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Pomposelli JJ, Rela M. Retransplantation in Living Donor Liver Transplantation. Transplantation 2024:00007890-990000000-00759. [PMID: 38771077 DOI: 10.1097/tp.0000000000005072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
The need for retransplantation after living donor liver transplantation can occur early, mainly because of technical difficulties such as hepatic artery thrombosis or as a result of early allograft dysfunction as a symptom of small-for-size syndrome. Patients with autoimmune diseases may develop progressive graft failure from recurrent disease. The ethics of retransplantation can be complicated by the cause of the initial liver disease, which may be self-inflicted or the outcome of malignancy. This is especially true in countries without the availability of deceased donors for salvage, and a second living donor would be needed. Nevertheless, patients who experience early or late graft failure should be considered for retransplant if they are deemed acceptable candidates. When a living donor is required for retransplant, the equipoise between donor risk and autonomy and recipient outcome should be considered.
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Affiliation(s)
- James J Pomposelli
- University of Colorado, Anschutz Medical Campus, Aurora, CO
- Colorado Center for Transplantation Care, Research, and Education, Aurora, CO
| | - Mohamed Rela
- King's College Hospital, London, United Kingdom
- Rela Hospital, Chennai, Tamil Nadu, India
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2
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Yilmaz S, Sönmez T, Ünver MU, Ince V, Akbulut S, Sarici KB, Isik B. Enhanced Role of Multi-Pair Donor Swaps in Response to Size Incompatibility: The First Two 5-Way and the First 6-Way Liver Paired Exchanges. Am J Transplant 2024:S1600-6135(24)00338-1. [PMID: 38768752 DOI: 10.1016/j.ajt.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/22/2024] [Accepted: 05/14/2024] [Indexed: 05/22/2024]
Abstract
A significant portion of liver transplantations in many countries is conducted via living-donor liver transplantation (LDLT). However, numerous potential donors are unable to donate to their intended recipients due to factors such as blood-type incompatibility or size incompatibility. Despite this, an incompatible donor for one recipient may still be a viable donor for another patient. In recent decades, several transplant centers have introduced liver paired exchange (LPE) programs, facilitating donor exchanges between patients and their incompatible donors, thereby enabling compatible transplants. Initially, LPE programs in Asia primarily involved ABO-i pairs, resulting in 2-way exchanges mainly between blood-type A and B recipients and donors. This practice has led to a modest 1-2% increase in LDLTs at some centers. Incorporating size incompatibility alongside blood-type incompatibility further enhances the efficacy and significance of multiple-pair LPEs. Launched in July 2022, a single-center LPE program established at Inönü University Liver Transplant Institute in Malatya, Türkiye, has conducted thirteen 2-way, nine 3-way, four 4-way, two 5-way, and one 6-way LPEs until February 2024. In 2023 alone, this program facilitated 64 LDLTs, constituting 27.7% of the total 231 LDLTs performed. This paper presents the world's first two 5-way LPEs and the first 6-way LPE.
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Affiliation(s)
- Sezai Yilmaz
- Department of Surgery and Liver Transplantation, Inonu University Liver Transplant Institute, 44280, Malatya, Turkey.
| | - Tayfun Sönmez
- Department of Economics, Boston College, Chestnut Hill, MA 02467, USA.
| | - M Utku Ünver
- Department of Economics, Boston College, Chestnut Hill, MA 02467, USA.
| | - Volkan Ince
- Department of Surgery and Liver Transplantation, Inonu University Liver Transplant Institute, 44280, Malatya, Turkey.
| | - Sami Akbulut
- Department of Surgery and Liver Transplantation, Inonu University Liver Transplant Institute, 44280, Malatya, Turkey.
| | - Kemal Baris Sarici
- Department of Surgery and Liver Transplantation, Inonu University Liver Transplant Institute, 44280, Malatya, Turkey.
| | - Burak Isik
- Department of Surgery and Liver Transplantation, Inonu University Liver Transplant Institute, 44280, Malatya, Turkey.
