Impact of donor age on survival and fibrosis progression in patients with hepatitis C undergoing liver transplantation using HCV+ allografts.

Studies have suggested that the use of hepatitis C virus (HCV)-positive (HCV+) donor allografts has no impact on survival. However, no studies have examined the effect that HCV+ donor histology has upon recipient and graft survival. We evaluated the clinical outcome and impact of histological features in HCV patients transplanted using HCV+ livers. We reviewed all patients transplanted for HCV at our institution from 1988 to 2004; 39 received HCV+ allografts and 580 received HCV-negative (HCV-) allografts. Survival curves compared graft and patient survival. Each HCV+ allograft was stringently matched to a control of HCV- graft recipients. No significant difference in survival was noted between recipients of HCV+ livers and controls. Patients receiving HCV+ allografts from older donors (age > or =50 yr) had higher rates of graft failure (hazard ratio, 2.74) and death rates (hazard ratio, 2.63) compared to HCV- allograft recipients receiving similarly-aged older donor livers. Matched case-control analysis revealed that recipients of HCV+ allografts had more severe fibrosis post-liver transplantation than recipients of HCV- livers (P = 0.008). More advanced fibrosis was observed in HCV+ grafts from older donors compared to HCV+ grafts from younger donors (P = 0.012). In conclusion, recipients of HCV+ grafts from older donors have higher rates of death and graft failure, and develop more extensive fibrosis than HCV- graft recipients from older donors. Recipients of HCV+ grafts, regardless of donor age, develop more advanced liver fibrosis than recipients of HCV- grafts.     

Impact of Donor Age on the Results of Liver Transplantation in Hepatitis C Virus-Positive Recipients

Objective

Hepatitis C virus (HCV)-cirrhosis is the most frequent indication for orthotopic liver transplantation (OLT) among adults in most European and American transplant centers. The aim of this study was to analyze the impact of donor age on graft survival among HCV-positive cirrhotic transplant patients.

Materials and Methods

We performed an observational, retrospective study between March 1997 and December 2004, analyzing 340 liver transplantations. The patients were divided into 4 groups, considering whether the HCV infection was the indication for OLT and whether the age of the donor was older or younger than 48 years: group 1 (HCV, <48 years); group 2 (HCV, >48 years); group 3 (non-HCV, <48 years); and group 4 (non-HCV, >48 years).

Results

A univariate analysis showed that posttransplantation graft survival was clearly influenced by recipient HCV serologic status (P = .018). However, no graft survival differences were found when the analysis variable was age (>48 or <48 years). When both variables were studied, a positive HCV serology did not modify graft survival when the donor age was <48 years (P = .32), but had a statistically significant negative impact when the age was >48 years (P = .02).

Conclusions

The use of older donors for HCV recipients resulted in worse graft and patient survivals in our study. This difference in survival was not present in non-HCV recipients or when grafts for HCV recipients were procured from younger donors. Donor age <30 years was a protective factor for graft survival among HCV recipients.     

Liver transplantation for hepatitis C from donation after cardiac death donors: an analysis of OPTN/UNOS data

Donation after cardiac death (DCD) liver transplantation is increasing largely because of a shortage of organs. However, there are almost no data that have specifically assessed the impact of using DCD livers for HCV patients. We retrospectively studied adult primary DCD liver transplantation (630 HCV, 1164 non-HCV) and 54 129 donation after brain death (DBD) liver transplantation between 2002 and 2009 using the UNOS/OPTN database. With donation after brain death (DBD) livers, HCV recipients had significantly inferior graft survival compared to non-HCV recipients (p < 0.0001). Contrary to DBD donors, DCD livers used in HCV patients showed no difference in graft survival compared to non-HCV patients (p = 0.5170). Cox models showed DCD livers and HCV disease had poorer graft survival (HR = 1.80 and 1.28, p < 0.0001, respectively). However, the hazard ratio of DCD and HCV interaction was 0.80 (p = 0.02) and these results suggest that DCD livers on HCV disease do not fare worse than DCD livers on non-HCV disease. The graft survival of recent years (2006-2009) was significantly better than that in former years (2002-2005) (p = 0.0482). In conclusion, DCD liver transplantation for HCV disease showed satisfactory outcomes. DCD liver transplantation can be valuable option for HCV related end-stage liver disease.     

