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1
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Lo DJ, Magliocca JF, Ross-Driscoll K. Waitlist outcomes after acuity circle-based distribution in pediatric liver transplantation. Am J Transplant 2025:S1600-6135(25)00273-4. [PMID: 40389160 DOI: 10.1016/j.ajt.2025.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2025] [Revised: 04/20/2025] [Accepted: 05/11/2025] [Indexed: 05/21/2025]
Abstract
Pediatric liver transplant (LT) waitlist mortality remains unacceptably high. In 2020, the Organ Procurement and Transplantation Network (OPTN) implemented acuity circle (AC)-based liver distribution and national pediatric prioritization for pediatric donor livers. Using OPTN data, waitlist outcomes for pediatric LT candidates listed between February 4, 2016 and February 3, 2024, were studied by age group and era relative to AC implementation. There were 5,605 waitlist registrations and 3,778 liver transplants. At 1 year, cumulative incidence of transplant was 77.8% pre-AC vs 79.9% post-AC; cumulative incidence of mortality was 5.4% pre-AC vs 5.9% post-AC. Median allocation Model for End-Stage Liver Disease/Pediatric Model for End-Stage Liver Disease score at LT significantly decreased across all age groups post-AC (p<0.001). Candidates age 12-17 years experienced higher cumulative incidence of transplant (65.6% pre-AC vs 79.5% post-AC at 1 year), decreased median time to transplant (66 days pre-AC vs 37 days post-AC, p<0.001), and increased proportion of pediatric donor livers (37.9% pre-AC vs 66.2% post-AC, p<0.001). AC group was associated with increased likelihood of transplant for those age 12-17 years and increased likelihood of waitlist mortality for those age 1-5 years. LT candidates age 12-17 years derived the most benefit from AC-based liver distribution.
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Affiliation(s)
- Denise J Lo
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.
| | - Joseph F Magliocca
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Katherine Ross-Driscoll
- Department of Surgery, Indiana University, Indianapolis, IN, USA; Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, USA; Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
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2
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Li Z, Jones O, Takamatsu F, Stunguris J, Magyar CTJ, Selzner N, Kamath B, Avitzur Y, Ling S, Jones N, Bandsma RHJ, Miserachs M, Sapisochin G, Cattral M, Ghanekar A, Siddiqui A, Ng VL, Sayed BA. Living-donor availability improves pediatric patient survival in a large North American center: An intention-to-treat analysis. Liver Transpl 2025:01445473-990000000-00607. [PMID: 40266271 DOI: 10.1097/lvt.0000000000000629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2025] [Accepted: 04/01/2025] [Indexed: 04/24/2025]
Abstract
Although living-donor liver transplantation (LDLT) is increasingly adopted for pediatric liver transplantation, there is limited data on whether live donation extends benefits to patients from the time of listing. This study investigated the benefits of pediatric LDLT through an intention-to-treat analysis. Pediatric candidates listed between 2001 and 2023 at a single Canadian center were categorized as pLDLT (with a potential live donor) or pDDLT (without a live donor). The primary endpoint was overall survival from the time of listing. The secondary endpoint involved the waitlist outcomes described by the probabilities of receiving liver transplantation or waitlist dropout. Among 474 candidates, 219 (46.2%) had potential live donors. The pLDLT group had a higher likelihood of receiving a liver transplantation (adjusted HR: 1.38, 95% CI: 1.16-1.64) and a lower risk of dying without a transplant (adjusted HR: 0.11, 95% CI: 0.01-0.82) compared to the pDDLT group. Survival rates from the time of listing were significantly better in the pLDLT group at 1-(98.6% vs. 87.6%), 5-(96.6% vs. 84.4%), and 10-(96.6% vs. 83.1%) years. Having a potential live donor was linked to a 72% reduction in mortality risk (adjusted HR: 0.28, 95% CI: 0.12-0.64). Although the number of patients listed annually increased over the study period, the waiting time for deceased donation shortened. This correlated with increased LDLT utilization, suggesting LDLT not only improved outcomes but also shortened wait times even for pDDLT patients. Having a potential live donor is associated with substantial survival benefit. Pediatric programs offering LDLT can expand the donor pool and decrease the waiting time for DDLT, supporting the argument for making LDLT a standard for pediatric candidates.
