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Kaltenmeier C, Liu H, Zhang X, Ganoza A, Crane A, Powers C, Gunabushanam V, Behari J, Molinari M. Survival after live donor versus deceased donor liver transplantation: propensity score-matched study. BJS Open 2024; 8:zrae058. [PMID: 38837956 PMCID: PMC11152206 DOI: 10.1093/bjsopen/zrae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 04/10/2024] [Accepted: 04/20/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND For individuals with advanced liver disease, equipoise in outcomes between live donor liver transplant (LDLT) and deceased donor liver transplant (DDLT) is uncertain. METHODS A retrospective cohort study was performed using data extracted from the Scientific Registry of Transplant Recipients. Adults who underwent first-time DDLT or LTDL in the United States between 2002 and 2020 were paired using propensity-score matching with 1:10 ratio without replacement. Patient and graft survival were compared using the model for end-stage liver disease (MELD) score for stratification. RESULTS After propensity-score matching, 31 522 DDLT and 3854 LDLT recipients were included. For recipients with MELD scores ≤15, LDLT was associated with superior patient survival (HR = 0.92; 95% c.i. 0.76 to 0.96; P = 0.013). No significant differences in patient survival were observed for MELD scores between 16 and 30. Conversely, for patients with MELD scores >30, LDLT was associated with higher mortality (HR 2.57; 95% c.i. 1.35 to 4.62; P = 0.003). Graft survival was comparable between the two groups for MELD ≤15 and for MELD between 21 and 30. However, for MELD between 16 and 20 (HR = 1.15; 95% c.i. 1.00 to 1.33; P = 0.04) and MELD > 30 (HR = 2.85; 95% c.i. 1.65 to 4.91; P = 0.001), graft survival was considerably shorter after LDLT. Regardless of MELD scores, re-transplantation rate within the first year was significantly higher after LDLT. CONCLUSIONS In this large propensity score-matched study using national data, comparable patient survival was found between LDLT and DDLT in recipients with MELD scores between 16 and 30. Conversely, for patients with MELD > 30, LDLT was associated with worse outcomes. These findings underscore the importance of transplant selection for patients with high MELD scores.
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Affiliation(s)
- Christof Kaltenmeier
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hao Liu
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Xingyu Zhang
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Armando Ganoza
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew Crane
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Colin Powers
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Vikraman Gunabushanam
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jaideep Behari
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michele Molinari
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Yun SO, Kim J, Rhu J, Choi GS, Joh JW. Benefit of living donor liver transplantation in graft survival for extremely high model for end-stage liver disease score ≥35. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1293-1303. [PMID: 37799067 DOI: 10.1002/jhbp.1376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/23/2023] [Accepted: 07/27/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND AND AIMS Living liver donation with high model for end-stage liver disease (MELD) score was discouraged despite organ shortage. This study aimed to compare graft survival between living donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT) recipients with extremely high-MELD (score of ≥35). METHODS Between 2008 and 2018, 359 patients who underwent liver transplantation with a MELD score ≥35 were enrolled. We compared graft survival between LDLT and DDLT after propensity score matching (PSM) and performed subgroup analysis according to donor type. RESULTS After PSM, there was no statistical difference in graft survival between the LDLT and DDLT groups (p = .466). Old age, acute on chronic liver failure, re-transplantation, preoperative intensive care unit stay and red blood cell (RBC) transfusion during the operation were risk factors for graft failure (p = .046, .005, .032, .015 and .001, respectively). Biliary complications were more common in the LDLT group (p = .021), while viral infection, postoperative uncontrolled ascites, and postoperative hemodialysis were more common in the DDLT group (p = .002, .018, and .027, respectively). In the LDLT group, acute chronic liver failure, intraoperative RBC transfusion, and early postoperative complications were risk factors for graft failure (p = .007, <.001, and .001, respectively). CONCLUSION Our study showed that LDLT is not inferior to DDLT in graft survival if appropriate risk evaluation is performed in cases of extremely high-MELD scores. This result will help overcome organ shortages in high-MELD liver transplantation.
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Affiliation(s)
- Sang Oh Yun
- Department of Surgery, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Dongdaemun-gu, Seoul, Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Gangnam-gu, Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Gangnam-gu, Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Gangnam-gu, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Gangnam-gu, Korea
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Kulkarni AV, Reddy R, Arab JP, Sharma M, Shaik S, Iyengar S, Kumar N, Sabreena, Gupta R, Premkumar GV, Menon BP, Reddy DN, Rao PN, Reddy KR. Early living donor liver transplantation for alcohol-associated hepatitis. Ann Hepatol 2023; 28:101098. [PMID: 37028597 DOI: 10.1016/j.aohep.2023.101098] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 01/15/2023] [Accepted: 03/02/2023] [Indexed: 04/09/2023]
Abstract
INTRODUCTION AND OBJECTIVES Lately, there has been a steady increase in early liver transplantation for alcohol-associated hepatitis (AAH). Although several studies have reported favorable outcomes with cadaveric early liver transplantation, the experiences with early living donor liver transplantation (eLDLT) are limited. The primary objective was to assess one-year survival in patients with AAH who underwent eLDLT. The secondary objectives were to describe the donor characteristics, assess the complications following eLDLT, and the rate of alcohol relapse. MATERIALS AND METHODS This single-center retrospective study was conducted at AIG Hospitals, Hyderabad, India, between April 1, 2020, and December 31, 2021. RESULTS Twenty-five patients underwent eLDLT. The mean time from abstinence to eLDLT was 92.4 ± 42.94 days. The mean model for end-stage liver disease and discriminant function score at eLDLT were 28.16 ± 2.89 and 104 ± 34.56, respectively. The mean graft-to-recipient weight ratio was 0.85 ± 0.12. Survival was 72% (95%CI, 50.61-88) after a median follow-up of 551 (23-932) days post-LT. Of the 18 women donors,11 were the wives of the recipient. Six of the nine infected recipients died: three of fungal sepsis, two of bacterial sepsis, and one of COVID-19. One patient developed hepatic artery thrombosis and died of early graft dysfunction. Twenty percent had alcohol relapse. CONCLUSIONS eLDLT is a reasonable treatment option for patients with AAH, with a survival of 72% in our experience. Infections early on post-LT accounted for mortality, and thus a high index of suspicion of infections and vigorous surveillance, in a condition prone to infections, are needed to improve outcomes.
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Affiliation(s)
| | - Raghuram Reddy
- Department of Liver Transplantation, AIG Hospitals, Hyderabad, India.
| | - Juan Pablo Arab
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Mithun Sharma
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Sameer Shaik
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Sowmya Iyengar
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Naveen Kumar
- Department of Psychiatry, AIG Hospitals, Hyderabad, India
| | - Sabreena
- Department of Psychiatry, AIG Hospitals, Hyderabad, India
| | - Rajesh Gupta
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | | | | | | | | | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, USA.
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Özbilgin M, Egeli T, Ağalar C, Özkardeşler S, Oğuz VA, Akarsu M, Sağol Ö, Ünek T, Karademir S, Astarcıoğlu I. Complications and Long-Term Outcomes in Adult Patients Undergoing Living Donor Liver Transplantation Because of Fulminant Hepatitis. Transplant Proc 2023; 55:1186-1192. [PMID: 37137763 DOI: 10.1016/j.transproceed.2023.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/05/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND The present study investigates the complications that may occur during long-term follow-up in patients aged 18 years and older undergoing living donor liver transplantation (LDLT) in our clinic because of fulminant hepatitis. METHODS The study included patients aged 18 years and older with a minimum survival of 6 months who underwent an LDLT between June 2000 and June 2017. The demographic data of the patients were evaluated in terms of late-term complications. RESULTS Of the 240 patients who met the study criteria, 8 (3.3%) underwent LDLT for fulminant hepatitis. The indication for transplantation in patients with fulminant hepatitis was cryptogenic liver hepatitis in 4 patients, acute hepatitis B infection in 2 patients, hemochromatosis in 1 patient, and toxic hepatitis in 1 patient. Of the 240 patients, 65 (27%) undergoing LDLT underwent a liver biopsy for suspected rejection because of an elevation in liver function test results during follow-up. Histopathologic scoring was carried out according to the Banff scoring system. A diagnosis of late acute rejection was made in only 1 of the 8 patients (12.5%) who underwent LDLT for fulminant hepatitis. CONCLUSION Patients with fulminant hepatitis must be prepared for an LDLT, if available, while waiting for a cadaveric donor. The results of the present study suggest that LDLTs in patients with fulminant hepatitis are safe, and the outcomes are acceptable in terms of survival and complications.