Older donor livers show early severe histological activity, fibrosis, and graft failure after liver transplantation for hepatitis C

BACKGROUND: In hepatitis C virus (HCV)-positive liver transplant recipients, infection of the allograft and recurrent liver disease are important problems. Increased donor age has emerged as an important variable affecting patient and graft survival; however, specific age cutoffs and risk ratios for poor histologic outcomes and graft survival are not clear. METHODS: A longitudinal database of all HCV-positive patients transplanted at our center during an 11-year period was used to identify 111 patients who received 124 liver transplants. Graft survival and histological endpoints (severe activity and fibrosis) of HCV infection in the allografts were compared as a function of donor age at transplantation. RESULTS: By Kaplan-Meier analyses, older allografts showed earlier failure and decreased time to severe histological activity and fibrosis as compared with allografts from younger donors. By Cox proportional hazards analysis, older allografts were at greater risk for all severe histologic features and decreased graft survival as compared with younger allografts (P< or =0.02 for all outcomes). Analysis of donor age as a dichotomous variable showed that donors greater than 60 yr were at high risk for deleterious histologic outcomes and graft failure. An age cutoff of 60 yr showed a sensitivity of 94% and specificity of 67% for worse graft survival by receiver operating characteristics curve. CONCLUSIONS: Advanced donor age is associated with more aggressive recurrent HCV and early allograft failure in HCV-positive liver transplant recipients. Consideration of donor age is important for decisions regarding patient selection, antiviral therapy, and organ allocation.     

Using elderly donors in liver transplantation

AIM: Elderly donors are half of the grafts available in our center for liver transplantation. We retrospectively investigated their characteristics, outcomes, and variables related to graft failure. MATERIAL AND METHODS: From 1996 to 2003, 540 (46.4%) of 1163 donors were older than 60 years of age and 236 grafts (43.4%) were transplanted, whereas the others were refused. The clinical investigated variables were examined among this cohort. RESULTS: The median age of donors increased from 37 to 62 years. Donors older than 60 years of age were more often refused than younger ones (66% vs 44%); HCV-positive (9.9% vs 5.4%); HbcAb-positive (18.6% vs 12.6%), and steatotic (35.7% vs 13.9%; P < .01). Among donors older than 60 years, the main parameter to refuse the graft was the grade of steatosis. The variables related to the graft loss from donors older than 60 years were as follows: model for end stage liver disease (MELD) recipient >15 (65% vs 39%), cold ischemia time >10 hours (25% vs 13%), high blood losses (3987 +/- 4764 vs 2664 +/- 2043 mL), and year of liver transplantation after 2000 (26% vs 46%; P < .01). The 1-, 3-, and 5-year graft survival rates were significantly lower among donors older than 60 years than other donors: 75%, 65%, and 62% versus 85%, 83%, and 78%, respectively (P < .001). CONCLUSION: Donors older than 60 years of age provided liver transplants to half of our recipients. The graft survival rate of these organs was lower than that of younger donors and to improve it the other risk variables for poor outcome should be reduced, including MELD score of the recipient and prolonged cold ischemia time.     

Impact of donor age and year of transplantation on graft and patient survival following liver transplantation for hepatitis C virus

