Applicability of living donor liver transplantation in a program of adult liver transplantation

Introduction

The aim of this study was to investigate the applicability of living donor liver transplantation in a program of adult liver transplantation.

Patients and methods

We studied the outcomes of the evaluation of 71 potential donor candidates for 53 adult candidates to liver transplantation.

Results

Ten of the potential donor candidates did not complete their evaluation. Among the remaining 61 potential donors, 29 (47.5%) were considered to be suitable donors. Only 17 (24% of the 71 initial candidates) underwent donation. The main causes for unsuitability for liver donation were a small remnant liver and vascular anatomic variants.

Conclusion

Fewer than 25% of potential liver donors became effective donors leading us to conclude that adult living donor liver transplantation has a low applicability.     

Experience after the evaluation of 700 potential donors for living donor liver transplantation in a single center.

Adequate selection of donors is a major prerequisite for living donor liver transplantation (LDLT). Few centers report on the entire number of potential donors considered or rejected for living donation. From April 1998 to July 2003, a total of 111 living donor liver transplantations were performed at our institution, with 622 potential donors for 297 adult recipients and 78 potential donors for 52 pediatric recipients evaluated. In the adult group, only 89 (14%) potential donors were considered suitable, with a total of 533 (86%) potential donors rejected. Of these, 67% were excluded either at initial screening or during the first and second steps of the evaluation procedure. In 31% of all cases, the evaluation of donors was canceled because of recipient issues. In the pediatric group, 22 (28%) donors were selected, with the other 56 (72%) rejected. Costs of the complete evaluation process accounted for 4,589 Euro (Euro) per donor. The evaluation of a potential living donor is a complex and expensive process. We present the results on the evaluation of the largest group of potential donors for adults reported in the literature. Only 14% of potential donors in our series were considered suitable candidates. It has not yet been established who should cover the expenses of the evaluation of all rejected donors. In conclusion, all efforts should be made in order to develop an effective screening protocol for the evaluation of donors with the aim of saving time and resources for a liver transplantation program.     

Nonalcoholic steatohepatitis in donors for living donor liver transplantation

BACKGROUND: In 2003, we encountered the first donor death for living donor liver transplantation in Japan, which was related to nonalcoholic steatohepatitis (NASH). The aim of this study was to retrospectively investigate the prevalence of NASH among a living donor liver transplantation donor population and to analyze the postoperative course for both donors and recipients of NASH grafts to minimize risk for donors. METHODS: The study population comprised 263 donors who donated the right lobe of the liver between February 1998 and April 2003. Their zero-hour biopsy specimens were screened retrospectively. Regarding severe steatosis or NASH, long-term follow-up results for laboratory data from donors were investigated along with changes in graft histologic findings in recipients. RESULTS: NASH was diagnosed histopathologically in three cases (1.1%). Pathologic examination showed that a donor who died in 2003 had the most severe NASH among the three cases. The remaining two NASH donors had uneventful postoperative courses without complications. All grafts showed improvement with respect to the steatosis and histologic findings of NASH. CONCLUSIONS: Donor safety is a top priority in living donor liver transplantation. To exclude patients with NASH from potential donor lists, careful evaluation, including selective preoperative liver biopsy, should be carried out.     

Preoperative helical computerized tomography estimation of donor liver volume

BACKGROUND: The purpose of this study was to evaluate the accuracy of spiral computed tomography (CT) and 3-D imaging models in measuring total and segmental liver volume in potential living donors. METHODS: A prospective study was undertaken to assess the correlation between the volumes of potential donor livers determined via helical CT and the actual volumes measured during operation in 150 donor candidates. Left-lateral segment (S2,3) or left-lobe (S2,3,4) transplantation was performed in 36 cases with 96 right-lobe liver transplants (S5,6,7,8). Ten donor candidates were refused owing to inadequate liver volumes, and 8 for other reasons. RESULTS: The regression analysis model showed a significant correlation between the preoperative CT estimates of graft volume and intraoperative weight measurement of harvested grafts in living liver donors (F: 5525.37; P < .05); 97.7% of changes in CT volume were explained by differences in graft mass (R2: 0.977). CONCLUSION: Preoperative estimation of segmental volumes of the donor liver is necessary to avoid donor-recipient size disparity, thereby preventing hepatic failure of donors after harvesting. It has a major impact on donor selection and type of surgical management. The accuracy of helical CT was high to determine total and segmental liver volumes.     

