25-29, and ≥30) and patient/graft survival after LDLT and the association of donor type (living versus deceased) on outcomes stratified by MELD.

RESULTS

There were 4495 LDLTs included with 5.9% at MELD 25-29 and 1.9% at MELD ≥30. LDLTs at MELD 25-29 and ≥30 LDLT have substantially increased since 2010 and 2015, respectively. Patient survival at MELD ≥30 was not different versus MELD <20: adjusted hazard ratio 1.67 (95% confidence interval, 0.96-2.88). However, graft survival was worse: adjusted hazard ratio (aHR) 1.69 (95% confidence interval, 1.07-2.68). Compared with deceased-donor liver transplant, LDLT led to superior patient survival at MELD <20 (aHR 0.92; P = 0.024) and 20-24 (aHR 0.70; P < 0.001), equivalent patient survival at MELD 25-29 (aHR 0.97; P = 0.843), but worse graft survival at MELD ≥30 (aHR 1.68, P = 0.009).

CONCLUSIONS

Although patient survival remains acceptable, the benefits of LDLT may be lost at MELD ≥30.

Outcomes of Living Donor Liver Transplantation Compared with Deceased Donor Liver Transplantation

Improved surgical techniques and revolutionary immunosuppressive agents have enhanced the long-term outcomes for liver transplantation, with more patients seeking the benefits of liver transplantation, and demand is high. In this review, we hope to delineate where the current data supporting favorable outcomes in using live donation to expand the donor pool compared with the outcomes seen in deceased donor liver transplants. Advances in surgery, transplant and center comfort has made live donor transplantation an asset with favorable patient outcomes in comparison to decease donor data.

Transplant oncology - Current indications and strategies to advance the field

Liver transplantation (LT) was originally described by Starzl as a promising strategy to treat primary malignancies of the liver. Confronted with high recurrence rates, indications drifted towards non-oncologic liver diseases with LT finally evolving from a high-risk surgery to an almost routine surgical procedure. Continuously improving outcomes following LT and evolving oncological treatment strategies have driven renewed interest in transplant oncology. This is not only reflected by constant refinements to the criteria for LT in patients with HCC, but especially by efforts to expand indications to other primary and secondary liver malignancies. With new patient-centred oncological treatments on the rise and new technologies to expand the donor pool, the field has the chance to come full circle. In this review, we focus on the concept of transplant oncology, current indications, as well as technical and ethical aspects in the context of donor organs as precious resources.

Liver Transplantation for Hepatocellular Carcinoma: A Narrative Review and A Glimpse into The Future

Liver transplantation (LT) is a highly effective treatment for carefully selected patients with hepatocellular carcinoma (HCC). In this review, we explored the development of LT selection criteria and organ allocation policies, comparing original data to underscore their historical progression into the intricate task of quantitatively estimating pre- and post-LT survivals. We emphasized the role of biomarkers such as serum alpha-fetoprotein, Des-gamma-carboxy-prothrombin, circulating tumor cells, and circulating tumor DNA in predicting patient outcomes. Additionally, we examined the transplant-associated survival benefits and the difficulties in accurately calculating these benefits. We also reviewed recent advancements in targeted therapy and checkpoint inhibitors for advanced, inoperable HCC and projected their integration into LT for HCC. We further discussed the growing use of living donor liver transplants in the United States and compared its outcomes with those of deceased donor liver transplants. Furthermore, we examined the progress in machine perfusion techniques, which have shown potential in improving patient outcomes and enlarging the donor pool. These advancements present opportunities to enhance LT patient survivals, refine selection criteria, establish new priority metrics, develop innovative bridging and downstaging strategies, and formulate redesigned LT strategies for HCC treatments.

