Allograft survival following adult-to-adult living donor liver transplantation

Outcomes of Living Donor Liver Transplantation Compared with Deceased Donor Liver Transplantation

Improved surgical techniques and revolutionary immunosuppressive agents have enhanced the long-term outcomes for liver transplantation, with more patients seeking the benefits of liver transplantation, and demand is high. In this review, we hope to delineate where the current data supporting favorable outcomes in using live donation to expand the donor pool compared with the outcomes seen in deceased donor liver transplants. Advances in surgery, transplant and center comfort has made live donor transplantation an asset with favorable patient outcomes in comparison to decease donor data.

Transplant oncology - Current indications and strategies to advance the field

Liver transplantation (LT) was originally described by Starzl as a promising strategy to treat primary malignancies of the liver. Confronted with high recurrence rates, indications drifted towards non-oncologic liver diseases with LT finally evolving from a high-risk surgery to an almost routine surgical procedure. Continuously improving outcomes following LT and evolving oncological treatment strategies have driven renewed interest in transplant oncology. This is not only reflected by constant refinements to the criteria for LT in patients with HCC, but especially by efforts to expand indications to other primary and secondary liver malignancies. With new patient-centred oncological treatments on the rise and new technologies to expand the donor pool, the field has the chance to come full circle. In this review, we focus on the concept of transplant oncology, current indications, as well as technical and ethical aspects in the context of donor organs as precious resources.

Association between visceral obesity and tumor recurrence in hepatocellular carcinoma recipients undergoing liver transplantation

BACKGROUND

Excessive visceral obesity in recipients of living donor liver transplantation (LDLT) is associated with mortality, and a recent study reported the correlation between visceral adiposity of male LDLT recipients and hepatocellular carcinoma (HCC) recurrence. However, there is no study on the relationship between the donor's visceral adiposity and surgical outcomes in LDLT recipients. We investigated the association of the visceral-to-subcutaneous fat area ratio (VSR) in donors and recipients with HCC recurrence and mortality in LDLT.

METHODS

We analyzed 1386 sets of donors and recipients who underwent LDLT between January 2008 and January 2018. The maximal chi-square method was used to determine the optimal cutoff values for VSR for predicting overall HCC recurrence and mortality. Cox regression analyses were performed to evaluate the association of donor VSR and recipient VSR with overall HCC recurrence and mortality in recipients.

RESULTS

The cutoff values of VSR was determined as 0.73 in males and 0.31 in females. High donor VSR was significantly associated with overall HCC recurrence (adjusted hazard ratio [HR]: 1.43, 95% confidence interval [CI]: 1.06-1.93, p = 0.019) and mortality (HR: 1.35, 95% CI: 1.03-1.76, p = 0.030). High recipient VSR was significantly associated with overall HCC recurrence (HR: 1.40, 95% CI: 1.04-1.88, p = 0.027) and mortality (HR: 1.50, 95% CI: 1.14-1.96, p = 0.003).

CONCLUSIONS

Both recipient VSR and donor VSR were significant risk factors for HCC recurrence and mortality in LDLT recipients. Preoperative donor VSR and recipient VSR may be strong predictors of the surgical outcomes of LDLT recipients with HCC.

The John S. Najarian symposium: The past, present, and future of surgery and transplantation, May 20, 2022, Minneapolis, MN

Dr John S Najarian (1927-2020), chairman of the Department of Surgery at the University of Minnesota from 1967 to 1993, was a pioneer in surgery, clinical immunology and transplantation. A Covid-delayed Festschrift was held in his honor on May 20, 2022. The speakers reflected on his myriad contributions to surgery, transplantation, and resident/fellow training, as well as current areas of ongoing research to improve clinical outcomes. Of note, Dr Najarian was a founder of the journal Clinical Transplantation.

Association of sex-specific donor skeletal muscle index with surgical outcomes in living donor liver transplantation recipients

BACKGROUND

A recent study reported a correlation between the muscle mass of male donors and graft failure in living donor liver transplantation (LDLT) recipients. We investigated the association of sex-specific donor skeletal muscle index (SMI) with mortality and graft failure in LDLT recipients.

METHODS

We retrospectively analysed 2750 sets of donors and recipients between January 2008 and January 2018. The recipient outcomes were analysed by dividing the data according to donor sex. Cox regression analyses were performed to evaluate the association between donor SMI by sex and 1-year mortality and graft failure in recipients.

RESULTS

In the male donor group, robust donor (increased SMI) was significantly associated with higher risks for mortality (hazard ratio [HR]: 1.03, 95% confidence interval [CI]: 1.00-1.06, p = .023) and graft failure (HR: 1.04, 95% CI: 1.01-1.06, p = .007) at 1 year. In the female donor group, the robust donor was significantly associated with lower risks for mortality (HR: 0.92, 95% CI: 0.87-0.97, p = .003) and graft failure (HR: 0.95, 95% CI: 0.90-1.00, p = .032) at 1 year.

CONCLUSIONS

Donor SMI was associated with surgical outcomes in recipients. Robust male and female donors were a significant negative and protective factor for grafts respectively.

Potential association between public medical insurance, waitlist mortality, and utilization of living donor liver transplantation: An analysis of the Scientific Registry of Transplant Recipients

BACKGROUND

The Affordable Care Act (ACA) and subsequent Medicaid expansion has increased utilization of public health insurance. Living donor liver transplantation (LDLT) increases access to transplant and is associated with improved survival but consistently represents < 5% of LT in the United States.

STUDY DESIGN

National registry data were analyzed to evaluate the impact of insurance payor on waitlist mortality and LDLT rates at LDLT centers since implementation of the ACA.

RESULTS

Public insurance [Medicare RR 1.18 (1.13-1.22) P < .001, Medicaid RR 1.22 (1.18-1.27) P < .001], Latino ethnicity (P < .001), and lower education level (P = .02) were associated with increased waitlist mortality at LDLT centers. LDLT recipients were more likely to have private insurance (70.4% vs. 59.4% DDLT, P < .001), be Caucasian (92.1% vs. 83% DDLT, P < .001), and have post-secondary education (66.8% vs. 54.1% DDLT, P < .001). Despite 78% of LDLT centers being located in states with Medicaid expansion, there was no change in LDLT utilization among recipients with Medicaid (P = .196) or Medicare (P = .273).