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3
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van der Meeren PE, de Wilde RF, Sprengers D, IJzermans JNM. Benefit and harm of waiting time in liver transplantation for HCC. Hepatology 2023:01515467-990000000-00646. [PMID: 37972979 DOI: 10.1097/hep.0000000000000668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/26/2023] [Indexed: 11/19/2023]
Abstract
Liver transplantation is the most successful treatment for limited-stage HCC. The waiting time for liver transplantation (LT) can be a critical factor affecting the oncological prognosis and outcome of patients with HCC. Efficient strategies to optimize waiting time are essential to maximize the benefits of LT and to reduce the harm of delay in transplantation. The ever-increasing demand for donor livers emphasizes the need to improve the organization of the waiting list for transplantation and to optimize organ availability for patients with and without HCC. Current progress in innovations to expand the donor pool includes the implementation of living donor LT and the use of grafts from extended donors. By expanding selection criteria, an increased number of patients are eligible for transplantation, which necessitates criteria to prevent futile transplantations. Thus, the selection criteria for LT have evolved to include not only tumor characteristics but biomarkers as well. Enhancing our understanding of HCC tumor biology through the analysis of subtypes and molecular genetics holds significant promise in advancing the personalized approach for patients. In this review, the effect of waiting time duration on outcome in patients with HCC enlisted for LT is discussed.
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Affiliation(s)
- Pam Elisabeth van der Meeren
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roeland Frederik de Wilde
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dave Sprengers
- Department of Gastroenterology & Hepatology, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jan Nicolaas Maria IJzermans
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Yilmaz S, Sönmez T, Ünver MU, Ince V, Akbulut S, Isik B, Emre S. The first 4-way liver paired exchange from an interdisciplinary collaboration between health care professionals and design economists. Am J Transplant 2023; 23:1612-1621. [PMID: 37419452 DOI: 10.1016/j.ajt.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/05/2023] [Accepted: 06/26/2023] [Indexed: 07/09/2023]
Abstract
We report initial results of a liver paired exchange (LPE) program established at the Liver Transplant Institute at Inonu University through collaboration with design economists. Since June 2022, the program has been using a matching procedure that maximizes the number of living donor liver transplants (LDLTs) to the patients in the pool subject to the ethical framework and the logistical constraints of the program. In 1 4-way and 4 2-way exchanges, 12 LDLTs have been performed via LPE in 2022. The 4-way exchange, generated in the same match run with a 2-way exchange, is a first worldwide. This match run generated LDLTs for 6 patients, revealing the value of the capacity to carry out larger than 2-way exchanges. With only 2-way exchanges, only 4 of these patients would receive a LDLT. The number of LDLTs from LPE can be increased by developing the capacity to perform larger than 2-way exchanges in either high-volume centers or multicenter programs.
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Affiliation(s)
- Sezai Yilmaz
- Inonu University Liver Transplant Institute, Malatya, Turkey.
| | - Tayfun Sönmez
- Boston College, Department of Economics, Chestnut Hill, Massachusetts, USA
| | - M Utku Ünver
- Boston College, Department of Economics, Chestnut Hill, Massachusetts, USA; Deakin University, Professorial Research Fellow, Burwood, Victoria, Australia
| | - Volkan Ince
- Inonu University Liver Transplant Institute, Malatya, Turkey
| | - Sami Akbulut
- Inonu University Liver Transplant Institute, Malatya, Turkey
| | - Burak Isik
- Inonu University Liver Transplant Institute, Malatya, Turkey
| | - Sukru Emre
- Inonu University Liver Transplant Institute, Malatya, Turkey
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Khan IAR, Sengupta B, Momani H, Abdulla RA, Tawfeeq MA, Al Qahtani MS. Paired Exchange Liver Transplantation Using an Altruistic Living Donor: First Case in Saudi Arabia-A Case Report. Transplant Proc 2023; 55:1927-1929. [PMID: 37524584 DOI: 10.1016/j.transproceed.2023.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 04/29/2023] [Accepted: 05/16/2023] [Indexed: 08/02/2023]
Abstract
Paired exchange (PE) living donor organ transplantation is an innovation designed to expand the pool of organs available for transplantation. In PE liver transplantation, the donor organs are exchanged between the 2 pairs to overcome blood group incompatibility or volume mismatch. There are ethical and logistic issues surrounding PE. This is the first report of PE liver transplantation in Saudi Arabia using an altruistic donor (AD). The AD may facilitate the exchange because there is no reciprocal expectation of transplantation from the AD. Paired exchange may increase only a small number of donated liver allografts. This may be the only solution for some families and in some countries.