Guidelines for donor selection and an overview of the donor operation in living related liver transplantation

Guidelines for donor selection and an overview of the donor operation are reported on the basis of our experience with 120 cases of living related liver transplantation (LRLT) in pediatric patients. Once the parents had clearly expressed their desire to serve as donors, tests were performed to functionally and anatomically screen the donor livers to determine whether or not the parents' general physical condition allowed them to serve as donors. We then evaluated which of the two parental candidates was more suitable as a donor. The wishes of the family as to which parent should serve as donor was considered secondary and taken into account only in a few cases in which certain functional and/or anatomical abnormalities were uncovered that made the prime candidate less suitable. For the 120 LRLTs, 135 candidates were evaluated as potential donors, 15 (11.1%) of whom were rejected for various reasons. The mean volume of blood loss during the donor operation decreased significantly from 489 g in the first 60 LRLTs to 390 g in the latter 60 LRLTs; this was accompanied by a significant decrease in the mean volume of autologous blood transfused from 449 g to 390 g. Mean cold ischemia time of the graft increased significantly from 71.4 to 128.0 min, while mean operation time conversely decreased from 6.7 to 6.2 h. Bile leakage from the cut surface of the remnant lver, which was the only postoperative surgical complication encountered, was noted in five cases. We conclude that donor candidates should be strictly selected according to basic guidelines, taking into account both the results of preoperative screening and the wishes of the family. With this accumuled experience, we have been able to simplify our LRLT operative procedure, resulting in decreases in blood loss volume, blood transfused, and operation time.     

Live donor adult liver transplantation using right lobe grafts: donor evaluation and surgical outcome

HYPOTHESIS: Live donor adult liver transplantation (LDALT) is a safe and efficacious treatment for patients with end-stage liver disease. DESIGN: Case-control study. SETTING: Hepatobiliary surgery and liver transplantation unit. PATIENTS: From December 10, 1998, through April 10, 2000, a single team performed 15 LDALT procedures with 2 simultaneous living donor kidney transplants. During this period, 66 potential donors were screened and evaluated. INTERVENTIONS: Potential donors were evaluated with 3-dimensional helical computed tomographic scan, including volume renderings for hepatic lobar volume, vascular anatomy, virtual resection planes, and morphologic features. Suitable donors undergo complete medical and psychiatric evaluation and preoperative arteriography. MAIN OUTCOME MEASURES: Donor demographics, evaluation data, operative data, hospital length of stay, and morbidity. RESULTS: A total of 38 men (58%) and 28 women (42%) were evaluated with 15 donors participating in LDALT. Two additional donors provided kidney grafts for simultaneous transplantation at the time of LDALT. Thirty-two donors (48%) were rejected for either donor or recipient reasons, and 10 patients (15%) elected not to participate after initial screening. Three-dimensional volume renderings by helical computed tomographic scan predicted right lobe liver volume within 92% of actual graft volume. Donor morbidity, including all complications, was 67% with no mortality. Residual liver regenerated to approximately 70% of initial volume within 1 week and 80% within 1 month after surgery. CONCLUSIONS: Donor evaluation is an important component of LDALT. Significant donor morbidity is encountered even with careful selection. To minimize donor morbidity, groups considering initiating living donor programs should have expertise in hepatic resection and vena cava preservation using the "piggyback" technique during liver transplantation.     

Hepatic artery-portal vein fistula formation after percutaneous liver biopsy in a living liver donor

Percutaneous liver biopsy is a relatively safe method of assessing liver histology in living subjects. The current report depicts a case of arterioportal fistula in a living liver donor who underwent percutaneous liver biopsy as part of the routine transplant workup at our institution. The experience questions the utility of routine percutaneous liver biopsies as part of the living liver donor screening.     

Right lobe living donor liver transplantation.