CONCLUSION

Despite Medicaid expansion, registry data suggests that patients with public medical insurance may experience higher waitlist mortality and underutilize LDLT at centers offering LDLT. It is possible that Medicaid expansion has not increased access to LDLT.

Outcomes in Living Donor Compared With Deceased Donor Primary Liver Transplantation in Lower Acuity Patients With Model for End-Stage Liver Disease Scores <30

Although recent studies have reported favorable outcomes in living donor liver transplantation (LDLT), it remains unclear which populations benefit most from LDLT. This study aims to evaluate LDLT outcomes compared with deceased donor LT (DDLT) according to Model for End-Stage Liver Disease (MELD) score categories. Using data from the United Network for Organ Sharing registry, outcomes were compared between 1486 LDLTs; 13,568 donation after brain death (DBD)-DDLTs; and 1171 donation after circulatory death (DCD)-DDLTs between 2009 and 2018. Because LDLT for patients with MELD scores >30 was rare, all patients with scores >30 were excluded to equalize LDLT and DDLT cohorts. Risk factors for 1-year graft loss (GL) were determined separately for LDLT and DDLT. Compared with LDLT, DBD-DDLT had a lower risk of 30-day (adjusted hazard ratio [aHR], 0.60; P < 0.001) and 1-year GL (aHR, 0.57; P < 0.001). The lower risk of GL was more prominent in the mid-MELD score category (score 15-29). Compared with LDLT, DCD-DDLT had a lower risk of 30-day GL but a comparable risk of 1-year GL, regardless of MELD score category. In LDLT, significant ascites was an independent risk for GL in patients with mid-MELD scores (aHR, 1.68; P = 0.02), but not in the lower-MELD score group. The risk of 1-year GL in LDLT patients with ascites who received a left liver was higher than either those who received a right liver or those without ascites who received a left liver. In LDLT, combinations of MELD scores of 15 to 29, moderate/severe ascites, and the use of a left liver are associated with worse outcomes. These findings help calibrate appropriate patient and graft selection in LDLT.

Meta-analysis and meta-regression of outcomes for adult living donor liver transplantation versus deceased donor liver transplantation

Prior single center or registry studies have shown that living donor liver transplantation (LDLT) decreases waitlist mortality and offers superior patient survival over deceased donor liver transplantation (DDLT). The aim of this study was to compare outcomes for adult LDLT and DDLT via systematic review. A meta-analysis was conducted to examine patient survival and graft survival, MELD, waiting time, technical complications, and postoperative infections. Out of 8600 abstracts, 19 international studies comparing adult LDLT and DDLT published between 1/2005 and 12/2017 were included. U.S. outcomes were analyzed using registry data. Overall, 4571 LDLT and 66,826 DDLT patients were examined. LDLT was associated with lower mortality at 1, 3, and 5 years posttransplant (5-year HR 0.87 [95% CI 0.81-0.93], p < .0001), similar graft survival, lower MELD at transplant (p < .04), shorter waiting time (p < .0001), and lower risk of rejection (p = .02), with a higher risk of biliary complications (OR 2.14, p < .0001). No differences were observed in rates of hepatic artery thrombosis. In meta-regression analysis, MELD difference was significantly associated with posttransplant survival (R2 0.56, p = .02). In conclusion, LDLT is associated with improved patient survival, less waiting time, and lower MELD at LT, despite posing a higher risk of biliary complications that did not affect survival posttransplant.

Current status of adult liver transplantation: utilization of living donor versus deceased donor graft

PURPOSE OF REVIEW

This article will summarize prior and recent studies comparing outcomes between living donor and deceased donor liver transplantation (LT) in adults and provide a rationale and framework for expanding living donor liver transplantation (LDLT) in Western countries to address the growing critical organ shortage.

RECENT FINDINGS

There is a growing body of evidence demonstrating superior survival outcomes in LDLT in addition to a multitude of other advantages including shorter cold ischemia times, opportunity for pretransplant medical optimization, and expansion of transplant eligibility. Additionally, these outcomes continue to improve with center volume and experience.

SUMMARY

LDLT in adults emerged in response to an effective donor organ shortage created by the critical discrepancy between donor graft supply and demand. Overcoming this organ shortage and an increasing waitlist mortality requires a liver transplant framework that fully integrates LDLT into liver disease management although continuing to fully maximize deceased donor graft utilization at experience, capable centers. Optimizing both living and deceased donor graft utilization will drastically increase patients' access to LT.

Estimating the effect of increasing utilization of living donor liver transplantation using observational data

There has been a recent increase in enthusiasm for expansion of living donor liver transplantation (LDLT) programmes. Using all adults initially placed on the waiting list in the United States, we estimated the risk of overall mortality under national strategies which differed in their utilization of LDLT. We used a generalization of inverse probability weighting which can estimate the effect of interventions in the setting of finite resources. From 2005 to 2015, 93 812 eligible individuals were added to the waitlist: 51 322 received deceased donor grafts while 1970 underwent LDLT. Individuals who underwent LDLT had more favourable prognostic factors, including lower mean MELD score at transplant (14.6 vs. 20.5). The 1-year, 5-year and 10-year cumulative incidence of death under the current level of LDLT utilization were 18.0% (95% CI: 17.8, 18.3%), 41.2% (95% CI: 40.8, 41.5%) and 57.4% (95% CI: 56.9, 57.9%) compared to 17.9% (95% CI: 17.7, 18.2%), 40.6% (95% CI: 40.2, 40.9%) and 56.4% (95% CI: 55.8, 56.9%) under a strategy which doubles LDLT utilization. Expansion of LDLT utilization would have a measurable, modest effect on the risk of mortality for the entire cohort of individuals who begin on the transplant waiting list.

The combination of a male donor's high muscle mass and quality is an independent protective factor for graft loss after living donor liver transplantation

We evaluated the hypothesis that grafts from donors with high muscle mass and quality may have a better outcome after living-donor-liver-transplantation (LDLT) than those from usual donors. A total of 376 primary adult-to-adult LDLT cases were enrolled in this study. Donor skeletal muscle mass index (SMI) and intramuscular adipose tissue content (IMAC) were used as markers of muscle mass and quality. In male donor cases (n = 198), those with higher SMI and lower IMAC than age-adjusted values were defined as the "high muscularity donors" (n = 38) and the others were defined as the "control" (n = 160). The high muscularity donor showed better 1-year (97% vs 82%, P = .020) and overall graft survival rate (88% vs 67%, P = .024) than the control group after LDLT. Contrastingly, the influence of the muscularity was not observed in female donor cases. Multivariable analysis including donor age confirmed that a high muscularity donor was an independent protective factor for overall graft survival after LDLT (hazard ratio, 0.337; 95% CI: 0.101-0.838; P = .017). Our study first confirmed that high muscle mass and quality of a male donor is a protective factor of allograft loss after LDLT, independently from donor age.