Increasing practice and acceptable outcomes of high-MELD living donor liver transplantation in the USA

Recent deceased-donor allocation changes in the United States may have increased high-Model for End-Stage Liver Disease (MELD) living donor liver transplantation (LDLT); however, outcomes in these patients remain poorly defined. We aimed to examine the impact of the MELD score on LDLT outcomes. Using UNOS data (January 1, 2010-December 31, 2021), LDLT recipients were identified and stratified into low-MELD (<15), intermediate-MELD (15-24), and high-MELD (≥25) groups. We compared outcomes between MELD-stratified LDLT groups and between MELD-stratified LDLT and donation after brain death liver transplantation recipients. We used Kaplan-Meier analysis to compare graft survival rates and multivariable Cox proportional hazards modeling to identify factors associated with graft outcomes. Of 3558 LDLTs, 1605 (45.1%) were low-MELD, 1616 (45.4%) intermediate-MELD, and 337 (9.5%) high-MELD. Over the study period, the annual number of LDLTs increased from 282 to 569, and the proportion of high-MELD LDLTs increased from 3.9% to 7.7%. Graft survival was significantly higher in low-MELD versus high-MELD LDLT recipients (adjusted HR = 1.36, 95% CI: 1.03-1.79); however, 5-year survival exceeded 70.0% in both groups. We observed no significant difference in graft survival between high-MELD LDLT and high-MELD donation after brain death liver transplantation recipients (adjusted HR: 1.25, 95% CI:0.99-1.58), with a 5-year survival of 71.5% and 77.3%, respectively. Low LDLT center volume (<3 LDLTs/year) and recipient life support requirement were both associated with inferior graft outcomes among high-MELD LDLT recipients. While higher MELD scores confer graft failure risk in LDLT, high-MELD LDLT outcomes are acceptable with similar outcomes to MELD-stratified donation after brain death liver transplantation recipients. Future practice guidance should consider the expansion of LDLT recommendations to high-MELD recipients in centers with expertise to help reduce donor shortage.

Type of donor liver transplant does not affect pregnancy outcomes-a systematic review and meta-analysis

Liver transplant (LT) has become increasingly common among reproductive-aged women. The effect of the type of liver donor, either a living donor LT (LDLT) or a deceased donor LT, on pregnancy outcomes is unknown. As such, we aim to review the available literature and assess obstetric, pregnancy, or delivery outcomes in LDLT. We conducted a comprehensive literature review of MEDLINE, EMBASE, Cochrane, and Scopus databases. Random-effect meta-regression assessed the association between the percentage of women who underwent LDLT (independent variable) and the proportion of outcomes. Meta-regression results were expressed as a regression coefficient, which transforms the proportion of outcomes of interest associated with a 1% increase in the percentage of LDLT patients. A value of 0 denotes no relationship between the outcomes and LDLT. A total of 6 articles (438 patients) were included, with a total of 806 pregnancies. Eighty-eight (20.09%) patients underwent LDLT. None of the studies segregated the data based on the type of donor LT. The median time from LT to pregnancy was 4.86 (4.62-5.03) years. Twelve (1.5%) stillbirths were reported. LDLT was statistically significantly associated with a higher rate of stillbirths (coefficient 0.002, p < 0.001; I 2 0%). The type of donor LT was not associated with an increased risk of other obstetric, pregnancy, or delivery complications. This is the first meta-analysis to evaluate the effect of the type of donor LT on pregnancy outcomes. This study highlights the lack of robust literature addressing this important topic. The results suggest that pregnancy outcomes after LDLT and deceased donor LT are comparable. Despite LDLT being statistically significantly associated with a higher rate of stillbirths, the association is weak and is unlikely to be clinically significant.

Novel Benchmark for Adult-to-Adult Living-donor Liver Transplantation: Integrating Eastern and Western Experiences

OBJECTIVE

To define benchmark values for adult-to-adult living-donor liver transplantation (LDLT).

BACKGROUND

LDLT utilizes living-donor hemiliver grafts to expand the donor pool and reduce waitlist mortality. Although references have been established for donor hepatectomy, no such information exists for recipients to enable conclusive quality and comparative assessments.