BACKGROUND: The shortage of livers for transplantation has prompted transplant centers to seek alternatives to conventional cadaveric liver transplantation. Left lateral segmentectomy from living donors has proven to be a safe operation for the donor with excellent results in the pediatric population. Left lobectomy, conceived to supply more tissue, still provides insufficient liver mass for an average size adult patient. Right lobectomy could supply a graft of adequate size. METHODS: Donors were considered only after recipients were listed according to United Network for Organ Sharing (UNOS) criteria. Donor evaluation included liver biopsy, magnetic resonance imaging, and celiac and mesenteric angiography. The donor operation consisted of a right lobectomy uniformly performed throughout the series as described herein. RESULTS: Twenty-five right lobe living donor liver transplants were performed between adults, with no significant complications in donors. Recipient and graft survival was 88%, with three recipient deaths secondary to uncontrolled sepsis in patients at high risk for liver transplant; all three had functioning grafts. CONCLUSIONS: Right lobe living donor liver transplantation poses challenges that require a meticulous surgical technique to minimize morbidity in the recipient. Right lobectomies for living donation can be performed safely with minimal risk to both donor and recipient although providing adequate liver mass for an average size adult patient.     

成人右半肝活体肝移植21例分析

目的 探讨成人右半肝活体肝移植供受者处理的关键性技术问题。方法 回顾性分析2007年4月至2009年5月首都医科大学附属北京佑安医院肝胆外科完成21例成人右半肝活体肝移植的资料。 结果 供者术后无死亡,发生并发症23例次,按照Clavien系统分级：Ⅰ级15例次,Ⅱ级8例次。经积极非手术治疗后,所有供者均痊愈。受者术后发生胆道并发症7例,均经外科手术处理痊愈,术后1个月内死亡4例。移植物含肝中静脉4例,不含肝中静脉17例,两组受者1年存活率分别为75%与76%（χ2 = 1.000,P = 0.617）。 结论 右半肝活体肝移植是治疗终末期肝病尤其是各种原因导致的急性肝功能衰竭的重要手段。仔细术前评估,精细手术操作,合理地分配肝中静脉并保证移植物和残肝的功能性体积,术后密切监护、妥善处理并发症是供受者安全的重要保证。     

Recent Advance in Living Donor Liver Transplantation

Living donor liver transplantation (LDLT)has been performed in more than 2000 cases around the world. This procedure is considered to have certain advantages over cadaveric liver transplantation, because detailed preoperative evaluation of the donor liver is possible and superior graft quality is available. The indication has recently been widened to include adult patients. The results of LDLT have been reported to be very good. In this article,several considerations on LDLT,including living donor selection and application to adult patients, are discussed. Between June 1990 and March 2001, 143 patients underwent LDLT at Shinshu University Hospital. During this period, 160 patients were determined to be candidates for liver transplantation in our institution, and 185 candidates were evaluated as potential donors for these patients. Thirty-eight of 185 donor candidates were excluded for reasons including liver dysfunction and withdrawal of consent. The recipients included 60 adults, 50 (83%) of whom are currently alive. Taking into account the worldwide shortage of cadaveric organ donation,the importance of LDLT will probably never diminish. This procedure should be established on the basis of profound consideration of donor safety as well as accumulated expertise of hepatobiliary surgery.     

Preoperative imaging evaluation of potential living liver donors: reasons for exclusion from donation in adult living donor liver transplantation

Accurate pretransplant evaluation of a potential donor in living donor liver transplantation (LDLT) is essential in preventing postoperative liver failure and optimizing safety. The aim of this study was to investigate the reasons for exclusion from donation of potential donors in adult LDLT. From September 2003 to June 2006, 266 potential donors were evaluated for 215 recipients: 220 potential donors for 176 adult recipients; 46 for 39 pediatric recipients. Imaging modalities including Doppler ultrasound, computerized tomography (CT), and magnetic resonance (MR) angiography provided vascular evaluation and MR cholangiopancreatography to evaluate biliary anatomy. Calculation of liver volume and assessment of steatosis were performed by enhanced and nonenhanced CT, respectively. In the adult group, only 83 (37.7%) potential donors were considered suitable for LDLT. Of the 137 unsuitable potential donors, 36 (26.2%) candidates were canceled because of recipient issues that included death of 15 recipients (10.9%), main portal vein thrombosis (8%), recipient condition beyond surgery (5%), and no indication for liver transplantation due to disease improvement (2%). The remaining 101 (73.8%) candidates who were excluded included steatosis (27.7%), an inadequate remnant volume (57.4%), small-for-size graft (8.9%), HLA-homozygous donor leading to one-way donor-recipient HLA match (3%), psychosocial problems (4%), as well as variations of hepatic artery (4%), portal vein (1%), and biliary system anatomy (5%). Anatomic considerations were not the main reason for exclusion of potential donors. An inadequate remnant liver volume (<30%) is the crucial point for the adult LDLT decision.     

