Living donor liver transplants: potential disadvantages

Abstract   Living donor liver transplants (LDLTs) have provided many patients with a lifesaving option. Yet this option remains a significant undertaking, with potentially serious consequences for both the donor and the recipient. The donor is obviously the individual with the most to lose. The exact risks to the donor are difficult to quantify because reporting adverse donor events is not mandatory and no registry exists. The risk to the donor also depends on the extent of the donor resection. By some estimates, the risk of donor mortality is 0.3% to 1.0%. The reported risk of donor complications varies greatly in the literature—ranging from 5 to 60%. Reported complications are usually short-term complications, since most donors are not followed by the transplant center after the first year. Very few studies have examined other issues that are important for the donor, such as the quality of life after donation, the time to full recovery, and the financial impact of donation. For the recipient, an LDLT is a lifesaving procedure. Especially in countries where deceased donation is scarce, the benefits of an LDLT for the recipient are obvious. However, analysis of national data from the United States demonstrates that, at least for adults, results of an LDLT may be inferior, as compared with a whole-liver transplant from a deceased donor. Moreover, the surgical complication rate after an LDLT is significantly higher. As LDLTs continue to gain in popularity, careful evaluation and re-evaluation of both donor and recipient outcomes are necessary to optimize results.     

Living donor liver transplantation: issues regarding left liver grafts

BackgroundThe necessity of widening the indications for living donor liver transplantation (LDLT) has been emphasised. Clarification of the advantages and limitations of using a left liver graft for LDLT in adults is essential for donor safety.MethodsBetween June 1990 and November 2002, 185 patients underwent LDLT at Shinshu University Hospital, Japan. In 97 of these, the graft comprised the left liver with or without the left portion of the caudate lobe. The peri-hepatectomy profiles of the donors, significance of left liver grafts, postoperative courses of the donors and recipients, and survival of the recipients were investigated.ResultsAll the donors recovered well and returned to a normal lifestyle. None required banked-blood transfusion or repeat surgery, and postoperative liver function tests had satisfactory results. The cold ischaemic time for the graft was 127±54 minutes. The graft volumes (GVs) ranged from 230 to 625 ml, and GV/standard liver volume (SV) ratios varied from 22% to 65%, at the time of transplantation. Although 85% of the liver grafts had GV/SV ratios <50%, no patient developed immediate postoperative liver failure. Patient survival rates were 89%, 84% and 84% at 1, 3 and 5 years, respectively.DiscussionAlthough LDLT using a left liver graft imposes potential postoperative complications (a small liver is more vulnerable to injury, and recipients of small grafts are at higher risk of complications during recovery), such grafts have yielded acceptable results in adult LDLT, with minimal burden to the donors.     

Living donor liver transplantation: Eastern experiences

BACKGROUND: The techniques of living donor liver transplantation (LDLT) developed rapidly in the 1990s to compensate for a severe deficiency in the availability of liver grafts from cadaveric donors for the treatment of patients with end-stage liver disease. This tendency was particularly prominent in East Asia, as brain-death donors have remained largely unavailable for a variety of reasons. Thanks to refinements in surgical technique and postoperative management for LDLT, the cumulative total of LDLTs in East Asian countries has exceeded 2000 and, importantly, donor mortality has yet to be encountered. Moreover, indications for LDLT have been successfully expanded from paediatric to adult cases, following the introduction of right lobe graft. The significance of LDLT under conditions of limited opportunities for cadaveric liver transplantation, as experienced in these countries, differs significantly from that seen with the numerous opportunities for cadaveric donors in Europe and the USA. This review describes not only the experiences of East Asia, but also the specific differences from Western countries, such as indications, graft size issues and ABO blood type combinations, to shed light on the future of liver transplantation.     

Diagnosis of hepatic steatosis and fibrosis by transient elastography in asymptomatic healthy individuals: a prospective study of living related potential liver donors

Background This prospective study aimed to assess the ability of transient elastography to identify histologic parameters, including steatosis, in asymptomatic healthy individuals such as potential liver donors, and to compare these findings with results in liver disease patients. Methods Forty-seven patients with abnormal liver function and/or hepatitis symptoms and 80 living related potential liver donors were consecutively enrolled, and liver biopsy and a Fibroscan test were performed in each subject. Histologic parameters were evaluated according to METAVIR scale by a single pathologist. Results In liver disease patients, stiffness was significantly correlated with fibrosis stage (Spearman correlation coefficient, 0.700; P < 0.001), and the optimal stiffness cutoff values for F ≥ 2, F ≥ 3, and F = 4 were 7.35, 8.85, and 15.1 kPa respectively. In potential liver donors, however, stiffness was not correlated with fibrosis (0.023; P = 0.851). In the latter group, the area under the receiver-operating characteristics curve was 0.70 (95% confidence interval, 0.58–0.81), and the optimal stiffness cutoff value was 4.00 for F ≥ 2, which was lower than that in liver disease patients. Steatosis was not correlated with stiffness (0.088; P = 0.463) in potential liver donors. Conclusions Transient elastography has limited value for detecting steatosis in asymptomatic healthy individuals, and the cutoff value for fibrosis should be reevaluated in these subjects.     