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Affiliation(s)
- Mücahit Özbilgin
- Department of General Surgery, Dokuz Eylül University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit, Izmir, Turkey.
| | - Tufan Egeli
- Department of General Surgery, Dokuz Eylül University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit, Izmir, Turkey
| | - Cihan Ağalar
- Department of General Surgery, Dokuz Eylül University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit, Izmir, Turkey
| | - Sevda Özkardeşler
- Department of Anesthesiology and Reanimation, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Vildan Avkan Oğuz
- Department of Infectious Diseases, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Mesut Akarsu
- Department of Gastroenterology, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Özgül Sağol
- Department of Pathology, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Tarkan Ünek
- Department of General Surgery, Dokuz Eylül University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit, Izmir, Turkey
| | - Sedat Karademir
- Department of General Surgery, Güven Hospital, Ankara, Turkey
| | - Ibrahim Astarcıoğlu
- Department of General Surgery, Memorial Bahçelievler Hospital, Istanbul, Turkey
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5
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Park CS, Yoon YI, Kim N, Hwang S, Ha TY, Jung DH, Song GW, Moon DB, Ahn CS, Park GC, Kim KH, Cho YP, Lee SG. Analysis of outcomes and renal recovery after adult living-donor liver transplantation among recipients with hepatorenal syndrome. Am J Transplant 2022; 22:2381-2391. [PMID: 35615988 DOI: 10.1111/ajt.17105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 01/25/2023]
Abstract
When timely access to deceased-donor livers is not feasible, living-donor liver transplantation (LDLT) is an attractive option for patients with hepatorenal syndrome (HRS). This study's primary objective was to describe outcomes after LDLT among HRS recipients, and the secondary objective was to determine predictors of poor renal recovery after LDLT. This single-center, retrospective study included 2185 LDLT recipients divided into HRS (n = 126, 5.8%) and non-HRS (n = 2059, 94.2%) groups. The study outcomes were survival and post-LT renal recovery. The HRS group had a higher death rate than the non-HRS group (17.5% vs. 8.6%, p < 0.001). In the HRS group, post-LT renal recovery occurred in 69.0%, and the death rate was significantly lower in association with HRS recovery compared with non-recovery (5.7% vs. 43.6%, p < 0.001). Multivariable analysis indicated that post-LT sepsis (p < 0.001) and non-recovery of HRS (p < 0.001) were independent negative prognostic factors for survival. Diabetes mellitus (p = 0.01), pre-LT peak serum creatinine ≥3.2 mg/dl (p = 0.002), time interval from HRS diagnosis to LDLT ≥38 days (p = 0.01), and post-LT sepsis (p = 0.03) were important negative prognostic factors for renal recovery after LDLT. In conclusion, post-LT renal recovery was important for survival, and the interval from HRS to LDLT was significantly associated with post-LT renal recovery.
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Affiliation(s)
- Cheon-Soo Park
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.,Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young-In Yoon
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Nayoung Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Shin Hwang
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Tae-Yong Ha
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Dong-Hwan Jung
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Gi-Won Song
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Deok-Bog Moon
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Chul-Soo Ahn
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Gil-Chun Park
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ki-Hun Kim
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yong-Pil Cho
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sung-Gyu Lee
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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6
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Shingina A, Ziogas I, Vutien P, Uleryk E, Shah PS, Renner E, Bhat M, Tinmouth J, Kim J. Adult-to-adult living donor liver transplantation in acute liver failure – Do outcomes justify the risks? Transplant Rev (Orlando) 2022; 36:100691. [DOI: 10.1016/j.trre.2022.100691] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
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7
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Wong TC, Fung JY, Pang HH, Leung CK, Li H, Sin S, Ma K, She BW, Dai JW, Chan AC, Cheung T, Lo C. Analysis of Survival Benefits of Living Versus Deceased Donor Liver Transplant in High Model for End-Stage Liver Disease and Hepatorenal Syndrome. Hepatology 2021; 73:2441-2454. [PMID: 33006772 PMCID: PMC8252626 DOI: 10.1002/hep.31584] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIMS Previous recommendations suggested living donor liver transplantation (LDLT) should not be considered for patients with Model for End-Stage Liver Disease (MELD) > 25 and hepatorenal syndrome (HRS). APPROACH AND RESULTS Patients who were listed with MELD > 25 from 2008 to 2017 were analyzed with intention-to-treat (ITT) basis retrospectively. Patients who had a potential live donor were analyzed as ITT-LDLT, whereas those who had none belonged to ITT-deceased donor liver transplantation (DDLT) group. ITT-overall survival (OS) was analyzed from the time of listing. Three hundred twenty-five patients were listed (ITT-LDLT n = 212, ITT-DDLT n = 113). The risk of delist/death was lower in the ITT-LDLT group (43.4% vs. 19.8%, P < 0.001), whereas the transplant rate was higher in the ITT-LDLT group (78.3% vs. 52.2%, P < 0.001). The 5-year ITT-OS was superior in the ITT-LDLT group (72.6% vs. 49.5%, P < 0.001) for patients with MELD > 25 and patients with both MELD > 25 and HRS (56% vs. 33.8%, P < 0.001). Waitlist mortality was the highest early after listing, and the distinct alteration of slope at survival curve showed that the benefits of ITT-LDLT occurred within the first month after listing. Perioperative outcomes and 5-year patient survival were comparable for patients with MELD > 25 (88% vs. 85.4%, P = 0.279) and patients with both MELD > 25 and HRS (77% vs. 76.4%, P = 0.701) after LDLT and DDLT, respectively. The LDLT group has a higher rate of renal recovery by 1 month (77.4% vs. 59.1%, P = 0.003) and 3 months (86.1% vs, 74.5%, P = 0.029), whereas the long-term estimated glomerular filtration rate (eGFR) was similar between the 2 groups. ITT-LDLT reduced the hazard of mortality (hazard ratio = 0.387-0.552) across all MELD strata. CONCLUSIONS The ITT-LDLT reduced waitlist mortality and allowed an earlier access to transplant. LDLT in patients with high MELD/HRS was feasible, and they had similar perioperative outcomes and better renal recovery, whereas the long-term survival and eGFR were comparable with DDLT. LDLT should be considered for patients with high MELD/HRS, and the application of LDLT should not be restricted with a MELD cutoff.
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Affiliation(s)
- Tiffany Cho‐Lam Wong
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - James Yan‐Yue Fung
- Department of MedicineThe University of Hong KongHong KongChina,Department of MedicineQueen Mary HospitalHong KongChina
| | - Herbert H. Pang
- School of Public HealthThe University of Hong KongHong KongChina
| | | | - Hoi‐Fan Li
- Department of SurgeryThe University of Hong KongHong KongChina
| | - Sui‐Ling Sin
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - Ka‐Wing Ma
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - Brian Wong‐Hoi She
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - Jeff Wing‐Chiu Dai
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - Albert Chi‐Yan Chan
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - Tan‐To Cheung
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - Chung‐Mau Lo
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
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8
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Is living donor liver transplantation justified in high model for end-stage liver disease candidates (35+)? Curr Opin Organ Transplant 2019; 24:637-643. [DOI: 10.1097/mot.0000000000000689] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Trapero-Marugán M, Little EC, Berenguer M. Stretching the boundaries for liver transplant in the 21st century. Lancet Gastroenterol Hepatol 2018; 3:803-811. [DOI: 10.1016/s2468-1253(18)30213-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 06/20/2018] [Accepted: 06/22/2018] [Indexed: 12/12/2022]
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10
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Feng S. Living donor liver transplantation in high Model for End-Stage Liver Disease score patients. Liver Transpl 2017; 23:S9-S21. [PMID: 28719072 DOI: 10.1002/lt.24819] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/28/2017] [Indexed: 01/02/2023]
Affiliation(s)
- Sandy Feng
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, San Francisco, CA
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11
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Living donor liver transplantation: eliminating the wait for death in end-stage liver disease? Nat Rev Gastroenterol Hepatol 2017; 14:373-382. [PMID: 28196987 DOI: 10.1038/nrgastro.2017.2] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Adult-to-adult living donor liver transplantation (A2ALDLT), outside of Asia, remains an important yet underutilized gift of life. For patients with end-stage liver disease, A2ALDLT is a proven transplantation option, with lower waiting list mortality and suffering, and equivalent or better allograft and patient survival than deceased-donor liver transplantation (DDLT). The risks to living donors and the benefit to their recipients have been carefully defined with long-term level 1 and 2 evidence-based study. An overview of the development and practice of living donor liver transplant (LDLT), including donor and recipient surgical allograft innovation, is provided. The issues of recipient selection, outcomes and morbidity, including disease-variable study and challenges past and present are presented in comparison with DDLT cohorts, and future insights are described. Central to practice is the careful and concise review of donor evaluation and selection and donor outcome, morbidity, quality of life and present and future strategies for donor advocacy and growth of the technique.
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12
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Goldaracena N, Spetzler VN, Sapisochin G, J E, Moritz K, Cattral MS, Greig PD, Lilly L, McGilvray ID, Levy GA, Ghanekar A, Renner EL, Grant DR, Selzner M, Selzner N. Should We Exclude Live Donor Liver Transplantation for Liver Transplant Recipients Requiring Mechanical Ventilation and Intensive Care Unit Care? Transplant Direct 2015; 1:e30. [PMID: 27500230 PMCID: PMC4946477 DOI: 10.1097/txd.0000000000000543] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 08/15/2015] [Indexed: 12/29/2022] Open
Abstract
Patients with acute and chronic liver disease often require admission to intensive care unit (ICU) and mechanical ventilation support before liver transplantation (LT). Rapid disease progression and high mortality on LT waiting lists makes live donor LT (LDLT) an attractive option for this patient population.
