The International Liver Transplant Society Guideline on Living Liver Donation

Outcomes and Risk Factors for Liver Transplantation Using Graft-to-Recipient Weight Ratio Less Than 0.8 Graft From Living Donors: Multicentric Cohort Study

OBJECTIVE

To compare graft survival after living donor liver transplantation (LDLT) in patients receiving graft-to-recipient weight ratio (GRWR) <0.8 versus GRWR≥0.8 grafts and identify risk factors for graft loss using GRWR<0.8 grafts.

BACKGROUND

Favorable outcomes after LDLT using GRWR<0.8 grafts were recently reported; however, these results have not been validated using multicenter data.

METHODS

This multicentric cohort study included 3450 LDLT patients. Graft survival was compared between 1:3 propensity score-matched groups and evaluated using various Cox models in the entire population. Risk factors for graft loss with GRWR<0.8 versus GRWR≥0.8 grafts were explored within various subgroups using interaction analyses, and outcomes were stratified according to the number of risk factors.

RESULTS

In total, 368 patients (10.7%) received GRWR<0.8 grafts (GRWR<0.8 group), whereas 3082 (89.3%) received GRWR≥0.8 grafts (GRWR≥0.8 group). The 5-year graft survival rate was significantly lower with GRWR<0.8 grafts than with GRWR≥0.8 grafts (85.2% vs 90.1%, P =0.013). Adjusted hazard ratio for graft loss using GRWR<0.8 grafts in the entire population was 1.66 (95% CI: 1.17-2.35, P =0.004). Risk factors exhibiting significant interactions with GRWR<0.8 for graft survival were age ≥60 years, Model for End-stage Liver Disease score ≥15, and male donor. When ≥2 risk factors were present, GRWR<0.8 grafts showed a higher risk of graft loss compared with GRWR≥0.8 graft in LDLT (hazard ratio 2.98, 95% CI: 1.79-4.88, P <0.001).

CONCLUSIONS

GRWR<0.8 graft showed inferior graft survival than controls (85.2% vs 90.1%), especially when ≥2 risk factors for graft loss (among age 60 years or above, Model for End-stage Liver Disease score ≥15, or male donor) were present.

Applying LASSO logistic regression for the prediction of biliary complications after ex vivo liver resection and autotransplantation in patients with end-stage hepatic alveolar echinococcosis

BACKGROUND

The purpose of this study was to explore the relevant risk factors associated with biliary complications (BCs) in patients with end-stage hepatic alveolar echinococcosis (HAE) following ex vivo liver resection and autotransplantation (ELRA) and to establish and visualize a nomogram model.

METHODS

This study retrospectively analysed patients with end-stage HAE who received ELRA treatment at the First Affiliated Hospital of Xinjiang Medical University between August 1, 2010 and May 10, 2023. The least absolute shrinkage and selection operator (LASSO) regression model was applied to optimize the feature variables for predicting the incidence of BCs following ELRA. Multivariate logistic regression analysis was used to develop a prognostic model by incorporating the selected feature variables from the LASSO regression model. The predictive ability, discrimination, consistency with the actual risk, and clinical utility of the candidate prediction model were evaluated using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA). Internal validation was performed by the bootstrapping method.

RESULTS

The candidate prediction nomogram included predictors such as age, hepatic bile duct dilation, portal hypertension, and regular resection based on hepatic segments. The model demonstrated good discrimination ability and a satisfactory calibration curve, with an area under the ROC curve (AUC) of 0.818 (95% CI 0.7417-0.8958). According to DCA, this prediction model can predict the risk of BCs occurrence within a probability threshold range of 9% to 85% to achieve clinical net benefit.

CONCLUSIONS

A prognostic nomogram with good discriminative ability and high accuracy was developed and validated to predict BCs after ELRA in patients with end-stage HAE.

The incidence of adverse outcome in donors after living donor liver transplantation: A meta-analysis of 60,829 donors

The scarcity of liver grafts has prompted developments in living donor liver transplantations (LDLT), with previous literature illustrating similar outcomes in recipients compared to deceased donor transplants. However, significant concerns regarding living donor morbidity and mortality have yet to be examined comprehensively. This study aims to provide estimates of the incidence of various outcomes in living liver donors. In this meta-analysis, Medline and Embase were searched from inception to July 2022 for articles assessing the incidence of outcomes in LDLT donors. Complications in the included studies were classified into respective organ systems. Analysis of incidence was conducted using a generalized linear mixed model with Clopper-Pearson intervals. Eighty-seven articles involving 60,829 living liver donors were included. The overall pooled incidence of complications in LDLT donors was 24.7% (CI: 21.6%-28.1%). The incidence of minor complications was 17.3% (CI: 14.7%-20.3%), while the incidence of major complications was lower at 5.5% (CI: 4.5%-6.7%). The overall incidence of donor mortality was 0.06% (CI: 0.0%-0.1%) in 49,027 individuals. Psychological complications (7.6%, CI: 4.9%-11.5%) were the most common among LDLT donors, followed by wound-related (5.2%, CI: 4.4%-6.2%) and respiratory complications (4.9%, CI: 3.8%-6.3%). Conversely, cardiovascular complications had the lowest incidence among the subgroups at 0.8% (CI: 0.4%-1.3%). This study presents the incidence of post-LDLT outcomes in living liver donors, illustrating significant psychological, wound-related, and respiratory complications. While significant advancements in recent decades have contributed towards decreased morbidity in living donors, our findings call for targeted measures and continued efforts to ensure the safety and quality of life of liver donors post-LDLT.

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation

Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.

Pre-operative assessment of living liver donors' liver anatomy and volumes

Decades of experience supports LDLT as a favorable strategy to reduce waitlist mortality. The multiple regenerative pathways of hepatocytes and other hepatic cells justify the rationale behind it. Nonetheless, living liver donation is still underused and its broader implementation is challenging, mostly due to variability in practices leading to concerns related to donor safety. A non-systematic literature search was conducted for peer-reviewed original articles related to pre-operative evaluation of living liver donor candidates. Eligible studies were synthesized upon consensus for discussion in this up-to-date review. Review of the literature demonstrate that the importance of preoperative assessment of vascular, biliary and liver volume to ensure donor safety and adequate surgical planning for graft procurement is widely recognized. Moreover, data indicates that anatomic variants in vascular and biliary systems in healthy donors are common, present in up to 50% of the population. Therefore, comprehensive mapping and visualizations of each component is needed. Different imaging modalities are reported across practices and are discussed in detail. Lastly, assessment of liver volume must take into account several technical and donor factors that increase the chances of errors in volume estimation, which occurs in up to 10% of the cases. Experience suggests that maximizing donor safety and lessening their risks is a result of integrated experience between hepatobiliary and transplant surgery, along with multidisciplinary efforts in performing a comprehensive pre-operative donor assessment. Although technical advances have increased the accuracy of volume estimation, over- or under-estimation remains a challenge that needs further attention.

Autoimmune Hepatitis on a Living Liver Donor: An Unexpected Long-Term Complication

In Western countries, deceased donor liver transplantation remains the standard of care for patients with end-stage liver disease. Living donor liver transplantation is a viable and feasible strategy for patients with end-stage liver disease designed to mitigate the deceased organ shortage. Donor safety is the primary concern because liver donors, ideally, should not have any complication. We report a case of middle-aged woman without a history of chronic liver disease who developed autoimmune hepatitis more than 20 years after live liver donation. Changes in these patients' liver enzymes should prompt swift referral to an hepatologist for initial liver disease work-up.

An international survey of venous thromboembolic events and current practices of peri-operative VTE prophylaxis after living donor hepatectomy

BACKGROUND

Venous thromboembolic complications are an uncommon but significant cause of morbidity & mortality after live donor hepatectomy . The precise incidence of these events and the current practices of centers performing living donor liver transplantation worldwide are unknown.

METHODS

An online survey was shared amongst living donor liver transplantation centers containing questions regarding center activity, center protocols for donor screening, peri-operative thromboembolic prophylaxis and an audit of -perioperative venous thromboembolic events after live donor hepatectomy in the previous five years (2016-2020).