The Risk of Going Small: Lowering GRWR and Overcoming Small-For-Size Syndrome in Adult Living Donor Liver Transplantation

OBJECTIVE

The aim of this study was to determine the outcomes of living donor liver transplantation (LDLT) according to various graft-to-recipient weight ratio (GRWR).

BACKGROUND

The standard GRWR in LDLT is >0.8%. Our center accepted predicted GRWR ≥0.6% in selected patients.

METHODS

Data from patients who underwent LDLT from 2001 to 2017 were included. Patients were stratified according to actual GRWR (Group 1:GRWR ≤0.6%; Group 2: 0.6%<GRWR≤ 0.8%; Group 3:GRWR >0.8%).

RESULTS

There were 545 LDLT (group 1 = 39; group 2 = 159; group 3 = 347) performed. Pretransplant predicted GRWR showed good correlation to actual GRWR (R = 0.834) and these figures differed within a ± 10%margin (P = 0.034) using an equivalence test. There were more left lobe grafts in group 1 (33.3%) than group 2 (10.7%) and 3 (2.9%). Median donor age was <35 years and steatosis >10% was rare.There was no difference in postoperative complication, vascular and biliary complication rate between groups. Over one-fifth (20.5%) of group 1 patients required portal flow modulation (PFM) and was higher than group 2 (3.1%) and group 3 (4%) (P = 0.001). Twenty-six patients developed small-for-size syndrome (SFSS): 5 of 39 (12.8%) in group 1 and 21 of 159 (13.2%) in group 2 and none in group 3 (P < 0.001). There were 2 hospital mortalities; otherwise, the remaining patients [24/26 (92.3%)] survive with a functional liver graft. The 5-year graft survival rates were 85.4% versus 87.8% versus 84.7% for group 1, 2, and 3, respectively (P = 0.718). GRWR did not predict worse survivals in multivariable analysis.

CONCLUSIONS

Graft size in LDLT can be lowered to 0.6% after careful recipient selection, with low incidence of SFSS and excellent outcomes. Accurate graft weight prediction, donor-recipient matching, meticulous surgical techniques, appropriate use of PFM, and vigilant perioperative care is important to the success of such approach.

Current Status of Living Donor Liver Transplantation in the United States

Adult-to-adult living donor liver transplantation (LDLT) was introduced in response to the shortage of deceased donor liver grafts. The number of adult living donor transplants is increasing due to improved outcomes and increasing need. Advantages of LDLT include optimization of the timing of transplant, better organ quality, and lower rates of recipient mortality compared to staying on the wait list for deceased donor liver transplant. Donor safety remains the major focus when considering LDLT. Recent advancements have supported the increased use of LDLT to help decrease wait list death and improve long-term survival of transplant recipients.

Living Donor Liver Transplantation in South Asia: Single Center Experience on Intermediate-Term Outcomes

BACKGROUND

There is paucity of data on intermediate-term post liver transplant outcomes from South Asia. The objective of this study was to determine survival outcomes in patients who underwent living donor liver transplantation (LDLT) in a busy liver transplant center in Pakistan.

METHODS

This study was a review of patients who underwent LDLT between 2012 and 2016. A total of 321 patients were included in this study. Early (within 90 days) and late (>90 days) morbidity and mortality was assessed. Estimated 1- and 4-year survival was determined.

RESULTS

Median age was 48 (18-73) years. Male to female ratio was 4.5:1. Out of total 346 complications, 184 (57.3%) patients developed 276 (79.7%) complications in early post-transplant period, whereas there were 70 (21.3%) late complications. Most common early complication was pleural effusion in 46 (16.6%) patients. Biliary complications were the most common late complication and were seen in 31/70 (44.2%) patients. Overall 21.4% patients had a biliary complication. The 3-month mortality was 14%. The estimated 1- and 4-year OS for a MELD cutoff of 30 was 84.5 versus 72 and 80 versus 57% (P = 0.01). There was no donor mortality.

CONCLUSION

Acceptable intermediate-term post-transplant outcomes were achieved with LDLT. There is a need to improve outcomes in high-MELD patients.

Predictive Factors of Liver Dysfunction After Right Hemihepatectomy for Adult Living Donor Liver Transplantation

BACKGROUND

Living liver donors represent a special group of patients. They are healthy individuals who are exposed to a major surgery, in which the dominant liver proportion is extracted as a graft. Of all potential donor-related morbidities, posthepatectomy liver dysfunction (PHLD) is the most significant as it may be directly related to donor mortality. We aimed to review our data of adult living donor liver transplantation (LDLT) utilizing the right hemiliver grafts to determine the incidence and potential predictors for the development of PHLD, defined according to the International Study Group of Liver Surgery.

METHODS

We reviewed the data of all adult living donors who underwent right hemihepatectomy during the period between May 2004 and 2016.

RESULTS

During the study period, 434 cases underwent right hemihepatectomy for adult LDLT. We divided our cases into 2 groups according to the occurrence of PHLD. A significant lower residual liver volume and percentage were noted in PHLD group. Longer intensive care unit stay and hospital stay, and more postoperative morbidities, were observed in PHLD group. PHLD occurred in 50 cases (11.5%), and most of them were grade A (47 cases [10.8%]). Two cases (0.5%) had grade B requiring diuretic therapy, and 1 case (0.2%) had grade C requiring ultrasound guided tube drainage and surgical exploration finally.

CONCLUSIONS

We should not underestimate the risks of liver donation surgery, especially when utilizing the right hemiliver graft. Donor safety should be ensured by accurate preoperative volumetric assessment of the remnant liver and remnant liver volume limitations must be strictly followed.