Computer-assisted planning in living donor liver operation

INTRODUCTION: The appropriate recipient/donor match is a prerequisite for successful living donor liver transplantation (LDLT). A precise knowledge of the liver anatomy and the functional liver volume plays a key role in allocating live liver donor candidates. With the new software HepaVision, we obtained information on liver mapping by means of virtual 3-dimensional non-invasive imaging reconstructions and were able to perform a virtual simulation of the liver transsection. Aim of our study was to investigate, whether this new computer technology is advantageous in surgery planning for LDLT. METHODS: From January 2002 until December 2004 355 liver transplantations were performed in our department, of which 36 were LDLT. According to our evaluation protocol 135 potential donors (63 male, 72 female) between 18 to 59 years received preoperatively an all-in-one CT. The acquired data sets were further analysed with the software HepaVision (MeVis, Germany). RESULTS: Of the 135 evaluated donors, we excluded 99 (73 %) from donation based on the HepaVision-data. Reason for exclusion was an inadequate liver volume (70.8 %) or a risk related anatomical anomaly (2.2 %). In the remaining 36 cases a successful graft donation was possible. There were no postoperative complications in the donors and recipients, directly related to a misjudgment of the anatomy or miscalculation of the liver volume. CONCLUSION: The systematic use of HepaVision for surgery planning proved to be indispensable for proper donor selection. A virtual simulation of the liver transsection on 3D-model additionally increased the safety of the operation, consequently decreasing the risk for the donor.     

Selection of liver-transplant candidates for adult-to-adult living donor liver transplantation as the only surgical option for end-stage liver disease.

The selection of living donor liver transplantation (LDLT) recipients in regions where deceased donor liver transplantation (DDLT) is rarely performed might be different from that in other centers at which LDLT is an alternative option to DDLT. Records of adult (age > or = 18 yr) patients referred to our center were reviewed to analyze the selection process of LDLT candidates. Among the 533 LDLT candidates, 165 (31%) were rejected due to recipient issues. Advanced hepatocellular carcinoma (HCC) was the most common reason for rejection (n = 55). Among the remaining recipients, 120 patients (22%) were rejected due to donor issues. LDLT was eventually performed in 249 (47%) of the evaluated recipients. There are few options for candidates who are unable to find live donors in regions where DDLT is unrealistic. A more effective and precise approach to recipient and donor evaluation should be pursued.     

One hundred nine living donor liver transplants in adults and children: a single-center experience

OBJECTIVE: To summarize the evolution of a living donor liver transplant program and the authors' experience with 109 cases. SUMMARY BACKGROUND DATA: The authors' institution began to offer living donor liver transplants to children in 1993 and to adults in 1998. METHODS: Donors were healthy, ages 18 to 60 years, related or unrelated, and ABO-compatible (except in one case). Donor evaluation was thorough. Liver biopsy was performed for abnormal lipid profiles or a history of significant alcohol use, a body mass index more than 28, or suspected steatosis. Imaging studies included angiography, computed tomography, endoscopic retrograde cholangiopancreatography, and magnetic resonance imaging. Recipient evaluation and management were the same as for cadaveric transplant. RESULTS: After ABO screening, 136 potential donors were evaluated for 113 recipients; 23 donors withdrew for medical or personal reasons. Four donor surgeries were aborted; 109 transplants were performed. Fifty children (18 years or younger) received 47 left lateral segments and 3 left lobes; 59 adults received 50 right lobes and 9 left lobes. The average donor hospital stay was 6 days. Two donors each required one unit of banked blood. Right lobe donors had three bile leaks from the cut surface of the liver; all resolved. Another right lobe donor had prolonged hyperbilirubinemia. Three donors had small bowel obstructions; two required operation. All donors are alive and well. The most common indications for transplant were biliary atresia in children (56%) and hepatitis C in adults (40%); 35.6% of adults had hepatocellular carcinoma. Biliary reconstructions in all children and 44 adults were with a Roux-en-Y hepaticojejunostomy; 15 adults had duct-to-duct anastomoses. The incidence of major vascular complications was 12% in children and 11.8% in adult recipients. Children had three bile leaks (6%) and six (12%) biliary strictures. Adult patients had 14 (23.7%) bile leaks and 4 (6.8%) biliary strictures. Patient and graft survival rates were 87.6% and 81%, respectively, at 1 year and 75.1% and 69.6% at 5 years. In children, patient and graft survival rates were 89.9% and 85.8%, respectively, at 1 year and 80.9% and 78% at 5 years. In adults, patient and graft survival rates were 85.6% and 77%, respectively, at 1 year. CONCLUSION: Living donor liver transplantation has become an important option for our patients and has dramatically changed our approach to patients with liver failure. The donor surgery is safe and can be done with minimal complications. We expect that living donor liver transplants will represent more than 50% of our transplants within 3 years.     