RESULTS

Fifty-one centers from twenty countries completed the survey. These centers had cumulatively performed 11500 living donor liver transplants between 2016-2020. All centers included pre-operative l assessment for thromboembolic risk amongst potential liver donors in their protocols. Testing for inherited prothrombotic conditions was performed by 58% of centers. Dual-mode prophylaxis was the most common practice (65%), while eight and four centers used single mode or no routine prophylaxis respectively. Twenty (39%) and 15 (29%) centers reported atleast one perioperative deep venous thrmobosis or pulmonary embolism event respectively. There was one donor mortality directly related to post-operative pulmonary embolism. Overall incidence of deep venous thrombosis and pulmonary embolism events was 3.65 and 1.74 per 1000 live donor hepatectomies respectively. Significant variations in center practices and incidence of thromboembolic events was identified in the survey primarily divided along world regions. 75% of participating centers agreed on the need for clear international guidelines.

CONCLUSION

Venous thromboembolic events after live donor hepatectomy are an uncommon but important cause of donor morbidity. There is significant variation in practice among centers. Evidence-based guidelines regarding risk assessment, and peri-operative prophylaxis are needed.

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.

A systematic review of the factors significantly influencing the quality of life of living liver donors

Objectives

This systematic review aimed to synthesize the literature on factors influencing the quality of life in living liver donors post-donation and to provide a reference for developing targeted interventions in clinical practice.

Methods

A systematic search guided by the PRISMA 2020 approach was performed on specific databases: PubMed, EMBASE, CINHAL with full text, Web of Science, and ProQuest Dissertations & Theses databases. Peer-reviewed articles published in English from inception to October 2022 covering cross-sectional studies and longitudinal studies on factors affecting the quality of life of living liver donors after donation were included in this systematic review. The methodological quality of the studies was examined using a modified version of the National Institutes of Health Quality Assessment Tool.

Results

A total of 6,576 studies were retrieved, and 16 eligible studies were finally included. Four types of independent influencing factors: sociodemographic (gender, donor age, education, ethnicity, and marital status), donation-related (length of hospital stay and number of hospitalizations/hospital visits related to donation surgery, recipient outcome, time from donation, complications, donation decision, ambivalence about donating, donor-recipient relationship), health-related (body mass index and pre-donation physical symptoms), and psychosocial (pre-donation physical and mental score, household income, anxiety, depression), were extracted from the included studies. Several studies consistently identified old age, recipient death, recent donation, postoperative complications experienced by donors, and donor concerns about their well-being as negative influencing factors on physical function. Female donors, low education levels, longer hospital stays, and/or more hospital visits due to donation, poor recipient outcome, recent donation, pre-donation concerns regarding their well-being, and first-degree relative and spouse/partner donors were reported in several studies as negative predictors for psychological status. Factors affecting social function were considered by only two included articles.

Conclusions

The quality of life of living liver donors could be affected by both donation surgery and psychosocial factors. Based on the above-influencing factors, clinical nurses can develop targeted interventions to improve the quality of life of living liver donors.

Donor safety of remnant liver volumes of less than 30% in living donor liver transplantation: A systematic review and meta-analysis

PURPOSE

This meta-analysis aimed to investigate the acceptability of donor remnant liver volume (RLV) to total liver volume (TLV) ratio (RLV/TLV) being <30% as safe in living donor liver transplantations (LDLTs).

METHODS

Online databases were searched from January 2000 to June 2022. Pooled odds ratios (ORs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using fixed- or random-effects model.

RESULTS

One prospective and seven retrospective studies comprising 1935 patients (164 RLV/TLV <30% vs. 1771 RLV/TLV ≥30%) were included. Overall (OR = 1.82; 95% CI [1.24, 2.67]; p = .002) and minor (OR = 1.88; 95% CI [1.23, 2.88]; p = .004) morbidities were significantly lower in the RLV/TLV ≥30% group than in the RLV/TLV <30% group (OR = 1.82; 95% CI [1.24, 2.67]; p = .002). No significant differences were noted in the major morbidity, biliary complications, and hepatic dysfunction. Peak levels of bilirubin (SMD = .50; 95% CI [.07, .93]; p = .02) and international normalized ratio (SMD = .68; 95% CI [.04, 1.32]; p = .04) were significantly lower in the RLV/TLV ≥ 30% group than in the RLV/TLV <30% group. No significant differences were noted in the peak alanine transferase and aspartate transaminase levels and hospital stay.

CONCLUSIONS

Considering the safety of the donor as the top priority, the eligibility of a potential liver donor in LDLT whose RLV/TLV is expected to be <30% should not be accepted.

Fibroprogression and Cirrhosis Occurring in Living Liver Donor: First Case Report

Background

Limited dead donor pool paved the way for living liver donation so that waitlist mortality could be reduced. With over two decades of experience in the East as well as in the West, right lobe adult-to-adult living donor liver transplantation has become an established intervention. The short-term surgical outcomes, complications and health-related quality of life are well known. There is dearth of data on long-term health of remnant liver of donors, especially after a decade of donation.

Case description

A 56-year-old lady who donated her right liver lobe 11 years back for her husband with end-stage liver disease. Recipient is doing well till date. She was incidentally found to have thrombocytopenia on follow-up. Her haematological evaluation was negative for blood dyscrasias. Further evaluation demonstrated biopsy-proven cirrhosis with endoscopic evidence of portal hypertension. Aetiological workup was done, which ruled out viral, autoimmune causes as well as Wilson's disease and hemochromatosis. This donor had gained weight post-donation with body mass index of 32.4 kg/m2 and dyslipidaemia. The final diagnosis of fibro progression due to non-alcoholic fatty liver disease was made.

Conclusion

We report the first case of cirrhosis developing in a right lobe living liver donor. While selecting living liver donors, extensive evaluation is done to rule out all potential aetiologies remaining silent but later could lead on to chronic liver disease. Although all other aetiologies, which could induce inflammation and fibrosis, are ruled out at the time of donation, lifestyle liver disease, especially non-alcoholic fatty liver disease, can occur in remnant liver post-donation. This case underscores the importance of regular follow-up of liver donors.

Living donor liver transplantation: A multi-disciplinary collaboration towards growth, consensus, and a change in culture

INTRODUCTION

Living donor liver transplantation (LDLT) reduces liver transplant waitlist mortality and provides excellent long-term outcomes for persons with end stage liver disease. Yet, utilization of LDLT has been limited in the United States (US).

METHODS

In October 2021, the American Society of Transplantation held a consensus conference to identify important barriers to broader expansion of LDLT in the US, including data gaps, and make recommendations for impactful and feasible mitigation strategies to overcome these barriers. Domains addressed encompassed the entirety of the LDLT process. Representation from international centers and living donor kidney transplantation were included for their perspective/experience in addition to members across disciplines within the US liver transplantation community. A modified Delphi approach was employed as the consensus methodology.

RESULTS

The predominant theme permeating discussion and polling results centered on culture; the beliefs and behaviors of a group of people perpetuated over time.

CONCLUSIONS

Creating a culture of support for LDLT in the US is key for expansion and includes engagement and education of stakeholders across the spectrum of the process of LDLT. A shift from awareness of LDLT to acknowledgement of benefit of LDLT is the primary goal. Propagation of the maxim "LDLT is the best option" is pivotal.

Low utilization of adult-to-adult LDLT in Western countries despite excellent outcomes: International multicenter analysis of the US, the UK, and Canada

BACKGROUND & AIMS

Adult-to-adult living donor liver transplantation (LDLT) offers an opportunity to decrease the liver transplant waitlist and reduce waitlist mortality. We sought to compare donor and recipient characteristics and post-transplant outcomes after LDLT in the US, the UK, and Canada.

METHODS

This is a retrospective multicenter cohort-study of adults (≥18-years) who underwent primary LDLT between Jan-2008 and Dec-2018 from three national liver transplantation registries: United Network for Organ Sharing (US), National Health Service Blood and Transplantation (UK), and the Canadian Organ Replacement Registry (Canada). Patients undergoing retransplantation or multi-organ transplantation were excluded. Post-transplant survival was evaluated using the Kaplan-Meier method, and multivariable adjustments were performed using Cox proportional-hazards models with mixed-effect modeling.