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Affiliation(s)
- Nicolas Goldaracena
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Vinzent N Spetzler
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Gonzalo Sapisochin
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Echeverri J
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Kaths Moritz
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Mark S Cattral
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Paul D Greig
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Les Lilly
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Ian D McGilvray
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Gary A Levy
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Anand Ghanekar
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Eberhard L Renner
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - David R Grant
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Markus Selzner
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Nazia Selzner
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
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13
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Jiang L, Yan L, Tan Y, Li B, Wen T, Yang J, Zhao J. Adult-to-adult right-lobe living donor liver transplantation in high model for end-stage liver disease score recipients with hepatitis B virus-related benign liver diseases. Surg Today 2013; 43:1039-48. [DOI: 10.1007/s00595-013-0539-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 07/05/2012] [Indexed: 01/30/2023]
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14
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Park YH, Hwang S, Ahn CS, Kim KH, Moon DB, Ha TY, Song GW, Jung DH, Park GC, Namgoong JM, Park HW, Park CS, Kang SH, Jung BH, Lee SG. Living donor liver transplantation for patients with alcoholic liver disease. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2013; 17:14-20. [PMID: 26155208 PMCID: PMC4304503 DOI: 10.14701/kjhbps.2013.17.1.14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 02/05/2013] [Accepted: 02/18/2013] [Indexed: 12/20/2022]
Abstract
Backgrounds/Aims Since most transplantation studies for alcoholic liver disease (ALD) were performed on deceased donor liver transplantation, little was known following living donor liver transplantation (LDLT). Methods The clinical outcome of 18 ALD patients who underwent LDLT from Febraury 1997 to December 2004 in a large-volume liver transplantation center was assessed retrospectively. Results The model for end-stage liver disease score was 23±11, and mean pretransplant abstinence period was 16±13 months, with 14 (77.8%) patients being abstinent for at least 6 months. Graft types were right lobe grafts in 11, left lobe grafts in 2 and dual grafts in 5. Graft to recipient body weight ratio was 0.94±0.16. The relapse rates in patients who did and did not maintain 6 months of abstinence were 7.1% and 50%, respectively (p=0.097). Younger recipient age was a significant risk factor for alcohol relapse (p=0.027). Five recipients with antibody to hepatitis B surface antigen (HBsAg) received core antibody-positive liver graft, but two of them showed positive HBsAg seroconversion. Overall 5-year patient survival rate following LDLT was 87.8%, with a 5-year relapse rate of 16.7%. Conclusions Pretransplant abstinence for 6 months appears to be benefical for preventing posttransplant relapse. Life-long prophylactic measure should be followed after use of anti-HBc-positive liver grafts regardless of hepatitis B viral marker status of the recipient.
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Affiliation(s)
- Yo-Han Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Man Namgoong
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyung-Woo Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chun-Soo Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Hwa Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bo-Hyeon Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Yuan D, Liu F, Wei YG, Li B, Yan LN, Wen TF, Zhao JC, Zeng Y, Chen KF. Adult-to-adult living donor liver transplantation for acute liver failure in China. World J Gastroenterol 2012; 18:7234-41. [PMID: 23326128 PMCID: PMC3544025 DOI: 10.3748/wjg.v18.i48.7234] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 07/25/2012] [Accepted: 08/04/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the long-term outcome of recipients and donors of adult-to-adult living-donor liver transplantation (AALDLT) for acute liver failure (ALF).
METHODS: Between January 2005 and March 2010, 170 living donor liver transplantations were performed at West China Hospital of Sichuan University. All living liver donor was voluntary and provided informed consent. Twenty ALF patients underwent AALDLT for rapid deterioration of liver function. ALF was defined based on the criteria of the American Association for the Study of Liver Diseases, including evidence of coagulation abnormality [international normalized ratio (INR) ≥ 1.5] and degree of mental alteration without pre-existing cirrhosis and with an illness of < 26 wk duration. We reviewed the clinical indications, operative procedure and prognosis of AALDTL performed on patients with ALF and corresponding living donors. The potential factors of recipient with ALF and corresponding donor outcome were respectively investigated using multivariate analysis. Survival rates after operation were analyzed using the Kaplan-Meier method. Receiver operator characteristic (ROC) curve analysis was undertaken to identify the threshold of potential risk factors.
RESULTS: The causes of ALF were hepatitis B (n = 18), drug-induced (n = 1) and indeterminate (n = 1). The score of the model for end-stage liver disease was 37.1 ± 8.6, and the waiting duration of recipients was 5 ± 4 d. The graft types included right lobe (n = 17) and dual graft (n = 3). The mean graft weight was 623.3 ± 111.3 g, which corresponded to graft-to-recipient weight ratio of 0.95% ± 0.14%. The segment Vor VIII hepatic vein was reconstructed in 11 right-lobe grafts. The 1-year and 3-year recipient’s survival and graft survival rates were 65% (13 of 20). Postoperative results of total bilirubin, INR and creatinine showed obvious improvements in the survived patients. However, the creatinine level of the deaths was increased postoperatively and became more aggravated compared with the level of the survived recipients. Multivariate analysis showed that waiting duration was independently correlated with increased mortality (P = 0.014). Furthermore, ROC curve revealed the cut-off value of waiting time was 5 d (P = 0.011, area under the curve = 0.791) for determining the mortality. The short-term creatinine level with different recipient’s waiting duration was described. The recipients with waiting duration ≥ 5 d showed the worse renal function and higher mortality than those with waiting duration < 5 d (66.7% vs 9.1%, P = 0.017). In addition, all donors had no residual morbidity. Furthermore, univariate analysis did not show that short assessment time induced the high morbidity (P = 0.573).
CONCLUSION: Timely AALDLT for patients with ALF greatly improves the recipient survival. However, further systemic review is needed to investigate the optimal treatment strategy for ALF.
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16
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Carlisle EM, Testa G. Adult to adult living related liver transplantation: Where do we currently stand? World J Gastroenterol 2012; 18:6729-36. [PMID: 23239910 PMCID: PMC3520161 DOI: 10.3748/wjg.v18.i46.6729] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 08/03/2012] [Accepted: 08/14/2012] [Indexed: 02/06/2023] Open
Abstract
Adult to adult living donor liver transplantation (AALDLT) was first preformed in the United States in 1997. The procedure was rapidly integrated into clinical practice, but in 2002, possibly due to the first widely publicized donor death, the number of living liver donors plummeted. The number of donors has since reached a steady plateau far below its initial peak. In this review we evaluate the current climate of AALDLT. Specifically, we focus on several issues key to the success of AALDLT: determining the optimal indications for AALDLT, balancing graft size and donor safety, assuring adequate outflow, minimizing biliary complications, and maintaining ethical practices. We conclude by offering suggestions for the future of AALDLT in United States transplantation centers.
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Lee JP, Kwon HY, Park JI, Yi NJ, Suh KS, Lee HW, Kim M, Oh YK, Lim CS, Kim YS. Clinical outcomes of patients with hepatorenal syndrome after living donor liver transplantation. Liver Transpl 2012; 18:1237-44. [PMID: 22714872 DOI: 10.1002/lt.23493] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Liver transplantation (LT) is the treatment of choice for hepatorenal syndrome (HRS). However, the clinical benefits of living donor liver transplantation (LDLT) are not yet well established. We, therefore, investigated the outcomes of patients with HRS who underwent LDLT and patients with HRS who received transplants from deceased donors. This study focused on 71 patients with HRS out of a total of 726 consecutive adult Korean patients who underwent LT at a single Asian center. We compared 48 patients who underwent LDLT with 23 patients who underwent deceased donor liver transplantation (DDLT). Patients with HRS showed poorer survival than patients without HRS (P = 0.01). Poorer survival was associated with higher in-hospital mortality for patients with HRS (18.3% versus 5.2%, P < 0.001). In comparison with DDLT, LDLT was associated with younger donors and shorter ischemic times. The survival rate with LDLT was significantly higher than the survival rate with DDLT (P = 0.02). Among patients with high Model for End-Stage Liver Disease scores (≥30) or type 1 HRS, the survival rates for the LDLT group were not inferior to those for the DDLT group. LDLT significantly improved recipient survival after adjustments for several risk factors (hazard ratio = 0.20, 95% confidence interval = 0.05-0.85, P = 0.03). Kidney function was significantly improved after LT, and there was no difference between LDLT and DDLT. No patients in the HRS cohort required maintenance renal replacement therapy. In conclusion, LDLT may be a beneficial option for patients with HRS.
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Affiliation(s)
- Jung Pyo Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
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Quintini C, Hashimoto K, Uso TD, Miller C. Is there an advantage of living over deceased donation in liver transplantation? Transpl Int 2012; 26:11-9. [PMID: 22937787 DOI: 10.1111/j.1432-2277.2012.01550.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Living donor liver transplantation (LDLT) is a well-established strategy to decrease the mortality in the waiting list and recent studies have demonstrated its value even in patients with low MELD score. However, LDLT is still under a high level of scrutiny because of its technical complexity and ethical challenges as demonstrated by a decline in the number of procedures performed in the last decade in Western Countries. Many aspects make LDLT different from deceased donor liver transplantation, including timing of transplantation, procedure-related complications as well as immunological factors that may affect graft outcomes. Our review suggests that in selected cases, LDLT offers significant advantages over deceased donor liver transplantation and should be used more liberally.