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Affiliation(s)
- Zhihao Li
- HBP & Multi-Organ Transplant Program, Division of General Surgery, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Owen Jones
- HBP & Multi-Organ Transplant Program, Division of General Surgery, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Fernanda Takamatsu
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Jennifer Stunguris
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Center, The Hospital for Sick Children, Toronto, Canada
| | - Christian T J Magyar
- HBP & Multi-Organ Transplant Program, Division of General Surgery, Ajmera Transplant Centre, University Health Network, Toronto, Canada
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Nazia Selzner
- HBP & Multi-Organ Transplant Program, Division of General Surgery, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Binita Kamath
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Center, The Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Center, The Hospital for Sick Children, Toronto, Canada
| | - Simon Ling
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Center, The Hospital for Sick Children, Toronto, Canada
| | - Nicola Jones
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Center, The Hospital for Sick Children, Toronto, Canada
| | - Robert H J Bandsma
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Center, The Hospital for Sick Children, Toronto, Canada
| | - Mar Miserachs
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Center, The Hospital for Sick Children, Toronto, Canada
| | - Gonzalo Sapisochin
- HBP & Multi-Organ Transplant Program, Division of General Surgery, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Mark Cattral
- HBP & Multi-Organ Transplant Program, Division of General Surgery, Ajmera Transplant Centre, University Health Network, Toronto, Canada
- Transplant and Regenerative Medicine Center, The Hospital for Sick Children, Toronto, Canada
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Anand Ghanekar
- HBP & Multi-Organ Transplant Program, Division of General Surgery, Ajmera Transplant Centre, University Health Network, Toronto, Canada
- Transplant and Regenerative Medicine Center, The Hospital for Sick Children, Toronto, Canada
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Asad Siddiqui
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vicky L Ng
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Center, The Hospital for Sick Children, Toronto, Canada
| | - Blayne A Sayed
- HBP & Multi-Organ Transplant Program, Division of General Surgery, Ajmera Transplant Centre, University Health Network, Toronto, Canada
- Transplant and Regenerative Medicine Center, The Hospital for Sick Children, Toronto, Canada
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Canada
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3
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Hwang CS, Aqul AA, Kwon YK. Expanding pediatric liver transplants: the role of split grafts, allocation policies, and machine perfusion. Curr Opin Organ Transplant 2025:00075200-990000000-00174. [PMID: 40173002 DOI: 10.1097/mot.0000000000001220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2025]
Abstract
PURPOSE OF REVIEW Pediatric liver transplant waitlist mortality remains disproportionately high, particularly among infants under one year old. Despite the success of split liver transplantation (SLT) in improving pediatric access to transplants, its utilization remains limited. This review examines barriers to SLT adoption, explores the impact of pediatric-focused allocation policies, and evaluates the potential of machine perfusion technology in expanding the pediatric donor pool. RECENT FINDINGS Studies have demonstrated that SLT outcomes are comparable to whole graft transplants when performed at experienced centers. However, logistical challenges, technical expertise, and policy limitations hinder its widespread adoption. Countries with pediatric-prioritized allocation and mandatory SLT policies, such as Italy and the United Kingdom, have significantly reduced pediatric waitlist mortality. Additionally, machine perfusion technology has emerged as a promising solution, allowing for ex vivo graft splitting and reducing ischemic injury, which may enhance graft utilization. SUMMARY A multifaceted approach is necessary to improve pediatric liver transplant outcomes, including stronger pediatric-first allocation policies, SLT training expansion, and integration of machine perfusion technologies. Implementing these strategies in the United States could significantly reduce pediatric waitlist mortality without negatively impacting adult transplant candidates.
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Affiliation(s)
- Christine S Hwang
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center
- Division of Pediatric Transplantation, Children's Medical Center
| | - Amal A Aqul
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Texas Southwestern, Dallas, Texas, USA
| | - Yong Kyong Kwon
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center
- Division of Pediatric Transplantation, Children's Medical Center
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Gadour E. Lesson learnt from 60 years of liver transplantation: Advancements, challenges, and future directions. World J Transplant 2025; 15:93253. [PMID: 40104199 PMCID: PMC11612893 DOI: 10.5500/wjt.v15.i1.93253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 09/06/2024] [Accepted: 09/14/2024] [Indexed: 11/26/2024] Open
Abstract
Over the past six decades, liver transplantation (LT) has evolved from an experimental procedure into a standardized and life-saving intervention, reshaping the landscape of organ transplantation. Driven by pioneering breakthroughs, technological advancements, and a deepened understanding of immunology, LT has seen remarkable progress. Some of the most notable breakthroughs in the field include advances in immunosuppression, a revised model for end-stage liver disease, and artificial intelligence (AI)-integrated imaging modalities serving diagnostic and therapeutic roles in LT, paired with ever-evolving technological advances. Additionally, the refinement of transplantation procedures, resulting in the introduction of alternative transplantation methods, such as living donor LT, split LT, and the use of marginal grafts, has addressed the challenge of organ shortage. Moreover, precision medicine, guiding personalized immunosuppressive strategies, has significantly improved patient and graft survival rates while addressing emergent issues, such as short-term complications and early allograft dysfunction, leading to a more refined strategy and enhanced post-operative recovery. Looking ahead, ongoing research explores regenerative medicine, diagnostic tools, and AI to optimize organ allocation and post-transplantation car. In summary, the past six decades have marked a transformative journey in LT with a commitment to advancing science, medicine, and patient-centered care, offering hope and extending life to individuals worldwide.
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Affiliation(s)
- Eyad Gadour
- Department of Gastroenterology and Hepatology, King Abdulaziz National Guard Hospital, Ahsa 36428, Saudi Arabia
- Internal Medicine, Zamzam University College, Khartoum 11113, Sudan
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5
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Aoki H, Ito T, Hirata M, Okumura S, Masano Y, Ogawa E, Haga H, Hatano E. Adverse effects of graft congestion and ameliorative effects of hepatocyte growth factor after liver transplantation in rats. Liver Transpl 2025; 31:11-23. [PMID: 39225679 PMCID: PMC11643138 DOI: 10.1097/lvt.0000000000000449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 07/23/2024] [Indexed: 09/04/2024]
Abstract
Living donor liver transplantation (LT) and deceased donor split-LT often result in congestion within liver grafts. The regenerative process and function of congested areas, especially graft congestion associated with LT, are not well understood. Therefore, we created new rat models with congested areas in partially resected livers and orthotopically transplanted these livers into syngeneic rats to observe liver regeneration and function in congested areas. This study aimed to compare liver regeneration and the function of congested areas after liver resection and LT, and to explore a new approach to ameliorate the adverse effects of graft congestion. Although the congested areas after liver resection regenerated normally on postoperative day 7, the congested areas after LT had poor regeneration with abscess development on postoperative day 7. Necrotic areas in congested areas were larger after LT than after liver resection on postoperative days 1, 3, and 7 ( p < 0.05, p < 0.05, and p < 0.01, respectively). Although congested areas after liver resection did not affect survival, in the LT model, the survival of rats with congested areas was significantly poorer even with larger grafts than that of rats with smaller noncongested grafts ( p = 0.04). Hepatocyte growth factor administration improved the survival rate of rats with congested grafts from 41.7% to 100%, improved the regeneration of congested areas, and significantly reduced the size of necrotic areas ( p < 0.05). Thus, congested areas in liver grafts may negatively impact recipients. Short-term administration of hepatocyte growth factor may improve postoperative outcomes of recipients with graft congestion and contribute to more effective use of liver grafts (approval number: MedKyo-23137, Institutional Ethics Committee/Kyoto University).