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Affiliation(s)
- Iftikhar A R Khan
- Department of Transplant Surgery, Multi-Organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia.
| | - Bodhisatwa Sengupta
- Department of Transplant Surgery, Multi-Organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Hammam Momani
- Department of Transplant Surgery, Multi-Organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Rehab A Abdulla
- Multi-Organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Mansour A Tawfeeq
- Department of Transplant Surgery, Multi-Organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Mohammed S Al Qahtani
- Department of Transplant Surgery, Multi-Organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
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Rangaswamy B, Hughes CB, Sholosh B, Dasyam AK. Unconventional Strategies for Solid Organ Transplantation and Special Transplantation Scenarios. Radiol Clin North Am 2023; 61:901-912. [PMID: 37495296 DOI: 10.1016/j.rcl.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Solid organ transplantation is the only long-term therapeutic option for patients with end-organ failure but cadaveric and living donor transplant pools are unable to meet the demand for organ transplantation. Newer techniques, innovative strategies and altruistic donors can help bridge this wide gap between the number of organ donors and recipients. Domino liver transplantation, paired organ donation, and ABO incompatible transplants are some of the ways to ensure increased transplant organ availability. Split liver transplantation and ex vivo liver resection and auto transplantation are considered surgically challenging but are being done at tertiary transplant centers.
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Affiliation(s)
| | - Christopher B Hughes
- Department of Surgery, Liver Transplantation at the Thomas E. Starzl Transplantation Institute, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Biatta Sholosh
- Department of Radiology, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Anil K Dasyam
- Department of Radiology, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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Liapakis A, Jesse MT, Pillai A, Bittermann T, Dew MA, Emre S, Hunt H, Kumar V, Locke J, Mohammad S, Olthoff K, Verna EC, Lentine KL. Living donor liver transplantation: A multi-disciplinary collaboration towards growth, consensus, and a change in culture. Clin Transplant 2023:e14953. [PMID: 36890717 DOI: 10.1111/ctr.14953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/14/2023] [Accepted: 02/26/2023] [Indexed: 03/10/2023]
Abstract
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.
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Affiliation(s)
- AnnMarie Liapakis
- Yale School of Medicine and Yale New Haven Transplant Center, New Haven, Connecticut, USA
| | - Michelle T Jesse
- Transplant Institute, Henry Ford Health System, Detroit, Michigan, USA
| | - Anjana Pillai
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | | | - Mary Amanda Dew
- University of Pittsburgh School of Medicine and Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sukru Emre
- Ege University School of Medicine, Izmir, Turkey
| | - Heather Hunt
- Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) Living Donor Committee, Richmond, Virginia, USA
| | - Vineeta Kumar
- Department of Medicine, Division of Nephrology/Transplant, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jayme Locke
- Department of Medicine, Division of Nephrology/Transplant, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Saeed Mohammad
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kim Olthoff
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University, New York, USA
| | - Krista L Lentine
- Saint Louis University Transplant Center, St. Louis, Missouri, USA
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Kwon YK, Kaur N, Etesami K, Zielsdorf S, Kim B, Kahn J, Yanni G, Padilla A, Han H, Genyk Y. Living donor liver paired exchange between pediatric and adult recipients due to donor graft size mismatch. Am J Transplant 2023; 23:440-442. [PMID: 36695680 DOI: 10.1016/j.ajt.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/16/2022] [Accepted: 10/04/2022] [Indexed: 01/13/2023]
Abstract
Living donor liver transplantation is an effective means to decrease organ shortage. However, many potential living donors are currently being denied due to ABO incompatibility or inadequate donor liver volume. Liver paired exchange (LPE) provides a practical solution to overcome these obstacles, and yet the first case of LPE in the United States was only recently reported in 2020. Here, we report world's first case of LPE involving pediatric and adult recipients to avoid surgical complexity of the pediatric recipient and to increase the graft-to-recipient weight ratio of the adult recipient between 2 ABO compatible pairs. As living donor liver transplantation becomes more widely adopted, the need for pair exchange to improve surgical safety and postoperative outcomes between 2 ABO compatible pairs is likely to increase.