BACKGROUND: Hepatitis C virus (HCV) infection has become the most common indication for liver transplantation (LT). Graft and patient survival are adversely affected by recurrent infection of the graft. Recent publications have described an inferior outcome for recently transplanted HCV patients and have highlighted the impact of advancing donor age on severity of recurrent HCV. The donor age at which a measurable impact on graft and patient outcome can be observed has not clearly been defined. In addition, the impact of donor age on graft and patient survival for non-HCV patients needs to be examined. METHODS: We have examined a large European liver transplant database to define the impact of transplantation date and donor age on graft and patient survival for HCV patients (n = 4,736) and the impact for a comparison group of transplanted alcoholic liver disease patients (ALD, n = 5,406). RESULTS: For the entire cohorts, graft and patient survival of HCV patients was inferior to ALD patients. Since 1987, there has been a steady and ongoing improvement in the outcome of transplanted ALD patients, an improvement not observed for HCV patients. Every year since 1989, there has been an increase in liver donor age. Graft and patient survival for both ALD and HCV cohorts was adversely affected by advancing donor age. Comparison of graft and patient survival for HCV and ALD cohorts was made according to donor age (donor age subgrouped <20, 20-30, 30-40, 40-50, 50-60 and >60 years of age). For donors younger than 40 years of age, HCV and ALD recipient graft and patient survival are not significantly different. For donors older than 40, HCV recipient graft survival is inferior to ALD graft survival, an inferiority that increases for each advancing decade of donor age. For donors older than 50 years, HCV recipient patient survival is inferior to ALD patient survival, an inferiority that increases when the donor age is greater than 60 years. CONCLUSION: The results of liver transplantation for European HCV patients is inferior to a comparison group of ALD patients, and have not improved during the past 15 years. Liver donor age has increased significantly during that period. Advancing donor age has an adverse influence on graft and patient survival for ALD and HCV patients, but a significantly greater impact is observed for HCV patients when the donor is older than 40 years.     

Liver transplantation from anti-hepatitis C virus-positive donors: our experience

Background

Hepatitis C (HCV) is among the most common causes of end-stage liver disease worldwide. The donor shortage leads us to consider alternative organ sources such as HCV-positive donors. The outcomes of these transplants must be evaluated thoroughly since there is universal recurrence of disease among HCV-positive liver transplant recipients.

Methods

From January 2005 to April 2011, we performed 143 liver transplants (OLT) to treat end-stage liver disease secondary to HCV infection. Thirteen patients (9,1%) received livers from HCV-positive donors. A control group consisted of 130 HCV-positive patients who underwent OLT during the same period with organs from HCV-negative donors. Donor HCV status was assessed by 2 tests: HCV antibodies and viral load. Not only recipient and graft survivals were analyzed, but also frequency, timing and severity of hepatitis recurrence.

Results

Among 143 transplants performed in HCV-positive recipients during a 6-year period from January 1, 2005, to April 30, 2011, 9.1% of patients received an organ from an anti-HCV-positive donor, 72.7% of whom showed a negative viral load. The vast majority (80%) of our patients suffered hepatitis during their follow-up, 22.4% of which were severe cases.

Conclusions

No significant difference in patient or graft survival was observed between the 2 groups. A high percentage of grafts with initial positive serology for HCV showed no viral replication. Grafts from HCV-positive donors can be considered to be a safe, effective source for liver donation.     

Marginal grafts: finding the correct treatment for fatty livers

The influence of steatosis on the outcome of orthotopic liver transplantation (OLT) was evaluated in 860 liver transplantations carried out in 784 patients from October 1990 to August 2001. Donor variables considered were: age, hepatic enzymes, bilirubin, total and warm ischemia times, macrovesicular and microvesicular steatosis. Recipient variables considered were: age, UNOS status, Child-Pugh score and indication for OLT. Patient and graft survival were the main outcome indicators. Macrovesicular steatosis affecting 15% or more of the hepatocytes was the only variable independently associated with shorter patient and graft survival ( P=0.0012 and 0.0028). A significantly worse prognosis was to be expected if >15% macrovesicular steatosis was associated with a total ischemia time >10 h ( P=0.048), or donor age >65 years ( P=0.016) or with HCV-positive recipients ( P=0.0014). From our study we can conclude that macrovesicular steatosis involving 15% or more of the hepatocytes identifies marginal livers. The risk of graft non-function or patient loss after OLT rises if macrovesicular steatosis >15% is associated with long ischemia time, high donor age, or HCV positivity in recipients.     