METHODS

Patients undergoing LDLT were analyzed in 15 high-volume centers (≥10 cases/year) from 3 continents over 5 years (2016-2020), with a minimum follow-up of 1 year. Benchmark criteria included a Model for End-stage Liver Disease ≤20, no portal vein thrombosis, no previous major abdominal surgery, no renal replacement therapy, no acute liver failure, and no intensive care unit admission. Benchmark cutoffs were derived from the 75th percentile of all centers' medians.

RESULTS

Of 3636 patients, 1864 (51%) qualified as benchmark cases. Benchmark cutoffs, including posttransplant dialysis (≤4%), primary nonfunction (≤0.9%), nonanastomotic strictures (≤0.2%), graft loss (≤7.7%), and redo-liver transplantation (LT) (≤3.6%), at 1-year were below the deceased donor LT benchmarks. Bile leak (≤12.4%), hepatic artery thrombosis (≤5.1%), and Comprehensive Complication Index (CCI ® ) (≤56) were above the deceased donor LT benchmarks, whereas mortality (≤9.1%) was comparable. The right hemiliver graft, compared with the left, was associated with a lower CCI ® score (34 vs 21, P < 0.001). Preservation of the middle hepatic vein with the right hemiliver graft had no impact neither on the recipient nor on the donor outcome. Asian centers outperformed other centers with CCI ® score (21 vs 47, P < 0.001), graft loss (3.0% vs 6.5%, P = 0.002), and redo-LT rates (1.0% vs 2.5%, P = 0.029). In contrast, non-benchmark low-volume centers displayed inferior outcomes, such as bile leak (15.2%), hepatic artery thrombosis (15.2%), or redo-LT (6.5%).

CONCLUSIONS

Benchmark LDLT offers a valuable alternative to reduce waitlist mortality. Exchange of expertise, public awareness, and centralization policy are, however, mandatory to achieve benchmark outcomes worldwide.

Systematic review and meta-analysis of open versus laparoscopy-assisted versus pure laparoscopic versus robotic living donor hepatectomy

The value of minimally invasive approaches for living donor hepatectomy remains unclear. Our aim was to compare the donor outcomes after open versus laparoscopy-assisted versus pure laparoscopic versus robotic living donor hepatectomy (OLDH vs. LALDH vs. PLLDH vs. RLDH). A systematic literature review of the MEDLINE, Cochrane Library, Embase, and Scopus databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (up to December 8, 2021). Random-effects meta-analyses were performed separately for minor and major living donor hepatectomy. The risk of bias in nonrandomized studies was assessed using the Newcastle-Ottawa Scale. A total of 31 studies were included. There was no difference in donor outcomes after OLDH versus LALDH for major hepatectomy. However, PLLDH was associated with decreased estimated blood loss, length of stay (LOS), and overall complications versus OLDH for minor and major hepatectomy, but also with increased operative time for major hepatectomy. PLLDH was associated with decreased LOS versus LALDH for major hepatectomy. RLDH was associated with decreased LOS but with increased operative time versus OLDH for major hepatectomy. The scarcity of studies comparing RLDH versus LALDH/PLLDH did not allow us to meta-analyze donor outcomes for that comparison. There seems to be a marginal benefit in estimated blood loss and/or LOS in favor of PLLDH and RLDH. The complexity of these procedures limits them to transplant centers with high volume and experience. Future studies should investigate self-reported donor experience and the associated economic costs of these approaches.

Prevalence and factors associated with depression and anxiety in living liver donors: A systematic review and meta-analysis

OBJECTIVE

This study aimed to systematically review the prevalence and factors associated with depression and anxiety in living liver donors after liver transplantation.

