A Donor Age-Based and Graft Volume-Based Analysis for Living Donor Liver Transplantation in Elderly Recipients. Transplant Direct. 2017;3:e168. [PMID: 28706971 PMCID: PMC5498009 DOI: 10.1097/txd.0000000000000688]

Outcomes of living donor liver transplant recipients receiving grafts with the graft-to-recipient weight ratio less than 0.6%: A matched pair analysis

We sometimes experience living donor liver transplantation (LDLT) involving very small grafts with graft-to-recipient weight ratio (GRWR) < 0.6% when the actual graft size is smaller than predicted. The outcomes in this situation have not been fully investigated. The present study aimed to determine the graft outcomes of LDLT with GRWR < 0.6%. We retrospectively reviewed 280 cases of adult LDLT performed at our institution between January 2000 and March 2021. In our institution, the lower limit for graft volume/standard liver volume ratio was 30%. The patients were divided into 2 groups according to the cutoff value of 0.6% for actual GRWR. Graft survival and surgical outcomes, including small-for-size syndrome (SFSS), were compared between the groups using propensity score matching analysis. Risk factors associated with SFSS in recipients with GRWR < 0.6% were also evaluated. Fifty-nine patients received grafts with GRWR < 0.6%. After propensity score matching, similar graft survival rates were observed for GRWR < 0.6% (n = 53) and GRWR ≥ 0.6% (n = 53) ( p = 0.98). However, patients with GRWR < 0.6% had a significantly worse 3-month graft survival rate (86.8% vs. 98.1%, p = 0.03) and higher incidence of SFSS ( p < 0.001) than patients with GRWR ≥0.6%. On multivariate analysis, Model for End-Stage Liver Disease score and donor age were associated with SFSS in patients with GRWR < 0.6%. The same factors were also associated with graft survival. In conclusion, although similar overall graft survival rates were observed for LDLT with GRWR < 0.6% and GRWR ≥ 0.6%, GRWR < 0.6% was associated with an increased risk of SFSS. Appropriate donor and recipient selection is important for successful LDLT with very small grafts.

An Analysis of 10,000 Cases of Living Donor Liver Transplantation in Japan: Special Reference to the Graft-Versus-Recipient Weight Ratio and Donor Age

OBJECTIVE

To analyze 10,000 cases of living donor liver transplantation (LDLT) recipient data to elucidate outcomes with special reference to the graft-versus-recipient weight ratio (GRWR), based on the Japanese Liver Transplantation Society (JLTS) registry.

BACKGROUND

The JLTS registry has been accurate and complete in characterizing and following trends in patient characteristics and survival of all patients with LDLT.

METHODS

Between November 1989 and August 2021, 10,000 patients underwent LDLT in Japan. The procedures performed during the study period included pediatric liver transplantation (age <18 years, n = 3572) and adult liver transplantation (age ≥18 years, n=6428). Factors related to patient survival (PS) and graft survival (GS) were also analyzed.

RESULTS

The GRWR was <0.7, 0.7 to <0.8, 0.8 to <3, 3 to <5, and ≥5 in 0.2%, 2.0%, 61.8%, 31.8%, and 2.6% of pediatric patients and <0.6, 0.6 to <0.7, 0.7 to <0.8, and ≥0.8 in 8.0%, 12.7%, 17.7%, and 61.5% of adult patients, respectively. Among pediatric recipients, the PS rate up to 5 years was significantly better in cases with a GRWR ≤5 than in those with a GRWR >5. When the GRWR and donor age were combined, among adult recipients 50 to 60 years old, the early PS and GS up to 5 years were significantly better in cases with a GRWR ≥0.7, than in those with a GRWR <0.7. (P = 0.02). In adults, a multivariate analysis showed that GRWR <0.6, transplant era (<2011), donor age (>60 years), recipient age (>60 years), model for end-stage liver disease score (≥20), and center volume (<10) were significant prognostic factors for long-term PS.

CONCLUSION

Although a satisfactory long-term PS and GS, especially in the recent era (2011-2021), was achieved in the JLTS series, a GRWR ≥5 in pediatric cases and relatively old donors with a GRWR <0.7 in adult cases should be managed with caution.

Impact of donor age on recipient morbidity and mortality after living donor liver transplantation

BACKGROUND

Evidence for use of graft from older donors in living donor liver transplantation (LDLT) has been conflicting. This study aims to clarify the impact of donor age on recipient morbidity and mortality after adult LDLT.

METHODS

A total of 90 live liver donors and recipients who underwent primary adult-to-adult LDLT were divided into three groups according to donor age: donors in 20s (D-20s) group, donors in 30s and 40s (D-30s and 40s) group and donors in 50s & 60s (D-50s and 60s) group. Multivariate analyses were conducted to look for independent risk/prognostic factors. Donor age was analysed as a continuous variable to determine an optimal cut off.

RESULTS

Overall donor morbidity was 4/90 (4.44%), major donor morbidity was 1/90 (1.11%) and there was no donor mortality. Recipients in the D-20s group had better 1-, 3- and 5-year recipient survival than recipients in the D-50s and 60s group (96%, 91%, 91% versus 73%, 58%, 58%, respectively) (P = 0.020). Donor age was identified to be an independently significant risk factor for increased major complications (P = 0.007) and prognostic factor for reduced overall survival (P = 0.014). The optimal donor age cut off was determined to be 46.5 years old.

