Dual-graft adult living donor liver transplantation with ABO-incompatible graft: short-term and long-term outcomes

Advocating for a "shift-to-left" in transplant oncology: left grafts, RAPID and dual graft

The extension of liver transplantation to new oncologic indications might exacerbate the shortage of grafts. Living donor liver transplantation (LDLT) may emerge as a viable resource, although its diffusion in the Western world is still very limited. Several groups have advocated for minimizing the impact on donors by reducing the extent of donor hepatectomy, i.e., shifting from right-lobe to left-lobe or left-lateral segment donation ("shift-to-left"). This is particularly relevant when dealing with non-established indications and could make it more acceptable both for potential donors and for the recipients. Left grafts can be transplanted straightforward, despite a higher risk of small-for-size syndrome, or they can be used in the setting of dual-graft LDLT or RAPID procedures, despite technical complexity. This review will expose the most relevant features of each technique, highlighting their strengths and pitfalls and focusing on outcomes. This wide set of tools should be available at high-volume transplant centers, to propose the best technique to adapt to donor-recipient matching.

Prior to ABOi liver transplant with PD-1 inhibitor in patients with hepatocellular carcinoma: A case report

BACKGROUND

Liver transplantation (LT) is a unique and effective method for treating end-stage liver diseases and acute liver failure, bringing hope to many patients with liver cancer. LT is currently widely used in the treatment of liver diseases. However, there have been no patients with liver cancer who have undergone ABO-incompatible (ABOi) LT after treatment with the programmed cell death protein 1 (PD-1) inhibitor reported in the literature.

CASE PRESENTATION

A patient with liver cancer who received sintilimab injection, an anti-PD1 therapy, before LT was admitted in the transplantation centre. This patient underwent ABOi LT. The perioperative treatment strategy of this patient was reported. A desensitisation protocol was conducted urgently for the patient before operation, and the immunosuppression programme of LT was adjusted. After operation, isoagglutinin titer and liver function indicators were strictly monitored. The patient recovered well after operation, and no sign of rejection reaction was observed.

CONCLUSION

We reported a patient with hepatocellular carcinoma (HCC) who received PD-1 inhibitor treatment before operation and successfully underwent ABOi LT. The present case report provides novel insights into the perioperative management of utilizing PD-1 inhibitors prior to ABOi LT in patients diagnosed with hepatocellular carcinoma (HCC).

Dual Graft Living Donor Liver Transplantation for High Acuity Patients: A Single-Center Experience

Background

The outcomes of dual graft living donor liver transplantation (DGLDLT) in high acuity patients remain underreported. The objective of this study was to report long-term outcomes from a single center in this select group of patients.

Methods

This was a retrospective review of patients who underwent DGLDLT between 2012 and 2017 (n = 10). High acuity patients were defined as patients with model for end stage liver disease (MELD) ≥30 or Child Pugh score ≥11. We looked at 90-day morbidity and mortality and 5-year overall survival (OS).

Results

The median MELD score and Child Pugh score were 30 (26.7-35) and 11 (11-11.2). The median recipient weight was 105 (95.2-113.7) and ranged from 82 to 132 kg. Out of 10 patients, 4 (40%) required perioperative renal replacement therapy, and 8 (80%) required hospital admission for optimization. The estimated graft to recipient weight ratio (GRWR) with right lobe graft alone was <0.8 in all patients, between 0.75 and 0.65 in 5 (50%) patients, and <0.65 in 5 (50%) patients. The 90-day mortality was 3/10 (30%), and there were 3/10 (30%) deaths during long-term follow-up. Among 155 high acuity patients, the 1-year OS with standard LDLT, standard LDLT with GRWR <0.8, and DGLDLT was 82%, 76%, and 58%, respectively (P = 0.123). With a median follow-up of 40.6 (1.9-74.4) months, the 5-year OS for DGLDLT was 50%.

Conclusion

The use of DGLDLT in high acuity patients should be prudent and low GRWR grafts should be considered a viable alternative in selected patients.