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Affiliation(s)
- Hikaru Aoki
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Ito
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masaaki Hirata
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinya Okumura
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuki Masano
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Eri Ogawa
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hironori Haga
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | - Etsuro Hatano
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Sun Q, Cao H, Bai X, Han X, You W, Sun Z, Zhang Y, Wu X, Fang F, Wu F, Yang L, Yan S, Ding Y, Wang W. Adult split liver transplantation to treat liver cancer: a single-center retrospective study. World J Emerg Med 2025; 16:57-62. [PMID: 39906109 PMCID: PMC11788118 DOI: 10.5847/wjem.j.1920-8642.2024.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2024] [Accepted: 12/25/2024] [Indexed: 02/06/2025] Open
Abstract
BACKGROUND The increasing morbidity of liver cancer has led to a growing demand for transplantation. Split liver transplantation (SLT) is a promising way to ameliorate organ shortages. However, the safety and efficacy of SLT are still controversial. The aim of this study was to assess the clinical outcome of SLT in liver cancer patients at our center. METHODS A total of 74 patients who received liver transplantation at a tertiary hospital from March 2019 to July 2023 were retrospectively studied, of whom 37 recipients underwent SLT and 37 recipients underwent whole-graft liver transplantation (WGLT). Clinical data were analyzed and compared between patients who underwent SLT and WGLT. RESULTS SLT and WGLT were successfully performed, with no intraoperative transplant-related mortality. Postoperatively, no significant differences in total bilirubin (TB, P=0.266), alanine transaminase (ALT, P=0.403) and aspartate transaminase (AST, P=0.160) levels within 30 d were detected between the two groups. The transplant-related mortality rates were 8.1% in the SLT group and 5.4% in the WGLT group within 30 d of surgery (P=1.000), and 10.8% and 8.1%, respectively, at 90 d after surgery (P=1.000). There were no significant differences in overall survival (OS) and progress-free survival (PFS) between the SLT and WGLT groups (P=0.910, P=0.190). CONCLUSION Our results show that SLT does not imply additional risks in treating liver cancer compared with WGLT.
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Affiliation(s)
- Qiang Sun
- Department of Hepatobiliary Pancreatic Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Haoze Cao
- Department of Hepatobiliary Pancreatic Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Xuesong Bai
- Department of Hepatobiliary Pancreatic Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Xin Han
- Department of Hepatobiliary Pancreatic Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Wanlu You
- Department of Hepatobiliary Pancreatic Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zhongquan Sun
- Department of Hepatobiliary Pancreatic Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Yixin Zhang
- Department of Hepatobiliary Pancreatic Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Xiaochang Wu
- Department of Hepatobiliary Surgery, Huzhou Central Hospital, Zhejiang University Huzhou Hospital, Huzhou 313002, China
| | - Feng Fang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Fan Wu
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Lianyue Yang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Sheng Yan
- Department of Hepatobiliary Pancreatic Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Yuan Ding
- Department of Hepatobiliary Pancreatic Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Weilin Wang
- Department of Hepatobiliary Pancreatic Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
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Lau NS, McCaughan G, Ly M, Liu K, Crawford M, Pulitano C. Long-term machine perfusion of human split livers: a new model for regenerative and translational research. Nat Commun 2024; 15:9809. [PMID: 39532864 PMCID: PMC11557707 DOI: 10.1038/s41467-024-54024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 10/30/2024] [Indexed: 11/16/2024] Open
Abstract
Recent advances in machine perfusion have revolutionised the field of transplantation by prolonging preservation, permitting evaluation of viability prior to implant and rescue of discarded organs. Long-term perfusion for days-to-weeks provides time to modify these organs prior to transplantation. By using long-term normothermic machine perfusion to facilitate liver splitting and subsequent perfusion of both partial organs, possibilities even outside the clinical arena become possible. This model remains in its infancy but in the future, could allow for detailed study of liver injury and regeneration, and ex-situ treatment strategies such as defatting, genetic modulation and stem-cell therapies. Here we provide insight into this new model for research and highlight its great potential and current limitations.
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Affiliation(s)
- Ngee-Soon Lau
- Centre for Organ Assessment Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Geoffrey McCaughan
- Centre for Organ Assessment Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Mark Ly
- Centre for Organ Assessment Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Ken Liu
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Michael Crawford
- Centre for Organ Assessment Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Carlo Pulitano
- Centre for Organ Assessment Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia.
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia.
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia.