Small-for-size grafts increase recurrence of hepatocellular carcinoma in liver transplantation beyond milan criteria

Living donor liver transplantation (LDLT) has been reported to have high rates of hepatocellular carcinoma (HCC) recurrence compared with deceased donor liver transplantation (DDLT). This has been assumed to be due to the frequent use of small-for-size grafts (SFSGs) in LDLT rather than DDLT, but the relationship between graft size and prognosis remains controversial. This study aimed to clarify the effect of SFSGs on the oncologic outcomes of patients with HCC who underwent LDLT. Between January 2005 and December 2015, 597 consecutive patients underwent LDLT. Among these patients, those with HCC who underwent LDLT were randomly matched at a 1:3 ratio (graft-to-recipient body weight ratio [GRWR] < 0.8%:GRWR > 0.8%) according to propensity score. HCC recurrence and patient survival were analyzed using the Kaplan-Meier method and log-rank test. In addition, stratified subgroup analysis based on the Milan criteria was performed. SFSG was defined as a GRWR < 0.8%. Using propensity score matching, 82 patients with GRWR < 0.8% and 246 patients with GRWR ≥ 0.8% were selected. For patients with HCC within the Milan criteria, no significant difference of HCC recurrence (P = 0.82) and patient survival (P = 0.95) was found based on GRWR. However, for patients with HCC beyond the Milan criteria, 1-, 3-, and 5-year recurrence-free survival rates were 52.4%, 49.3%, and 49.3%, respectively, for patients with GRWR < 0.8%, and 76.5%, 68.3%, and 64.3%, respectively, for patients with GRWR ≥ 0.8% (P = 0.049). The former group exhibited poor patient survival rates (P = 0.047). In conclusion, for patients with HCC within the Milan criteria, no significant difference in oncologic outcomes was found based on liver graft size. However, among the patients with HCC beyond the Milan criteria, SFSG recipients showed poor oncologic outcomes. Because extended criteria are frequently used in LDLT for HCC, a recipient's prognosis can be improved if a liver graft of appropriate size is carefully selected during donor selection. Liver Transplantation 24 35-43 2018 AASLD.

Avoiding ICU Admission by Using a Fast-Track Protocol Is Safe in Selected Adult-to-Adult Live Donor Liver Transplant Recipients

Background

We evaluated patient characteristics of live donor liver transplant (LDLT) recipients undergoing a fast-track protocol without intensive care unit (ICU) admission versus LDLT patients receiving posttransplant ICU care.

Methods

Of the 153 LDLT recipients, 46 patients were included in our fast-track protocol without ICU admission. Both, fast-tracked patients and ICU-admitted patients were compared regarding donor and patient characteristics, perioperative characteristics, and postoperative outcomes and complications. In a subgroup analysis, we compared fast-tracked patients with patients who were admitted in the ICU for less than 24 hours.

Results

Fast-tracked versus ICU patients had a lower model for end-stage liver disease score (13 ± 4 vs 18 ± 7; P < 0.0001), lower preoperative bilirubin levels (51 ± 50 μmol/L vs 119.4 ± 137.3 μmol/L; P < 0.001), required fewer units of packed red blood cells (1.7 ± 1.78 vs 4.4 ± 4; P < 0.0001), and less fresh-frozen plasma (2.7 ± 2 vs 5.8 ± 5; P < 0.0001) during transplantation. Regarding postoperative outcomes, fast-tracked patients presented fewer bacterial infections within 30 days (6.5% [3] vs 29% [28]; P = 0.002), no episodes of pneumonia (0% vs 11.3% [11]; P = 0.02), and less biliary complications within the first year (6% [3] vs 26% [25]; P = 0.001). Also, fast-tracked patients had a shorter posttransplant hospital stay (10.8 ± 5 vs 21.3 ± 29; P = 0.002). In the subgroup analysis, fast-tracked vs ICU patients admitted for less than 24 hours had lower requirements of packed red blood cells (1.7 ± 1.78 vs 3.9 ± 4; P = 0.001) and fresh-frozen plasma (2.7 ± 2 vs 5.8 ± 4.5; P = 0.0001).

Conclusions

Fast-track of selected patients after LDLT is safe and feasible. An objective score to perioperatively select LDLT recipients amenable to fast track is yet to be determined.

Changes in Muscle Strength and Six-Minute Walk Distance Before and After Living Donor Liver Transplantation

BACKGROUND

Impaired exercise capacity and muscle weakness are important characteristics of liver transplantation recipients. Perioperative rehabilitation has been introduced to promote early mobilization of patients and to prevent postoperative pulmonary complications. However, it is unknown how physical status recovers during the hospital stay after a liver transplant. The purpose of this study was to evaluate the changes in clinical indicators that represent the functional exercise capacity and muscle strength before and after living donor liver transplantation (LDLT).

METHODS

We retrospectively reviewed 21 consecutive patients who underwent LDLT with perioperative rehabilitation from April 2014 to December 2015. Twelve patients who were tested for 6-minute walk distance, hand-grip strength, and isometric knee extensor muscle strength before and 4 weeks after LDLT were enrolled.

RESULTS

At the preoperative baseline, the 6-minute walk distance significantly correlated with the Model for End-stage Liver Disease score and pulmonary functions (vital capacity, forced vital capacity, and forced expiratory volume in 1 second of predictive values). Comparisons between the preoperative and postoperative values revealed significant decreases in weight, Barthel Index, hand-grip strength, and isometric knee extensor muscle strength. Changes in hand-grip strength and isometric knee extensor muscle strength after LDLT correlated with the preoperative Model for End-stage Liver Disease score.

CONCLUSIONS

Physical functional status had not been fully recovered 4 weeks after LDLT. Further investigation regarding developing a strategy for prevention of muscle atrophy before LDLT and recovery of physical fitness after LDLT would be helpful.

Defining long-term outcomes with living donor liver transplantation in North America

OBJECTIVES

To compare long-term survival of living donor liver transplant (LDLT) at experienced transplant centers with outcomes of deceased donor liver transplant and identify key variables impacting patient and graft survival.

BACKGROUND

The Adult-to-Adult Living Donor Liver Transplantation Cohort Study is a prospective multicenter National Institutes of Health study comparing outcomes of LDLT and deceased donor liver transplant and associated risks.

METHODS

Mortality and graft failure for 1427 liver recipients (963 LDLT) enrolled in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study who received transplant between January 1, 1998, and January 31, 2014, at 12 North American centers with median follow-up 6.7 years were analyzed using Kaplan-Meier and multivariable Cox models.