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19
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Poon KS, Chen TH, Jeng LB, Yang HR, Li PC, Lee CC, Yeh CC, Lai HC, Su WP, Peng CY, Chen YF, Ho YJ, Tsai PP. A high model for end-stage liver disease score should not be considered a contraindication to living donor liver transplantation. Transplant Proc 2012; 44:316-9. [PMID: 22410005 DOI: 10.1016/j.transproceed.2012.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To analyze the outcomes of patients with high Model for End-Stage Liver Disease (MELD) scores who underwent adult-to-adult live donor liver transplantation (A-A LDLT). MATERIALS AND METHODS From September 2002 to October 2010, a total of 152 adult patients underwent A-A LDLT in our institution. Recipients were stratified into a low MELD score group (Group L; MELD score≤30) and a high MELD score group (Group H; MELD score>30) to compare short-term and long-term outcomes. RESULTS Of the 152 adult patients who underwent A-A LDLT, 9 were excluded from the analysis because they received ABO-incompatible grafts. Group H comprised 23 and Group L 120 patients. The median follow-up was 21.5 months (range, 3 to 102 m). The mean MELD score was 15.6 in Group L and 36.7 in Group H. There were no significant differences in the mean length of stay in the intensive care unit (Group L: 3.01 days vs Group H: 3.09 days, P=.932) or mean length of hospital stay (Group L: 17.89 days vs. Group H: 19.91 days, P=0.409). There were no significant differences in 1-, 3-, or 5-year survivals between patients in Groups L versus H (91.5% vs 94.7%; 86.4% vs 94.7%; and 86.4% vs 94.7%; P=.3476, log rank). CONCLUSION The short-term and long-term outcomes of patients with high MELD scores who underwent A-A LDLT were similar to those of patients with low MELD scores. Therefore, we suggest that high MELD scores are not a contraindication to LDLT.
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Affiliation(s)
- K-S Poon
- Organ Transplantation Center, Department of Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan
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20
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Máthé Z, Kóbori L, Görög D, Fehérvári I, Nemes B, Gerlei Z, Doros A, Németh A, Mándli T, Fazakas J, Járay J. The first successful adult right-lobe living donor liver transplantation in Hungary. Orv Hetil 2010; 151:3-7. [DOI: 10.1556/oh.2010.28782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A világszerte fennálló szervdonorhiány csökkentésének egyik lehetősége az élő donoros májtranszplantáció. A szerzők beszámolnak a Magyarországon először végzett felnőttkori élő donoros májtranszplantációval szerzett tapasztalataikról. Az átültetés testvérek között történt, 2007. november 19-én. A 33 éves egészséges férfi donor májának jobb lebenye (V–VIII. szegmentum) került eltávolításra és beültetésre az autoimmun hepatitis talaján kialakult cirrhosisban szenvedő, egy éve májtranszplantációs várólistán levő, 23 éves nőbetegbe. A jobb májlebeny beültetése saját hepatectomia után orthotopicus helyzetben történt. A májfunkció gyorsan javult a transzplantációt követően. A donort szövődménymentes posztoperatív szak után, stabil májfunkciós paraméterekkel, a 10. napon otthonába bocsátottuk. Dolgozik, aktív életet él, a kontrollvizsgálatok a máj jelentős regenerációját mutatták. A recipiens két évvel a májátültetés után, kompenzált májfunkcióval szintén aktív életet él és rendszeres ellenőrzés alatt áll. A felnőttkori élő donoros májtranszplantáció előnye a lerövidíthető várakozási idő és a tervezhető műtét. Az eljárás a donor biztonságának maximális előtérbe helyezésével, jól szelektált esetekben, alkalmas lehet a szervhiány csökkentésére.
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Affiliation(s)
| | - László Kóbori
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Dénes Görög
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Imre Fehérvári
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Balázs Nemes
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Zsuzsa Gerlei
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Attila Doros
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Andrea Németh
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Tamás Mándli
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - János Fazakas
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Jenő Járay
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
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Abstract
Liver transplantation has become a lifesaving procedure for patients who have chronic end-stage liver disease and acute liver failure. The satisfactory outcome of liver transplantation has led to insufficient supplies of deceased donor organs, particularly in East Asia. Hence, East Asian surgeons are concentrating on developing and performing living-donor liver transplantation (LDLT). This review article describes an update on the present status of liver transplantation, mainly in adults, and highlights some recent developments on indications for transplantation, patient selection, donor and recipient operation between LDLT and deceased-donor liver transplantation (DDLT), immunosuppression, and long-term management of liver transplant recipients. Currently, the same indication criteria that exist for DDLT are applied to LDLT, with technical refinements for LDLT. In highly experienced centers, LDLT for high-scoring (>30 points) Model of End-Stage Liver Disease (MELD) patients and acute-on-chronic liver-failure patients yields comparably good outcomes to DDLT, because timely liver transplantation with good-quality grafting is possible. With increasing numbers of liver transplantations and long-term survivors, specialized attention should be paid to complications that develop in the long term, such as chronic renal failure, hypertension, diabetes mellitus, dyslipidemia, obesity, bone or neurological complications, and development of de novo tumors, which are highly related to the immunosuppressive treatment.
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Affiliation(s)
- Deok-Bog Moon
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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22
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Abstract
PURPOSE OF REVIEW In this review we focus on three challenging aspects of liver transplantation: living donor liver transplant, transplantation in HIV-positive recipients and down-staging of hepatocellular carcinoma for liver transplantation. RECENT FINDINGS The adult-to-adult living donor liver transplantation cohort study is providing valuable information on recipient and donor outcomes associated with living donor liver transplantation. The recipient outcomes with living donor liver transplantation are comparable to those with deceased donor liver transplantation for most diseases, but increased hepatocellular carcinoma recurrence has been reported with living donor liver transplantation. Donor morbidity is not infrequent and donor mortality remains a concern. Liver transplantation for HIV-positive recipients is associated with equivalent outcomes as HIV-negative recipients for selected recipients. Transplantation in coinfected recipients (HIV and HCV+) is associated with less favorable outcomes. Drug interaction between immunosuppression and highly active antiretroviral therapy is increasingly recognized and requires major modifications in dosing. Down-staging hepatocellular carcinoma to within transplant criteria is being used in some centers using loco-regional therapy. Waiting time after loco-regional therapy is currently the best predictor of recurrence. The role of newer chemotherapeutics is being tested as part of neoadjuvant therapy after resection or loco-regional therapy. SUMMARY Living donor liver transplantation is a viable strategy to increase transplantation and reduce death on the waiting list. Donor morbidity should be the subject of further efforts to minimize these risks. The increased recurrence risk with living donor liver transplantation for hepatocellular carcinoma warrants further study. Careful coordination between transplant professionals and HIV experts is necessary to monitor issues of posttransplant care of the HIV-infected recipient. The role of loco-regional therapies in down-staging patients with hepatocellular carcinoma is expanding.
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23
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Broering DC, Walter J, Braun F, Rogiers X. Current status of hepatic transplantation. Anatomical basis for liver transplantation. Curr Probl Surg 2008; 45:587-661. [PMID: 18692622 DOI: 10.1067/j.cpsurg.2008.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2025]
Affiliation(s)
- Dieter C Broering
- Head Professor of Transplant Surgery/Surgical Oncology, University Hospital of Schleswig-Holstein Campus, Kiel, Germany
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24
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Campsen J, Blei AT, Emond JC, Everhart JE, Freise CE, Lok AS, Saab S, Wisniewski KA, Trotter JF, the Adult-to-Adult Living Donor Liver Transplantation Cohort Study Group. Outcomes of living donor liver transplantation for acute liver failure: the adult-to-adult living donor liver transplantation cohort study. Liver Transpl 2008; 14:1273-80. [PMID: 18756453 PMCID: PMC3732478 DOI: 10.1002/lt.21500] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Collaborators] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
For acute liver failure (ALF), living donor liver transplantation (LDLT) may reduce waiting time and provide better timing compared to deceased donor liver transplantation (DDLT). However, there are concerns that a partial graft would result in reduced survival of critically ill LDLT recipients and that the rapid evolution of ALF would lead to selection of inappropriate donors. We report outcomes for ALF patients (and their donors) evaluated for LDLT between 1998 and April 2007 from the Adult-to-Adult Living Donor Liver Transplantation Cohort. Of the 1201 potential LDLT recipients, 14 had ALF, only 6 of whom had an identified cause. The median time from listing to first donor evaluation was 1.5 days, and the median time from evaluation to transplantation was 1 day. One patient recovered without liver transplant, 3 of 10 LDLT recipients died, and 1 of 3 DDLT recipients died. Five of the 10 living donors had a total of 7 posttransplant complications. In conclusion, LDLT is rarely performed for ALF, but in selected patients it may be associated with acceptable recipient mortality and donor morbidity.