CONCLUSION

Older donors are associated with poorer recipient outcomes after adult-to-adult LDLT. Usage of liver grafts from older donors should be carefully considered when choosing liver grafts for patients undergoing LDLT.

A comparison of postoperative pain between transumbilical and suprapubic incision in laparoscopic liver resection

BACKGROUND

In laparoscopic liver resection, few reports have investigated the influence of type of incision on postoperative pain in laparoscopic liver resection. We therefore conducted the present study to clarify the difference in postoperative pain between two types of incision.

METHODS

Nineteen patients who underwent laparoscopic lateral sectionectomy were enrolled. In 11 patients with a transumbilical incision and eight with a suprapubic incision, the operation duration, blood loss, length of incision, duration of intravenous fentanyl infusion immediately after surgery and rescue dosage, and period of regular oral nonsteroidal anti-inflammatory drugs were evaluated.

RESULTS

There was no significant difference between the two groups in patients' background characteristics, operation time, or amount of blood loss. The length of suprapubic incision was significantly longer than the umbilical incision. Concerning the postoperative pain management, the duration of intravenous fentanyl administration was 1 day (1-2 days) for umbilical incisions and 1.5 days (1-2 days) for suprapubic incisions, showing no significant difference. Regarding the rescue dosage of fentanyl, the results were comparable between the groups. Regarding the postoperative duration of regular nonsteroidal anti-inflammatory drug administration, there was also no significant difference between the groups (transumbilical: 14 [5-35] days vs suprapubic: 8 [7-32]).

CONCLUSIONS

Postoperative pain is comparable between umbilical and suprapubic incision in patients who underwent laparoscopic left lateral segmentectomy. In terms of postoperative pain, either a transumbilical incision or a suprapubic incision can be selected for specimen extraction.

The outcomes of thrombotic microangiopathy after liver transplantation: A nationwide survey in Japan

BACKGROUND

Although thrombotic microangiopathy (TMA) is recognized as one of the poor-prognosis factors after liver transplantation, the precise outcome of TMA is unclear. We sought to elucidate the factors affecting the outcome of TMA after liver transplantation in Japan, based on the data from a nationwide survey.

METHODS

One hundred cases of post-transplant TMA were accumulated from 17 Japanese centers of which two cases were excluded because the cause of death was obviously not related to TMA (recurrence of original diseases as primary sclerosing cholangitis and hepatocellular carcinoma), and the remaining 98 cases were enrolled in this study. The patient survival after the development of TMA and the factors that affected the patients' outcomes were retrospectively analyzed.

RESULTS

All cases were living-donor liver transplant cases, and the 1-, 3-, and 5-year patient survival rates after transplantation were 66.9%, 64.6%, and 62.2%, respectively. In a multivariate analysis, the requirement of renal replacement therapy during TMA treatment was the only factor that was significantly related to poor outcome after the development of TMA.

CONCLUSION

The outcomes of TMA were generally poor. The progression of renal dysfunction despite intensive treatment might be the only factor related to the poor prognosis after the development of TMA.

The Significant Prognostic Factors in Prolonged Intensive/High Care Unit Stay After Living Donor Liver Transplantation

BACKGROUND

Prolonged stay in an intensive/high care unit (ICU/HCU) after living donor liver transplantation (LDLT) is a significant event with possible mortality.

METHODS

Adult-to-adult LDLTs (n = 283) were included in this study. Univariate and multivariate analyses were performed for the factors attributed to the prolonged ICU/HCU stay after LDLT.

RESULTS

Recipients who stayed in the ICU/HCU 9 days or longer were defined as the prolonged group. The prolonged group was older (P = .0010), had a higher model for end-stage liver disease scores (P < .0001), and had higher proportions of patients with preoperative hospitalization (P < .0001). Delirium (P < .0001), pulmonary complications (P < .0001), sepsis (P < .0001), reintubation or tracheostomy (P < .0001), relaparotomy due to bleeding (P = .0015) or other causes (P < .0001), and graft dysfunction (P < .0001) were associated with prolonged ICU/HCU stay. Only sepsis (P = .015) and graft dysfunction (P = .019) were associated with in-hospital mortality among patients with prolonged ICU/HCU stay or graft loss within 9 days of surgery. Among these patients, grafts from donors aged <42 years and with a graft-to-recipient weight ratio of >0.76% had significantly higher graft survival than grafts from others (P = .0013 and P < .0001, respectively).

CONCLUSION

Prolonged ICU/HCU stay after LDLT was associated with worse short-term outcomes. The use of grafts of sufficient volume from younger donors might improve graft survival.