RESULTS

Survival probability at 10 years was 70% for LDLT and 64% for deceased donor liver transplant. Unadjusted survival was higher with LDLT (hazard ratio = 0.76, P = 0.02) but attenuated after adjustment (hazard ratio = 0.98, P = 0.90) as LDLT recipients had lower mean model for end-stage liver disease (15.5 vs 20.4) and fewer received transplant from intensive care unit, were inpatient, on dialysis, were ventilated, or with ascites. Posttransplant intensive care unit days were less for LDLT recipients. For all recipients, female sex and primary sclerosing cholangitis were associated with improved survival, whereas dialysis and older recipient/donor age were associated with worse survival. Higher model for end-stage liver disease score was associated with increased graft failure. Era of transplantation and type of donated lobe did not impact survival in LDLT.

CONCLUSIONS

LDLT provides significant long-term transplant benefit, resulting in transplantation at a lower model for end-stage liver disease score, decreased death on waitlist, and excellent posttransplant outcomes. Recipient diagnosis, disease severity, renal failure, and ages of recipient and donor should be considered in decision making regarding timing of transplant and donor options.Clinical Trials ID: NCT00096733.

Bile duct kinking after adult living donor liver transplantation: Case reports and literature review

Regeneration of the partial allograft and the growth of children may cause kinking of the biliary tract after pediatric living donor liver transplantation (LDLT), but bile duct kinking after adult LDLT is rarely reported. We herein presented two patients who suffered from anastomotic strictures caused by severe bile duct kinking after LDLT. The first patient was a 57-year-old woman with hepatitis B virus (HBV)-related liver cirrhosis, who developed biliary stricture 5 months after receiving right-lobe LDLT. Subsequently, endoscopic and percutaneous treatments were attempted, but both failed to solve the problem. The second was a 44-year-old woman also having HBV-related liver cirrhosis. Biliary stricture occurred 14 months after LDLT. Likewise, the guide wire failed to pass through the stricture when endoscopic interventions were conducted. Afterwards, both of the two cases underwent reexploration, showing that compensatory hypertrophy of the allografts resulted in kinking and sharp angulation of the bile ducts, and the anastomotic sites were found to be severely stenotic. Finally, re-anastomosis by Roux-en-Y procedure was successfully performed, and long-term stenosis-free survival was achieved in both of them. Our experience suggests that bile duct kinking after LDLT may play a role in the high incidence of anastomotic strictures in adult LDLT recipients, which may also result in the treatment failure of the non-surgical techniques for anastomotic strictures. Re-anastomosis in the form of Roux-en-Y hepaticojejunostomy is an effective surgical option for the treatment of such a condition.

Comparison of Different Scoring Systems Based on Both Donor and Recipient Characteristics for Predicting Outcome after Living Donor Liver Transplantation

BACKGROUND AND OBJECTIVES

In order to provide a good match between donor and recipient in liver transplantation, four scoring systems [the product of donor age and Model for End-stage Liver Disease score (D-MELD), the score to predict survival outcomes following liver transplantation (SOFT), the balance of risk score (BAR), and the transplant risk index (TRI)] based on both donor and recipient parameters were designed. This study was conducted to evaluate the performance of the four scores in living donor liver transplantation (LDLT) and compare them with the MELD score.

PATIENTS AND METHODS

The clinical data of 249 adult patients undergoing LDLT in our center were retrospectively evaluated. The area under the receiver operating characteristic curves (AUCs) of each score were calculated and compared at 1-, 3-, 6-month and 1-year after LDLT.

RESULTS

The BAR at 1-, 3-, 6-month and 1-year after LDLT and the D-MELD and TRI at 1-, 3- and 6-month after LDLT showed acceptable performances in the prediction of survival (AUC>0.6), while the SOFT showed poor discrimination at 6-month after LDLT (AUC = 0.569). In addition, the D-MELD and BAR displayed positive correlations with the length of ICU stay (D-MELD, p = 0.025; BAR, p = 0.022). The SOFT was correlated with the time of mechanical ventilation (p = 0.022).

CONCLUSION

The D-MELD, BAR and TRI provided acceptable performance in predicting survival after LDLT. However, even though these scoring systems were based on both donor and recipient parameters, only the BAR provided better performance than the MELD in predicting 1-year survival after LDLT.

Early post-transplant survival: Interaction of MELD score and hospitalization status

BACKGROUND & AIMS

Urgency-based allocation that relies on the MELD score prioritizes patients at the highest risk of waitlist mortality. However, identifying patients at greatest risk for short-term post-transplant mortality is needed in order to optimize the potential gains in overall survival obtained through improved long-term management of transplant recipients. There are limited data on the predictive ability of MELD score for early post-transplant mortality, and no data assessing the interaction between MELD score and hospitalization status.

METHODS

We analyzed UNOS data from 2002 to 2013 on 50,838 non-status 1 single-organ liver transplant recipients and fit multivariable logistic models to evaluate the association and interaction between MELD score and pre-transplant hospitalization status on short-term post-transplant mortality.

RESULTS

There was a significant interaction (p<0.01) between laboratory MELD score and hospitalization status on three-, six-, and 12-month post-transplant mortality in multivariable logistic models. This interaction was most pronounced in patients with a laboratory MELD score <25 transplanted from an ICU, whose adjusted predicted three-, six-, and 12-month post-transplant mortality approximated those of patients with a MELD score ⩾30. Compared to hospitalized patients with a MELD score of 30-34, those with a MELD score ⩾35 in an ICU had significantly increased risk of three-month (OR: 1.54, 95% CI: 1.21-1.97), 6-month (OR: 1.35, 95% CI: 1.09-1.67), and 12-month (OR: 1.25, 95% CI: 1.03-1.52) post-transplant mortality.

DISCUSSION

Pre-transplant ICU status modifies the risk of early post-transplant mortality, independent of MELD score. This should be considered when determining candidacy for transplantation in order to optimize efficient use of a scarce resource.