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Affiliation(s)
- Jeffrey Campsen
- Division of Transplant Surgery, University of Colorado, Aurora, CO
| | - Andres T. Blei
- Department of Medicine, Northwestern University, Chicago, IL
| | - Jean C. Emond
- Department of Surgery, Columbia Presbyterian Medical Center, New York, NY
| | - James E. Everhart
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Chris E. Freise
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Anna S. Lok
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Sammy Saab
- Department of Medicine, University of California Los Angeles, Los Angeles, CA
- Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | | | - James F. Trotter
- Division of Transplant Surgery, University of Colorado, Aurora, CO
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Collaborators
Jean C Emond, Robert S Brown, Rudina Odeh-Ramadan, Taruna Chawla, Scott Heese, Michael M I Abecassis, Andreas Blei, Patrice Al-Saden, Abraham Shaked, Kim M Olthoff, Mary Kaminski, Mary Shaw, James F Trotter, Igal Kam, Carlos Garcia, Rafik Mark Ghobrial, Ronald W Busuttil, Lucy Artinian, Chris E Freise, Norah A Terrault, Dulce MacLeod, Robert M Merion, Anna S F Lok, Akinlolu O Ojo, Brenda W Gillespie, Douglas R Armstrong, Margaret Hill-Callahan, Terese Howell, Lan Tong, Tempie H Shearon, Karen A Wisniewski, Monique Lowe, Jeffrey H Fair, Carrie A Nielsen, Carl L Berg, Timothy L Pruett, Jaye Davis, Robert A Fisher, Mitchell L Shiffman, Ede Fenick, April Ashworth, James E Everhart, Leonard B Seeff, Patricia R Robuck, Jay H Hoofnagle,
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25
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Hot topics in liver transplantation: organ allocation--extended criteria donor--living donor liver transplantation. J Hepatol 2008; 48 Suppl 1:S58-67. [PMID: 18308415 DOI: 10.1016/j.jhep.2008.01.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Liver transplantation has become the mainstay for the treatment of end-stage liver disease, hepatocellular cancer and some metabolic disorders. Its main drawback, though, is the disparity between the number of donors and the patients needing a liver graft. In this review we will discuss the recent changes regarding organ allocation, extended donor criteria, living donor liver transplantation and potential room for improvement. The gap between the number of donors and patients needing a liver graft forced the transplant community to introduce an objective model such as the modified model for end-stage liver disease (MELD) in order to obtain a transparent and fair organ allocation system. The use of extended criteria donor livers such as organs from older donors or steatotic grafts is one possibility to reduce the gap between patients on the waiting list and available donors. Finally, living donor liver transplantation has become a standard procedure in specialized centers as another possibility to reduce the donor shortage. Recent data clearly indicate that center experience is of major importance in achieving good results. Great progress has been made in recent years. However, further research is needed to improve results in the future.
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26
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Abstract
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.
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Affiliation(s)
- Robert S Brown
- Center for Liver Diseases and Transplantation, Columbia College of Physicians and Surgeons, New York, New York 10032, USA.
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27
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Walter J, Burdelski M, Bröring DC. Chances and risks in living donor liver transplantation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2008; 105:101-107. [PMID: 19633759 PMCID: PMC2696717 DOI: 10.3238/arztebl.2008.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Accepted: 10/22/2007] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Liver transplantation is the first-line therapy in treatment of end-stage liver diseases. Due to the mismatch of available donor organs and growing waiting lists in Germany, live donation is of great interest. METHODS Selective literature review. RESULTS AND DISCUSSION Pediatric living donor liver transplantation almost eliminated waiting list mortality in children and achieved excellent short and long term survival. The situation in adult-to-adult living donor liver transplantation is different, due to the need for extensive donor resection and smaller graft volume for the recipient. Careful donor evaluation and defined selection criteria are essential to minimize the donor's risk and to achieve results comparable to whole organ transplantation. Living donor liver transplantation offers the recipient certain advantages such as superior graft quality, but the procedure should be reserved for selected patients. Donor safety is the highest priority in this procedure. Living donor transplantation should remain in the hands of experienced centers.
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Affiliation(s)
- Jessica Walter
- Klinik für Allgemeine und Thoraxchirurgie, Universitätsklinikum Schleswig-Holstein, Arnold-Heller-Strasse 7, Kiel, Germany
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Marubashi S, Dono K, Asaoka T, Hama N, Gotoh K, Miyamoto A, Takeda Y, Nagano H, Umeshita K, Monden M. Risk factors for graft dysfunction after adult-to-adult living donor liver transplantation. Transplant Proc 2006; 38:1407-10. [PMID: 16797318 DOI: 10.1016/j.transproceed.2006.02.091] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Indexed: 02/07/2023]
Abstract
The aim of this study was to investigate the risk factors for graft dysfunction after adult-to-adult living donor liver transplantation (LDLT). Thirty-nine adults with chronic cirrhosis underwent LDLT between 1999 and 2004. Their postoperative courses were uneventful with no vascular or bile duct complications early after LDLT, except one mild hepatic artery stenosis. The preoperative MELD scores were significantly higher in the failed graft group (n=5) than the functioning graft group (n=34; P=.004), while the graft liver weight/standard liver volume ratio was similar between these groups. We concluded that a high preoperative MELD score was associated with postoperative graft failure and that graft size had little impact on graft outcome. Although large grafts would seem intuitively more suitable for sick recipients, we did not show a benefit among this cohort; the MELD score was the best predictor, a finding that is also most consistent with donor safety.
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Affiliation(s)
- S Marubashi
- Department of Surgery and Clinical Oncology, Osaka University, Graduate School of Medicine, Osaka, Japan
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Sugawara Y, Makuuchi M. Living donor liver transplantation to patients with hepatitis C virus cirrhosis. World J Gastroenterol 2006; 12:4461-4465. [PMID: 16874855 PMCID: PMC4125630 DOI: 10.3748/wjg.v12.i28.4461] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2005] [Revised: 10/12/2005] [Accepted: 11/18/2005] [Indexed: 02/06/2023] Open
Abstract
Living donor liver transplantation (LDLT) is an alternative therapeutic option for patients with end-stage hepatitis C virus (HCV) cirrhosis because of the cadaveric organ shortage. HCV infection is now a leading indication for LDLT among adults worldwide, and there is a worse prognosis with HCV recurrence. The antivirus strategy after transplantation, however, is currently under debate. Recent updates on the clinical and therapeutic aspects of living donor liver transplantation for HCV are discussed in the present review.
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Affiliation(s)
- Yasuhiko Sugawara
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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Saad WEA, Saad NEA, Davies MG, Bozorgdadeh A, Orloff MS, Patel NC, Abt PL, Lee DE, Sahler LG, Kitanosono T, Sasson T, Waldman DL. Elective Transjugular Intrahepatic Portosystemic Shunt Creation for Portal Decompression in the Immediate Pretransplantation Period in Adult Living Related Liver Transplant Recipient Candidates: Preliminary Results. J Vasc Interv Radiol 2006; 17:995-1002. [PMID: 16778233 DOI: 10.1097/01.rvi.0000223683.87894.a4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To evaluate (i) the efficacy of purposeful creation of transjugular intrahepatic portosystemic shunts (TIPS) before transplantation to optimize potential living related liver transplantation (LRLTx) and (ii) the efficacy of TIPS creation in this setting in reducing perioperative resource utilization. MATERIALS AND METHODS Retrospective review was performed of the records of patients who underwent adult LRLTx with or without preoperative TIPS creation from October 2003 through April 2005. Patients were evaluated for preoperative parameters (Child-Pugh class, Model for End-stage Liver Disease score, Acute Physiology and Chronic Health Evaluation [APACHE] II score, and coagulation parameters), intraoperative parameters (blood transfusion requirements and operative time), and postoperative parameters (intensive care unit stay, hospital stay, and 30-day repeat operation and mortality rates). Comparison between the two treatment groups was made with the Mann-Whitney U test. Within the TIPS group, comparison of blood transfusion requirements was performed by one-way analysis of variance based on the degree of portosystemic gradient reduction after TIPS creation. RESULTS Sixteen patients were included in the TIPS group, and 12 patients were included in the group without TIPS. Median time between TIPS and transplantation was 2 days. There was no statistical difference in the preoperative, intraoperative, and postoperative parameters between groups except for the APACHE II score (P<.002), which was higher in the TIPS group. Despite this, the outcome and postoperative hospital resource utilization were similar between groups. Intraoperative blood transfusion based on the degree of portosystemic gradient reduction after TIPS creation was not significantly different between groups. CONCLUSIONS Newly created TIPS do not interfere with the intraoperative technical and perioperative clinical aspects of adult LRLTx. Preoperative TIPS creation before transplantation may reduce the postoperative morbidity and mortality seen in liver transplant recipients who have a greater APACHE II score at the outset of treatment.
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Affiliation(s)
- Wael E A Saad
- Department of Imaging Sciences, Section of Vascular/Interventional Radiology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, New York 14642, USA.
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Castaing D, Azoulay D, Danet C, Thoraval L, Tanguy Des Deserts C, Saliba F, Samuel D, Adam R. Medical community preferences concerning adult living related donor liver transplantation. ACTA ACUST UNITED AC 2006; 30:183-7. [PMID: 16565648 DOI: 10.1016/s0399-8320(06)73151-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To assess acceptance and acceptable estimated mortality levels for right lobe adult-to-adult living related liver transplantation for the medical and allied professions. METHODS A paper questionnaire was sent to the physicians practicing with the French Graft Agency (Etablissement Français des Greffes) and to all nurses and ancillary staff of the Paul Brousse Hospital Hepatobiliary Center. Responses were received from surgeons: 38/73; internists specialized in hepatology: 44/120; nurses: 98/100; health care assistants: 45/86; others: 17/20. RESULTS Acceptance of living donor transplantation is above average for all professional categories and indications may be extended including patients with cancer. Acceptable mortality for the donor was 4%, except among internists (0.7%). Currently, the real risk of mortality for the donor (1%) is lower. Acceptable mortality for the recipient was between 15 and 20%. CONCLUSIONS Acceptance of adult living donor liver transplantation among health care professionals is clearly above average. Thus the psychological involvement of transplantation teams, which is very strong in such situations, should not hamper the development of this type of transplantation.