Short- and Long-Term Outcomes with the Use of Kidneys and Livers Donated after Cardiac Death

The shortage of deceased donor kidneys and livers for transplantation has prompted the use of organs from donors deceased after cardiac death (DCD). We used the UNOS database to examine patient and graft survival following transplantation of DCD organs compared to those following grafts from donors deceased after brain death (DBD; for livers, grafts from donors < 60 years old were labeled '< 60 yrs'). Of 44035 deceased donor kidney transplant recipients, 1177 (3%) received a DCD kidney. There was no difference in patient or graft survival at 5 years (DCD vs. DBD: 81.3% vs. 80.8% and 66.9% vs. 66.5%; p = 0.70 and p = 0.52 respectively). Of 24688-deceased donor liver transplant recipients, 345 (1.4%) were from DCD donors and 20289 (82%) were from '< 60 yrs' DBD donors. Three-year patient and graft survival were inferior in the DCD group (DCD vs. '< 60 yrs' DBD: 77% vs. 80% and 65% vs. 75%; p = 0.016 and p < 0.0001 respectively) but were comparable to current alternatives, '>/= 60 yrs' DBD livers (donor age >/= 60) and split livers. DCD livers are a reasonable option when death is imminent. Our study demonstrates good outcomes using DCD kidneys and livers and encourages their use.     

Liver Transplantation from Donors Aged 80 Years and Over: Pushing the Limit

Older donors are a growing part of the total donor pool but no definite consensus exists on the limit of age for their acceptance. From November 1998 to January 2003, in a retrospective case-control multicenter study, we compared the outcome of 30 orthotopic liver transplantations (OLTs) with octogenarian donors and of 60 chronologically correlated OLTs performed with donors <40 years. The percentage of refusal was greater among older than younger donors (48.2 vs. 14.3%; p < 0.001). Cold ischemia was significantly shorter in the older than younger groups. Recipients with hepatocarcinoma and older age received octogenarian grafts more frequently. No differences were seen in post-operative complications and 6-month graft and patient survival. However, long-term survival was lower in patients transplanted with octogenarian donors (p = 0.04). Interestingly, the mortality related to hepatitis C recurrence was greater in patients with octogenarian donors. Accordingly, the long-term survival of HCV-positive patients who received older grafts was lower than those receiving younger grafts (p = 0.05). Octogenarian livers can be used safely but a careful donor evaluation and a short cold ischemia are required to prevent additional risk factors. However, hepatitis C recurrence is associated with a greater mortality in patients who received octogenarian grafts raising concerns whether to allocate these livers to HCV-positive recipients.     

Hepatitis C Positive Grafts may be used in Orthotopic Liver Transplantation: A Matched Analysis

Hepatitis C (HCV)-positive liver grafts have been increasingly used in patients with decompensated liver disease from HCV because of critical shortage of available organs. Fifty-nine recipients of HCV-positive grafts were matched to patients who received HCV-negative grafts. All recipients were transplanted for HCV liver disease. Matching variables were (1) status, (2) pre-transplant creatinine, (3) recipient age, (4) donor age, (5) warm ischemia time, and (6) year of transplantation. Both unmatched and matched analyses were performed on patient survival, graft survival, and time to HCV recurrence. There was no significant statistical difference in patient, graft, or HCV recurrence-free survival between recipients of HCV-positive and HCV-negative grafts with matched and unmatched analyses (p > 0.05). The 3-year estimates of HCV disease-free survival were 12% (+/- 9%) and 19% (+/- 7%) using HCV-positive and -negative grafts, respectively. The use of HCV-positive grafts in recipients with HCV does not appear to affect patient survival, graft survival, or HCV recurrence when compared with the use of HCV-negative grafts. Our results suggest that HCV-positive grafts can be used in a HCV liver transplant recipient.     

Transplantation of kidneys from HCV-positive donors: a safe strategy?