Liver regeneration after living donor transplantation: adult-to-adult living donor liver transplantation cohort study

Adult-to-adult living donors and recipients were studied to characterize patterns of liver growth and identify associated factors in a multicenter study. Three hundred and fifty donors and 353 recipients in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) receiving transplants between March 2003 and February 2010 were included. Potential predictors of 3-month liver volume included total and standard liver volumes (TLV and SLV), Model for End-Stage Liver Disease (MELD) score (in recipients), the remnant and graft size, remnant-to-donor and graft-to-recipient weight ratios (RDWR and GRWR), remnant/TLV, and graft/SLV. Among donors, 3-month absolute growth was 676 ± 251 g (mean ± SD), and percentage reconstitution was 80% ± 13%. Among recipients, GRWR was 1.3% ± 0.4% (8 < 0.8%). Graft weight was 60% ± 13% of SLV. Three-month absolute growth was 549 ± 267 g, and percentage reconstitution was 93% ± 18%. Predictors of greater 3-month liver volume included larger patient size (donors and recipients), larger graft volume (recipients), and larger TLV (donors). Donors with the smallest remnant/TLV ratios had larger than expected growth but also had higher postoperative bilirubin and international normalized ratio at 7 and 30 days. In a combined donor-recipient analysis, donors had smaller 3-month liver volumes than recipients adjusted for patient size, remnant or graft volume, and TLV or SLV (P = 0.004). Recipient graft failure in the first 90 days was predicted by poor graft function at day 7 (HR = 4.50, P = 0.001) but not by GRWR or graft fraction (P > 0.90 for each). Both donors and recipients had rapid yet incomplete restoration of tissue mass in the first 3 months, and this confirmed previous reports. Recipients achieved a greater percentage of expected total volume. Patient size and recipient graft volume significantly influenced 3-month volumes. Importantly, donor liver volume is a critical predictor of the rate of regeneration, and donor remnant fraction affects postresection function. Liver Transpl 21:79-88, 2015. © 2014 AASLD.

Superior survival using living donors and donor-recipient matching using a novel living donor risk index

The deceased-donor organ supply in the U.S. has not been able to keep pace with the increasing demand for liver transplantation. We examined national Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) data from 2002-2012 to assess whether living donor liver transplantation (LDLT) has surpassed deceased donor liver transplantation (DDLT) as a superior method of transplantation, and used donor and recipient characteristics to develop a risk score to optimize donor and recipient selection for LDLT. From 2002-2012, there were 2,103 LDLTs and 46,674 DDLTs that met the inclusion criteria. The unadjusted 3-year graft survival for DDLTs was 75.5% (95% confidence interval [CI]: 75.1-76.0%) compared with 78.9% (95% CI: 76.9-80.8%; P<0.001) for LDLTs that were performed at experienced centers (>15 LDLTs), with substantial improvement in LDLT graft survival over time. In multivariate models, LDLT recipients transplanted at experienced centers with either autoimmune hepatitis or cholestatic liver disease had significantly lower risks of graft failure (hazard ratio [HR]: 0.56, 95% CI: 0.37-0.84 and HR: 0.76, 95% CI: 0.63-0.92, respectively). An LDLT risk score that included both donor and recipient variables facilitated stratification of LDLT recipients into high, intermediate, and low-risk groups, with predicted 3-year graft survival ranging from >87% in the lowest risk group to <74% in the highest risk group.

CONCLUSION

Current posttransplant outcomes for LDLT are equivalent, if not superior, to DDLT when performed at experienced centers. An LDLT risk score can be used to optimize LDLT outcomes and provides objective selection criteria for donor selection in LDLT.

Comparing living donor and deceased donor liver transplantation: A matched national analysis from 2007 to 2012

A complete evaluation of living donor liver transplantation (LDLT) in the United States has been difficult because of the persistent low volume and the lack of adequate comparisons with deceased donor liver transplantation (DDLT). Recent reports have suggested outcomes equivalent to those for DDLT, but these studies did not adjust for differences in recipient selection. From a linkage between the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified 14,282 patients at 62 centers who underwent DDLT from 2007 to 2012 and 715 patients at 35 centers who underwent LDLT during the same period. Then, we performed 1:1 propensity score matching for 708 LDLT recipients based on age, Model for End-Stage Liver Disease (MELD) score, and pretransplant patient status. The median follow-up was 2 years. Compared with DDLT recipients, LDLT recipients were more likely to be white (84.5% versus 72.2%) and female (41.1% versus 31.7%), to have lower MELD scores (15 versus 19), and to be classified preoperatively as independent (65.3% versus 46.7%) and not hospitalized (91.3% versus 78.4%). The posttransplant length of stay (LOS), in-hospital mortality, costs, and survival were similar between the groups, but LDLT recipients were more likely to be readmitted within 30 days (44.9% versus 37.1%, P = 0.001). After matching, the difference in 30-day readmission rates persisted (45.1% versus 33.8%, P = 0.001), but there were no differences in the LOS, costs, patient survival, or graft survival. This national report shows that LDLT is associated with higher readmission rates in comparison with DDLT, but the results are comparable for other key patient metrics.

Importance of donor-recipient age gradient to the prediction of graft outcome after living donor liver transplantation

PURPOSE

Advanced donor age is a well-known risk factor for poor graft function after living donor liver transplantation (LDLT). In addition, advanced recipient age has a significant impact because of the high prevalence of comorbidities. We investigated the relationship between donor-recipient age gradient (DRAG) and the posttransplant outcomes in LDLT.

METHODS

We included 821 consecutive adult recipients who underwent LDLT from June 1997 to May 2011. According to the value of DRAG, they were divided into 2 groups: Negative years (the donor was younger than the recipient) and positive years (the donor was older than the recipient). These groups were further divided into subgroups (≤-21, -20 to -1, 0 to 20, and ≥21 years). We collected retrospectively patient characteristics, laboratory results, medical and surgical complications, and graft loss.

RESULTS

The positive DRAG group had higher level of posttransplant alkaline phosphatase, but a lower incidence of biliary complications. The negative DRAG group, particularly DRAG ≤ -21 years was associated with the superior 1-, 3-, 5-, and 10-year graft survivals. Recipients with DRAG ≥ 21 showed persistently inferior graft survival during the observation period. In cases of young donors, transplants utilizing lower DRAG seen between young donors and older recipients showed more favorable graft survival than that of young-to-young transplants.

CONCLUSION

This study demonstrated that DRAG and a fixed donor age limit could be significant factors to predict graft survival after LDLT. Patients should carefully consider the worse graft survival if the donor is older than the recipient by ≥20.