METHODS

Five English language electronic databases and four Chinese language electronic databases were searched from inception to February 2023. Two investigators independently extracted the data and assessed the study quality. The pooled prevalence was calculated using STATA software (version 14.0). We performed a narrative review to summarize the factors associated with depression and anxiety in living liver donors after liver transplantation. The protocol of this study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) database, registration number: CRD42021290071.

RESULTS

This study included 39 articles involving 18,577 participants. The pooled prevalence was 6.3% [95% confidence interval (CI) (4.1-8.9%)] for depression in living liver donors, and 10.0% [95% CI (4.0-18.1%)] for anxiety. Prevalence of clinically significant depressive or anxiety symptoms was higher (15.7% and 17.4%) compared with disorders (2.7% and 2.2%). The prevalence of depression and anxiety was highest within 3 months post-donation. Specifically, female donors, serious postoperative complications, and recipients' poor health/death have been reported as factors having a negative influence on depression and anxiety.

CONCLUSIONS

Collected evidence showed that the overall prevalence of depression or anxiety of living liver donors was high. Therefore, early detection and timely treatment of psychological disorders are crucial to promote positive psychiatric health outcomes and ensure the quality of life of living liver donors.

'It is a life changing experience': The experiences of living kidney donors who live in rural Australia

INTRODUCTION

A growing body of research has examined the physical, psychological, social and financial impacts of living kidney donation. However, little is known about the unique experiences or additional burdens faced by living donors from regional or remote locations.

OBJECTIVE

To explore the experiences of living kidney donors who live outside metropolitan centres and to determine how support services could be orientated to better meet their unique needs.

DESIGN/SETTING/PARTICIPANTS

Seventeen living kidney donors participated in semistructured telephone interviews. Qualitative data were analysed using thematic analysis.

FINDINGS

Eight themes were identified: (1) donor's emotional well-being is influenced by the recipient's outcome, (2) varied levels of access to medical support and other important services in rural areas, (3) travel takes a toll on time, finances and well-being, (4) varied level of financial impact, (5) medical, emotional and social challenges, (6) both lay and health professional support is valued, (7) varied levels of knowledge and experiences accessing information and (8) a worthwhile experience overall.

CONCLUSION

Despite many challenges, and travel adding to the complexity, rural living kidney donors generally consider it to be a worthwhile experience. The provision of additional emotional, practical and educational support would be welcomed by this group.

Current Status of Living Donor Liver Transplantation: Impact, Advantages, and Challenges

PURPOSE OF THIS REVIEW

This review provides an overview of the current status of Living Donor Liver Transplant (LDLT). It discusses the impact of LDLT on waitlist and post-transplantation outcomes, highlighting the technical challenges and unique advantages of LDLT.

RECENT FINDINGS

Recent findings show that LDLT offers several theoretical advantages over deceased donor liver transplant, including shorter wait times, better graft quality, and improved post-transplant outcomes. Non-alcoholic fatty liver disease (NAFLD) and hepatocellular carcinoma (HCC) are emerging as the leading indications for adult LDLT in the US. LDLT demonstrates comparable or better overall survival rates and organ-specific outcomes compared to deceased donor transplants. However, challenges exist, including donor and recipient risks such as biliary complications and small-for-size syndrome. Ongoing research focuses on refining surgical techniques, exploring minimally invasive approaches, utilizing predetermined donors to modulate the recipient's immune system, and ensuring ethical practices. LDLT is a valuable solution for patients with end-stage liver failure or disorders requiring transplantation. It offers advantages such as shorter wait times as well as improved waitlist and post-transplant outcomes. Continued research and advancements in LDLT will benefit patients in need of liver transplantation.