RESULTS

A total of 2,954 living donor liver transplants were performed (US: n = 2,328; Canada: n = 529; UK: n = 97). Canada has maintained the highest proportion of LDLT utilization over time (proportion of LDLT in 2008 - US: 3.3%; Canada: 19.5%; UK: 1.7%; p <0.001 - in 2018 - US: 5.0%; Canada: 13.6%; UK: 0.4%; p <0.001). The 1-, 5-, and 10-year patient survival was 92.6%, 82.8%, and 70.0% in the US vs. 96.1%, 89.9%, and 82.2% in Canada vs. 91.4%, 85.4%, and 66.7% in the UK. After adjustment for characteristics of donors, recipients, transplant year, and treating transplant center as a random effect, all countries had a non-statistically significantly different mortality hazard post-LDLT (Ref US: Canada hazard ratio 0.53, 95% CI 0.28-1.01, p = 0.05; UK hazard ratio 1.09, 95% CI 0.59-2.02, p = 0.78).

CONCLUSIONS

The use of LDLT has remained low in the US, the UK and Canada. Despite this, long-term survival is excellent. Continued efforts to increase LDLT utilization in these countries may be warranted due to the growing waitlist and differences in allocation that may disadvantage patients currently awaiting liver transplantation.

LAY SUMMARY

This multicenter international comparative analysis of living donor liver transplantation in the United States, the United Kingdom, and Canada demonstrates that despite low use of the procedure, the long-term outcomes are excellent. In addition, the mortality risk is not statistically significantly different between the evaluated countries. However, the incidence and risk of retransplantation differs between the countries, being the highest in the United Kingdom and lowest in the United States.

Identification of hepatic steatosis in living liver donors by machine learning models

Selecting an optimal donor for living donor liver transplantation is crucial for the safety of both the donor and recipient, and hepatic steatosis is an important consideration. We aimed to build a prediction model with noninvasive variables to evaluate macrovesicular steatosis in potential donors by using various prediction models. The study population comprised potential living donors who had undergone donation workup, including percutaneous liver biopsy, in the Republic of Korea between 2016 and 2019. Meaningful macrovesicular hepatic steatosis was defined as >5%. Whole data were divided into training (70.5%) and test (29.5%) data sets based on the date of liver biopsy. Random forest, support vector machine, regularized discriminant analysis, mixture discriminant analysis, flexible discriminant analysis, and deep neural network machine learning methods as well as traditional logistic regression were employed. The mean patient age was 31.4 years, and 66.3% of the patients were men. Of the 1652 patients, 518 (31.4%) had >5% macrovesicular steatosis on the liver biopsy specimen. The logistic model had the best prediction power and prediction performances with an accuracy of 80.0% and 80.9% in the training and test data sets, respectively. A cut-off value of 31.1% for the predicted risk of hepatic steatosis was selected with a sensitivity of 77.7% and specificity of 81.0%. We have provided our model on the website (https://hanseungbong.shinyapps.io/shiny_app_up/) under the name DONATION Model. Our algorithm to predict macrovesicular steatosis using routine parameters is beneficial for identifying optimal potential living donors by avoiding superfluous liver biopsy results.

Dualistic role of platelets in living donor liver transplantation: Are they harmful?

Platelets are anucleate fragments mainly involved in hemostasis and thrombosis, and there is emerging evidence that platelets have other nonhemostatic potentials in inflammation, angiogenesis, regeneration and ischemia/reperfusion injury (I/R injury), which are involved in the physiological and pathological processes during living donor liver transplantation (LDLT). LDLT is sometimes associated with impaired regeneration and severe I/R injury, leading to postoperative complications and decreased patient survival. Recent studies have suggested that perioperative thrombocytopenia is associated with poor graft regeneration and postoperative morbidity in the short and long term after LDLT. Although it is not fully understood whether thrombocytopenia is the cause or result, increasing platelet counts are frequently suggested to improve posttransplant outcomes in clinical studies. Based on rodent experiments, previous studies have identified that platelets stimulate liver regeneration after partial hepatectomy. However, the role of platelets in LDLT is controversial, as platelets are supposed to aggravate I/R injury in the liver. Recently, a rat model of partial liver transplantation (LT) was used to demonstrate that thrombopoietin-induced thrombocytosis prior to surgery accelerated graft regeneration and improved the survival rate after transplantation. It was clarified that platelet-derived liver regeneration outweighed the associated risk of I/R injury after partial LT. Clinical strategies to increase perioperative platelet counts, such as thrombopoietin, thrombopoietin receptor agonist and platelet transfusion, may improve graft regeneration and survival after LDLT.

Visceral Fat Area Is an Independent Risk Factor for Overweight or Obese Nonalcoholic Fatty Liver Disease in Potential Living Liver Donors

BACKGROUND

The present study aimed to evaluate the correlation between hepatic steatosis (HS), determined by biopsy, and visceral adiposity, measured by computed tomography (CT), in overweight or obese potential living liver donors, and to investigate the risk factors for overweight or obese nonalcoholic fatty liver disease (NAFLD).

METHODS

This retrospective study included 375 overweight or obese (body mass index ≥23 kg/m²) potential living liver donors (mean age, 30.4 ± 9.5 years; 273 men) who underwent liver biopsies and abdominal CT examinations in 2017 and 2018. Anthropometry, laboratory parameters, body composition, and HS were assessed. Correlations were analyzed using Pearson's correlation coefficient, and logistic regression was used to identify independent predictors of overweight or obese NAFLD.

RESULTS

Visceral fat area (VFA) was positively correlated with the degree of HS in men (r = 0.307; P < .001) and women (r = 0.387; P < .001). Multivariable logistic regression analysis showed that alanine aminotransferase (odds ratio [OR], 1.017; 95% confidence interval [CI], 1.001-1.033; P = .033) and VFA (OR, 1.015; 95% CI, 1.008-1.022; P < .001) were independent risk factors for overweight or obese NAFLD in men, and VFA (OR, 1.029; 95% CI, 1.011-1.047; P = .002) was an independent risk factor for overweight or obese NAFLD in women.

CONCLUSION

Visceral adiposity was positively correlated with the degree of HS in overweight or obese potential living liver donors. Additionally, visceral adiposity may be an independent risk factor for overweight or obese NAFLD in potential living liver donors.

Outcomes of living liver donors are worse than those of matched healthy controls

BACKGROUND & AIMS

Donor death is the most serious complication of living liver donation but is reported rarely. We investigated the actual mortality of living liver donors (LLDs) compared with matched control groups based on analysis of the Korean National Health Insurance Services (NHIS) database.

METHODS

This cohort study included 12,372 LLDs who donated a liver graft between 2002 and 2018, and were registered in the Korean Network for Organ Sharing. They were compared to 3 matched control groups selected from the Korean NHIS and comprising a total of 123,710 individuals: healthy population (Group I); general population without comorbidities (Group II); and general population with comorbidities (Group III).

RESULTS

In this population, 78.5% of living liver donors were 20-39 years old, and 64.7% of all donors were male. Eighty-nine donors (0.7%) in the LLD group died (68 males and 21 females), a mortality rate (/1,000 person-years) of 0.91 (0.74-1.12). Mortality rate ratio and the adjusted hazard ratio of the LLD group was 2.03 (1.61-2.55) and 1.71 (1.31-2.25) compared to Control Group I, 0.75 (0.60-0.93) and 0.63 (0.49-0.82) compared to Control Group II, and 0.58 (0.46-0.71) and 0.49 (0.39-0.60) compared to Control Group III. LLD group, depression, and lower income were risk factors for adjusted mortality. The incidence of liver failure, depression, cancer, diabetes, hypertension, brain infarction, brain hemorrhage, and end-stage renal disease in the LLD group was significantly higher than in Control Group I.