Improving outcomes in DCDD liver transplantation: there can only be strength in numbers

In the United States, liver transplantation using donation after circulatory determination of death (DCDD) donors is challenged by persistently inferior graft survival compared with donation after neurological death (DND), along with declining rates of liver transplantation relative to the total number of DCDD donors. Advances in adult-to-adult living donor liver transplantation graft survival temporally related to the Adult-to-Adult Living Donor Liver Transplantation Cohort Study consortium suggest that a similarly focused collaborative effort may serve to stimulate evolution within DCDD liver transplantation. Without a multi-center consortium to support innovative trials, the current state of DCDD liver transplantation is unlikely to progress.

Operative outcomes of adult living donor liver transplantation and deceased donor liver transplantation: a systematic review and meta-analysis

Living donor liver transplantation (LDLT) has emerged as an alternative to deceased donor liver transplantation (DDLT) because of the increasing number of patients waiting for liver transplantation (LT). However, whether it can achieve operative outcomes similar to those achieved with DDLT for adult patients remains controversial. We conducted this meta-analysis to compare the operative outcomes of LDLT and DDLT recipients. A literature search was performed to identify clinical controlled studies comparing LDLT and DDLT that were published before October 2013. Four perioperative outcomes [duration of the recipient operation (DRO), red blood cell (RBC) transfusion requirement, length of the hospital stay, and cold ischemia time (CIT)] and 5 postoperative complication outcomes (biliary complications, vascular complications, intra-abdominal bleeding, perioperative death, and retransplantation) were the main outcomes assessed. Nineteen studies with a total of 5450 patients were included in the meta-analysis. In comparison with DDLT, LDLT was associated with a significantly longer DRO and a shorter CIT. We found that biliary complications [odds ratio (OR) = 3.08, 95% confidence interval (CI) = 1.97-4.81, P < 0.001], vascular complications (OR = 2.16, 95% CI = 1.32-3.54, P = 0.002), and retransplantation (OR = 1.76, 95% CI = 1.09-2.83, P = 0.02) occurred more frequently for LDLT recipients, and the subgroup analysis indicated that the biliary complication rate decreased dramatically with greater LDLT experience. No significant difference was observed in RBC transfusion requirements, the lengths of hospital stays, intra-abdominal bleeding rates, or perioperative mortality between LDLT and DDLT recipients. In conclusion, LDLT is associated with a higher rate of surgical complications after transplantation. A reduction of postoperative complication rates can be achieved as centers gain greater experience with LDLT. However, LDLT is still an excellent alternative to DDLT because it facilitates access to LT.

Prediction factors of postoperative hyperbilirubinemia in living right lobe donor: a single-center analysis of 210 cases

BACKGROUND

Hyperbilirubinemia in living liver donor is very common, but the causes are still unclear.

AIMS

We sought to clarify the risk factors and predictors of nonobstructive hyperbilirubinemia among living donors.

METHODS

We divided 210 consecutive right liver lobe donors into two groups according to the peak total bilirubin postoperatively. We collected data on preoperative, intraoperative, and postoperative biochemical measurements retrospectively, performing multivariate logistic regression analysis adjusting for potential confounders of the risk of hyperbilirubinemia.

RESULTS

There were significant differences between the two groups in donor age, body mass index, operative time, blood loss, macrovescicular steatosis, allogeneic blood transfusion rate, intensive care unit stay, hospital stay and Clavien score after donation (P < .05). Age, graft/donor weight, operative time, and blood loss were significantly associated with the risk of hyperbilirubinemia upon logistic regression analysis.

CONCLUSION

Hyperbilirubinemia, one type of hepatic dysfunction after a living donor procedure, was associated with multiple independent risk factors.

Liver regeneration after liver transplantation

BACKGROUND/PURPOSE

The liver has a remarkable capacity to regenerate after injury or resection. The aim of this review is to outline the mechanisms and factors affecting liver regeneration after liver transplantation.

METHODS

Relevant studies were reviewed using Medline, PubMed and Springer databases.

RESULTS

A variety of cytokines (such as interleukin-6 and tumor necrosis factor-α), growth factors (like hepatocyte growth factor and transforming growth factor-α) and cells are involved in liver regeneration. Several factors affect liver regeneration after transplantation such as ischemic injury, graft size, immunosuppression, steatosis, donor age and viral hepatitis.

CONCLUSION

Liver regeneration has been studied for many years. However, further research is essential to reveal the complex processes affecting liver regeneration, which may provide novel strategies in the management of liver transplantation recipients and donors.

Results of liver transplantation from donors over 75 years: case control study

INTRODUCTION

The use of elderly donors can increase the pool of organs available for transplant. The aim of this study was to analyze the outcomes of grafts from donors older than 75 years.

PATIENTS AND METHODS

We selected 29 patients transplanted from January 2003 to January 2010 with livers from donors older than 75 years for comparison with a control group (58 patients), selected among patients transplanted immediately before or after each study case. Data analyzed using SPSS 15.0 were considered statistically significant at P < .05.

RESULTS

Statistically significant differences were evident in the mean age of donors (78.3 ± 2.9 vs 50.4 ± 17.8 years, P < .001), levels of aspartate aminotransferase alanine aminotransferase (30.8 ± 18.13/24.9 ± 14.4 vs 53.81 ± 68.4/39.37 ± 39.94 U/L, P < .05), and waiting list time of (122.4 ± 94.3 vs 169.2 ± 135.5 days, P = .034) of elderly donor versus control graft cohorts. The median follow-up was 32 months (range: 4-88.0) No differences were observed at 1 and 3 years after transplantation: graft survival was 78% and 61% in the older donor group and 83% and 71% in the younger donor group, respectively.

CONCLUSION

The use of expanded donors from elderly subjects can increase the donor pool with good results.

Elderly Transplant Recipients

While the total number of organs transplanted in this country has increased over the years, there is still an ever-widening gap between the need for organs and our capacity to meet that need as the overall waiting list continues to grow. This is due in part to significant advances in transplant techniques and outcomes such that Americans with organ failure now seek transplants in greater numbers. Additionally, life-expectancy gains in the United States are creating an aging population who are more likely to suffer organ failure than younger Americans. The national transplant waiting list has continued to shift toward older candidates. The Scientific Registry of Transplant Recipients (SRTR) reported that at the end of 2007, 59.7% of all 97,248 candidates on the waiting list for all organs were 50 years old or older, and 14.9% were 65 years or older. These percentages are substantially higher than they were in 1998 (41.5 and 8.1%, respectively) [1].

