Clinical outcomes of right-lobe split-liver versus orthotopic liver transplants from donors more than 70 years old

Risk factors of massive blood transfusion in liver transplantation: consequences and a new index for prediction including the donor

BACKGROUND

Massive blood transfusion (MBT) is a common occurrence in liver transplant (LT) patients. Recipient-related risk factors include cirrhosis, history of multiple surgeries and suboptimal donors. Despite advances in surgical techniques, anesthetic management and graft preservation have decreased the need for transfusions, this complication has not been completely eliminated.

METHODS

One thousand four hundred and sixty-nine LT were performed at our institution between May 2003 and December 2020, and data was available regarding transfusion for 1198 of them. We divided the patients into two groups, with regards to transfusion of 6 or more units of packed red blood cells in the first 24 h posttransplant, and we analyzed the differences between the groups.

RESULTS

Out of the 1198 patients, 607 (50.7%) met criteria for MBT. Survival was statistically lower at 1, 3, and 5 years when comparing the groups that had MBT to those that did not (92.6%, 85.2% and 79.7%, respectively, in the non MBT group, vs. 78.1%, 71.6% y 66.8%, respectively, in the MBT group). MBT was associated with a 1.5 mortality risk as opposed to non-MBT patients. Logistical regression analysis of our variables yielded the following results for a new model, including serum creatinine (OR 1.97), sodium (OR 1.73), hemoglobin (OR 1.99), platelets (OR 1.37), INR (OR 1.4), uDCD (OR 2.13) and split liver donation.

CONCLUSION

Massive blood transfusion impacts patient survival in a statistically significant way. The most significant risk factors are preoperative hemoglobin, INR and serum creatinine.

Feasibility and Safety of Split-Liver Transplantation in a Nascent Framework of Deceased Donation

Split-liver transplantation (SLT) is a valuable option for optimizing the use of good-quality deceased donor grafts. It is not routinely reported outside the West because of limited deceased donor numbers, technical and organizational constraints, lack of experience, and a predominant living donor liver transplantation (LDLT) practice. At our center, 20% of the liver transplantations (LTs) are from deceased donors. We report our experience of SLT and compare outcomes with pediatric and adult LDLT recipients. A prospectively maintained database of all LT recipients between September 2009 and March 2017 was analyzed. Each pediatric SLT recipient was matched to 2 pediatric LDLT recipients for age, weight, urgency, and year of transplant. Each adult SLT recipient was similarly matched to 2 adult LDLT recipients for age, Model for End-Stage Liver Disease score, and year of transplant. Intraoperative and postoperative parameters, including recovery time, morbidity (biliary and vascular complications, Clavien grade >IIIA complications), and mortality were compared. In total, 40 SLTs were performed after splitting 20 deceased donor livers (in situ, n = 11; hybrid split, n = 3; and ex vivo, n = 6). Recipients included 22 children and 18 adults. There were 18 livers that were split conventionally (extended right lobe and left lateral segment [LLS]), and 2 were right lobe-left lobe SLTs. Also, 3 LLS grafts were used as auxiliary grafts for metabolic liver disease. Perioperative mortality in SLT recipients occurred in 3 patients (2 children and 1 adult). Incidence of vascular, biliary, and Clavien grade >IIIA complications were similar between matched adult and pediatric SLT and LDLT groups. In conclusion, SLT is an effective technique with outcomes comparable to living donor grafts for adult and pediatric recipients. Using SLT techniques at centers with limited deceased donors optimizes the use of good-quality whole grafts and reduces the gap between organ demand and availability.

Management of biliary complications after liver transplantation

Biliary complications (BC) currently represent a major source of morbidity after liver transplantation. Although refinements in surgical technique and medical therapy have had a positive influence on the reduction of postoperative morbidity, BC affect 5% to 25% of transplanted patients. Bile leak and anastomotic strictures represent the most common complications. Nowadays, a multidisciplinary approach is required to manage such complications in order to prevent liver failure and retransplantation.