CONCLUSIONS

Outcomes of the LLD group were worse than those of the matched healthy control group despite the small number of deaths and medical morbidities in this group. LLDs should receive careful medical attention for an extended period after donation.

LAY SUMMARY

The incidence of mortality, liver failure, depression, cancer, diabetes, hypertension, brain infarction, brain hemorrhage, and end-stage renal disease in the living liver donor group was significantly higher than in the matched healthy group. Careful donor evaluation and selection processes can improve donor safety and enable safe living donor liver transplantation.

Accuracy and Efficiency of Right-Lobe Graft Weight Estimation Using Deep-Learning-Assisted CT Volumetry for Living-Donor Liver Transplantation

CT volumetry (CTV) has been widely used for pre-operative graft weight (GW) estimation in living-donor liver transplantation (LDLT), and the use of a deep-learning algorithm (DLA) may further improve its efficiency. However, its accuracy has not been well determined. To evaluate the efficiency and accuracy of DLA-assisted CTV in GW estimation, we performed a retrospective study including 581 consecutive LDLT donors who donated a right-lobe graft. Right-lobe graft volume (GV) was measured on CT using the software implemented with the DLA for automated liver segmentation. In the development group (n = 207), a volume-to-weight conversion formula was constructed by linear regression analysis between the CTV-measured GV and the intraoperative GW. In the validation group (n = 374), the agreement between the estimated and measured GWs was assessed using the Bland–Altman 95% limit-of-agreement (LOA). The mean process time for GV measurement was 1.8 ± 0.6 min (range, 1.3–8.0 min). In the validation group, the GW was estimated using the volume-to-weight conversion formula (estimated GW [g] = 206.3 + 0.653 × CTV-measured GV [mL]), and the Bland–Altman 95% LOA between the estimated and measured GWs was −1.7% ± 17.1%. The DLA-assisted CT volumetry allows for time-efficient and accurate estimation of GW in LDLT.

Pediatric liver transplantation for autoimmune liver disease: Ten-year experience from a liver transplant center in India

Liver transplantation (LT) has emerged as the best therapeutic modality for end-stage liver disease in pediatric autoimmune liver disease (AILD). We aimed to describe our experience of pediatric living donor liver transplantation for AILD from India over a period of 10 years. We did a retrospective analysis of 244 liver transplants at our center over the last 10 years to identify children with AILD (18 years or younger). We aimed to describe the demographic features, clinical profile, graft survival, patient outcome, and predictors of mortality in our cohort. Between July 2010 and May 2020, 13 liver transplants were performed for AILD out of total 244 children transplanted over the last 10 years at our center. Mean (standard deviation [SD]) age at LT was 12 (± 3.84) years. Leading indications for LT were decompensated liver disease (61.5%), acute-on-chronic liver failure (23.1%), acute liver failure (ALF) (7.7%), and recurrent cholangitis and growth failure (7.7%). Mean Pediatric End-stage Liver Disease (PELD) score/model for end-stage liver disease (MELD) score and international normalized ratio (INR) (SD) at presentation were 24 (± 12.81) and 2.48 (± 1.54), respectively. Median discharge duration was 23 days (interquartile range [IQR] 21-36 days). 30.7% (4/13) of the subjects had no postoperative complications. Diarrhea (15.3%), pneumonia (7.7%), jejunostomy site bleed (7.7%), tacrolimus toxicity (7.7%), and vascular complications (7.7%) were seen, which resolved with satisfactory graft function. Three subjects died post-LT; causes of death included sepsis (n=3), renal dysfunction (n=1), and pneumonia (n=1). Others have been well on follow-up with no graft rejection or need for re-transplantation. Overall, 1-year and 5-year patient survival rates were 76.9% and 70%, respectively. Lower platelet count, autoimmune hepatitis (AIH) 2, and PELD/MELD score were found to be significant predictors of mortality on univariate analysis, which were not significant on multivariate modelling. The complications, graft and patient survival rates in our experience were quite encouraging, and are comparable with the best centers worldwide. After instituting appropriate treatment, early referral of such patients to an equipped center should be facilitated.

Safety and Threshold Analysis of Preoperative Platelets in Right Lobe Living Donors for Liver Transplantation

BACKGROUND

Low perioperative platelet count is a powerful independent risk factor for posthepatectomy liver failure. Usually, categorical effect of thrombocytopenia was taken into account; upper thresholds were not studied in depth, exclusively in living liver donors.

METHODS

Living liver donors who underwent right hepatectomy were included. Preoperative characteristics of donors were identified and examined to predict posthepatectomy liver failure. To eliminate selection bias, one-to-one propensity score matching was performed.

RESULTS

There were a total of 139 living donors and 40 (29%) donors developed posthepatectomy liver failure in the aftermath of the operation. Remnant liver volume ratio and preoperative platelet count were identified as adjustable independent risk factors (OR: 0.89 and 0.99, 95% CI: 0.79-0.99 and 0.98-0.99, respectively). After propensity score matching, odds ratio of preoperative platelet count was 0.99 (95% CI: 0.98-1.00).

CONCLUSIONS

Preoperative platelet count, in addition to remnant liver volume ratio, can be used as a surrogate marker to predict the risk of posthepatectomy liver failure in living liver right lobe donors. Probability curves figured out from logistic regression analysis, in this regard, provided an explicit perspective of platelets having a decisive role on liver donor safety. Thus, remaining in safer remnant liver volume ratio limits with respect to preoperative platelet count should be addressed in safe donor selection strategies.

Reduction of Visceral Adiposity as a Predictor for Resolution of Nonalcoholic Fatty Liver in Potential Living Liver Donors

This study aimed to determine the factors associated with resolution of nonalcoholic fatty liver (NAFL) after lifestyle intervention in potential living liver donors as assessed by the gold standards in a longitudinal setting. This retrospective study included 115 potential living liver donors (mean age, 30.5 ± 7.5 years; 101 men) with NAFL who underwent paired liver biopsies and abdominal computed tomography (CT) examinations before and after lifestyle intervention between January 2011 and December 2018. Anthropometry, laboratory parameters, body composition, and hepatic steatosis (HS) were evaluated before and after lifestyle intervention. Anthropometry, laboratory parameters, body composition, and HS were significantly decreased after lifestyle intervention (all, P < 0.001). Relative changes in HS were weakly correlated with relative changes in the visceral fat area (VFA; r = 0.278; P = 0.003) and subcutaneous fat area (r = 0.382; P < 0.001), but not with body weight, body mass index, or skeletal muscle area. Patients with resolved NAFL after lifestyle intervention had significantly lower VFA at follow-up than those with persistent NAFL (mean ± standard deviation, 69.8 ± 39.1 versus 91.5 ± 41.4 cm² ; P = 0.01). Multivariable logistic regression analysis demonstrated that the relative reduction of VFA (odds ratio per percent, 1.031; 95% confidence interval, 1.010-1.053; P = 0.004) was a significant independent factor associated with resolved NAFL after lifestyle intervention. In potential living liver donors with NAFL, the reduction of VFA is a significant factor associated with the resolution of NAFL after lifestyle intervention.

Non-alcoholic fatty liver disease and obesity among adult donors are major challenges to living donor liver transplantation: A single-centre experience

OBJECTIVES

Obesity and non-alcoholic fatty liver disease (NAFLD) are rampant in South East Asia. There is paucity of data exploring its' impact on donor suitability for living donor liver transplantation (LDLT). We aimed to describe and examine the factors related to non-utilization of potential donors in our LDLT programme.

METHODS

This is an analysis of prospectively collected data on potential donors for an adult LDLT programme, between January 2017 and December 2019.

RESULTS

Fifty-five donors for 33 potential recipients were evaluated. The mean age was 31.6 ± 8.5 years, 52.7% were female and the ethnic divisions were: Chinese (50.9%), Indian (25.5%) and Malay (23.6%). The mean body mass index (BMI) among potential donors was 25.1 ± 4.0 kg/m²; 25.5% of donors had normal BMI, 23.6% were overweight and 50.9% were obese. Using the CAP modality of Fibroscan®, we identified the following grades of hepatic steatosis: 36.6% S0, 19.5% S1, 2.4% S2 and 41.5% S3. The non-utilization rate of our donors was 74.5% (41/55) and the main reasons were significant hepatic steatosis and/or obesity. Compared to suitable donors, unsuitable donors had significantly greater mean BMI, mean CAP scores, higher rates of dyslipidaemia and NAFLD.