Live donors in liver transplantation

Living donor liver transplantation (LDLT) has been controversial since its inception. Begun in response to deceased donor organ shortage and waiting list mortality, LDLT was initiated in 1989 in children, grew rapidly after its first general application in adults in the United States in 1998, and has declined since 2001. There are significant risks to the living donor, including the risk of death and substantial morbidity, and 2 highly publicized donor deaths are thought to have contributed to decreased enthusiasm for LDLT. Significant improvements in outcomes have been seen over recent years, and data, including from the National Institutes of Health-funded Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL), have established a survival benefit from pursuing LDLT. Despite this, LDLT still composes less than 5% of adult liver transplants, significantly less than in kidney transplantation where living donors compose approximately 40% of all transplantations performed. The ethics, optimal utility, and application of LDLT remain to be defined. In addition, most studies to date have focused on posttransplantation outcomes and have not included the effect of the learning curve on outcome or the potential impact of LDLT on waiting list mortality. Further growth of LDLT will depend on defining the optimal recipient and donor characteristics for this procedure as well as broader acceptance and experience in the public and in transplant centers.     

Living donor liver transplantation for fulminant hepatic failure

Aim: The aim of this study was to investigate the safety of living donor liver transplantation (LDLT) for fulminant hepatic failure (FHF) patients. Methods: We reviewed the clinical indications, operative procedures and prognosis of LDLT performed on patients with FHF at the University of Tokyo. From January 1996 to August 2007, 96 patients were referred to our department due to severe acute hepatitis or FHF. Of these, 36 underwent LDLT and were the subjects of this study. Of the 36 patients who underwent LDLT, 32 were over 18 years old. The etiologies of FHF included non‐A, non‐B hepatitis in 23, hepatitis B virus in 11, Wilson's disease in one, and auto‐immune hepatitis in one. Graft type included right liver in 18, left liver in 16 and right paramedian sector in two. Results: Patient and graft survival rates at 5 years were 87% and 82%, respectively. Twenty‐three patients had postoperative complications: acute cellular rejection in 12, biliary stricture in eight, bile leakage in six, peritoneal hemorrhage in six and hepatic arterial thrombosis in four. Conclusion: The LDLT procedure provided satisfactory survival rates for FHF patients.     

Simplifying living donor liver transplantation

BACKGROUND:Living donor liver transplantation is a complex surgical operation.Treatment policies and operative techniques evolved in the last two decades.DATA SOURCES:Our center's experience in living donor liver transplantation was reviewed in conjunction with relevant publications in the literature.RESULTS:The surgical techniques and perioperative surgical therapeutics could be modified towards simplicity.Examples include regular inclusion of the middle hepatic vein without compromising the venous outflow...     

Risks faced by donors of right lobe for living donor liver transplantation

BACKGROUND:Because of the shortage of deceased donors with livers fit for transplantation,living donor liver transplantation(LDLT)is becoming an attractive alternative.Attention should be paid to the donors,especially to those of the right lobe.In this study,we evaluated the risks faced by donors of the right lobe for adult-to-adult LDLT.METHODS:The perioperative data from 105 consecutive living donors of the right lobe performed in West China Hospital from January 2002 to December 2007 were retrospectively...     

Living donor liver hilar variations: surgical approaches and implications

BACKGROUND: Varied vascular and biliary anatomies are common in the liver. Living donor hepatectomy requires precise recognition of the hilar anatomy. This study was undertaken to study donor vascular and biliary tract variations, surgical approaches and implications in living liver transplant patients. METHODS: Two hundred living donor liver transplantations were performed at our institution between 2004 and 2009. All donors were evaluated by volumetric computerized tomography (CT), CT angiography and magn...     

Asian contribution to living donor liver transplantation

Although the shortage of brain-dead donor organs is a worldwide problem, the situation is especially serious in Asia because of various cultural and social reasons, and cadaveric organ donation remains below 5 per million population per year. Living donor liver transplantation (LDLT) could provide an alternative for liver graft for patients with acute and chronic end-stage liver disease. This article introduces the important contributions to the development of LDLT by the leading Asian liver transplantation centers. The first successful adult LDLT using a left-lobe graft was reported by Makuuchi et al. from Japan in 1994. To overcome the barrier of graft-size matching for adult patients with use of a left-lobe graft, a trial of adult LDLT using a right-lobe graft with middle hepatic vein was reported with satisfactory outcome by Fan et al. from Hong Kong in 1997. Despite the impressive results of right-lobe LDLT, considerable debate persists concerning donor safety. Lee et al. from Korea initiated modified right-lobe liver grafting with interposition vein grafts to drain anterior segment and two left-lobe liver grafting to overcome graft-size insufficiency and to ensure donor safety in 1999 and 2000, respectively. In addition to technical innovations, indications for liver transplantation have been developed by Asian centers as LDLT activity has increased.     