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8
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Nakayama T, Akabane M, Imaoka Y, Esquivel CO, Melcher ML, Sasaki K. Does the introduction of the acuity circle policy change split liver transplantation practice? Liver Transpl 2024:01445473-990000000-00490. [PMID: 39412327 DOI: 10.1097/lvt.0000000000000513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 09/26/2024] [Indexed: 01/16/2025]
Abstract
With the acuity circles (AC) policy aiming to reduce disparities in liver transplantation (LT) access, the allocation of high-quality grafts has shifted, potentially affecting the use and outcomes of split LT. Data from the United Network for Organ Sharing (UNOS) database (February 4, 2016, to February 3, 2024) were analyzed, including 1470 candidates who underwent deceased donor split LT, with 681 adult and 789 pediatric cases. The study periods were divided into pre-AC (February 4, 2016, to February 3, 2020) and post-AC (February 4, 2020, to February 3, 2024). The study assessed changes in split LT volumes and examined the impact of center practices. Both adult and pediatric split LTs decreased in the initial 3 years after the policy change, followed by an increase in the final year, with an overall 11.9% and 13.9% decrease between the eras. Adult female split LT cases remained consistent, ensuring access for smaller recipients. High-quality "splittable" livers were increasingly allocated to high MELD patients (MELD-Na ≥30). Despite the overall decrease in case volume, adult split LT volume increased in newly active living donor liver transplantation centers, with 6 centers increasing living donor liver transplantation volume by over 50.0%. Pediatric split LT volumes decreased despite additional priorities for pediatric candidates. The number of split LTs decreased in the initial period after the AC policy introduction, but there was a consistent need for small female candidates. In the adult population, living donor liver transplantation and split LT demonstrated a synergistic effect in boosting center transplant volumes, potentially improving access for female candidates who need small grafts.
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Affiliation(s)
- Toshihiro Nakayama
- Division of Abdominal Transplant, Department of Surgery, Stanford University Medical Center, Stanford, California, USA
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9
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Barbier L, Hitchins C, Carr-Boyd P, Evans HM, McCall J. Comparison of Long-Term Outcomes Achieved With Live Donor and Split Deceased Donor Liver Grafts in Pediatric Liver Transplantation. Pediatr Transplant 2024; 28:e14843. [PMID: 39158057 DOI: 10.1111/petr.14843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 05/19/2024] [Accepted: 07/30/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND The aim of the present study was to compare the outcomes of pediatric LT with left liver grafts, obtained either from a living donor (LD) or a split deceased donor (sDD). METHODS Retrospective single-center study from 2002 to 2022. All pediatric LT with left liver grafts (not including middle hepatic vein) from LD or sDD were included. Reduced grafts were not included. RESULTS A total of 112 pediatric LT were performed: 58 with LD grafts and 54 with sDD grafts (17 split ex situ and 37 in situ). Donor characteristics were similar, apart from donor age (33 years in LD vs. 30 years in sDD, p = 0.03). Indications were similar with 55% biliary atresia in each group. Retransplantation was more frequently performed in the sDD group (2% vs. 15%, p = 0.01). Recipient age, weight, and PELD score at transplant were not significantly different between groups. Cold ischemia time was longer for sDD (158 min in LD vs. 390 min in sDD; p < 0.0001). Posttransplant peak ALT was higher with sDD grafts (1470 vs. 1063, p = 0.018), and hospital stay was longer with sDD grafts (27 vs. 21 days, p = 0.005). However, there was no difference between groups in terms of major morbidity (Dindo-Clavien grade ≥3), vascular and biliary complications, and 90-day mortality. Patient survival at 10 years was 93.1% for LD and 92.8% for sDD (p = 0.807). Graft survival at 10 years was 89.7% for LD and 83.1% for sDD (p = 0.813). CONCLUSIONS Technically similar LD and sDD grafts achieve very similar postoperative and long-term outcomes with excellent patient and graft survival.
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Affiliation(s)
- Louise Barbier
- New Zealand Liver Transplant Unit, Te Toka Tumai, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Peter Carr-Boyd
- New Zealand Liver Transplant Unit, Te Toka Tumai, Auckland, New Zealand
| | - Helen M Evans
- Department of Pediatric Gastroenterology, Starship Child Health, Te Toka Tumai, Auckland, New Zealand
- Department of Pediatrics, University of Auckland, Auckland, New Zealand
| | - John McCall
- New Zealand Liver Transplant Unit, Te Toka Tumai, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
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10
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Krendl FJ, Cardini B, Laimer G, Singh J, Resch T, Oberhuber R, Schneeberger S. Normothermic Liver Machine Perfusion and Successful Transplantation of Split Liver Grafts: From Proof of Concept to Clinical Implementation. Transplantation 2024; 108:1410-1416. [PMID: 38548703 DOI: 10.1097/tp.0000000000004997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
BACKGROUND Normothermic liver machine perfusion (NLMP) is advancing the field of liver transplantation (LT). Beyond improved preservation and organ assessment, NLMP helps to increase organ utilization. We herein address the feasibility and merit of NLMP in split liver transplantation (SLT) to postpone the transplantation of the second split graft to the following day. METHODS We analyzed the perfusion characteristics and outcomes of all consecutive adult recipients who underwent SLT following NLMP from February 1, 2018, to June 30, 2023. The primary endpoint was 90-d graft and patient survival. Secondary endpoints were posttransplant complications and 90-d morbidity. RESULTS Three right and 3 extended right SLT following NLMP have been performed. NLMP was uneventful in all cases. Perfusion characteristics differed according to graft volume. Mean perfusion time was 17:00 h (±05:13) and bile production ranged between 8 and 21 mL/h. All split grafts fulfilled predefined center viability criteria during NLMP and were transplanted on the following day. The 90-d graft and patient survival rate was 100%. Three patients (50%) required an early relaparotomy, and 2 patients (33.3%) developed biliary complications. The 90-d morbidity as recorded by the comprehensive complication index was 62.7 (±24.7). CONCLUSIONS NLMP of split liver grafts is technically feasible and safe. Through prolongation of preservation time, NLMP allows to safely postpone transplantation of the second split liver graft to the next day.