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Affiliation(s)
- Yong K Kwon
- Division of Abdominal Organ Transplantation and Hepato-Biliary and Pancreatic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Division of Abdominal Organ Transplantation, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Navpreet Kaur
- Division of Abdominal Organ Transplantation and Hepato-Biliary and Pancreatic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kambiz Etesami
- Division of Abdominal Organ Transplantation and Hepato-Biliary and Pancreatic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Division of Abdominal Organ Transplantation, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Shannon Zielsdorf
- Division of Abdominal Organ Transplantation and Hepato-Biliary and Pancreatic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Division of Abdominal Organ Transplantation, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Brian Kim
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jeffrey Kahn
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - George Yanni
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Ana Padilla
- Transplant Institute, Keck Medical Center of USC, Los Angeles, California, USA
| | - Hyosun Han
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Yuri Genyk
- Division of Abdominal Organ Transplantation and Hepato-Biliary and Pancreatic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Division of Abdominal Organ Transplantation, Children's Hospital Los Angeles, Los Angeles, California, USA.
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Abstract
By 2014, strategies to prevent antibody-mediated rejection (AMR) after ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) were established in Japan and expanded primarily to Asia, where LDLT is now the predominant form of LT owing to the scarcity of brain-dead donors. A desensitization protocol consisting of rituximab (375 mg/m 2 ), plasma pheresis, tacrolimus, and mycophenolate mofetil before LDLT, followed by standard immunosuppression, is currently the best option in terms of safety and efficacy. Rituximab administration is now known not to increase the risk of hepatocellular carcinoma recurrence, and the feasibility of rituximab for LDLT for acute liver failure and the need for desensitization before LDLT in children older than 1 y have been documented. Strategies are needed to distinguish patients at high risk of AMR from those at low risk and to adjust immunosuppression to prevent both AMR and infection. Specific single-nucleotide polymorphisms in genes encoding Fcγ receptors affecting the cytotoxicity of rituximab on B cells could be useful for adjusting immunosuppression levels to decrease infectious complications. Immunological accommodation after ABO-I transplantation could be provided by immune factors in both the grafts and recipients.
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Liver Paired Exchange: Programmatic Hopes and Fears. Transplantation 2022; 107:849-854. [PMID: 36445920 DOI: 10.1097/tp.0000000000004397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The dearth of deceased liver donors has created a supply demand gap, necessitating creation of living donor liver transplantation. However, living donor liver transplantation has relied on directed donation, whereby many potential directed donors are rejected based on ABO blood group incompatibility, hepatic size incompatibility, or the need for biliary or arterial reconstruction during transplant surgery. Much like kidney paired exchange, liver paired exchange (LPE) circumvents these incompatibility issues by relying on anonymous, nondirected, or bridge donors that are better anatomical or histological matches for recipients. Although Asia has taken the lead in LPE, the process has only recently been adopted in North America, with the first successful surgery done in the United States in 2019. Our review article sheds light on the process of LPE and the success of LPE in the United States thus far and, additionally, highlights the several logistical and ethical challenges that must be considered as transplant centers adopt and scale up LPE across the United States to address the increased demand for liver allografts.
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Vargas PA, Goldaracena N. Right vs Left Hepatectomy for LDLT, Safety and Regional Preference. CURRENT TRANSPLANTATION REPORTS 2022. [DOI: 10.1007/s40472-022-00386-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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