Efficacy and Safety of Weight Reduction of the Donor in Hepatic Steatosis for Living Donor Liver Transplantation

Safety of right liver donation after improving steatosis through weight loss in living donors: a retrospective study

BACKGROUND

Living donor liver transplantation using hepatic steatosis-improved grafts mitigates donor shortage. Herein, we aimed to evaluate the safety and feasibility of right-lobe adult-to-adult living donor liver transplantation using grafts improved through donor weight loss.

METHODS

In this retrospective study conducted in a single institution in the Republic of Korea, we reviewed the medical records of living liver donors who lost ≥ 10% of their body weight to improve steatosis before right lobe donation between January 2015 and December 2020. Overall, 1040 right-lobe donors were included, with 150 and 890 donors in the weight loss and control (non-steatosis) groups, respectively.

RESULTS

We performed 1:1 individual matching using the greedy matching method, by which 124 patients were included in each group. The median period from the date of the first visit to donation was 113 (interquartile range: 78-184) days in the weight loss group. As body weight changed from 82.8 ± 13.7 kg to 70.8 ± 11.8 kg (p < 0.0001), body mass index also improved from 27.8 ± 3.9 kg/m2 to 23.8 ± 3.1 kg/m2 (p < 0.0001). No significant between-group differences existed in the postoperative laboratory data for living donors and recipients. The incidence of postoperative complications in donors was comparable between the groups (control group, 9.7%; weight loss group, 13.7%; p = 0.3185). The graft and recipient survival rates were comparable between the groups (p = 1.000).

CONCLUSION

Weight loss through diet and exercise significantly could improve hepatic steatosis in living donor candidates for liver transplantation, with the surgical outcomes in recipients and donors being equivalent to those in recipients and non-steatotic donors.

Long-Term Outcomes of Recipients of Liver Transplants from Living Donors Treated with a Very Low-Calorie Diet

The increasing prevalence of steatotic liver disease (SLD) in potential living donors is concerning, as it limits donor's availability amid rising demand. OPTIFAST very low-calorie diet (VLCD), a meal replacement product, effectively reduces weight and hepatic steatosis before transplantation. However, data on the outcomes of recipients of VLCD-treated donors are lacking. We conducted a single-center, retrospective study on 199 living donor liver transplant recipients at Toronto General Hospital, Canada, between January 2015 and January 2020. We compared the 1-year posttransplant outcomes between recipients who received organs from donors treated with VLCD (N = 34) for either weight loss or steatosis reduction, with those who did not require treatment (N = 165). Our analysis revealed no statistically significant differences in the rates of postoperative complications (23% vs 32.4%, p=0.3) or intensive care unit stays (70.9% vs 70.6%, p=1) between recipients of non-VLCD and VLCD grafts. Following adjusted multivariate logistic regression, receipt of VLCD grafts was not associated with increased hospital length of stay. In addition, one-year mortality did not differ between the two groups (4.2% non-VLCD recipients vs 2.9% VLCD recipients, p=0.6). OPTIFAST VLCD treatment for liver donors demonstrates positive and safe outcomes in recipients, expanding the pool of potential living donors for increased organ availability.

Living Donor Liver Transplantation: Left Lobe or Right Lobe

Living Donor Liver Transplantation (LDLT) has seen great advancements since its inception in 1988. Herein, the nuances of LDLT are discussed spanning from donor evaluation to the recipient operation. Special attention is given to donor anatomy and graft optimization techniques in the recipient.

Preventing Small-for-size Syndrome in Living Donor Liver Transplantation: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference

Small-for-size syndrome (SFSS) is a well-recognized complication following liver transplantation (LT), with up to 20% developing this following living donor LT (LDLT). Preventing SFSS involves consideration of factors before the surgical procedure, including donor and recipient selection, and factors during the surgical procedure, including adequate outflow reconstruction, graft portal inflow modulation, and management of portosystemic shunts. International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplant Society of India Consensus Conference was convened in January 2023 to develop recommendations for the prediction and management of SFSS in LDLT. The format of the conference was based on the Grading of Recommendations, Assessment, Development, and Evaluation system. International experts in this field were allocated to 4 working groups (diagnosis, prevention, anesthesia, and critical care considerations, and management of established SFSS). The working groups prepared evidence-based recommendations to answer-specific questions considering the currently available literature. The working group members, independent panel, and conference attendees served as jury to edit and confirm the final recommendations presented at the end of the conference by each working group separately. This report presents the final statements and evidence-based recommendations provided by working group 2 that can be implemented to prevent SFSS in LDLT patients.

Reduction of Visceral Adiposity as a Predictor for Resolution of Nonalcoholic Fatty Liver in Potential Living Liver Donors

This study aimed to determine the factors associated with resolution of nonalcoholic fatty liver (NAFL) after lifestyle intervention in potential living liver donors as assessed by the gold standards in a longitudinal setting. This retrospective study included 115 potential living liver donors (mean age, 30.5 ± 7.5 years; 101 men) with NAFL who underwent paired liver biopsies and abdominal computed tomography (CT) examinations before and after lifestyle intervention between January 2011 and December 2018. Anthropometry, laboratory parameters, body composition, and hepatic steatosis (HS) were evaluated before and after lifestyle intervention. Anthropometry, laboratory parameters, body composition, and HS were significantly decreased after lifestyle intervention (all, P < 0.001). Relative changes in HS were weakly correlated with relative changes in the visceral fat area (VFA; r = 0.278; P = 0.003) and subcutaneous fat area (r = 0.382; P < 0.001), but not with body weight, body mass index, or skeletal muscle area. Patients with resolved NAFL after lifestyle intervention had significantly lower VFA at follow-up than those with persistent NAFL (mean ± standard deviation, 69.8 ± 39.1 versus 91.5 ± 41.4 cm² ; P = 0.01). Multivariable logistic regression analysis demonstrated that the relative reduction of VFA (odds ratio per percent, 1.031; 95% confidence interval, 1.010-1.053; P = 0.004) was a significant independent factor associated with resolved NAFL after lifestyle intervention. In potential living liver donors with NAFL, the reduction of VFA is a significant factor associated with the resolution of NAFL after lifestyle intervention.

Defatting strategies in the current era of liver steatosis

Liver steatosis is emerging as a major cause of chronic liver disease worldwide, mainly due to the increasing rate of obesity, type 2 diabetes, and metabolic syndrome. Because of the increased incidence of liver steatosis, many organs are currently declined for transplantation despite high demand and waiting list mortality. Defatting strategies have recently emerged as a means of rapidly reducing liver steatosis to expand the pool of available organs. This review summarises advances in defatting strategies in experimental and human models of liver steatosis over the last 20 years.