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Affiliation(s)
- Felix J Krendl
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Gregor Laimer
- Interventional Oncology/Stereotaxy and Robotics, Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jessica Singh
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Resch
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
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11
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Chen H, Hu Z, Xu Q, He C, Yang X, Shen W, Lin Z, Li H, Zhuang L, Cai J, Lerut J, Zheng S, Lu D, Xu X. The adverse impact of perioperative body composition abnormalities on outcomes after split liver transplantation: a multicenter retrospective cohort study. Int J Surg 2024; 110:3543-3553. [PMID: 38489552 PMCID: PMC11175784 DOI: 10.1097/js9.0000000000001303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 02/23/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Split liver transplantation (SLT) increases graft availability, but it's safe and effective utilization is insufficiently documented. This study aimed to investigate the association between perioperative body composition abnormalities and outcomes in adult SLT. MATERIALS AND METHODS Two hundred forty recipients who underwent SLT in three centers were enrolled in this retrospective cohort study. Body composition abnormalities including sarcopenia, myosteatosis, visceral obesity, and sarcopenic obesity were evaluated at baseline and 1 month after surgery using computed tomography. Their impact on outcomes including early allograft dysfunction, early complications, ICU stay, graft regeneration rate, and survival was analyzed. RESULTS Recipients with sarcopenia or myosteatosis had a higher risk of early allograft dysfunction, higher early complication rate, and longer length of ICU stay (all P <0.05), while there was no difference in graft regeneration rate. Recipient and graft survival were significantly worse for recipients with body composition abnormalities (all P <0.05). In multivariable Cox-regression analysis, sarcopenia [hazard ratio (HR)=1.765, P =0.015], myosteatosis (HR=2.066, P =0.002), and visceral obesity (HR=1.863, P =0.008) were independently associated with shorter overall survival. Piling up of the three factors increased the mortality risk stepwise ( P <0.001). Recipients experienced skeletal muscle loss and muscle fat infiltration 1 month after surgery. Postoperative worsening sarcopenia (HR=2.359, P =0.009) and myosteatosis (HR=1.878, P =0.026) were also identified as independent risk factors for mortality. CONCLUSION Sarcopenia, myosteatosis, and their progression negatively affect outcomes including early allograft dysfunction, early complications, ICU stay and survival after SLT. Systemic evaluation and dynamic monitoring of body composition are valuable.
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Affiliation(s)
- Hao Chen
- Zhejiang University, School of Medicine
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health
| | - Zhihang Hu
- Zhejiang University, School of Medicine
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health
| | - Qingguo Xu
- Organ Transplantation Center, Affiliated Hospital of Qingdao University, Qingdao, People’s Republic of China
| | - Chiyu He
- Zhejiang University, School of Medicine
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health
| | - Xinyu Yang
- Zhejiang University, School of Medicine
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health
| | - Wei Shen
- Zhejiang University, School of Medicine
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health
| | - Zuyuan Lin
- Zhejiang University, School of Medicine
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health
| | - Huigang Li
- Zhejiang University, School of Medicine
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health
| | - Li Zhuang
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital
| | - Jinzhen Cai
- Organ Transplantation Center, Affiliated Hospital of Qingdao University, Qingdao, People’s Republic of China
| | - Jan Lerut
- Starzl Unit of Abdominal Transplantation, University Hospitals Saint Luc, Université catholique Louvain, Brussels, Belgium
| | - Shusen Zheng
- Zhejiang University, School of Medicine
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health
- National Center for Healthcare Quality Management in Liver Transplant
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, People’s Republic of China
| | - Di Lu
- Zhejiang University, School of Medicine
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health
- National Center for Healthcare Quality Management in Liver Transplant
| | - Xiao Xu
- Zhejiang University, School of Medicine
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health
- National Center for Healthcare Quality Management in Liver Transplant
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12
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Sneiders D, van Dijk ABRM, Darwish-Murad S, van Rosmalen M, Erler NS, IJzermans JNM, Polak WG, Hartog H. Quantifying the Disadvantage of Small Recipient Size on the Liver Transplantation Waitlist, a Longitudinal Analysis Within the Eurotransplant Region. Transplantation 2024; 108:1149-1156. [PMID: 37953483 PMCID: PMC11042512 DOI: 10.1097/tp.0000000000004804] [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: 01/13/2023] [Revised: 05/16/2023] [Accepted: 06/03/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Small adult patients with end-stage liver disease waitlisted for liver transplantation may face a shortage of size-matched liver grafts. This may result in longer waiting times, increased waitlist removal, and waitlist mortality. This study aims to assess access to transplantation in transplant candidates with below-average bodyweight throughout the Eurotransplant region. METHODS Patients above 16 y of age listed for liver transplantation between 2010 and 2015 within the Eurotransplant region were eligible for inclusion. The effect of bodyweight on chances of receiving a liver graft was studied in a Cox model corrected for lab-Model for End-stage Liver Disease (MELD) score updates fitted as time-dependent variable, blood type, listing for malignant disease, and age. A natural spline with 3 degrees of freedom was used for bodyweight and lab-MELD score to correct for nonlinear effects. RESULTS At the end of follow-up, the percentage of transplanted, delisted, and deceased waitlisted patients was 49.1%, 17.9%, and 24.3% for patients with a bodyweight <60 kg (n = 1267) versus 60.1%, 15.1%, and 18.6% for patients with a bodyweight ≥60 kg (n = 10 520). To reach comparable chances for transplantation, 60-kg and 50-kg transplant candidates are estimated to need, respectively, up to 2.8 and 4.0 more lab-MELD points than 80-kg transplant candidates. CONCLUSIONS Decreasing bodyweight was significantly associated with decreased chances to receive a liver graft. This resulted in substantially longer waiting times, higher delisting rates, and higher waitlist mortality for patients with a bodyweight <60 kg.