CONCLUSION

NAFLD and obesity represent major challenges to an emerging LDLT programme in Malaysia.

Change in hepatic volume profile in potential live liver donors after lifestyle modification for reduction of hepatic steatosis

PURPOSE

We aimed to evaluate changes in hepatic volume and hemiliver volume percentage in potential liver donors after hepatic steatosis (HS) reduction through lifestyle modification.

METHODS

Fifty liver donor candidates with HS (macrovesicular fat [MaF] ≥ 20%) underwent abdominal computed tomography (CT) and liver biopsy before (baseline) and after (follow-up) lifestyle modification. According to the change in MaF, subjects were classified as group A (MaF reduction ≥ 20%, n = 25), and group B (MaF reduction < 20%, n = 25). The hepatic volume and hemiliver volume percentage were measured using CT volumetric analysis.

RESULTS

Volume percentage of the left hemiliver + S1 (over the whole liver) significantly increased at follow-up in group A (P < 0.001) but not in group B (P = 0.598). The absolute volume change of the right hemiliver and its percentage change from the baseline were significantly greater than those of the left hemiliver + S1 in group A (P < 0.007). There were no significant differences in these values in group B (P = 0.064 and 0.507, respectively). The percentage of subjects that earned the benefit of becoming suitable donors from the change in hepatic volume distribution caused by HS improvement was 52.0% (13/25) and 40.0% (10/25) in group A and group B, respectively. Regarding posthepatectomy liver failure, none was identified in group A after donation, whereas 12% (3/25) was identified in group B.

CONCLUSION

Hepatic volume profile may change considerably in potential liver donors with HS (MaF ≥ 20%) after HS reduction through lifestyle modification. Reevaluation of the hepatic volume is required before liver procurement after lifestyle modification in these subjects.

A Meta-Analysis on the Incidence of Donor Related Depression after Liver Transplant

AIM

Living donor liver transplantation (LDLT) is increasing, yet gaps exist in the understanding of psychological wellbeing of donors after liver transplant. This meta-analysis seeks to evaluate the incidence and risk factors for donor-related depression after liver transplantation.

METHODS

A search was conducted on Medline and Embase database. Articles assessing incidence of depression in LDLT donors were included. Incidence was pooled after Freeman-Tukey double-arcsine transformation. For risk factors, dichotomous variables were analyzed with generalized linear model while a conventional meta regression with logit transformation was conducted for continuous variables.

RESULTS

Of 1,069 abstracts, 40 articles underwent full-text review. 17 articles were included. The pooled incidence of depression among 1,888 LT donors was 7.66% (CI: 4.47% - 12.80%). Depression rates were significantly higher in Asian compared to Western studies (RR: 1.73, CI: 1.19 - 2.52, p=0.0039). Female gender (p<0.001), Caucasian ethnicity (p=0.047), employment status (p<0.001) and lower education levels (p=0.044) were significantly associated with depression. Donor relationship with recipients was not a significant risk factor.

CONCLUSIONS

LDLT remains a core aspect of the treatment of end-stage liver disease. However, the high depression rates after LT suggest that there remains room for improvement in the care of donors' mental health post-transplant.

Assessment of the global practice of living donor liver transplantation

Criteria that drive the selection and utilization of living liver donors are limited. Herein, the global availability of living donor liver transplantation (LDLT) and components of donor selection and utilization were assessed via an international survey. There were 124 respondents representing 41 countries, including 47 from Asia/Middle East (A/ME), 20 from Europe, and 57 from the Americas. Responses were obtained from 94.9% of countries with ≥10 LDLT cases/year. Most centers (82.3%) have defined donor age criteria (median 18-60 years), while preset recipient MELD cutoffs (median 18-30) were only reported in 54.8% of programs. Overall, 67.5% of programs have preset donor BMI (body mass index) ranges (median 18-30), and the mean acceptable macrosteatosis was highest for A/ME (20.2 ± 9.2%) and lowest for Americas (16.5 ± 8.4%, P = 0.04). Americas (56.1%) and European (60.0%) programs were more likely to consider anonymous donors versus A/ME programs (27.7%, P = 0.01). There were no differences in consideration of complex anatomical variations. Most programs (75.9%) perform donor surgery via an open approach, and A/ME programs are more likely to use microscopic arterial reconstruction. Despite variations in practice, key aspects of living donor selection were identified. These findings provide a contemporary reference point as LDLT continues to expand into areas with limited access to liver transplantation.

Controlled attenuation parameter measured using transient elastography for the noninvasive assessment of macrovesicular steatosis in potential living liver donors

PURPOSE

This study aimed to determine the diagnostic performance of the controlled attenuation parameter (CAP) measured using transient elastography (TE) for assessing macrovesicular steatosis (MaS) in potential living liver donors using same-day biopsy as a reference standard.

METHODS

This retrospective study included 204 living liver donor candidates who underwent TE and liver biopsy on the same day between July 2013 and June 2014. The histologic degree of MaS was determined. The area under the receiver operating characteristic curve (AUROC) was used to evaluate the performance of CAP for diagnosing MaS of >10%, and the optimal cutoff value was identified using the maximal Youden index.

RESULTS

Based on liver biopsy, 185 subjects had MaS of ≤10% and 19 had MaS of >10%. The CAP value was significantly correlated with the percentage of MaS on liver biopsy (r=0.635, P<0.001), and the median CAP value was significantly higher in subjects with MaS of >10% than in those with MaS of ≤10% (300 dB/m vs. 209 dB/m, P<0.001). The AUROC for diagnosing MaS of >10% by CAP was 0.938 (95% confidence interval, 0.896 to 0.967), and a CAP of >259 dB/m yielded a sensitivity of 84.2% and a specificity of 92.4%.

CONCLUSION

The CAP measured using TE was significantly correlated with MaS and accurately detected substantial MaS in potential living liver donors. The CAP is a promising tool for the noninvasive diagnosis of MaS and may be used to screen unsuitable living liver donor candidates.

Cut-off values of skeletal muscle index and psoas muscle index at L3 vertebra level by computerized tomography to assess low muscle mass

BACKGROUND & AIMS

Computerized tomography (CT) is considered the gold standard for the evaluation of total skeletal muscle quantity. Skeletal muscle assessments at the L3 vertebra level revealed significantly correlated with total body muscle measurements. Clinicians need cut-offs to evaluate low muscle mass in various patients who already had CT imaging without any additional cost. This assessment is important to help the physicians to stratify the patients for mortality and other complications. It may also enable the diagnosis of malnutrition by the GLIM criteria. Few studies reported cut-offs in different populations. We aimed to provide cut-off values for total skeletal muscle index (SMI) and psoas muscle mass index (PMI) at the L3 vertebra level in the Turkish population.

METHODS

We assessed the preoperative plain CT images of living adult liver donors who were admitted to a single transplantation center between June 2010 and April 2018. We derived cut-off values with two alternative methods, the 5th percentile value or mean minus two standard deviations and from two groups of study participants, i.e. the total study population and the younger subgroup aged between 18 and 40.

RESULTS

The study population involved 601 subjects with a mean age of 32.5 ± 9 (range: 18-59 years) and 326 (54.2%) was male. The younger subgroup was composed of 482 individuals with a mean age of 28.8 ± 5.9 and 55.6% male. In patients aged between 18 and 40, PMI and SMI cut-offs by using the 5th percentile were 5.40 cm²/m², 41.42 cm²/m² for males; and 3.56 cm²/m², 30.70 cm²/m² for females; respectively. The cut-offs of PMI and SMI by using mean minus two standard deviations were 4.62 cm²/m², 38.67 cm²/m² for males; and 2.66 cm²/m², 27.8 cm²/m² for females; respectively. These cut-offs were comparable to the other populations.