Comparing High- and Low-Model for End-Stage Liver Disease Living-Donor Liver Transplantation to Determine Clinical Efficacy: A Systematic Review and Meta-Analysis (CHALICE Study)

INTRODUCTION

Various studies have demonstrated that low-Model for End-Stage Liver Disease (MELD) living-donor liver transplant (LDLT) recipients have better outcomes with improved patient survival than deceased-donor liver transplantation (DDLT) recipients. LDLT recipients gain the most from being transplanted at MELD <25-30; however, some existing data have outlined that LDLT may provide equivalent outcomes in high-MELD and low-MELD patients, although the term "high" MELD is arbitrarily defined in the literature and various cut-off scores are outlined between 20 and 30, although most commonly, the dividing threshold is 25. The aim of this meta-analysis was to compare LDLT in high-MELD with that in low-MELD recipients to determine patient survival and graft survival, as well as perioperative and postoperative complications.

METHODS

Following PROSPERO registration CRD-42021261501, a systematic database search was conducted for the published literature between 1990 and 2021 and yielded a total of 10 studies with 2183 LT recipients; 490 were HM-LDLT recipients and 1693 were LM-LDLT recipients.

RESULTS

Both groups had comparable mortality at 1, 3 and 5 years post-transplant (5-year HR 1.19; 95% CI 0.79-1.79; p-value 0.40) and graft survival (HR 1.08; 95% CI 0.72, 1.63; p-value 0.71). No differences were observed in the rates of major morbidity, hepatic artery thrombosis, biliary complications, intra-abdominal bleeding, wound infection and rejection; however, the HM-LDLT group had higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay.

CONCLUSIONS

The high-MELD LDLT group had similar patient and graft survival and morbidities to the low-MELD LDLT group, despite being at higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The data, primarily sourced from high-volume Asian centers, underscore the feasibility of living donations for liver allografts in high-MELD patients. Given the rising demand for liver allografts, it is sensible to incorporate these insights into U.S. transplant practices.

Imaging Evaluation of the Living Liver Donor: A Systems-Based Approach

Liver transplant is the definitive treatment of end-stage liver disease and early hepatocellular carcinoma. The number of liver transplant surgeries done is highly affected by the number and availability of deceased donor organs. Living donor liver transplantation has emerged as an alternative source of donors, increasing the availability of organs for transplant. Many factors must be considered when choosing living donor candidates to maintain a high level of donor safety and organ survival. To that end, potential donors undergo a rigorous pre-donation workup.

Impact of living donor liver transplantation on long-term cardiometabolic and graft outcomes in cirrhosis due to nonalcoholic steatohepatitis

BACKGROUND AND AIM

Non-alcoholic steatohepatitis (NASH) is a leading indication for liver transplantation (LT). This study aimed to determine whether living donor LT (LDLT) recipients experienced less recurrent NASH, cirrhosis, and cardiometabolic complications compared to deceased donor LT (DDLT).

METHOD

Patients with LDLT and DDLT for NASH between February 2002 and May 2018 at University Health Network (UHN) were compared. Cox Proportional Hazard model was used to analyze overall survival (OS), Fine and Gray's Competing Risk models were conducted to analyze cumulative incidence of post LT outcomes.

RESULTS

One hundred and ninety-nine DDLTs and 66 LDLTs were performed for NASH cirrhosis. Time and rate of recurrence of NAFLD and NASH were comparable in both groups. Graft cirrhosis was more common in DDLT recipients (n = 14) versus LDLT (n = 0) (p < .0001). Significant fibrosis (Fibrosis ≥ F2) developed in 50 recipients (12 LDLT and 38 DDLT) post LT (DDLT vs. LDLT: HR = 1.00, 95% CI = (.52-1.93), p = .91) and there was no difference in time to significant fibrosis (p = .57). There was no difference in development of post-transplant diabetes, dyslipidemia, metabolic syndrome, cardiovascular disease, and cancers. LDLT group had better renal function at 10 years (MDRD eGFR of 57.0 mL/min vs. 48.5 mL/min, p = .047). Both groups had a comparable OS (HR = 1.83 (95% CI = .92-3.62), p = .08).

