How to Perform Selective Liver Biopsy in Living Liver Donors Using Plain Computed Tomography

Optimal surgical workup to ensure safe recovery of the donor after living liver donation - A systematic review of the literature and expert panel recommendations

BACKGROUND

The essential premise of living donor liver transplantation is the assurance that the donors will have a complication-free perioperative course and a prompt recovery. Selection of appropriate donors is the first step to support this premise and is based on tests that constitute the donor workup. The exclusion of liver pathologies and assessment of liver anatomy and volume in the donor candidate are the most important elements in the selection of the appropriate candidate.

OBJECTIVE

To determine whether there is evidence to define an optimal donor surgical workup that would improve short-term outcomes of the donor after living liver donation.

DATA SOURCES

Ovid Medline, Embase, Scopus, Google Scholar, and Cochrane Central.

METHODS

Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel.

RESULTS

Although a liver biopsy remains the only method to exactly determine the percentage and type of steatosis and to detect other liver pathologies, its routine use is not supported. Both magnetic resonance imaging (MRI) and computed tomography (CT) appear to be adequate for quantifying liver volume; the preference for one or the other is often based on center expertise. MRI is clearly a better technique to assess biliary anatomy, although aberrant biliary anatomy may not be clearly detected. MRI is also more accurate than CT in determining low grades of steatosis. CT angiography is the imaging test of choice to assess the vascular anatomy. There is no evidence of the need for catheter angiography in the modern evaluation of a living liver donor.

CONCLUSIONS

A donor liver biopsy is indicated if abnormalities are present in serological or imaging tests. Both MRI and CT imaging appear to be adequate methodologies. The routine use of catheter angiography is not supported in view of the adequacy of CT angiography in delineating liver vascular anatomy. No imaging modality available to quantify liver volume is superior to another. Biliary anatomy is better defined with MRI, although poor definition can be expected, particularly for abnormal ducts.

Association between Subclinical Low Serum 25(OH)D in Donors and Fatty Liver Disease in Recipients after Living Donor Liver Transplantation

To explore subclinical fatty liver disease (FLD) in donors as a possible mechanism leading to FLD in recipients of living donor liver transplantation (LDLT), we extracted thirty donor-recipient pairs' serum DNA and explored the presence of CYP2R1 single nucleotide polymorphism (SNP) rs10741657 and vitamin D receptor (VDR) SNP rs2228530 A/G alleles using real-time polymerase chain reaction. We measured the serum 25(OH)D concentrations and investigated the CYP2R1 and VDR genotypes of the donors and recipients before and after LDLT for comparison with the histological findings from the donors on wedge biopsy, the recipients' removed native liver, and selective liver biopsy after LDLT. There was a significant difference in low serum 25(OH)D concentration between the donors and recipients before LDLT and in the recipients before versus after LDLT (13.90 ± 8.85 versus 47.9 ± 14.88 versus 11.82 ± 10.36, P < 0.001), and significant difference in FLD was detected on wedge biopsy from the donors and the native liver from the recipients as well as the native liver and follow-up biopsy from the recipients (P < 0.001). CYP2R1 and VDR genotype were predominant, both for the AG and for the GG alleles. For the donor VDR SNP rs2228570, low serum 25(OH)D was significantly different between genotypes AA and AG (P = 0.024) as well as between genotypes AA and AG plus GG (P = 0.042). Our data suggest that donors' VDR rs2228570 AA alleles may play a major role in low serum 25(OH)D regarding pathological FLD in recipients after LDLT.

Adult Living Donor Liver Transplantation for Acute-on-Chronic Liver Failure in High-Model for End-Stage Liver Disease Score Patients

The large volume of adult living donor liver transplantations (ALDLTs) at our center affords a unique opportunity to examine the impact of acute-on-chronic liver failure (ACLF) among high-Model for End-Stage Liver Disease MELD score patients. From February 1998 to March 2010, 1958 cirrhotic recipients were analyzed to study the relationship between MELD scores and ALDLT outcomes. A total of 327 high-MELD score recipients were categorized into ACLF and non-ACLF groups, and their outcomes were compared. The 5-year graft and patient survival in the high-MELD group were 75.2% and 76.4%, respectively, which were significantly worse than the low and intermediate MELD groups. The presence of ACLF associated with higher MELD scores appeared to be the dominant factor responsible for the inferior results of patients with MELD score of 30-34 points. The 5-year graft survivals in the ACLF group was 70.5% and in the non-ACLF group it was 81.0% (p = 0.035). Therefore, ALDLT should be performed as soon as possible in high-MELD score patients prior to ACLF development. Moreover, ACLF patients should be separately categorized when analyzing the outcomes of ALDLT. ALDLT for ACLF patients should not be discouraged because favorable outcomes can be expected through timely ALDLT and comprehensive management.