Clinical outcomes after ABO-incompatible liver transplantation: A systematic review and meta-analysis

BACKGROUND

ABO-incompatible liver transplantation (ABOi-LT) is increasingly used to overcome donor shortage. Evidence about disadvantage and advantage in comparison with ABO-compatible liver transplantation (ABOc-LT) needs to be performed in the early and late periods. Herein, We compared the short-term and long-term outcomes between ABOi-LT and ABOc-LT cohorts.

METHODS

We performed a meta-analysis based on the observation studies which included outcomes at ≥1 year after ABOi-LT and ABOc-LT procedures, based on the MEDLINE (via Pubmed), the Cochrance Central Register of Controlled Trials (CENTRAL), and EMBASE (via Ovid) systems. Two researchers independently screened each study according to the pre-established inclusion and exclusion criteria to assess the quality of each study and extracted data from published studies. The primary outcome indicators were all-cause mortality and graft survival at 1, 3 and 5 years after transplantation. In the meta-analysis, we based on the value of heterogeneity using a fixed-effect and a random-effect. A fixed-effect model was used if the value of I2 was less than or equal 50%; and a random-effect model was used if the value of I2 was greater than 50%.

FINDINGS

Out of 335 identified records, 29 records with 10,783 patients with liver transplants; 2137 of them were ABOi-LTs and the remaining 8646 were ABOc-LTs. There was no significant difference at 1-year, 3-year, and 5-year in all-cause mortality, death-censored graft survival and complication incidence rate between ABO-incompatible living donor liver transplantation (ABOi-LDLT) group and ABO-compatible living donor liver transplantation (ABOc-LDLT) group. Compared with ABO-compatible deceased donor liver transplantation (ABOc-DDLT), ABO-incompatible deceased donor liver transplantation (ABOi-DDLT) had a higher 1-year all-cause mortality, and the value of totally pooled odds ratio (OR) was 1.89 (1.28,2.80). However, there was no significant difference at 3-year and 5-year all-cause mortality between ABOi-DDLT and ABOc-DDLT groups. ABOi-DDLT group had a lower 1-year and 5-year death-censored graft survival than ABOc-DDLT, as the value of totally pooled OR was 1.91 (1.41,2.60) and 1.52 (1.12,2.05), respectively. No significant difference was detected at 3-year death-censored graft survival between ABOi-DDLT and ABOc-DDLT groups. ABOi-DDLT group had a higher complication incidence rate than ABOc-DDLT, and the value of totally pooled OR was 2.26 (1.53,3.33). We found no obvious bias except for the complication of living donor liver transplantation (LDLT; P = 0.038).

IN CONCLUSION

The short-term and long-term outcomes were worse after ABOi-DDLT than ABOc-DDLT in the all-cause mortality, death-censored graft survival, and complication incidence rate. However, the same outcomes were essentially comparable between ABOi-LDLT vs. ABOc-LDLT cohorts. Considering the current shortage of liver donors, we believe that ABOi-LT from living donor and deceased donors can save lives under emergency situations.

Living donor liver transplantation

PURPOSE OF REVIEW

As experience grows, living donor liver transplantation (LDLT) has become an effective treatment option to overcome the deceased donor organ shortage.

RECENT FINDINGS

Donor safety is the highest priority in LDLT. Strict donor selection according to structured protocols and center experience are the main factors that determine donor safety. However, with increased experience, many centers have explored increasing organ availability within living donation by means of ABO incompatible LDLT, dual graft LDLT, and anonymous living donation. Also, this growing experience in LDLT has allowed the transplant community to cautiously explore the role of liver transplantation for hepatocellular carcinoma outside of Milan criteria and patients with unresectable colorectal liver metastases.

SUMMARY

LDLT has become established as a viable strategy to ameliorate the organ shortage experienced by centers around the world. Improved understanding of this technique has allowed the improved utilization of live donor graft resources, without compromising donor safety. Moreover, LDLT may offer some advantages over deceased donor liver transplantation and a unique opportunity to assess the broader applicability of liver transplantation.