Hepatitis C Virus (HCV) infection is the most important cause of liver disease after renal transplantation (RT). The impact of HCV on patient and graft survival after RT remains controversial; however, the great majority of studies with large size and adequate follow-up have shown the detrimental impact of HCV on long-term patient and graft survival after RT. The use of kidneys from anti-HCV positive donors could help decrease the continuing disparity between the number of patients on the transplant waiting list and the number of patients receiving a transplant each year. Single-center experiences have suggested transplanting kidneys from anti-HCV positive donors only in anti-HCV positive dialysis patients. Such practice has not demonstrated any adverse effect on the short-term patient survival; the waiting times for RT were shortened. A better alternative seems to be a policy of transplanting kidneys from anti-HCV positive donors only in HCV RNA positive recipients. This requires HCV RNA testing of all anti-HCV positive dialysis patients awaiting RT. Matching donors and recipients for HCV genotype has been suggested; however, the assessment of donor HCV genotype is currently hampered by time constraints. Recent evidence based on large data base demonstrated that RT recipients of HCV-positive donors are at independent increased risk of mortality; unadjusted 3-year patient survival was 85% versus 93% (P=0.01) in all recipients of donor HCV-positive and HCV-negative kidneys, respectively. This was observed in all recipient subgroups including elderly and HCV-positive recipients. In the near future, rapid nucleic acid testing (NAT) of donors and recipients will allow the assessment of the HCV viremic status in order to maximize organ use. With appropriate informed consent, use of a renal graft from an HCV positive donor may be offered to an HCV infected recipient. Additional studies are needed to clarify the link between donor HCV-positive kidneys and patient mortality.     

Liver transplantation from controlled non-heart-beating donors

BACKGROUND: The use of organs from non-heart-beating donors (NHBDs) has been proposed as one way to increase the donor pool. However, few centers have transplanted livers from NHBDs. We report here the results of 19 liver transplants from controlled NHBDs. METHODS: From January 1993 through August 1999, 364 liver transplantations were performed from heart-beating donors (HBDs) and 19 liver transplantations were performed from NHBDs. Donor and recipient characteristics, posttransplant complications, and patient and allograft survival were compared. RESULTS: No differences in hepatic artery, portal vein, or biliary complications were noted between the groups. However, the rate of primary nonfunction was higher in recipients of livers from NHBDs (10.5% vs. 1.3%; P = .04). No difference in patient survival was seen between recipients of NHBDs or HBDs (72.6% vs. 84.8%; P =.36); however, allograft survival was lower in recipients who received livers from NHBDs (53.8% vs. 80.9%; P =.007). CONCLUSIONS: Liver transplantation from controlled NHBDs results in similar patient survival and post-transplant complications. However, primary nonfunction was higher and allograft survival was less in recipients of livers from NHBDs. The results of liver transplantation from controlled NHBDs are encouraging and should continue to be cautiously pursued as one way to help alleviate the current shortage of donor livers.     

Use of elderly donors (> 60 years) for liver transplantation

BACKGROUND: As the demand for liver transplantation has become greater than the availability of donor livers, the criteria for donor selection or rejection are more important than ever before. In view of an increasing number of patients on the waiting list, some centres are expanding their donor pool by relaxing the criteria, such as by using organs from elderly (> 60 years) brainstem-dead donors. In this study, we reviewed our experience of using elderly brain-dead donor livers, investigating the potential prognostic factors of the donor, and analysing the influence of donor age on early graft function and graft survival. METHODS: We retrospectively evaluated 106 cadaveric donor liver transplantations in 98 patients. Seven patients (6.6%, 7 vs 106) received livers from donors older than 60 years. Pre-transplantation characteristics of donors and the outcome of recipients were evaluated. Donor prognostic factors were analysed using Cox univariate analysis and confirmed by a multivariate forward stepwise Cox model. Early graft function was compared between recipients of grafts from donors older and younger than 60 years. RESULTS: There were no primary non-functions or re-transplants in the group receiving elderly grafts. Early graft function was similar in patients with grafts from elderly and younger donors. Univariate analysis demonstrated that prognostic factors had no relationship with long-term recipient survival. The 3-month and 1-year cumulative graft survival rates were 100% and 82% in the elderly graft group and 84% and 83% in the younger graft group, respectively. Kaplan-Meier curves and the log-rank test indicated that there was no difference in graft and patient survival rates between the two groups. CONCLUSIONS: Old age is not a contraindication for liver donation. Liver grafts from donors older than 60 years can be used safely.     