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Affiliation(s)
- Dimitri Sneiders
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Anne-Baue R. M. van Dijk
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sarwa Darwish-Murad
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Nicole S. Erler
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jan N. M. IJzermans
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wojciech G. Polak
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Hermien Hartog
- Department of HPB and Liver Transplantation, University Medical Center Groningen, Groningen, the Netherlands
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13
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Spada M, Angelico R, Trapani S, Masiero L, Puoti F, Colledan M, Cintorino D, Romagnoli R, Cillo U, Cardillo M. Tailoring allocation policies and improving access to paediatric liver transplantation over a 16-year period. J Hepatol 2024; 80:505-514. [PMID: 38122833 DOI: 10.1016/j.jhep.2023.11.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 11/13/2023] [Accepted: 11/16/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND & AIMS Mortality on the paediatric liver transplantation (pLT) waiting list (WL) is still an issue. We analysed the Italian pLT WL to evaluate the intention-to-treat (ITT) success rate and to identify factors influencing success. METHODS All children (<18 years) listed for pLT in Italy between 2002-2018 were included (Era 1 [2002-2007]: centre-based allocation; Era 2 [2008-2014]: national allocation; Era 3 [2015-2018]: national allocation+mandatory-split policy). RESULTS A total of 1,424 patients (median age: 2.0 [IQR 1.0-9.0] years; median weight: 12.0 kg [IQR 7-27]) were listed for pLT. Median WL time was 2 days (IQR 1-5) for Status 1 and 44 days (IQR 15-120) for non-Status 1 patients; 1,302 children (91.4%) were transplanted (67.3% with split grafts), while 50 children (3.5%) dropped off the WL (2.5% death, 1.0% clinical deterioration). Predictive factors for receiving LT included Status 1 (hazard ratio [HR] 1.66, p = 0.001), Status 1B (HR 1.96, p = 0.016), Status 2A (HR 2.15, p = 0.024) and each 1-point increase in PELD/MELD score. Children with recipient's weight >25 kg, blood group O or awaiting pLT combined with other organs had less chance of being transplanted. ITT patient survival rates were 90.5% at 1 year and 87.5% at 5 years, remaining stable across eras. Risk factors for ITT survival were re-transplantation (HR 5.83, p <0.001), Status 1 (HR 2.28, p = 0.006), Status 1B (HR 2.90, p = 0.014), Status 2A (HR 9.12, p <0.001), recipient weight <6 kg (HR 4.53, p <0.001) and low-volume activity (HR 4.38, p = 0.001). CONCLUSIONS In Italy, continuous adaption of paediatric organ allocation policies via the introduction of national allocation, paediatric prioritisation rules and a mandatory-split policy have helped maximise the use of donors for paediatric candidates and to minimise WL mortality without compromising outcomes. IMPACT AND IMPLICATIONS Globally, paediatric liver transplant candidates still suffer from high mortality. Over recent decades, the continuous adaption of organ allocation policies in Italy has led to excellent outcomes for children awaiting liver transplantation. The mortality rate of paediatric liver transplant candidates has been minimised to almost zero, mainly using grafts from deceased donors. Paediatric prioritisation rules, national organ exchange organisation and a mandatory-split liver policy have resulted in a unique allocation model for paediatric liver transplant candidates and represent a landmark for the paediatric transplant community.
