Global experience and perspective on anonymous nondirected live donation in living donor liver transplantation

Anonymous nondirected living liver donation (ANLLD), sometimes referred to as “altruistic” donation, occurs when a biologically unrelated person comes forward to donate a portion of his/her liver to a transplant candidate who is unknown to the donor. Here, we explore the current status of ANLLD with special consideration of published reports; US experience; impact on donor psychosocial outcomes; barriers to donation; and current global trends with respect to ethical considerations. Between 1998 and 2019, 105 anonymous nondirected living liver donor (ND-LLD) transplants have been documented in the US Scientific Registry of Transplant Recipients. Sixteen donors (15%) were reported to experience a postoperative complication. Currently, 89 donors remain alive (85%), 16 (15%) have unknown status, and none are confirmed deceased. Although there are only a handful of case series, these data suggest that ANLLD is a feasible option. While there are no liver-specific data, studies involving anonymous nondirected kidney donors suggest that anonymous donation does not adversely impact psychosocial outcomes in donors or recipients. There are substantial financial burdens and ethical considerations related to ANLLD. Further studies are required to assess donor demographics, psychosocial motivations, long-term health-related quality of life, and financial impact of ANLLD.     

Donor outcome and liver regeneration after right-lobe graft donation

Sufficiently detailed information on donor safety and the liver regeneration process following right-lobe living donation has been unavailable, so we evaluated donor outcome and liver regeneration in 13 males and 14 females (39.0 +/- 14.8 years old) who provided 27 right-lobe grafts without the middle hepatic vein. Preoperative total liver volume (TLV), graft volume, and postoperative changes in residual liver volume (RLV) were measured by volumetric computed tomography. Histological steatosis of the liver was graded as none, minimal (< or =10%), and mild (11-30%). The median follow-up period was 337 days. Estimated graft volume and actual graft weight were linearly correlated (Y = 177.85 + 0.795X, R(2) = 0.812, P < 0.0001). Graft-to-recipient weight ratio was 1.08 +/- 0.19%. Four donors had postoperative complications, but they resolved in response to conservative treatment. Postoperative hospital stay was 15.2 +/- 5.5 days. Peak liver enzyme values were significantly higher in donors with mild steatosis (n = 7) than without steatosis (n = 16) (P < 0.05). Donor RLV was 40.8 +/- 6.6% of original TLV at surgery, 79.8 +/- 12.0% by 6 months, and 97.2 +/- 10.8% by 12 months. At 3 months the liver of the older donors (> or =50 years) had grown significantly more slowly than in younger donors (70.4 +/- 9.2% vs. 79.3 +/- 9.6%, P = 0.0391). In conclusion, right hepatectomy without middle hepatic vein of living donors is a safe procedure with acceptable morbidity, and the residual liver regenerated to its preoperative size by 1 year. However, meticulous care should be taken in donors with liver steatosis and aged donors.     

Analysis of postsurgical complications in 75 living liver transplantation donors

Seventy-five living donor liver hepatectomies were performed at our transplantation center between April 1990 and December 2004. We collected the data from patient charts, files, and the Baskent University Liver Registry. There were 39 male and 36 female donors (mean age, 35.1 +/- 9.3 years). We have performed 29 (38.6%) left hepatic lobectomies, 18 (24%) left lateral segmentectomies, 26 (34.6%) right lobectomies, and two (2.6%) donors had simultaneous living donor nephrectomy plus left lobe hepatectomy. The mean remnant liver volume was 598 +/- 168 cm(3) (range, 410-915 cm(3)). The mean percentage of remnant liver for the donor was 55.2%. Mean postoperative hospital stay was 10 +/- 4.4 days. After surgery, there was no mortality or reoperation. We saw 15 (20%) postsurgical complications in 14 donors. Intra-abdominal collection was seen in five (6.6%) patients. Biliary leak was seen in four patients. Portal vein thrombosis was seen in one patient, and a pulmonary embolus developed in one liver donor. Patient safety must be the primary focus in living-donor liver transplantation. These donors face significant risks, including substantial morbidity and death. More experience, improved surgical techniques, and meticulous donor evaluation will help minimize morbidity and mortality for both living liver donors and recipients.     