CONCLUSIONS

Our study provided cut-offs to be used in CT images for PMI and SMI. There is a need for further longitudinal studies to verify whether these cut-offs are successful in predicting mortality or other adverse outcomes associated with low muscle mass.

Pneumoperitoneum-induced pneumothorax during laparoscopic living donor hepatectomy: a case report

Background

We present a living donor case with an unexpected large-volume pneumothorax diagnosed using lung ultrasound during a laparoscopic hepatectomy for liver transplantation (LT).

Case presentation

A 38-year-old healthy female living donor underwent elective laparoscopic right hepatectomy. The preoperative chest radiography (CXR) and computed tomography images were normal. The surgery was uneventfully performed with tolerable CO₂ insufflation and the head-up position. SpO₂ decreased and airway peak pressure increased abruptly after beginning the surgery. There were no improvements in the SpO₂ or airway pressure despite adjusting the endotracheal tube. Eventually, lung ultrasound was performed to rule out a pneumothorax, and we verified the stratosphere sign as a marker for the pneumothorax. The surgeon was asked to temporarily hold the surgery and cease with the pneumoperitoneum. Portable CXR verified a large right pneumothorax with a small degree of left lung collapse; thus, a chest tube was inserted on the right side. The hemodynamic parameters fully recovered and were stable, and the surgery continued laparoscopically. The surgeon explored the diaphragm and surrounding structures to detect any defects or injuries, but there were no abnormal findings. The postoperative course was uneventful, and a follow-up CXR revealed complete resolution of the two-sided pneumothorax.

Conclusion

This living donor case suggests that a pneumothorax can occur during laparoscopic hepatectomy due to the escape of intraperitoneal CO₂ gas into the pleural cavity. Because missing the chance to identify a pneumothorax early significantly decreases the safety for living donors, point-of-care lung ultrasound may help attending physicians reach the final diagnosis of an intraoperative pneumothorax more rapidly and to plan the treatment more effectively.

Association of Graft-to-Recipient Weight Ratio with the Prognosis Following Liver Transplantation: a Meta-analysis

BACKGROUND

Studies indicate that low graft-to-recipient weight ratio (GRWR) affect graft survival in adult-to-adult living donor liver transplantation. However, the potential role of GRWR in the prognosis of patients following living donor liver transplantation according to patient characteristics remains controversial. This study aimed to update the role of GRWR in patients following living donor liver transplantation.

METHODS

PubMed, Embase, and Cochrane Library were comprehensively searched for studies comparing low GRWR (< 0.8%) with normal GRWR (≥ 0.8%) in the prognosis following living donor liver transplantation from inception to March 2019. The 1-, 3-, and 5-year summary survival rates, small-for-size syndrome (SFSS), perioperative mortality, biliary complications, postoperative bleeding, and acute rejection were calculated using the random-effects model.

RESULTS

Eighteen studies comprising 4001 patients were included. Patients with low GRWR were associated with lower 1-year and 3-year survival rates compared to patients with normal GRWR, while no significant difference was found in the association of 5-year survival rate with low and normal GRWRs. Moreover, the risk of SFSS significantly increased in patients with low GRWR. Finally, no significant differences were observed in the association of low and normal GRWRs with the risk of perioperative mortality, biliary complications, postoperative bleeding, and acute rejection.

CONCLUSION

The results of this study indicated that low GRWR was associated with poor prognosis for patients following living donor liver transplantation, especially in terms of 1- and 3-year survival rates and SFSS.

Liver transplantation for non-resectable colorectal liver metastasis: where we are and where we are going

PURPOSE

Almost 50% of patients diagnosed with colorectal cancer (CRC) will develop liver metastasis (LM). Although their only long-term curative treatment is surgery, less than half of these patients can be eventually resected. Therefore, palliative chemotherapy is offered as a definitive option, though with poor results. Recently, the University of Oslo group has published encouraging results in the treatment of these patients with liver transplantation (LT), whereby worldwide interest in this option has been renewed.

METHODS

A literature review of LT for patients with unresectable colorectal metastasis was performed. This included information regarding patient selection, complications, overall survival (OS) and disease-free survival (DFS), immunosuppression, chemotherapy, and description of the ongoing trials.

RESULTS

Improvements in OS and DFS have been observed in consecutive published prospective trials, as patient selection has been refined. Papers reporting OS of patients who randomly presented similar selection criteria also exhibited good results.

CONCLUSION

LT within the available therapeutic options in patients with CRC-LM seems to be a compelling alternative in carefully selected patients. The ongoing trials will provide valuable information regarding selection criteria, immunosuppressive therapy and different modalities of adjuvant chemotherapy, which are, to our knowledge, the vital platform of LT in CRC-LM. Although some of the developing techniques involve living donors, graft availability for these patients remains a matter of major concern.

Is Portal Inflow Modulation Always Necessary for Successful Utilization of Small Volume Living Donor Liver Grafts?

Although the well-accepted lower limit of the graft-to-recipient weight ratio (GRWR) for successful living donor liver transplantation (LDLT) remains 0.80%, many believe grafts with lower GRWR may suffice with portal inflow modulation (PIM), resulting in equally good recipient outcomes. This study was done to evaluate the outcomes of LDLT with small-for-size grafts (GRWR <0.80%). Of 1321 consecutive adult LDLTs from January 2012 to December 2017, 287 (21.7%) had GRWR <0.80%. PIM was performed (hemiportocaval shunt [HPCS], n = 109; splenic artery ligation [SAL], n = 14) in 42.9% patients. No PIM was done if portal pressure (PP) in the dissection phase was <16 mm Hg. Mean age of the cohort was 49.3 ± 9.1 years. Median Model for End-Stage Liver Disease score was 14, and the lowest GRWR was 0.54%. A total of 72 recipients had a GRWR <0.70%, of whom 58 underwent HPCS (1 of whom underwent HPCS + SAL) and 14 underwent no PIM, whereas 215 had GRWR between 0.70% and 0.79%, of whom 51 and 14 underwent HPCS and SAL, respectively. During the same period, 1034 had GRWR ≥0.80% and did not undergo PIM. Small-for-size syndrome developed in 2.8% patients. Three patients needed shunt closure at 1 and 4 weeks and 60 months. The 1-year patient survival rates were comparable. In conclusion, with PIM protocol that optimizes postperfusion PP, low-GRWR grafts can be used for appropriately selected LDLT recipients with acceptable outcomes.

A paradigm shift in the intention-to-transplant children with biliary atresia: Outcomes of 101 cases and a review of the literature

For children with BA who do not benefit from Kasai surgery, the only therapeutic option is liver replacement and transplantation. The very decision to proceed for transplantation is a crucial point in time because it is the first step toward the preparation for the transplantation. The former time point is defined in this analysis as "intent-to-transplant" care pathway. In the life of every BA candidate for liver replacement, this point in time varies and mostly depends on the decision of their primary caring teams-about when to switch from supportive care to transplant, and thus to refer to a transplant center. This intent-to-transplant analysis of a series of 101 consecutive infants that were referred to a single transplant team showed that excellent overall outcome (97% survival) has been achieved overall. However, three deaths occurred that were clearly related to a late referral. This analysis and recent observations from other centers strongly support that the timing for referring these children to a transplant center and/or deciding to list them on the waiting list is currently too late and should be anticipated to what it is currently. This paradigm shift in the intention-to-transplant children is likely necessary for giving a better chance to an increased number of children and impacts positively on the general outcome. Networking and defining new tools for a rapid recognition of the infants who need early transplantation are necessary; centralization of these children may be helpful to achieve better outcomes than currently observed.

Recovery of the Psoas Muscle Index in Living Donors after a Right Lobe Hepatectomy for Liver Transplantation: A Single-Center Experience

OBJECTIVE

The development of sarcopenia leads to adverse postoperative outcomes. However, no study has investigated perioperative loss in core muscle and the correlation between core muscle and residual liver volume in living donors for liver transplant.