CONCLUSION

Overall, LDLT recipients had significantly better renal function by virtue of having early transplantation in their disease course. LDLT was also associated with significantly less graft cirrhosis, although OS and cardiometabolic outcomes were comparable between LDLT and DDLT.

Liver Transplantation for Acute Liver Failure- Indication, Prioritization, Timing, and Referral

Acute liver failure (ALF) is a major success story in gastroenterology, with improvements in critical care and liver transplant resulting in significant improvements in patient outcomes in the current era compared to the dismal survival rates in the pretransplant era. However, the ever-increasing list of transplant candidates and limited organ pool makes judicious patient selection and organ use mandatory to achieve good patient outcomes and prevent organ wastage. Several scoring systems exist to facilitate the identification of patients who need a liver transplant and would therefore need an early referral to a specialized liver unit. The timing of the liver transplant is also crucial as transplanting a patient too early would lead to those who would recover spontaneously receiving an organ (wastage), and a late decision might result in the patient becoming unfit for transplant (delisted) or have an advanced disease which would result in poor post-transplant outcomes. The current article reviews the indications and contraindications of liver transplant in ALF patients, the various prognostic scoring systems, etiology-specific outcomes, prioritization and timing of referral.

The trends in cost associated with liver transplantation in the US: Analysis of weighted hospital data

This study aims to evaluate recent annualized trends in the cost-burden of inpatient hospitalizations associated with liver transplantation (LT) in the US as stratified by patient demographics and medical characteristics. From 2016 to 2019 National Inpatient Sample was used to select patients who underwent LT, from which the weighted charge estimates were derived and converted to admission costs using inflation-adjusted charge-to-cost ratios. The adjusted values were stratified using select patient variables and graphed across the respective years to derive goodness-of-fit for each trend (expressed with R2 and p -values). From 2016 to 2019, the estimated total number of LT-related hospitalizations in the US were 6685, 7075, 7260, and 7815 cases respectively. There was a general increase in the total cost of LT-related hospitalizations over the years: $945.75, $1010.23, $1052.46, and $1143.84 in millions of dollars (0.98, 0.01). Furthermore, positive trends in total cost were observed in the following strata: patients aged 35-49 (0.92, 0.04) and above 65 (0.91, 0.05), Whites (0.99, 0.01), those with congestive heart failure (0.98, 0.01), ≥2 comorbidities (0.97, 0.02), hepatic encephalopathy (0.93, 0.04), and those with private insurance (0.93, 0.04), as well as LT performed in the Northeast (0.94, 0.03), Midwest (0.92, 0.04), and South (0.91, 0.04). Total cost associated with hepatitis C declined significantly (0.94, 0.03). With respect to mean costs, positive trends were observed in the following strata: those with other or cryptogenic liver disease (0.93, 0.03), ≥2 comorbidities (0.96, 0.02), and LT performed in the Northeast region (0.93, 0.04). The number of liver transplants performed in the US, as well as the associated costs, are rising. Given the apparent rising costs in specific patient populations, economic and public health policies must focus on cost containment within these groups to ensure appropriate usage of resources.

Association between Hepatocellular Carcinoma Recurrence and Graft Size in Living Donor Liver Transplantation: A Systematic Review

The aim of this work was to assess the association between graft-to-recipient weight ratio (GRWR) in adult-to-adult living donor liver transplantation (LDLT) and hepatocellular carcinoma (HCC) recurrence. A search of the MEDLINE and EMBASE databases was performed until December 2022 for studies comparing different GRWRs in the prognosis of HCC recipients in LDLT. Data were pooled to evaluate 1- and 3-year survival rates. We identified three studies, including a total of 782 patients (168 GRWR < 0.8 vs. 614 GRWR ≥ 0.8%). The pooled overall survival was 85% and 77% at one year and 90% and 83% at three years for GRWR < 0.8 and GRWR ≥ 0.8, respectively. The largest series found that, in patients within Milan criteria, the GRWR was not associated with lower oncological outcomes. However, patients with HCC outside the Milan criteria with a GRWR < 0.8% had lower survival and higher tumor recurrence rates. The GRWR < 0.8% appears to be associated with lower survival rates in HCC recipients, particularly for candidates with tumors outside established HCC criteria. Although the data are scarce, the results of this study suggest that considering the individual GRWR not only as risk factor for small-for-size-syndrome but also as contributor to HCC recurrence in patients undergoing LDLT would be beneficial. Novel perfusion technologies and pharmacological interventions may contribute to improving outcomes.