Living donor liver transplantation for hepatitis C related hepatocellular carcinoma in a haemophilia A patient

We report the first case of unrelated living liver transplantation for hepatitis C related hepatocellular carcinoma (HCC) in a Chinese patient with haemophilia A. The development of cirrhosis and HCC was insidious in this patient, who has previously failed interferon treatment despite low viral load and genotype 6a. With factor VIII and novoseven support, there were no operative complications and there was no need for blood transfusion. Postoperative pegulated interferon treatment resulted in viral clearance with no increased cellular rejection. The use of living donors represent a potential life saving therapeutic options for hepatitis C virus related complications in haemophiliac, especially in countries of organ shortage. Careful patient and donor choice, meticulous surgical expertise and proper counselling, however, are prudent requirements.     

Weight loss interventions in living donor liver transplantation as a tool in expanding the donor pool: A systematic review and meta-analysis

BACKGROUNDWith increasing rates of liver transplantation and a stagnant donor pool, the annual wait list removals have remained high. Living donor liver transplantation (LDLT) is an established modality in expanding the donor pool and is the primary method of liver donation in large parts of the world. Marginal living donors, including those with hepatic steatosis, have been used to expand the donor pool. However, due to negative effects of steatosis on graft and recipient outcomes, current practice excludes overweight or obese donors with more than 10% macro vesicular steatosis. This has limited a potentially important source to help expand the donor pool. Weight loss is known to improve or resolve steatosis and rapid weight loss with short-term interventions have been used to convert marginal donors to low-risk donors in a small series of studies. There is, however, a lack of a consensus driven standardized approach to such interventions. AIMTo assess the available data on using weight loss interventions in potential living liver donors with steatotic livers and investigated the feasibility, efficacy, and safety of using such donors on the donor, graft and recipient outcomes. The principal objective was to assess if using such treated donor livers, could help expand the donor pool.METHODSWe performed a comprehensive literature review and meta-analysis on studies examining the role of short-term weight loss interventions in potential living liver donors with hepatic steatosis with the aim of increasing liver donation rates and improving donor, graft, and recipient outcomes. RESULTSA total of 6 studies with 102 potential donors were included. Most subjects were males (71). All studies showed a significant reduction in body mass index post-intervention with a mean difference of -2.08 (-3.06, 1.10, I² = 78%). A significant reduction or resolution of hepatic steatosis was seen in 93 of the 102 (91.2%). Comparison of pre- and post-intervention liver biopsies showed a significant reduction in steatosis with a mean difference of -21.22 (-27.02, -15.43, I² = 56%). The liver donation rates post-intervention was 88.5 (74.5, 95.3, I² = 42%). All donors who did not undergo LDLT had either recipient reasons or had fibrosis/steatohepatitis on post intervention biopsies. Post-operative biliary complications in the intervention group were not significantly different compared to controls with an odds ratio of 0.96 [(0.14, 6.69), I² = 0]. The overall post-operative donor, graft, and recipient outcomes in treated donors were not significantly different compared to donors with no steatosis. CONCLUSIONUse of appropriate short term weight loss interventions in living liver donors is an effective tool in turning marginal donors to low-risk donors and therefore in expanding the donor pool. It is feasible and safe, with comparable donor, graft, and recipient outcomes, to non-obese donors. Larger future prospective studies are needed.     

Living liver donor hilar anatomical variations and impact of variant anatomy on transplant outcomes

Donor anatomy is an essential part of donor selection and operative planning in living donor liver transplantation. In this study, variations of hilar structures, and the effects of variant anatomy on donor and recipient outcomes were evaluated. Living donor liver transplantations in a single center between January 2013 and December 2020 were retrospectively reviewed. In total, 203 liver transplantations were analyzed. Type 1 arterial anatomy, type 1 portal vein anatomy and type 1 bile duct anatomy were observed in 144 (70.9%), 173 (85.2%), and 129 (63.5%) donors, respectively. Variant biliary anatomy was observed more frequent in donors with variant portal vein branching than in those with type 1 portal anatomy (60.0% vs 32.3%, P = .004). The overall survival rates calculated for each hilar structure were similar between recipients receiving grafts with type 1 anatomy and those receiving grafts with variant anatomy. When donors with variant anatomy and donors with type 1 anatomy were compared in terms of hilar structure, no significant difference was observed in the frequency of complications and the frequency of serious complications. Biliary variations are more common in individuals with variant portal vein anatomy. Donor anatomic variations are not risk factors for inferior results of recipient survival or donor morbidity.     

Evaluation outcomes of donors in living dono liver transplantation: a single-center analysis of 132 donors

BACKGROUND: Donor safety has always been a major concern and potential risk to the donor must be balanced against recipient benefit. However, lack of a standardized and uniform evaluation of perioperative complications is a serious limitation of the evaluation of donor morbidity. This study was designed to evaluate the outcomes of donors in adult living donor liver transplantation (LDLT) using the newer Clavien classification system in a single center in China. METHODS: We prospectively analyzed the outcome...