Improving the waiting list by using 75-year-old donors for recipients with hepatocellular carcinoma

The best treatment for hepatocellular carcinoma (HCC) associated with liver cirrhosis is liver transplantation and the best results are obtained when the tumors fulfill the Milan criteria. However, although the number of transplants is increasing, the organ deficit is growing, which lengthens time on the waiting list, increasing the risk of tumor progression of and exclusion from the list. The use of elderly donors is a valid option for patients on the transplant waiting list with HCC, reducing time on the waiting list. We report our experience with patients transplanted for HCC associated with hepatic cirrhosis using livers from donors >75 years of age. Our preliminary results supported the use of elderly suboptimal donors making it possible to give priority to these patients. All patients in the series achieved good graft function after a follow-up of 2 years with a 100% disease-free survival rate. More extensive long-term studies are needed to confirm these findings.

Safety of small-for-size grafts in adult-to-adult living donor liver transplantation using the right lobe

The problem of graft size is one of the critical factors limiting the expansion of adult-to-adult living donor liver transplantation (LDLT). We compared the outcome of LDLT recipients who received grafts with a graft-to-recipient weight ratio (GRWR) < 0.8% or a GRWR > or = 0.8%, and we analyzed the risk factors affecting graft survival after small-for-size grafts (SFSGs) were used. Between June 1997 and April 2008, 427 patients underwent LDLT with right lobe grafts at the Department of Surgery of Samsung Medical Center. Recipients were divided into 2 groups: group A with a GRWR < 0.8% (n = 35) and group B with a GRWR > or = 0.8% (n = 392). We retrospectively evaluated the recipient factors, donor factors, and operative factors through the medical records. Small-for-size dysfunction (SFSD) occurred in 2 of 35 patients (5.7%) in group A and in 14 of 392 patients (3.6%) in group B (P = 0.368). Graft survival rates at 1, 3, and 5 years were not different between the 2 groups (87.8%, 83.4%, and 74.1% versus 90.7%, 84.5%, and 79.4%, P = 0.852). However, when we analyzed risk factors within group A, donor age and middle hepatic vein tributary drainage were significant risk factors for graft survival according to univariate analysis (P = 0.042 and P = 0.038, respectively). Donor age was the only significant risk factor for poor graft survival according to multivariate analysis. The graft survival rates of recipients without SFSD tended to be higher than those of recipients with SFSD (85.3% versus 50.0%, P = 0.074). The graft survival rates of recipients with grafts from donors < 44 years old were significantly higher than those of recipients with grafts from donors > or = 44 years old (92.2% versus 53.6%, P = 0.005). In conclusion, an SFSG (GRWR < 0.8%) can be used safely in adult-to-adult right lobe LDLT when a recipient is receiving the graft from a donor younger than 44 years.

New prediction factors of small-for-size syndrome in living donor adult liver transplantation for chronic liver disease

Small-for-size syndrome (SFSS), which is characterized by synthetic dysfunction and prolonged cholestasis, is a major cause of worse short-term prognoses after living donor adult liver transplantation (LDALT). However, the risks of SFSS remain unclear. The aim of this study was to clarify the risks of SFSS, which were analysed in 172 patients who underwent LDALT for chronic liver disease. Graft types included left lobe with caudate lobe graft (n = 110) and right lobe graft (n = 62). Thirty-four cases (24 with left lobe grafts and 10 with right lobe grafts) were determined as SFSS. SFSS developed even if the actual graft-to-recipient standard liver volume ratio was >40%. Logistic regression analysis revealed three independent factors associated with SFSS development in left and right lobe grafts: donor age, actual graft-to-recipient native liver volume ratio, and Child's score. Donor age and actual graft-to-recipient native liver volume ratio may become predictive factors for SFSS development in left and right lobe grafts in patients undergoing LDALT.

Small-for-size liver graft injury--impact on tumor behavior

The success of liver transplantation has led to an ever-increasing demand for liver grafts. Since the first successful living donor liver transplantation, this surgical innovation has been well established in children and has significantly relieved the crisis of donor organ shortage for children. However, the extension of living donor liver transplantation to adult recipients is limited by the graft volume. The major concern of adult-to-adult living donor liver transplantation is the adequate graft that can be harvested from a living donor. Small-for-size graft injury is frequently observed. To develop novel effective treatments attenuating small-for-size liver graft injury during living donor liver transplantation, it is important to explore the precise mechanism of acute phase small-for-size graft damage. Recently, a number of clinical studies and animal experiments have been conducted to investigate the possible key issues on acute phase small-for-size liver graft injury, such as mechanical injury from shear stress, subsequent inflammatory responses, and imbalance of vasoregulatory factors. This review focuses on the mechanism of small-for-size liver graft injury based on the number of clinical and experimental studies. The latest research findings of the significance of acute phase liver graft injury on late phase tumor recurrence and metastasis are also addressed.

[Adult living-donor liver transplantation]

Living donor liver transplantation in adults continues to be controversial. Viewed as an alternative to prevent deaths on the waiting list, this type of transplant is the only possibility in Asian countries (Japan, Korea, China, etc) but is not widely applied in the west. This intervention is associated with significant donor morbidity (depending on the scale of the intervention) and mortality which, although sporadic, reduces its acceptance, especially in a context with high cadaveric donation. Outcomes in recipients are similar to those in cadaveric transplant recipients, although the high incidence of biliary complications could compromise long-term results. We describe the experience of Hospital Clínic in a total of 67 transplant recipients. Graft and patient survival at 1 and 5 years was 90.7%, 70.3%, 90.7% and 77.6%, respectively. Although the frequency of biliary complications was high (37.3%), death from sepsis and retransplantation only occurred in two patients.

Live donor adult liver transplantation

PURPOSE OF REVIEW

Because the gap between liver organ supply and demand continues to increase, adult living-donor liver transplantation continues to represent a significant pool of organs.

RECENT FINDINGS

With this in mind, we discuss recent issues in adult living-donor liver transplantation, including issues with donor evaluation and selection, donor liver biopsy, orphan organ allocation, donor morbidity and mortality, outcomes compared with deceased donor liver transplant from time of evaluation, death on the waiting list, and evolving recipient indications for living-donor liver transplantation.

SUMMARY

Increasing the number of living-donor liver transplants would allow us to expedite transplant, avoid death on the waitlist, and possibly save more lives by expanding the criteria for transplant. These benefits must always be weighed against the potential risks and complications to the donor, which can be significant.