Invasive aspergillosis in liver transplant recipients

BACKGROUND

Liver transplantation is increasing worldwide with underlying pathologies dominated by metabolic and alcoholic diseases in developed countries.

METHODS

We provide a narrative review of invasive aspergillosis (IA) in liver transplant (LT) recipients. We searched PubMed and Google Scholar for references without language and time restrictions.

RESULTS

The incidence of IA in LT recipients is low (1.8%), while mortality is high (∼50%). It occurs mainly early (<3 months) after LT. Some risk factors have been identified before (corticosteroid, renal, and liver failure), during (massive transfusion and duration of surgical procedure), and after transplantation (intensive care unit stay, re-transplantation, re-operation). Diagnosis can be difficult and therefore requires full radiological and clinicobiological collaboration. Accurate identification of Aspergillus species is recommended due to the cryptic species, and susceptibility testing is crucial given the increasing resistance of Aspergillus fumigatus to azoles. It is recommended to reduce the dose of tacrolimus (50%) and to closely monitor the trough level when introducing voriconazole, isavuconazole, and posaconazole. Surgery should be discussed on a case-by-case basis. Antifungal prophylaxis is recommended in high-risk patients. Environmental preventative measures should be implemented to prevent outbreaks of nosocomial aspergillosis in LT recipient units.

CONCLUSION

IA remains a very serious disease in LT patients and should be promptly sought and, if possible, prevented by clinicians when risk factors are identified.

Expanding the living donor pool using domino liver transplantation: a systematic review

INTRODUCTION

To this day, a discrepancy exists between donor liver demand and supply. Domino liver transplantation (DLT) can contribute to increasing the number of donor livers available for transplantation.

METHODS

The design of this systematic review was based on the Preferred Reporting Items for Systematic Reviews (PRISMA). A qualitative analysis of included studies was performed. Primary outcomes were mortality and peri- and postoperative complications related to DLT.

RESULTS

Twelve studies met the inclusion criteria. All included studies showed that DLT outcomes were comparable to outcomes of deceased donor liver transplantation (DDLT) in terms of mortality and complications. One-year patient survival rate ranged from 66.7% to 100%. Re-transplantation rate varied from 0 to 12.5%. Most frequent complications were related to biliary (3.7%-37.5%), hepatic artery (1.6%-9.1%), portal vein (12.5-33.3%) and hepatic vein events (1.6%), recurrence of domino donor disease (3.3%-17.4%) and graft rejection (16.7%-37.7%). The quality of the evidence was rated as moderate according to the Newcastle-Ottawa scale (NOS).

CONCLUSION

DLT outcomes were similar to DDLT in terms of mortality and complications. Even though DLT will not solve the entire problem of organ shortage, transplant programs should always consider using this tool to maximize the availability of liver grafts.

The John S. Najarian symposium: The past, present, and future of surgery and transplantation, May 20, 2022, Minneapolis, MN

Dr John S Najarian (1927-2020), chairman of the Department of Surgery at the University of Minnesota from 1967 to 1993, was a pioneer in surgery, clinical immunology and transplantation. A Covid-delayed Festschrift was held in his honor on May 20, 2022. The speakers reflected on his myriad contributions to surgery, transplantation, and resident/fellow training, as well as current areas of ongoing research to improve clinical outcomes. Of note, Dr Najarian was a founder of the journal Clinical Transplantation.