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Affiliation(s)
- Denis Castaing
- Centre Hépato-Biliaire, Hôpital Paul Brousse, UPRES 1596, Université Paris Sud, Villejuif.
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Pacheco-Moreira LF, Enne M, Balbi E, Halpern M, Peixoto A, Cerqueira A, Moreira E, Araujo C, Pereira JL, Martinho JM. Selection of donors for living donor liver transplantation in a single center of a developing country: lessons learned from the first 100 cases. Pediatr Transplant 2006; 10:311-5. [PMID: 16677354 DOI: 10.1111/j.1399-3046.2005.00465.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The selection of donors for living donor liver transplantation (LDLT) is one of the most important features in this kind of surgery. The aim of this study is to describe our initial experience in the donor evaluation process. From December 2001 to January 2005, 104 donors were evaluated for 70 recipients (65 potential donors were evaluated for 39 adult recipients, and 39 donors for 31 pediatric recipients). Only 30 donors were able to donate: 13 for the adult group, and 17 for the pediatric one. In general, the utilization rate of potential donors was 28.8% (30/104). For the adult patients, 65 potential donors were seen to perform 13 LDLT, which represents a utilization rate of potential donors of 20%. For the pediatric patients, this rate was 43.6%. The exclusion criteria were clinical in 22 cases (21%), anatomical in 13 cases (13%), psychosocial in nine cases (9%), and others in 12 (12%). Death of recipients led to exclusion 18 of donors (17%). Thirty-three percent of adults and 55% of pediatric recipients who had at least one potential donor to start the evaluation process were able to identify a living donor. In conclusion, the first limit for LDLT is the rigorous donor evaluation.
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Affiliation(s)
- Lucio F Pacheco-Moreira
- Liver Transplantation Unit, Clinical and Surgical Hepatology Program, Bonsucesso General Hospital, Public Health Assistance, Rio de Janeiro, Brazil.
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Nadalin S, Malagó M, Testa G, Schaffer R, Sotiropoulos GC, Frilling A, Broelsch CE. "Hepar divisum"--as a rare donor complication after intraoperative mortality of the recipient of an intended living donor liver transplantation. Liver Transpl 2006; 12:428-34. [PMID: 16498667 DOI: 10.1002/lt.20723] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In this study, we present our experience with 4 healthy donors having the rare condition of "hepar divisum" after the intraoperative death of the recipient of an intended right adult living donor liver transplantation (LDLT). The study included 4 donors and 4 intended right LDLT recipients affected by neuroendocrine tumor (n = 2), hepatocellular carcinoma (n = 1), and cryptogenic cirrhosis (n = 1). All 4 recipients died intraoperatively. At the time of recipient death, the dissection of the donor liver parenchyma was complete, the vessels intact, and the hepatic duct(s) already divided. In each case, reconstruction of the donor biliary tract was performed: hepaticojejunostomy (HJ) in 2 cases, each with 3 ducts, and duct-to-duct anastomosis in 2. Of the donors receiving the HJ, 1 had a cut surface bile leak and the other experienced an anastomotic leak, treated by percutaneous drainage and reoperation, respectively. The latter patient experienced recurrent HJ stenosis at 44 months and 50 months after the operation and was treated by percutaneous balloon dilatation. One duct-to-duct reconstruction was complicated by early stenosis (postoperative day 6) and treated with endoscopic stenting. In conclusion, in the case of intraoperative death of the recipient of an intended LDLT, when the parenchyma and the hepatic duct of the donor have already been divided, the options are completion of the donor hepatectomy or the status of "fegatum divisum" with reconstruction of biliary tract. The high incidence of biliary complication, however, is of concern. When more than 1 hepatic duct is present, the donor hepatectomy should be completed and the graft reallocated according to the policy of the transplant institution.
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Affiliation(s)
- Silvio Nadalin
- Department of General Surgery and Transplantation, University of Essen, Essen, Germany.
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Abstract
The first successful living donor liver transplantation (LDLT) was performed in a child in 1989 in Brisbane and in an adult in 1994 by the Shinshu group. Over the past few years, LDLT has increased worldwide and is now an established alternative to deceased donor liver transplantation. The surgical procedures for LDLT are more technically challenging than those for whole liver transplantation. LDLT requires a full understanding of the hepatobiliary anatomy and continuous technical refinement of the procedure. Some of the technical highlights include selective vascular occlusion techniques for donor hepatectomy, hepatic arterial reconstruction under the microscope and the introduction of intraoperative ultrasound, graft volume estimation and hepatic venous reconstruction, all of which have improved the success rate of LDLT over the past few years. This review focuses on recent trends and surgical techniques for LDLT.
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Affiliation(s)
- Yasuhiko Sugawara
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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Nadalin S, Bockhorn M, Malagó M, Valentin-Gamazo C, Frilling A, Broelsch C. Living donor liver transplantation. HPB (Oxford) 2006; 8:10-21. [PMID: 18333233 PMCID: PMC2131378 DOI: 10.1080/13651820500465626] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The introduction of living donor liver transplantation (LDLT) has been one of the most remarkable steps in the field of liver transplantation (LT). First introduced for children in 1989, its adoption for adults has followed only 10 years later. As the demand for LT continues to increase, LDLT provides life-saving therapy for many patients who would otherwise die awaiting a cadaveric organ. In recent years, LDLT has been shown to be a clinically safe addition to deceased donor liver transplantation (DDLT) and has been able to significantly extend the scarce donor pool. As long as the donor shortage continues to increase, LDLT will play an important role in the future of LT.
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Affiliation(s)
- S. Nadalin
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - M. Bockhorn
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - M. Malagó
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - C. Valentin-Gamazo
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - A. Frilling
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - C.E. Broelsch
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
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Aydogdu S, Arikan C, Kilic M, Ozgenc F, Akman S, Unal F, Yagci RV, Tokat Y. Outcome of pediatric liver transplant recipients in Turkey: single center experience. Pediatr Transplant 2005; 9:723-728. [PMID: 16269042 DOI: 10.1111/j.1399-3046.2005.00366.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
To summarize the evolution of the pediatric liver transplant program in a developing country. Between April 1997, and September 2003, 32 cadaveric (CD) and 35 living donor (LD) liver transplantations were performed on 61 children (median age 3.8 yr, range 0.5-16) at Ege University Organ Transplantation and Research Center. The patient's charts were reviewed retrospectively. The outcome of patient and graft survival was analyzed and the incidence of graft loss, complications and rejections was calculated. Indications for liver transplantation were metabolic liver disease (n = 17), biliary atresia (n = 14), viral hepatitis (n = 4), autoimmune hepatitis (n = 6), cryptogenic cirrhosis (n = 11), fulminant liver failure (n = 5) and others (n = 5). Seven of 61 children with chronic liver disease had hepatocellular carcinoma concomitantly. Median pediatric end-stage liver disease score was 23 (range 1-54). Seven children (11.4%) were UNOS status I, 44 (72%) were UNOS status II and 10 (16.6%) were UNOS status III. The median follow-up of the study population was 3.6 yr (range 0.5-6). Actuarial patient survival rates at 1, 2, 3 and 4 yr were 86, 86, 71.3 and 65% in the CD group vs. 80, 76, 67 and 67% in the LR group, respectively (p = NS). Patients listed as UNOS status 1 had lower survival rates than patients listed as UNOS status 2 and 3 (p < 0.05). The mortality rate was 26.2%. Graft survival rates were 81, 81, 75 and 64% at 1, 2, 3 and 4-yr respectively. Six patients (9%) underwent retransplantation. The main complications were infections (64.7%) and surgical complications (43.2%) (including biliary complication, vascular problems, postoperative bleeding, small for size and large for size). The incidence of acute cellular rejection was 39.3%, whereas chronic rejection was 7.4%. The result of liver transplantation in Turkish children was slightly inferior to those reported for North American and European children. However, an important characteristic of these patients that distinguishes them from Europe and North America is that most were UNOS status IIa and UNOS status I (44%). Despite technical and medical progress, infectious and biliary problems have continued to be an important cause of mortality in these patients.