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Affiliation(s)
- Marco Spada
- Divison of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, Research Unit of Clinical Hepatogastroenterology and Transplantation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Roberta Angelico
- HPB and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Silvia Trapani
- Italian National Transplant Center, National Institute of Health, Rome, Italy
| | - Lucia Masiero
- Italian National Transplant Center, National Institute of Health, Rome, Italy
| | - Francesca Puoti
- Italian National Transplant Center, National Institute of Health, Rome, Italy
| | - Michele Colledan
- Department of Organ Failure and Transplantation - ASST Papa Giovanni XXIII, Bergamo, Italy; Università Milano-Bicocca, Milan, Italy
| | - Davide Cintorino
- Department of Pediatrics for the Study of Abdominal Diseases and Abdominal Transplantation, ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), IRCCS -UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Renato Romagnoli
- General Surgery 2U, Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Padova, Padova, Italy
| | - Massimo Cardillo
- Italian National Transplant Center, National Institute of Health, Rome, Italy
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14
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Stoltz DJ, Gallo AE, Lum G, Mendoza J, Esquivel CO, Bonham A. Technical Variant Liver Transplant Utilization for Pediatric Recipients: Equal Graft Survival to Whole Liver Transplants and Promotion of Timely Transplantation Only When Performed at High-volume Centers. Transplantation 2024; 108:703-712. [PMID: 37635278 DOI: 10.1097/tp.0000000000004772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Technical variant liver transplantation (TVLT) is a strategy to mitigate persistent pediatric waitlist mortality in the United States, although its implementation remains stagnant. This study investigated the relationship between TVLT utilization, transplant center volume, and graft survival. METHODS Pediatric liver transplant recipients from 2010 to 2020 (n = 5208) were analyzed using the Scientific Registry of Transplant Recipients database. Transplant centers were categorized according to the average number of pediatric liver transplants performed per year (high-volume, ≥5; low-volume, <5). Graft survival rates were compared using Kaplan-Meier curves and log-rank tests. Cox proportional hazards models were used to identify predictors of graft failure. RESULTS High-volume centers demonstrated equivalent whole liver transplant and TVLT graft survival ( P = 0.057) and significantly improved TVLT graft survival compared with low-volume centers ( P < 0.001). Transplantation at a low-volume center was significantly associated with graft failure (adjusted hazard ratio, 1.6; 95% confidence interval, 1.14-2.24; P = 0.007 in patients <12 y old and 1.8; 95% confidence interval, 1.13-2.87; P = 0.013 in patients ≥12 y old). A subset of high-volume centers with a significantly higher rate of TVLT use demonstrated a 23% reduction in waitlist mortality. CONCLUSIONS Prompt transplantation with increased TVLT utilization at high-volume centers may reduce pediatric waitlist mortality without compromising graft survival.
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Affiliation(s)
- Daniel J Stoltz
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Amy E Gallo
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Grant Lum
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Julianne Mendoza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Carlos O Esquivel
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Andrew Bonham
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
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15
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Xiang Z, Li J, Zeng H, Xiang X, Gao F, Wang K, Wei X, Zheng S, Xu X. Current Understanding of Marginal Grafts in Liver Transplantation. Aging Dis 2024; 16:1036-1058. [PMID: 38607739 PMCID: PMC11964436 DOI: 10.14336/ad.2024.0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/14/2024] [Indexed: 04/14/2024] Open
Abstract
End-stage liver disease (ESLD), stemming from a spectrum of chronic liver pathologies including chronic liver failure, acute cirrhosis decompensation and hepatocellular carcinoma, imposes a significant global healthcare burden. Liver transplantation (LT) remains the only treatment for ESLD. However, the escalating mortality on transplant waitlists has prompted the utilization of marginal liver grafts in LT procedures. These grafts primarily encompass elderly livers, steatotic livers, livers from donation after circulatory death, split livers and those infected with the hepatitis virus. While the expansion of the donor pool offers promise, it also introduces concomitant risks. These encompass graft failure, biliary and cardiovascular complications, the recurrence of liver disease and reduced patient and graft survival. Consequently, various established strategies, ranging from improved donor-recipient matching to surgical interventions, have emerged to mitigate these risks. This article undertakes a comprehensive assessment of the current landscape, evaluating the viability of diverse marginal liver grafts. Additionally, it synthesizes approaches aimed at enhancing the quality of such marginal liver grafts. The overarching objective is to augment the donor pool and ameliorate the risk factors associated with the shortage of liver grafts.
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Affiliation(s)
- Ze Xiang
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China.
- Zhejiang University School of Medicine, Hangzhou 310058, China.
| | - Jiarui Li
- Zhejiang University School of Medicine, Hangzhou 310058, China.
| | - Huixuan Zeng
- Zhejiang University School of Medicine, Hangzhou 310058, China.
| | - Xiaonan Xiang
- Zhejiang University School of Medicine, Hangzhou 310058, China.
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, Cambridgeshire, UK.
| | - Fengqiang Gao
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China.
- Zhejiang University School of Medicine, Hangzhou 310058, China.
| | - Kai Wang
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China.
- Zhejiang University School of Medicine, Hangzhou 310058, China.
| | - Xuyong Wei
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China.
| | - Shusen Zheng
- Zhejiang University School of Medicine, Hangzhou 310058, China.
- Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China.
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China.
| | - Xiao Xu
- Zhejiang University School of Medicine, Hangzhou 310058, China.
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China.
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16
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Barrios O, Dopazo C, López-Boado MA, Gómez-Gavara C, Fundora Suarez Y, Torrents A, Llado L. Optimized results of the liver partition program for split-liver transplantation. Cir Esp 2024; 102:84-89. [PMID: 37980966 DOI: 10.1016/j.cireng.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/27/2023] [Indexed: 11/21/2023]
Abstract
INTRODUCTION Split liver transplantation is a procedure performed throughout Europe. In 2018 in Catalonia, the distribution of donors was redefined, being potential candidates for SPLIT all those under 35-years and it was made flexible the adult selection for the right graft. The study aim is to evaluate the effect of this modifications on the use of Split donors on the adult/pediatric waiting lists, as well as to evaluate the post-transplant results of adults who received a Split donor. METHODS Observational and retrospective study; 2 data collection periods "PRE" (2013-2017) and "POST" (2018-2021). The adults recipients results were analyzed by a propensity score matching. RESULTS In the first period 3 donors were registered and 3 pediatric patients and 2 adults recieved a transplant. In the POST period, 24 donations with liver bipartition were made, performing the transplant in 19 adults and 24 childrens. When comparing the adults waiting lists, a significant decrease was evidenced, both for adults (p = 0,0001) and on the children's waiting list (p = 0,0004), and up to 3 times there were no recipients on the pediatric waiting list. No significant differences between hospital morbidity or mortality or overall survival were observed in the group of adult recipients of Split grafts. CONCLUSIONS The flexibility in the selection of the adult recipient and the new distribution of donors makes possible to increase the bipartition rate, reducing the pediatric waiting list without worsening the adults results transplant recipients or their permanence on the waiting list.