Clinical outcomes of living donor liver transplantation for hepatitis C virus (HCV)-positive patients

BACKGROUND: Whether hepatitis C virus recurrence occurs earlier and with greater severity for living donor liver transplantation (LDLT) than for deceased donor liver transplantation (DDLT) has recently become a subject of debate. METHODS: We retrospectively evaluated clinical outcomes for a cohort of 91 HCV-positive patients who underwent LDLT at Kyoto University with a median follow-up period of 25 months. RESULTS: Overall 5-year patient survival for HCV patients was similar to that for non-HCV patients (n=209) who underwent right-lobe LDLT at our institute (69% vs. 71%). Survival rate of patients without HCC (n=34) tended to be better than that of patients with HCC (n=57) (82% vs. 60%, P=0.069). According to annual liver biopsy, rate of fibrosis progression to stage 2 or more (representing significant fibrosis) was 39% at 2 years after LDLT. Univariate analysis showed that female recipient and male donor represented significant risk factors for significant fibrosis. Progression to severe recurrence (defined as the presence of liver cirrhosis (F4) in a liver biopsy and/or the development of clinical decompensation) was observed in five patients. CONCLUSIONS: Postoperative patient survival was similar for HCV-positive and -negative recipients in our adult LDLT series. Rates of progression to severe disease due to HCV recurrence seemed comparable between our LDLT recipients and DDLT recipients described in the literature. Although longer-term follow-up is required, our results suggest that LDLT can produce acceptable outcomes also for patients suffering from HCV-related cirrhosis.     

Liver transplantation using donors older than 80 years: a single-center experience

AIM: The shortage of organs for orthotopic liver transplantation (OLT) has forced transplantation centers to expand the donor pool by using donors traditionally labeled as "extended criteria donors." One such example is OLT using a donor with advanced age. MATERIALS AND METHODS: We retrospectively evaluated 10 patients who received a liver graft from cadaveric donors older than 80 years. We analyzed pretransplantation donor and recipient characteristics, as well as the evolution of the recipients. RESULTS: All 10 donors were older than 80 years (median age, 83.5; range, 80-93). No steatosis (>30%) was accepted in the older donor group. Medium follow-up was 19.5 months. The most frequent cause for OLT was hepatitis C virus (HCV) cirrhosis (8/10 patients). We had 1 case of primary nonfunction, 1 patient died immediately after surgery because of extrahepatic complications (cardiac arrest), and 2 other patients had a severe HCV recurrence and died after 1 and 2 years from OLT, respectively. Five patients had HCV recurrence and biliary complications were present in 60% of the patients. No cases of acute or chronic rejection were described. Overall survival rates after 1 and 3 years were 80% and 40%, respectively. CONCLUSIONS: Old donor age is not an absolute contraindication to OLT. Liver grafts from donors older than 80 years can be used knowing that there is a high risk of postoperative complications. Furthermore, the increased risk of developing severe HCV recurrence, related to older donor age, suggests that such livers should be used in HCV-negative recipients.     

The outcome of liver grafts procured from hepatitis C-positive donors

BACKGROUND: The growing prevalence of hepatitis C virus (HCV) infection in the general population has resulted in an increased frequency of potential organ donors that carry the virus. The survival of grafts from HCV+ donors has not been studied in detail. METHODS: Two study populations were examined retrospectively to assess the survival of liver grafts procured from HCV+ donors. First, we evaluated the survival of all 13 HCV+ and 103 HCV- grafts that were transplanted at our institution to HCV+ recipients from January 1, 1995 to December 31, 1999. In parallel, we analyzed a subset of the United Network for Organ Sharing (UNOS) liver transplant database from the same 5-year time period that was comprised of 14,195 adult patients for whom donor and recipient HCV serologies were known. Kaplan-Meier graft survival for both patient populations was calculated based on donor and recipient HCV serologic status. A Cox proportional hazards analysis was performed on UNOS data to identify variables independently predicting graft survival. RESULTS: For transplants performed at our institution, we found no statistically significant difference in the Kaplan-Meier graft survival of HCV+ and HCV- grafts transplanted to HCV+ recipients (P=0.68). The incidence of biopsy-proven, recurrent HCV posttransplant was similar in recipients receiving either HCV+ or HCV- grafts (4/13 vs. 18/103, chi-square P=0.211). Analysis of UNOS data revealed that the survival of HCV+ grafts in HCV+ recipients was equivalent to the survival of HCV- grafts in HCV+ recipients. Unexpectedly, the survival of grafts in HCV+ recipients in general was significantly inferior to that of grafts in HCV- recipients. Multivariate analysis of all patients found recipient but not donor HCV status to be independently predictive of graft survival. CONCLUSIONS: Analysis of data from a single center and the national UNOS database suggests that transplantation of liver allografts from HCV+ donors to HCV+ recipients results in graft survival comparable to HCV- grafts transplanted to HCV+ recipients. In contrast, recipient HCV positivity is an independent predictor of graft failure compared with patients transplanted for other causes of liver disease.     