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Affiliation(s)
- S Aydogdu
- Department of Pediatrics, Division of Gastroenterology, Ege University School of Medicine, Izmir, Turkey
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Broering DC, Wilms C, Lenk C, Schulte am Esch J, Schönherr S, Mueller L, Kim JS, Helmke K, Burdelski M, Rogiers X. Technical refinements and results in full-right full-left splitting of the deceased donor liver. Ann Surg 2005; 242:802-813. [PMID: 16327490 PMCID: PMC1409882 DOI: 10.1097/01.sla.0000189120.62975.0d] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Splitting of the liver at the line of Cantlie of otherwise healthy people is accepted worldwide as a reasonable procedure for the donors in adult living donor liver transplantation. A similar operation is still considered as experimental if performed in the deceased donor liver. The aim of this study is to evaluate the technical evolution and the results of this variant splitting technique. PATIENTS AND METHODS From January 1999 to August 2004, a total of 35 transplants of hemilivers from deceased donors (segments V-VIII: n = 16 and segments (I)II-IV: n = 19) were performed in our center. Seven splits were performed in situ and 12 ex situ. Splitting of the vena cava was applied in 18 splits and splitting of the middle hepatic vein in 8. Seven adults and 12 adolescents received the left hemiliver with a mean age of 12 years (range, 3-64 years), of whom 21% were UNOS status 1. Recipients of right hemilivers were exclusively adults with a mean age of 48 years (range, 31-65 years), none of them were high urgent. The outcome of these 35 recipients of hemilivers was prospectively evaluated. RESULTS Mean deceased donor age was 27 years (range, 12-57 years), the donor's body weight ranged between 55 kg and 100 kg. The mean weight of the right and left hemilivers was 1135 g (range, 745-1432 g) and 602 g (range, 289-1100 g), respectively. The mean graft recipient weight ratio in left and right hemiliver group was 1.46% (range, 0.88%-3.54%) and 1.58% (range, 1.15%-1.99%), respectively. Median follow-up was 27.4 months (range, 1-68.3 months). Four patients died (actual patient survival FR group: 87.5% versus FL group: 89.5%), 3 due to septic MOF and 1 due to graft versus host disease. In each of the 2 groups, 2 recipients had to undergo retransplantation, which resulted in an actual right and left hemiliver survival rate of 75% and 84%, respectively. The causes for retransplantation were primary nonfunction in 2 left hemilivers, chronic graft dysfunction in 1 right hemiliver, and recurrence of the primary disease in 1 recipient of a right hemiliver. Primary poor function was observed in 1 recipient of a right hemiliver. Early and late biliary complications occurred in both right and left hemiliver groups at the rate of 37.5% (n = 6) and 21% (n = 4), respectively. Arterial, portal, and venous complications were not observed in either group. CONCLUSION The technical development of splitting along Cantlie's line is almost complete with the last challenge being the reduction of biliary complications. The key to success is the choice of adequate deceased donors and recipients. Full-right full-left splitting is safely possible and should be considered as a reasonable instrument to alleviate mortality on the adult waiting list and to reduce the need for adult and adolescent living donation.
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Affiliation(s)
- Dieter C Broering
- Department of Hepatobiliary Surgery and Solid Organ Transplantation, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.
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Olthoff KM, Merion RM, Ghobrial RM, Abecassis MM, Fair JH, Fisher RA, Freise CE, Kam I, Pruett TL, Everhart JE, Hulbert-Shearon TE, Gillespie BW, Emond JC. Outcomes of 385 adult-to-adult living donor liver transplant recipients: a report from the A2ALL Consortium. Ann Surg 2005; 242:314-23, discussion 323-5. [PMID: 16135918 PMCID: PMC1357740 DOI: 10.1097/01.sla.0000179646.37145.ef] [Citation(s) in RCA: 270] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The objective of this study was to characterize the patient population with respect to patient selection, assess surgical morbidity and graft failures, and analyze the contribution of perioperative clinical factors to recipient outcome in adult living donor liver transplantation (ALDLT). SUMMARY BACKGROUND DATA Previous reports have been center-specific or from large databases lacking detailed variables. The Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) represents the first detailed North American multicenter report of recipient risk and outcome aiming to characterize variables predictive of graft failure. METHODS Three hundred eighty-five ALDLT recipients transplanted at 9 centers were studied with analysis of over 35 donor, recipient, intraoperative, and postoperative variables. Cox regression models were used to examine the relationship of variables to the risk of graft failure. RESULTS Ninety-day and 1-year graft survival were 87% and 81%, respectively. Fifty-one (13.2%) grafts failed in the first 90 days. The most common causes of graft failure were vascular thrombosis, primary nonfunction, and sepsis. Biliary complications were common (30% early, 11% late). Older recipient age and length of cold ischemia were significant predictors of graft failure. Center experience greater than 20 ALDLT was associated with a significantly lower risk of graft failure. Recipient Model for End-stage Liver Disease score and graft size were not significant predictors. CONCLUSIONS This multicenter A2ALL experience provides evidence that ALDLT is a viable option for liver replacement. Older recipient age and prolonged cold ischemia time increase the risk of graft failure. Outcomes improve with increasing center experience.
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Affiliation(s)
- Kim M Olthoff
- Department of Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Affiliation(s)
- Henkie P Tan
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Montefiore University Hospital, Pittsburgh, PA 15213, USA
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Troisi R, Ricciardi S, Smeets P, Petrovic M, Van Maele G, Colle I, Van Vlierberghe H, de Hemptinne B. Effects of hemi-portocaval shunts for inflow modulation on the outcome of small-for-size grafts in living donor liver transplantation. Am J Transplant 2005; 5:1397-404. [PMID: 15888047 DOI: 10.1111/j.1600-6143.2005.00850.x] [Citation(s) in RCA: 206] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Graft hyperperfusion in small-for-size grafts (SFSG) is considered the main causal factor of small-for-size syndrome (SFSS). We compared SFSG with a graft-to-recipient body ratio < or =0.8, with and without graft inflow modulation (GIM) by means of a hemi-portocaval shunt (HPCS). Thirteen patients underwent adult-to-adult living donor liver transplantation (AALDLT): G1, n = 5 [4 right livers (RL) and 1 left liver (LL)] without GIM, and G2, n = 8 (4 RL and 4 LL) with GIM. In G2 patients, portal vein flow (PVF) was significantly reduced by HPCS: 190 +/- 70 mL/min/100 g liver in G2 vs. 401 +/- 225 ml/min in G1 (p = 0.002). One- and 6-month post-transplantation graft volume/standard liver volume (GV/SLV) ratio was of 72% and 79.5% in G1; 80% and 101% in G2 (p = ns). SFSS was observed in three G1 recipients (who were retransplanted), but in none of the G2 patients. At 1-year, patient and graft survival was respectively of 40% and 20% in G1, 87.5% and 75% in G2 (p = 0.024 and 0.03). It is concluded that drastic reduction of PVF by means of HPCS improves overall patient and graft survival by averting the occurrence of SFSS. Graft inflow modulation through HPCS reduces the risk of complications when transplanting SFSG in adult recipients.
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Affiliation(s)
- Roberto Troisi
- Department of General Surgery, Division of Hepato-Biliary and Transplantation Surgery, Ghent University Hospital Medical School, Belgium.
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41
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Northup PG, Berg CL. Living donor liver transplantation: the historical and cultural basis of policy decisions and ongoing ethical questions. Health Policy 2005; 72:175-85. [PMID: 15802153 DOI: 10.1016/j.healthpol.2004.08.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Adult-to-adult living donor liver transplantation (LDLT) is in a state of flux. Technical innovations and demand have outpaced internal and external regulatory efforts. This has led to a wide array of centers performing LDLT for a variety of indications without clear evidence on the risks to the donor or recipient or the system as a whole. The birth from necessity of LDLT in Asia has led to the extrapolation of the technique in America and Europe that has not been sufficiently studied in the appropriate populations. While there is a clear benefit in some patients, the appropriate donors and recipients have not been defined. Regulatory and ethical consideration should be focused on minimizing acceptable risk in donors and recipients and expanding the investigation into the costs and outcomes of this challenging procedure. The recently funded adult-to-adult living donor liver transplantation cohort sponsored by the National Institutes of Health aims to answer some of these questions over the next five years.
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Affiliation(s)
- Patrick Grant Northup
- Division of Gastroenterology and Hepatology, Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, VA, USA.
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Affiliation(s)
- James F Trotter
- Division of Gastroenterology/Hepatology, University of Colorado Health Sciences Center, 4200 E, 9th Avenue, B-154, Denver, CO 80262, USA.
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Lo CM, Fan ST, Liu CL, Yong BH, Wong Y, Lau GK, Lai CL, Ng IO, Wong J. Lessons learned from one hundred right lobe living donor liver transplants. Ann Surg 2004; 240:151-8. [PMID: 15213631 PMCID: PMC1356387 DOI: 10.1097/01.sla.0000129340.05238.a0] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the first 100 adult right lobe living donor liver transplants (LDLT) in a single center to determine whether the results have improved with technical modifications and better experience. SUMMARY BACKGROUND DATA Right lobe LDLT has been increasingly performed for adults with end-stage liver disease. Numerous modifications in technique have been introduced, and a learning curve is likely in view of its complexity. METHODS One hundred consecutive adult right lobe LDLTs performed between May 1996 and May 2002 were retrospectively studied by comparing the first 50 (group 1) with the last 50 cases (group 2). The median follow-up was 37 (27 to 79) months for group 1 and 15 (7 to 27) months for group 2. RESULTS The characteristics of donors and liver grafts were similar. In group 2, fewer recipients were intensive care unit (ICU)-bound or had hepatorenal syndrome before transplantation, and there was a lower disease severity as shown by a lower Child-Pugh score and Model for End-Stage Liver Disease (MELD) score. Significant improvements were found in the operation time, blood loss, ICU stay, and postoperative complication rate of the donors and in the operation time, transfusion requirements, number of reoperations, ICU stay, and hospital stay of the recipients in group 2. The hospital mortality rate of recipients was reduced from 16% to 0% (P = 0.006). Graft survival rates at 12 months and 24 months were improved from 80% and 74%, respectively, in group 1 to 100% and 96%, respectively, in group 2 (P = 0.002). After adjusting for differences in recipient risk factors (ICU-bound, hepatorenal syndrome, Child-Pugh score, and MELD score) in a multivariate Cox model, recipients in group 2 had significantly lower risk of graft loss (relative risk compared with group 1, 0.13; 95% CI, 0.03 to 0.66; P = 0.014). CONCLUSIONS There is a learning curve in adult right lobe LDLT. The results have significantly improved with technical refinement and better experience.