Cell Sources and Influencing Factors of Liver Regeneration: A Review

Liver regeneration (LR) is a set of complicated mechanisms between cells and molecules in which the processes of initiation, maintenance, and termination of liver repair are regulated. Although LR has been studied extensively, there are still numerous challenges in gaining its full understanding. Cells for LR have a wide range of sources and the feature of plasticity, and regeneration patterns are not the same under different conditions. Many patients undergoing partial hepatectomy develop cirrhosis or steatosis. The changes of LR in these cases are not clear. Many types of cells participate in LR. Hepatocytes, biliary epithelial cells, hepatic progenitor cells, and human liver stem cells can serve as the cell sources for LR. However, different types and degrees of damage trigger the response from the most suitable cells. Exploring the cell sources of LR is of great significance for accelerating recovery of liver function under different pathological patterns and developing a cell therapy strategy to cope with the shortage of donors for liver transplantation. In clinical practice, the background of the liver influences regeneration. Fibrosis and steatosis create different LR microenvironments and signal molecule interaction patterns. In addition, factors such as partial hepatectomy, aging, platelets, nerves, hormones, bile acids, and gut microbiota are widely involved in this process. Understanding the influencing factors of LR has practical value for individualized treatment of patients with liver diseases. In this review, we have summarized recent studies and proposed our views. We discuss cell sources and the influential factors on LR to help in solving clinical problems.

Older Donor Age Is a Risk Factor for Negative Outcomes After Adult Living Donor Liver Transplantation Using Small-for-Size Grafts

Adult-to-adult living donor liver transplantation (ALDLT) using small-for-size grafts (SFSGs), ie, a graft with a graft-to-recipient weight ratio (GRWR) <0.8%, has been a challenge that should be carefully dealt with, and risk factors in this category are unclear. Therefore, we aimed to examine the risk factors and outcomes of ALDLT using SFSGs over a 13-year period in 121 patients who had undergone their first ALDLT using SFSGs. Small-for-size syndrome (SFSS), early graft loss, and 1-year mortality were encountered in 21.6%, 14.9%, and 18.4% of patients, respectively. By multivariate analysis, older donor age (≥45 years) was an independent risk factor for SFSS (odds ratio [OR], 4.46; P = 0.004), early graft loss (OR, 4.11; P = 0.02), and 1-year mortality (OR, 3.76; P = 0.02). Child-Pugh C class recipients were associated with a higher risk of SFSS development (P = 0.013; OR, 7.44). Despite no significant difference between GRWR categories in the multivariate outcome analysis of the whole population, in the survival analysis of the 2 donor age groups, GRWR <0.6% was associated with significantly lower 1-year survival than the other GRWR categories in the younger donor group. Moreover, in the high final portal venous pressure (PVP) group (>15 mm Hg), younger ABO-compatible donors showed 100% 1-year survival with a significant difference from the group of other donors. Older donor age was an independent risk factor for SFSS, early graft loss, and 1-year mortality after ALDLT using SFSGs. GRWR should not be <0.6%, and PVP modulation is indicated when grafts from older or ABO-incompatible donors are used.

Impact of donor age on liver regeneration and function following adult living donor liver transplantation

The aim of the present study was to evaluate the impact of donor age on liver function and regeneration following living donor liver transplantation. Donors were divided into an elderly donor group (age >50 years old; n=8) and a young donor group (age <30 years old; n=35). The recipients were also divided into an elderly group (age >50 years old; n=5) and a young group (age <30 years old; n=25). Alanine aminotransferase, aspartate aminotransferase, total bilirubin (TB) and prothrombin time were recorded 1-5 days postoperatively. The liver regeneration ratio (LRR) was recorded 7 and 15 days postoperatively in donors and at 0.5, 1, 3 and 6 months postoperatively in recipients by contrast-enhanced multi-slice spiral computed tomography. Notably, the LRR in the young donor group was significantly increased compared with that in the elderly donor group at 7 days postoperatively (P<0.05). Among recipients, TB in the elderly group was significantly increased compared with that in the young group at 1-5 days postoperatively (P<0.05). The residual liver regeneration rate was decreased and the time of jaundice was prolonged in recipients in the elderly group 7 days postoperatively, but donor age had little impact on the short-term outcome of the residual liver and graft.

Feasibility of using marginal liver grafts in living donor liver transplantation

Liver transplantation (LT) is one of the most effective treatments for end-stage liver disease caused by related risk factors when liver resection is contraindicated. Additionally, despite the decrease in the prevalence of hepatitis B virus (HBV) over the past two decades, the absolute number of HBsAg-positive people has increased, leading to an increase in HBV-related liver cirrhosis and hepatocellular carcinoma. Consequently, a large demand exists for LT. While the wait time for patients on the donor list is, to some degree, shorter due to the development of living donor liver transplantation (LDLT), there is still a shortage of liver grafts. Furthermore, recipients often suffer from emergent conditions, such as liver dysfunction or even hepatic encephalopathy, which can lead to a limited choice in grafts. To expand the pool of available liver grafts, one option is the use of organs that were previously considered “unusable” by many, which are often labeled “marginal” organs. Many previous studies have reported on the possibilities of using marginal grafts in orthotopic LT; however, there is still a lack of discussion on this topic, especially regarding the feasibility of using marginal grafts in LDLT. Therefore, the present review aimed to summarize the feasibility of using marginal liver grafts for LDLT and discuss the possibility of expanding the application of these grafts.