Outcomes of adult-to-adult living donor liver transplantation: a single institution's experience with 335 consecutive cases

OBJECTIVE: To determine outcomes for both donors and recipients of adult-to-adult living donor liver transplantation (AALDLT) and independent factors impacting those outcomes. SUMMARY BACKGROUND DATA: Deceased donors for organ transplantation remain extremely rare, making living donor liver transplantation (LDLT) practically the sole therapeutic modality for patients with end-stage liver disease in Japan. METHODS: Retrospective analysis of initial LDLT for 335 consecutive adult (>or=18 years) patients performed between November 1994 and December 2003. RESULTS:: Of the 335 recipients, 275 received right-liver grafts and the remaining 60 recipients received non-right-liver grafts. Three of the 335 liver grafts were domino-splitting livers. Sixty of the 332 donors other than the domino-donors showed major postoperative complications. Multivariate analysis indicated that accumulation of case experience significantly and advantageously affected the surgical outcomes of these living liver donors, and right-liver donation and prolonged donor operation time were shown to be independent risk factors of major complications in the donors. Post-transplant patient and graft survival estimates were 73.1% and 72.5% at 1 year, 67.7% and 66.3% at 4 years, and 64.7% and 61.9% at 7 years, respectively. Obvious pretransplant encephalopathy, a higher (>or=31) modified Model for End-stage Liver Disease score (including points for persistent ascites and low serum sodium) and higher donor age (>or=50 years) were indicated as independent factors predictive of graft failure (graft loss or death) in the multivariate analysis. CONCLUSIONS: Graft type and degree of experience exerted a significant impact on the surgical outcomes of AALDLT donors but did not significantly affect the survival outcomes of AALDLT recipients. Better pretransplant conditions and younger age (<50 years) among the living donors appeared to be advantageous in terms of gaining better survival outcomes of patients undergoing AALDLT.     

Influence of donor histology on outcome in patients undergoing transplantation for hepatitis C

BACKGROUND: Risk factors for graft loss and recipient death in liver transplantation for hepatitis C virus (HCV) have been extensively investigated. Donor age was defined as one of the most important predictors of outcome in these patients; however, the mechanism leading to more severe recurrent hepatitis has not yet been investigated. METHOD: In a retrospective analysis, histological findings of 79 donor liver grafts were assessed according to criteria inflammation, fibrosis, fatty degeneration, and necrosis. These findings were correlated with the histological and clinical course of HCV-positive liver graft recipients. RESULTS: The overall 1-, 5- and 10-year graft survival figures were 85%, 77%, and 60%, respectively. We could not identify any correlation between outcome, fat content, and necrosis in the donor liver. However, stage 3 and 4 fibrosis 1 year after liver transplantation was significantly increased in the group of patients receiving a graft from a donor with portal inflammation (P<0.05). Additionally, the occurrence of intrahepatic inflammation was significantly increased in older donors (P<0.05) and donors with prolonged intensive care hospitalization (P<0.05). CONCLUSION: A number of risk factors for detrimental outcome in HCV-positive patients after liver transplantation have been identified. In particular, older donor age significantly impaired outcome in recent analysis, but due to donor shortage it is not possible to provide young grafts for all HCV-positive patients. Our data show that donor histology is helpful in identifying patients with more severe recurrent hepatitis prior to transplantation, and that especially in older donors, prolonged intensive care hospitalization should be avoided.