Problem of living liver donation in the absence of deceased liver transplantation program: Mansoura experience

Table 1 Living donor evaluation protocol

Potential donor: Is any living donor at our center after the recipient is informed of the accepted donor criteria. The criteria for living liver donors include an apparently healthy relative of the recipient aged between 21 and 45 years. Recipient, donor and their families are informed regarding the risks and benefits of right lobe hepatectomy for LDLT and both the donor and the recipient must sign an informed written consent to proceed to the evaluation process

Phase I: Confirmation of the relation between the living donor and the candidate recipient by the independent legal and ethical committee, confirmation of being within the accepted age limits, assessment of BMI, initial anesthetic and surgical evaluation, confirmation of ABO compatibility, complete blood count (CBC) and biochemistry assays, pregnancy test, abdominal Doppler ultrasound, serological tests for hepatitis C and B viruses (serum HCV RNA qualitative and quantitative assay using PCR, HBV surface antigen, HB core antibody, HB e antigen, HB e antibody, HB surface antibody), serological assessment for different viruses (human immunodeficiency virus (HIV), Epstein-Barr virus (EBV), Herpes virus I and II, Cytomegalovirus (CMV), Chagas disease and syphilis), electrocardiography (ECG), echocardiography, plain X-ray of the chest, exclusion of specific liver diseases (ferritin, transferrin, and serum iron), and reassessment after previous investigations

Phase II: Liver biopsy for assessment of degree of steatosis and detection of any pathological conditions

Phase III: Hepatic angiography to delineate the anatomy of the portal vein, hepatic artery and hepatic veins. Magnetic resonance cholangiopancreatography (MRCP) is performed to assess the anatomy of the biliary system. Liver volumetry to assess the right lobe graft size, residual donor liver volume and graft-recipient weight ratio (GRWR). The donor is accepted if GRWR > 0.8 and the residual donor liver volume ≥ 30%

Phase IV: All donors must sign a written informed consent including agreement to participate in LDLT

LDLT: Living donor liver transplantation.

Table 2 Number and ratio for each reason of donor exclusion during phase I of the living donor evaluation protocol

Phase	Step	n	Exclusion	n	% from the step
Phase I	Confirmation of the relative	1004	Non-related donor	2	0.19
	Age	1002	Over age limit	223	22.25
	BMI	779	Overweight	26	3.33
			Underweight	5	0.64
	Clinical evaluation	748	Uncontrolled HTN	2	0.26
	Initial surgical evaluation	746	Upper abdominal surgery	6	0.8
	Psychological evaluation	740	Algophobia	1	0.13
			Hesitation	3	0.4
	ABO compatibility	736	ABO incompatibility	102	13.85
		634	Withdrawal	23	3.62
	CBC and biochemistry	611	thrombocytopenia	3	0.49
			uncontrolled DM	4	0.65
			elevated liver enzymes	7	1.14
			hyperbilirubinemia	2	0.32
			hypoalbuminemia	1	0.16
		594	Family refusal	5	0.84
			Withdrawal	6	1.01
	Pregnancy test	583	Positive test	16	2.74
	Abdominal US	567	Splenomegaly	1	0.17
			Fatty liver	1	0.17
		565	Withdrawal	29	5.13
	Serological assessment	536	HCV positive	39	7.27
			HBV positive	34	6.34
			CMV positive	7	1.3
			EBV positive	1	0.18
			HCV and HBV positive	6	1.11
			HCV and CMV positive	1	0.18
		448	Withdrawal	9	2.0
	Anesthetic reassessment	439	Smoker	28	6.37
			IHD	2	0.45
			Rheumatic heart disease	3	0.68
			Valvular heart disease	3	0.68
			Atrial ectopics	1	0.22
		402	Withdrawal	31	7.71

HCV: Hepatitis C virus; HBV: Hepatitis B virus; CMV: Cytomegalovirus.

Table 3 Number and ratio for each reason of donor exclusion during phase II to IV of the living donor evaluation protocol

Phase	Step	n	Exclusion	n	% from the step
Phase II	Liver biopsy	371	Moderate steatosis	16	4.31
			Severe steatosis	9	2.42
			Portal tract fibrosis	27	7.27
			Bilharzial granuloma	10	2.69
			Reactive hepatitis change	4	1.07
			Focal portal infiltrate	1	0.26
			Portal lymphocyte infiltrate	1	0.26
			Hemosiderosis	1	0.26
			Focal necrotic areas	1	0.26
		301	Withdrawal	38	12.62
Phase III	Volumetry and anatomical assessment	263	Portal venous variants	2	0.76
			Biliary variants	6	2.28
			hepatic venous variants	8	3.04
			hepatic venous and biliary variants	1	0.38
			hepatic and portal venous variants	3	1.14
			Small for size graft	15	5.70
			Small residual left lobe	4	1.50
		224	Withdrawal	9	4.01
Phase IV	Informed consent	215	Withdrawal	3	1.39
	Donors underwent surgery	212