Congestion of the donor remnant right liver after extended left lobe donation

The clinical importance of congestion of the remnant right lobe has not yet been fully elucidated in donors who donate their left lobe with the middle hepatic vein. The impact of congestion on clinical course and liver regeneration in 52 donor remnant livers were evaluated. The donors were divided into three groups according to the degree of the congestion: the mild [congestion ratio (CR) < 10%], moderate (CR ranged from 10% to 25%) and severe congestion groups (CR > 25%). The regeneration ratio of the graft at postoperative day 7 (7 POD) was 22.0 ± 14.3% and inversely correlated with the CR in the remnant right lobe ( P  =   0.003). Aspartate aminotransferase and alanine aminotransferase at 7 POD were significantly higher in the severe CR group in comparison to the mild CR group ( P  =   0.003 and 0.019, respectively), but those of the three groups were comparable at 30 POD. The hospital stays were significantly longer in the severe CR group ( P  =   0.010). In conclusion, the congestion of the donors' remnant right liver can lead the transient liver dysfunction and poor regeneration. Therefore, the conversion of the graft from the left to right lobe might be appropriate according to the degree of the congestion.     

Living donor liver transplantation: effect of the type of liver graft donation on donor mortality and morbidity

To investigate the influence of the type of liver graft donation on donor mortality and morbidity. The clinical course of 87 living liver donors operated on at our center between 2002 and 2009 was retrospectively analysed and data pertaining to all complications were retrieved. No donor mortality was observed and no donor suffered any life‐threatening complication. Four donors (4.6%) developed biliary leakage, nine (10.3%) had to be readmitted to hospital and six (6.9%) required some or other type of reoperation related to the previous liver donation. Reoperations included incisional or diaphragmatic hernia repair (n = 4), biliary leakage repair (n = 1) and segmental colon resection combined with diaphragmatic hernia repair (n = 1). There was a statistically significant difference in hospital stay (P < 0.001), autologous blood transfusions (P < 0.001) and operating time (P < 0.005) when right lobe donations (Segments V–VIII) were compared with left lobe (Segments II–IV) and left lateral lobe (Segments II–III) donations, whereas no difference was found between these groups regarding hospital readmission, operative revisions and the incidence or severity of complications. Right lobe donation was associated with prolonged hospital stay, increased blood transfusions and prolonged operating time when compared with left and left lateral lobe donation, whereas donor mortality and morbidity did not differ between these groups.     

Extent of hepatectomy on splenic hypertrophy and platelet count in live liver donors

The extent of donor hepatectomy may affect splenic hypertrophy and platelet count. The subjects were 50 live liver donors. The ratio of the graft weight to total liver volume (GW/TLV) and the splenic hypertrophy ratio, expressed as the splenic volume one month after surgery divided by that before surgery, were calculated. The platelet count one month after surgery was divided by that before surgery to determine the rate of the platelet count decrease. The correlation of GW/TLV to the splenic hypertrophy ratio and the rate of the platelet count decrease were examined. The median (range) GW/TLV was 54 (28-71)%. The splenic hypertrophy ratio and the rate of the platelet count decrease was 133 (99-191)% and 92 (71-129)%, respectively. GW/TLV positively correlated with the splenic hypertrophy ratio (Spearman's correlation coefficient (r(s)) = 0.448, p = 0.001), and negatively correlated with the rate of the platelet count decrease (r(s) = -0.471, p < 0.001). Multivariate analysis revealed that GW/TLV influenced the splenic hypertrophy ratio [adjusted odds ratio (OR), 12.0; 95% confidence interval (CI), 1.32-9.04; p = 0.01] and the ratio of the platelet count decrease (adjusted OR, 11.6; 95% CI, 1.40-8.33; p = 0.01). Larger graft procurement might place living liver donors at higher risk for post-operative thrombocytopenia.     