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Affiliation(s)
- Chung-Mau Lo
- Centre for the Study of Liver Disease, and Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.
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Abstract
OBJECTIVE To evaluate the first 100 adult right lobe living donor liver transplants (LDLT) in a single center to determine whether the results have improved with technical modifications and better experience. SUMMARY BACKGROUND DATA Right lobe LDLT has been increasingly performed for adults with end-stage liver disease. Numerous modifications in technique have been introduced, and a learning curve is likely in view of its complexity. METHODS One hundred consecutive adult right lobe LDLTs performed between May 1996 and May 2002 were retrospectively studied by comparing the first 50 (group 1) with the last 50 cases (group 2). The median follow-up was 37 (27 to 79) months for group 1 and 15 (7 to 27) months for group 2. RESULTS The characteristics of donors and liver grafts were similar. In group 2, fewer recipients were intensive care unit (ICU)-bound or had hepatorenal syndrome before transplantation, and there was a lower disease severity as shown by a lower Child-Pugh score and Model for End-Stage Liver Disease (MELD) score. Significant improvements were found in the operation time, blood loss, ICU stay, and postoperative complication rate of the donors and in the operation time, transfusion requirements, number of reoperations, ICU stay, and hospital stay of the recipients in group 2. The hospital mortality rate of recipients was reduced from 16% to 0% (P = 0.006). Graft survival rates at 12 months and 24 months were improved from 80% and 74%, respectively, in group 1 to 100% and 96%, respectively, in group 2 (P = 0.002). After adjusting for differences in recipient risk factors (ICU-bound, hepatorenal syndrome, Child-Pugh score, and MELD score) in a multivariate Cox model, recipients in group 2 had significantly lower risk of graft loss (relative risk compared with group 1, 0.13; 95% CI, 0.03 to 0.66; P = 0.014). CONCLUSIONS There is a learning curve in adult right lobe LDLT. The results have significantly improved with technical refinement and better experience.
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Abstract
Adult living donor liver transplantation (LDLT) begun in response to deceased donor organ shortage and waiting list mortality, grew rapidly after its first general application in the United States in 1998. There are significant risks to the living donor, including the risk of death and substantial morbidity, and two highly publicized donor deaths have led to decreased LDLT since 2001. Significant improvements in outcomes have been seen over recent years that have not been reported in single center studies; however, LDLT still comprises less than 5% of adult liver transplants, significantly less than in kidney transplantation where living donors now comprise the majority. The ethics, optimal utility and application of LDLT remain to be defined. In addition, studies to date have focused on post-transplant outcomes and not included the potential impact of LDLT on waiting time mortality. Future analyses should include appropriate control or comparison groups that capture the effect of LDLT on overall mortality from the time of listing. 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.
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Affiliation(s)
- Mark W Russo
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Roberts JP, Brown RS, Edwards EB, Farmer DG, Freeman RB, Wiesner RH, Merion RM. Liver and intestine transplantation. Am J Transplant 2004; 3 Suppl 4:78-90. [PMID: 12694052 DOI: 10.1034/j.1600-6143.3.s4.8.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- John P Roberts
- University of California San Francisco, San Francisco, CA, USA
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Fan ST, Lo CM, Liu CL, Yong BH, Wong J. Determinants of hospital mortality of adult recipients of right lobe live donor liver transplantation. Ann Surg 2003; 238:864-69; discussion 869-70. [PMID: 14631223 PMCID: PMC1356168 DOI: 10.1097/01.sla.0000098618.11382.77] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To define the technical factors that might contribute to hospital mortality of recipients of right lobe live donor liver transplantation (LDLT) so as to perfect the design of the operation. SUMMARY BACKGROUND DATA Right lobe LDLT has been accepted as one of the treatments for patients with terminal hepatic failure, but the design and results of the reported series vary and the technical factors affecting hospital mortality have not been known. METHODS The data of 100 adult-to-adult right lobe LDLT performed between 1996 and 2002 were prospectively collected and retrospectively analyzed. All grafts except one contained the middle hepatic vein, which was anastomosed to the recipient middle/left hepatic vein in the first 84 recipients and directly into the inferior vena cava (with the right hepatic vein in form of venoplasty) in the subsequent 15 patients. Venovenous bypass was used routinely in the first 29 patients but not subsequently. RESULTS Eight patients died within the same hospital admission for liver transplantation. There was no hospital mortality in the last 53 recipients. Comparison of data of patients with or without hospital mortality showed that graft weight/body weight ratio, graft weight/estimated standard liver weight ratio, technical error resulting in occlusion/absence of the middle hepatic vein, use of venovenous bypass, the lowest body temperature recorded during surgery, the volume of intraoperative blood transfusion, fresh frozen plasma, and platelet infusion were significantly different between the two groups. However, the pretransplant intensive care unit status of the recipients, cold and warm ischemic time of the graft, and occurrence of biliary complications were not. By multivariate analysis, low body temperature recorded during operation, low graft weight/estimated standard liver weight ratio (</=0.35), and the middle hepatic vein occlusion were independent significant factors in determining hospital mortality. CONCLUSIONS To achieve a uniformly successful right lobe LDLT, the right lobe graft must contain a patent middle hepatic vein. With a completely patent middle hepatic vein, a graft size of >35% of the estimated standard graft weight may be sufficient for recipient survival. Hypothermia, which predisposes to coagulopathy and is enhanced by the use of venovenous bypass and massive blood, and blood product transfusion must be avoided.
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Affiliation(s)
- Sheung-Tat Fan
- Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.
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Malagó M, Testa G, Frilling A, Nadalin S, Valentin-Gamazo C, Paul A, Lang H, Treichel U, Cicinnati V, Gerken G, Broelsch CE. Right living donor liver transplantation: an option for adult patients: single institution experience with 74 patients. Ann Surg 2003; 238:853-62; discussion 862-3. [PMID: 14631222 PMCID: PMC1356167 DOI: 10.1097/01.sla.0000098619.71694.74] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To present an institutional experience with the use of right liver grafts in adult patients and to assess the practicability and efficacy of this procedure by analyzing the results. SUMMARY BACKGROUND DATA Living donor liver transplantation (LDLT) for the pediatric population has gained worldwide acceptance. In the past few years, LDLT has also become feasible for adult patients due to technical evolution in hepatobiliary surgery and increased experience with reduced-size and split-liver transplants. Nevertheless, some graft losses remain unexplained and are possibly due to unrecognized venous outflow problems. METHODS From April 1998 to September 2002, we performed 74 right LDLTs (segments 5-8). The 74 donors were selected from 474 candidates according to standard protocol. The median age of the donors was 35 years (range 18-58 years) and 51 years (range 18-64 years) in recipients. Standard and extended indications for transplantation were considered. Over the period reported, technical modifications in the bile duct anastomosis (duct-to-duct, end-to-end, or end-to-side) and a new graft implantation technique that provides maximized venous outflow, leading to outcome improvement, were developed. RESULTS 64.9% of patients had liver cirrhosis and 35.1% had malignancy. While 44 donors (59.5%) presented an uneventful postoperative course, 27% minor (pleural effusion, pneumonia, venous thrombosis, wound infection, incisional hernia) and 13.5% major (biliary leakage, death of a donor due to unrecognized hereditary liver disease, and consecutive liver insufficiency) complications were documented. In recipients, 23% biliary complications and 6.8% hepatic artery thrombosis occurred. The overall patient and graft survival rate after 1 year was 79.4% and 75.3%, respectively. In cases with extended indication, the patient survival rate was 74% and the graft survival rate 68% at 12 months. Using technical modifications in the last 10 recipients, including 2 critically decompensated cirrhotics, the survival rate was 100% at a median follow-up of 3.5 months. CONCLUSIONS In our transplant program, living donor liver transplantation has become a standard option in the adult patient population. The critical issue of this procedure is donor morbidity. Technical improvements in the harvesting and implantation of right grafts can also offer hope to patients with challenging forms of end-stage liver disease or malignant liver tumors.
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Affiliation(s)
- Massimo Malagó
- Department of General Surgery and Transplantation, University Hospital Essen, Essen, Germany
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Aseni P, Vertemati M, Minola E, Bonacina E. Massive haemoptysis after living donor liver transplantation. J Clin Pathol 2003; 56:876-8. [PMID: 14600139 PMCID: PMC1770121 DOI: 10.1136/jcp.56.11.876] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
A 27 year old man with hereditary haemorrhagic telangiectasia who developed progressive liver dysfunction underwent living related right lobe transplantation. Pulmonary arteriography did not reveal arteriovenous malformation or abnormal intrapulmonary venous channels. The postoperative course was characterised by persistent hypoxaemia and respiratory failure developed. On day 6, a massive haemoptysis developed and the patient died shortly thereafter. The native liver showed a nodular pseudocirrhotic transformation, with highly dilated and irregularly interconnected vein-like or arterial-like structures in the fibrous septa. Pathological examination of both lungs showed irregular thickening of the wall of the arteries, secondary to eccentric and/or concentric myointimal hyperplasia. This case suggests that massive haemoptysis can develop even when arteriovenous malformations are undetectable by pulmonary arteriography, and it questions the role and the appropriateness of living donor liver transplantation in high risk patients.
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Affiliation(s)
- P Aseni
- Department of General Surgery and Abdominal Organ Transplantation Niguarda Hospital, 20162 Milan, Italy
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