PATIENTS AND METHODS

A total of 457 adult healthy donors who underwent a right lobe hepatectomy without the middle hepatic vein for elective liver transplant were retrospectively analyzed. Abdominal computed tomography was performed within 1 month before surgery and the first week and 3 months after the surgery. The average psoas muscle area between lumbar vertebrae 3 and 4 was measured and normalized by height squared (psoas muscle index [PMI] = psoas muscle area/height²). The initial whole liver volume and remnant left lobe volume were measured on computed tomography images.

RESULTS

The study cohort included 279 men (61.1%) and 178 women (38.9%). The median preoperative PMIs were 420.9 mm²/m² (interquartile range, 360.6-487.0 mm²/m²) in men and 280.9 mm²/m² (interquartile range, 243.5-318.7 mm²/m²) in women. The PMIs in men and women significantly decreased during the first week after surgery, and gradually recovered to preoperative levels during the first 3 months after surgery. Based on the ratio between the remnant left lobe and initial whole liver volume (≥30%), the increase in remnant left lobe volume was not correlated with the decrease in PMI on postoperative day 7. A postoperative U-shaped recovery in the core muscles was present in both male and female donors, independent of the remnant liver ratio.

CONCLUSIONS

Despite the requirements of partial liver regeneration and surgical wound repair, healthy donors did not suffer from sustained core muscle loss after surgery.

Portal Vein Flow by Doppler Ultrasonography and Liver Volume by Computed Tomography in Living Donor Candidates: Correlation with Indocyanine Green Test

OBJECTIVES

Our goal was to investigate the correlation between indocyanine green test results and imaging parameters in living liver donor candidates.

MATERIALS AND METHODS

Our study included 219 healthy donor candidates who were evaluated with Doppler ultrasonography (portal vein time average flow), computed tomography (liver volume), liver biopsy (fat fraction), and indocyanine green retention rate at 15 minutes.

RESULTS

Portal vein time average flow (r= -0.375), fat-free liver volume/body weight ratio (r = -0.239), and portal vein time average flow × fat-free liver volume/body weight ratio (r = -0.424) showed significant correlations with indocyanine green retention rate at 15 minutes (all P < .001).

CONCLUSIONS

Imaging parameters were significantly correlated with indocyanine green retention rate at 15 minutes in living liver donor candidates.

Rationale and design of TransplantLines: a prospective cohort study and biobank of solid organ transplant recipients

INTRODUCTION

In the past decades, short-term results after solid organ transplantation have markedly improved. Disappointingly, this has not been accompanied by parallel improvements in long-term outcomes after transplantation. To improve graft and recipient outcomes, identification of potentially modifiable risk factors and development of biomarkers are required. We provide the rationale and design of a large prospective cohort study of solid organ transplant recipients (TransplantLines).

METHODS AND ANALYSIS

TransplantLines is designed as a single-centre, prospective cohort study and biobank including all different types of solid organ transplant recipients as well as living organ donors. Data will be collected from transplant candidates before transplantation, during transplantation, at 3 months, 6 months, 1 year, 2 years and 5 years, and subsequently every 5 years after transplantation. Data from living organ donors will be collected before donation, during donation, at 3 months, 1 year and 5 years after donation, and subsequently every 5 years. The primary outcomes are mortality and graft failure. The secondary outcomes will be cause-specific mortality, cause-specific graft failure and rejection. The tertiary outcomes will be other health problems, including diabetes, obesity, hypertension, hypercholesterolaemia and cardiovascular disease, and disturbances that relate to quality of life, that is, physical and psychological functioning, including quality of sleep, and neurological problems such as tremor and polyneuropathy.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the relevant local ethics committee. The TransplantLines cohort study is designed to deliver pioneering insights into transplantation and donation outcomes. The study design allows comprehensive data collection on perioperative care, nutrition, social and psychological functioning, and biochemical parameters. This may provide a rationale for future intervention strategies to more individualised, patient-centred transplant care and individualisation of treatment.

TRIAL REGISTRATION NUMBER

NCT03272841.

Living donor liver transplantation: post-operative imaging follow-up of right lobe liver donors

PURPOSE

To identify long-term post-operative imaging findings resulting from right lobe liver donation.

METHODS

This retrospective imaging review consisted of 42 adults (20 males, 22 females, mean age 36.6 years, range 18.7-55.9 years) who underwent right lobe liver donation with pre- and post-operative imaging between 1999 and 2006. The mean follow-up period was 30.2 months (range 12.3-69.6 months). Follow-up imaging evaluation included assessment of the biliary tree, particularly isolated bile ducts draining to and terminating at the cut surface (orphan ducts). Three-dimensional volumetry of the liver remnant was also assessed.

RESULTS

After liver donation, 29/42 (69%) participants demonstrated orphan ducts on follow-up imaging (95% confidence interval 52.9% to 82.4%). In those patients with orphan ducts, the main draining ducts were normal in 70% and dilated in 69%. Nearly all right lobe liver donors with orphan ducts had no clinical symptoms on follow-up (28/29); the only liver donor with clinical symptoms on follow-up was subsequently diagnosed with primary biliary cirrhosis. Mean regenerated liver volume was approximately 93%, with mean pre-operative total liver volume of 1552 ml (median 1504 ml, range 1040-2520 ml) and mean post-operative total liver volume of 1446 ml (median 1455 ml, range 964-2090 ml).

CONCLUSIONS

Orphan ducts are changes that may be seen after liver donation. The presence of these findings in the absence of clinical symptoms or abnormal hepatic chemistries does not require further work-up and should not be considered pathologic.

Readdressing the Middle Hepatic Vein in Right Lobe Liver Donation: Triangle of Safety

For equipoising donor safety and optimal recipient outcomes, we adopted an algorithmic "triangle of safety" approach to retrieve 3 types of right lobe liver grafts (RLGs), namely, the modified extended right lobe graft (MERLG), the partial right lobe graft (PRLG), and the modified right lobe graft (MRLG). Reconstruction to achieve a single wide anterior sector outflow was ensured in all patients. We present donor and recipient outcomes based on our approach in 665 right lobe (RL) living donor liver transplantations (LDLTs) performed from January 2013 to August 2015. There were 347 patients who received a MERLG, 117 who received a PRLG, and 201 who received a MRLG. A right lobe graft (RLG) with a middle hepatic vein was retrieved only in 3 out of 18 donors with steatosis >10%. Cold ischemia time was significantly more and remnant volume was less in the MRLG group. Of the donors, 29.3% had complications (26% Clavien-Dindo grade I, II) with no statistically significant difference among the groups. The Model for End-Stage Liver Disease score was higher in the MERLG group. There were 34 out of 39 with a graft-to-recipient weight ratio (GRWR) of <0.7% who received a MERLG with inflow modulation. Out of 4 patients who developed small-for-size syndrome in this group, 2 died. The 90-day patient survival rate was similar among different GRWRs and types of RLG. In conclusion, a selective and tailored approach for RL donor hepatectomy based on optimal functional volume and metabolic demands not only addresses the key issue of double equipoise in LDLT but also creates a safe path for extending the limits.

Specific issues concerning the management of patients on the waiting list and after liver transplantation

The present document is a second contribution collecting the recommendations of an expert panel of transplant hepatologists appointed by the Italian Association for the Study of the Liver (AISF) concerning the management of certain aspects of liver transplantation, including: the issue of prompt referral; the management of difficult candidates; malnutrition; living related liver transplants; hepatocellular carcinoma; and the role of direct acting antiviral agents before and after transplantation. The statements on each topic were approved by participants at the AISF Transplant Hepatology Expert Meeting organized by the Permanent Liver Transplant Commission in Mondello on 12-13 May 2017. They are graded according to the GRADE grading system.