Intrahepatic venous collaterals formation following outflow block in adult-to-adult living donor liver transplantation

A right liver graft without the middle hepatic vein (MHV) trunk is now commonly used in adult-to-adult living donor liver transplantation (LDLT), but it is unclear whether hepatic venous collaterals would develop in clinical patient just after occlusion of hepatic veins. Between January 2005 and October 2006, 56 consecutive adult patients underwent LDLT using right lobe grafts without MHV in our center. Twenty-four patients (42.9%) had MHV tributaries reconstruction. Vascular flow in the graft and interposition vein graft patency was checked by Doppler ultrasonography (US) daily during hospital stay and monthly follow-up after discharge for 2 y. Among 24 cases with MHV reconstruction, interpositional graft block occurred in one case within 7 d after transplantation. A reversed flow in MHV tributaries and collaterals between MHV and right hepatic vein (RHV) was detected by Doppler US. Vessel graft blocks were found in 10 of 22 cases of MHV tributaries reconstruction between 4 to 9 mo after transplantation. Collaterals formation between MHV and RHV developed in 4 of 10 cases of vessel graft block, and their graft function did not deteriorate. In conclusion, nearly half of the patients needed reconstruction of MHV tributaries when a right lobe graft without MHV was used in LDLT. The authors thought that the reconstruction of MHV tributaries should be established when the congested area was dominant by the clamping test or when the diameter of the tributaries was >5 mm. It was found that there may not be any problems if reconstructed vessel graft obstruction was found 3 mo after transplantation, as intrahepatic venous collaterals between MHV and RHV could develop.     

Endovascular interventions for hepatic artery complications immediately after pediatric liver transplantation

Hepatic artery complications after living donor liver transplantation (LDLT) can directly affect both graft and recipient outcomes. For this reason, early diagnosis and treatment are essential. In the past, relaparotomy was generally employed to treat them. Following recent advances in interventional radiology, favorable outcomes have been reported with endovascular treatment. However, there is ongoing discussion regarding the best and safe time for definitive endovascular interventions. We herein report a retrospective analysis for six children with early hepatic artery complication after pediatric LDLT who underwent endovascular treatment as primary therapy at our institution. We evaluate the usefulness of endovascular treatment for hepatic artery complication and its optimal timing. The mean patient age was 11.9 months and mean body weight at LDLT was 6.7 kg. The mean duration between the transplantation and first endovascular treatment was 5.3 days. Five of the six patients were technically successful treated by only endovascular treatment. Of these five patients, two developed biliary complications. Endovascular procedures were performed 10 times in six patients without any complications and nine of the 10 procedures were successful. By selecting optimal devices, our findings suggest that endovascular treatment can be feasible and safe in the earliest time period after pediatric LDLT.     

Long-term outcomes of endoscopic management for biliary strictures after living donor liver transplantation with duct-to-duct reconstruction

Biliary strictures after living donor liver transplantation (LDLT) with duct-to-duct (D-D) reconstruction are associated with postoperative morbidity and mortality. The aims of this study were to evaluate the long-term outcomes of endoscopic deployment of plastic stents, and to investigate factors associated with the stent deployment failure. Between April 2001 and May 2007, 96 patients received LDLT with D-D reconstruction at Okayama University Hospital. Among them, 41 patients (43%) had anastomotic biliary strictures, and all were referred first for endoscopic retrograde cholangiography (ERC). When deployment was unsuccessful, a percutaneous transhepatic procedure was employed. Successful stent deployment was achieved in 35 out of total 41 patients (85%) by both procedures. Among the 35 patients, 28 had their stents removed as a result of strictures resolution. Eight patients underwent ERC and repeated stent deployment as a result of recurrence of the strictures. Finally, 21 out of 41 (51%) patients with biliary stricture were completely treated by endoscopic therapy during the observation period (median 873 days: range 77–2060). By multivariate analysis, biliary leakage was associated with stent deployment failure. Endoscopic deployment of plastic stents is a first-line therapy for patients with biliary stricture after LDLT.