Living donor liver transplantation for noncirrhotic inheritable metabolic liver diseases: impact of the use of heterozygous donors

BACKGROUND: In living donor liver transplantation (LDLT), the liver donor is almost always a blood relative; therefore, the donor is sometimes a heterozygous carrier of inheritable diseases. The use of such carriers as donors has not been validated. The aim of the present study was to evaluate the outcome of LDLT for noncirrhotic inheritable metabolic liver disease (NCIMLD) to clarify the effects of using a heterozygous carrier as a donor. METHODS: Between June 1990 and December 2003, 21 patients with NCIMLD underwent LDLT at our institution. The indications for LDLT included type II citrullinemia (n = 7), ornithine transcarbamylase deficiency (n = 6), propionic acidemia (n = 3), Crigler-Najjar syndrome type I (n = 2), methylmalonic acidemia (n = 2), and familial amyloid polyneuropathy (n = 1). Of these 21 recipients, six underwent auxiliary partial orthotopic liver transplantation. RESULTS: The cumulative survival rate of the recipients was 85.7% at both 1 and 5 years after operation. All surviving recipients are currently doing well without sequelae of the original diseases, including neurological impairments or physical growth retardation. Twelve of the 21 donors were considered to be heterozygous carriers based on the modes of inheritance of the recipients' diseases and preoperative donor medical examinations. All donors were uneventfully discharged from the hospital and have been doing well since discharge. No mortality or morbidity related to the use of heterozygous donors was observed in donors or recipients. CONCLUSIONS: Our results suggest that the use of heterozygous donors in LDLT for NCIMLD has no negative impact on either donors or recipients, although some issues remain unsolved and should be evaluated in further studies.     

成人活体肝移植71例报道

目的 探讨开展成人活体肝移植初始阶段如何确保供、受者安全.方法 回顾性分析我院2007年4月至11月71例成人活体肝移植供、受者临床资料,分析评估方案、手术策略和并发症.结果 切取供者右半肝68例,其中带肝中静脉4例;切取带肝中静脉左半肝3例.术后出现并发症2例,1例胆漏,1例腹腔内出血,无供者死亡.受者外科并发症18例,其中胆道并发症12例,血管并发症3例,小肝综合征3例;病死率为10%(7/71).结论 在开展成人活体肝移植的初始阶段,采用严格的供、受者评估、选择合理的手术方式和术后处理可以最大程度地保证供、受者安全.     

Live donor liver transplantation in adults

Live donor liver transplantation (LDLT) was initiated in 1988 for children recipients. Its application to adult recipients was limited by graft size until the first right liver LDLT was performed in Hong Kong in 1996. Since then, right liver graft has become the major graft type. Despite rapid adoption of LDLT by many centers, many controversies on donor selection, indications, techniques, and ethics exist. With the recent known 11 donor deaths around the world, transplant surgeons are even more cautious than the past in the evaluation and selection of donors. The need for routine liver biopsy in donor evaluation is arguable but more and more centers opt for a policy of liberal liver biopsy. Donation of the middle hepatic vein (MHV) in the right liver graft was considered unsafe but now data indicate that the outcome of donors with or without MHV donation is about equal. Right liver LDLT has been shown to improve the overall survival rate of patients with chronic liver disease, acute or acute-on-chronic liver failure and hepatocellular carcinoma waiting for liver transplantation. The outcome of LDLT is equivalent to deceased donor liver transplantation despite a smaller graft size and higher technical complexity.     