Laparoscopic donor hepatectomy

Laparoscopic liver resection has been applied to treat most indications for liver resection during the past two decades. According to the literature, patient numbers have increased exponentially as a result, and surgical difficulty has increased as well. In expert centers, laparoscopic anatomical hemihepatectomy and major liver resection more than 3 segments have become the acceptable treatment. Moreover, with surgical innovations and accumulated experience, living donor liver transplantation has become an established treatment choice for patients on the transplant waiting list. It is even considered an inevitable choice in regions with limited access to organs from deceased donors. However, significant morbidity and rare but catastrophic mortality are associated with donor hepatectomy and remain major concerns. Therefore, to decrease the incidence of complications, a minimally invasive approach in donor hepatectomy was adopted in the early 2000s. Initially, a minimally invasive approach was used for left lateral sectionectomy for pediatric liver transplant, then for laparoscopy-assisted hemihepatectomy and pure laparoscopic/robotic right donor hepatectomy, and more recently, for adult living donor liver transplantation. The extent of procedure complexity and potential complications depends on the approach and the size of the graft to be harvested. Early results from expert teams have seemed promising in terms of shortened donor recovery and improved perioperative outcomes. However, the combination of these two highly sophisticated surgical procedures raise more concerns about donor safety, especially with regard to unexpected events during the operation. A high level of evidence is very difficult to achieve in this highly specialized surgical practice with limited penetration. Therefore, an international registry has been suggested to determine the risks and benefits before the use of laparoscopic right donor hepatectomy spreads.

The New Era of Transplant Oncology: Liver Transplantation for Nonresectable Colorectal Cancer Liver Metastases

Colorectal cancer (CRC) is the third most incident cancer worldwide. Most of CRC patients will develop distant metastases, mainly to the liver, and liver resection is the only potential chance for cure. On the other hand, only a small proportion of patients with hepatic CRC metastasis are candidates for upfront liver resection. Liver transplantation (LT) is an attractive option for patients with nonresectable CRC liver metastases (NRCLM) without extrahepatic involvement. Initial experiences with LT for NRCLM achieved very poor outcomes, with a 5-year overall survival (OS) lower than 20%. However, these initial studies did not have a standardized patient selection or neoadjuvant or adjuvant therapies. With recent advances in the surgical and medical oncology fields, the landscape has changed. Recent studies from Norway have shown an encouraging 5-year OS of 50% when transplanting patients with NRCLM. Nevertheless, the main concern when expanding the indications for LT is organ shortage. To manage this organ shortage, strategies utilizing live donor liver transplantation are gaining favor. A few ongoing trials are assessing the impact of LT in NRCLM patient survival. Therefore, the aim of this paper is to review the current status of LT for NRCLM.

The International Liver Transplantation Society Living Donor Liver Transplant Recipient Guideline

Living donor liver transplantation (LDLT) has been increasingly embraced around the world as an important strategy to address the shortage of deceased donor livers. The aim of this guideline, approved by the International Liver Transplantation Society (ILTS), is to provide a collection of expert opinions, consensus, and best practices surrounding LDLT. Recommendations were developed from an analysis of the National Library of Medicine living donor transplantation indexed literature using the Grading of Recommendations Assessment, Development and Evaluation methodology. Writing was guided by the ILTS Policy on the Development and Use of Practice Guidelines (www.ilts.org). Intended for use by physicians, these recommendations support specific approaches to the diagnostic, therapeutic, and preventive aspects of care of living donor liver transplant recipients.

Compared to cadaveric liver transplantation, live donor LT (LDLT) is challenged by ethical, medical and surgical considerations, many of which are still unresolved. The aim of this guideline is to provide a collection of expert opinions, consensus, and best practices surrounding LDLT.

Donor safety in living donor liver transplantation: The Korean organ transplantation registry study

Major concerns about donor safety cause controversy and limit the use of living donor liver transplantation to overcome organ shortages. The Korean Organ Transplantation Registry established a nationwide organ transplantation registration system in 2014. We reviewed the prospectively collected data of all 832 living liver donors who underwent procedures between April 2014 and December 2015. We allocated the donors to a left lobe group (n = 59) and a right lobe group (n = 773) and analyzed the relations between graft types and remaining liver volumes and complications (graded using the Clavien 5-tier grading system). The median follow-up was 19 months (range, 10-31 months). During the study period, 553 men and 279 women donated livers, and there were no deaths after living liver donation. The overall, biliary, and major complication (grade ≥ III) rates were 9.3%, 1.7%, and 1.9%, respectively. The graft types and remaining liver volume were associated with significantly different overall, biliary, and major complication rates. Of the 16 patients with major complications, 9 (56.3%) involved biliary complications (2 biliary strictures [12.5%] and 7 bile leakages [43.8%]). Among the 832 donors, the mean aspartate transaminase, alanine aminotransferase, and total bilirubin levels were 23.9 ± 8.1 IU/L, 20.9 ± 11.3 IU/L, and 0.8 ± 0.4 mg/dL, respectively, 6 months after liver donation. In conclusion, biliary complications were the most common types of major morbidity in living liver donors. Donor hepatectomy can be performed successfully with minimal and easily controlled complications. Our study shows that prospective, nationwide cohort data provide an important means of investigating the safety in living liver donation. Liver Transplantation 23 999-1006 2017 AASLD.

Long-Term Medical and Psychosocial Outcomes in Living Liver Donors

Due to the enduring organ shortage, living donor liver transplantation has been a valuable treatment strategy for advanced liver disease patients for over 20 years. A variety of reviews have summarized the extensive data now available on medical and psychosocial risks to living donors in the aftermath of donation. However, evidence on donor medical and psychosocial outcomes beyond the first year postdonation has not been synthesized in any previous review. The evidence base on such "long-term" outcomes has been growing in recent years. A review of this evidence would therefore be timely and could serve as an important resource to assist transplant centers in their efforts to fully educate prospective donors and gain informed consent, as well as develop appropriate postdonation clinical care and surveillance plans. We reviewed recent literature on long-term donor outcomes, considering (a) medical outcomes, including mortality risk, rates of complications, abnormalities detected in laboratory testing, and the progress of liver regeneration; and (b) donor-reported psychosocial outcomes reflecting physical, emotional, and interpersonal/socioeconomic well-being, as well as overall health-related quality of life. We summarize limitations and gaps in available evidence, and we provide recommendations for future research and clinical care activities focused on long-term outcomes in liver donors.

Noteworthy Literature Published in 2016 for Abdominal Organ Transplantation Anesthesiologists

More than 3000 peer-reviewed publications on the topic of liver transplantation were published in 2016. The goal of this article is to provide a concise review of pertinent literature for anesthesiologists who participate in liver transplantation. The authors selected and presented 33 articles published in 2016 on the topics of MELD policy; cardiovascular, pulmonary, and renal issues; coagulation and transfusion; anesthetic agents; hemodynamic monitors; acute liver failure; and donor issues.

The future of liver transplantation for viral hepatitis

In hepatitis C virus (HCV)-infected patients, transplantation can be justified by decompensated cirrhosis, hepatocellular carcinoma (HCC) or both. During the last decade, HCV infection accounted for about 30% of the indications for transplantation in Europe and North America. Direct antiviral agents (DAAs) are highly effective at curing HCV, even in patients with end-stage cirrhosis. In the future, the incidence of HCV-related decompensated cirrhosis will continue to decrease. The incidence of HCC will also decrease, but a large cohort of patients with cirrhosis will still be at risk of developing HCC even after HCV has been cured. They will continue to represent potential candidates for transplantation. Overall, HCV will account for a significantly lower proportion of indications for transplantation in the future. However, generalization of DAAs is unlikely to affect the total transplantation volume as the gap between donors and potential recipients markedly exceeds 30%. In addition, non-alcoholic steatohepatitis (NASH) is a rapidly growing indication for transplantation. The high barrier to resistance nucleos(t)ide analogues (NUCs) have been used for several years to treat hepatitis B virus (HBV) infection. Decompensated HBV cirrhosis now represents a very uncommon indication for transplantation. HCC remains the leading indication in HBV-infected patients awaiting transplantation. NUCs plus anti-HBs immune globulins or NUCs alone are highly effective at preventing post-transplant HBV recurrence. However, continuous prophylaxis is still needed as extrahepatic HBV particles persist with a potential for recurrence. Post-transplant immunosuppression facilitates recurrence. In the future, an important challenge will be to cure HBV by eliminating residual HBV particles.