Trends in adult-to-adult living donor liver transplant organ donation: the Johns Hopkins experience

Adult-to-adult living donor liver transplantation is an increasingly important option for 17000 patients awaiting liver transplantation in the United States. However, adult-to-adult living donor liver transplantation volumes peaked in 2001 (N = 518), and have gradually fallen in 2002 (N = 362), 2003 (N = 321), and 2004 (N = 323). Recent concerns about donor safety and ethical considerations have made careful analysis of donor availability and selection criteria critically important. We conducted a retrospective review of our active liver transplant recipient registry (N = 251) and compared it to our living donor registry (N = 231), which included all potential living donors before the selection process. Fifteen percent of recipients accounted for the majority (53%) of donor evaluations, whereas 42% of recipients did not have even a single donor evaluation. Recipient diagnosis appears to have a significant impact on donor availability, with donors rarely evaluated for patients with alcoholic cirrhosis. Careful and stringent selection criteria rule out 67% of potential donors.     

多层螺旋CT在活体肾移植供肾评估及取肾手术方式选择中的应用

目的 评价多层螺旋CT(MSCT)在活体肾移植供肾及取肾手术方式选择中的应用价值.方法 90例活体肾移植供者接受了MSCT平扫及动脉期、静脉期和排泄期的扫描.采用最大密度投影和容积再现技术进行血管成像,所有MSCT图像均由2位影像医师盲法下独立进行分析和评价.根据重建的CT图像,影像医师与肾移植医师进行讨论,选择左肾还是右肾作为供肾,并确定采用腹腔镜下取肾手术或是开放式取肾手术.结果 90例供者中,78例接受了左肾切取术,其中71例左侧供肾无明显变异者接受了常规腹腔镜下取肾手术,7例两侧肾脏均存在如副肾动脉、多支肾静脉,或者肾静脉位于腹主动脉后方等较明显变异,接受了左肾开放式取肾手术;12例因左肾存在明显变异,接受了右肾切取术,均行手辅助腹腔镜下取肾手术.所有术中记录的肾血管及集尿系统的解剖结构与术前MSCT评价一致,其准确率为100％.2位影像医师在评价肾动脉、肾静脉和集尿系统中显示了很好的一致性.90例取肾手术全部成功,移植术后受者未发生肾静脉血栓形成等血管并发症.结论 MSCT作为活体肾移植供者术前评价“一站式”检查方法,可以为供肾和取肾手术方式的选择提供准确、有价值的信息.     

Quality of life and psychiatric complications after adult living donor liver transplantation.

We investigated the psychosocial effects of a right hepatectomy on donors for adult living donor liver transplantation (ALDLT). Questionnaires were sent to 66 actual donors, who had undergone ALDLT between August 1998 and September 2003, as well as to 139 potential donors, who had been examined as possible candidates for ALDLT; the latter had been excluded and had not undergone surgery. All actual donors reported full recovery within an average period of 14.41 (standard deviation = 8.86) weeks; all had returned to their preoperative employment. In preparation for ALDLT, they had received significantly more support from their families in the decision-making process than the potential donors had (t = 2.02; degree of freedom = 79; P = 0.047); they also felt better informed about donation than the potential donors (t = 2.04; df = 64; P = 0.045). Psychiatric problems occurred in 6 (14%) female donors in the perioperative period, mostly in connection with unrealistic outcome expectations. Donors with severe postoperative complications (n = 3) demonstrated higher scores of psychiatric symptoms (chi-square = 6.39; df = 2; P = 0.041). When we compared potential and actual donors, a significant difference in emotional quality of life was not demonstrated (t = 0.41; df = 76; P = 0.684), and it corresponded to that of the normative sample. For donors, perceived emotional quality of life did not depend on the course of recovery of the recipients. Six to 9 months after donation, potential donors reported a significantly higher physical quality of life than actual donors (t = 2.20; df = 56; P = 0.032). In conclusion, female donors, donors with their own major complications, or donors with unrealistic outcome expectations should be provided with adequate psychosocial care. With regard to the psychosocial outcome, ALDLT is a safe intervention for the donor.