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Affiliation(s)
- Oriana Barrios
- Departamento de Cirugía HBP y Trasplante Hepático, Hospital Universitari de Bellvitge, Barcelona, Spain.
| | - Cristina Dopazo
- Departamento de Cirugía HBP y Trasplante Hepático, Hospital Universitari Vall d´Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Miguel Angel López-Boado
- Departamento de Cirugía HBP y Trasplante Hepático, Hospital Clinic Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Concepción Gómez-Gavara
- Departamento de Cirugía HBP y Trasplante Hepático, Hospital Universitari Vall d´Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Yiliam Fundora Suarez
- Departamento de Cirugía HBP y Trasplante Hepático, Hospital Clinic Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Abiguei Torrents
- Organización Catalana de Trasplantes (OCATT), Servicio Catalán de Salud, Cataluña, Spain
| | - Laura Llado
- Departamento de Cirugía HBP y Trasplante Hepático, Hospital Universitari de Bellvitge, Barcelona, Spain
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17
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Lauterio A, Cillo U, Spada M, Trapani S, De Carlis R, Bottino G, Bernasconi D, Scalamogna C, Pinelli D, Cintorino D, D'Amico FE, Spagnoletti G, Miggino M, Romagnoli R, Centonze L, Caccamo L, Baccarani U, Carraro A, Cescon M, Vivarelli M, Mazaferro V, Ettorre GM, Rossi M, Vennarecci G, De Simone P, Angelico R, Agnes S, Di Benedetto F, Lupo LG, Zamboni F, Zefelippo A, Patrono D, Diviacco P, Laureiro ZL, Gringeri E, Di Francesco F, Lucianetti A, Valsecchi MG, Gruttadauria S, De Feo T, Cardillo M, De Carlis L, Colledan M, Andorno E. Improving outcomes of in situ split liver transplantation in Italy over the last 25 years. J Hepatol 2023; 79:1459-1468. [PMID: 37516203 DOI: 10.1016/j.jhep.2023.07.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND & AIMS Split liver transplant(ation) (SLT) is still considered a challenging procedure that is by no means widely accepted. We aimed to present data on 25-year trends in SLT in Italy, and to investigate if, and to what extent, outcomes have improved nationwide during this time. METHODS The study included all consecutive SLTs performed from May 1993 to December 2019, divided into three consecutive periods: 1993-2005, 2006-2014, and 2015-2019, which match changes in national allocation policies. Primary outcomes were patient and graft survival, and the relative impact of each study period. RESULTS SLT accounted for 8.9% of all liver transplants performed in Italy. A total of 1,715 in situ split liver grafts were included in the analysis: 868 left lateral segments (LLSs) and 847 extended right grafts (ERGs). A significant improvement in patient and graft survival (p <0.001) was observed with ERGs over the three periods. Predictors of graft survival were cold ischaemia time (CIT) <6 h (p = 0.009), UNOS status 2b (p <0.001), UNOS status 3 (p = 0.009), and transplant centre volumes: 25-50 cases vs. <25 cases (p = 0.003). Patient survival was significantly higher with LLS grafts in period 2 vs. period 1 (p = 0.008). No significant improvement in graft survival was seen over the three periods, where predictors of graft survival were CIT <6 h (p = 0.007), CIT <6 h vs. ≥10 h (p = 0.019), UNOS status 2b (p = 0.038), and UNOS status 3 (p = 0.009). Retransplantation was a risk factor in split liver graft recipients, with significantly worse graft and patient survival for both types of graft (p <0.001). CONCLUSIONS Our analysis showed Italian SLT outcomes to have improved over the last 25 years. These results could help to dispel reservations regarding the use of this procedure. IMPACT AND IMPLICATIONS Split liver transplant(ation) (SLT) is still considered a challenging procedure and is by no means widely accepted. This study included all consecutive in situ SLTs performed in Italy from May 1993 to December 2019. With more than 1,700 cases, it is one of the largest series, examining long-term national trends in in situ SLT since its introduction. The data presented indicate that the outcomes of SLT improved during this 25-year period. Improvements are probably due to better recipient selection, refinements in surgical technique, conservative graft-to-recipient matching, and the continuous, yet carefully managed, expansion of donor selection criteria under a strict mandatory split liver allocation policy. These results could help to dispel reservations regarding the use of this procedure.
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Affiliation(s)
- Andrea Lauterio
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padova, Italy
| | - Marco Spada
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Silvia Trapani
- Italian National Transplant Center-Istituto Superiore Di Sanità, Rome, Italy
| | - Riccardo De Carlis
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; PhD Course in Clinical and Experimental Sciences, University of Padua, Padua, Italy
| | - Giuliano Bottino
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Davide Bernasconi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Centre-B4, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Chiara Scalamogna
- North Italy Transplant Program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Domenico Pinelli
- Department of Organ Failure and Transplantation, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Davide Cintorino
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | | | - Gionata Spagnoletti
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Marco Miggino
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Renato Romagnoli
- Liver Transplant Center, General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Leonardo Centonze
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Lucio Caccamo
- Division of General Surgery and Liver Transplantation, Fondazione Cà Granda IRCCS, Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Umberto Baccarani
- Department of Medicine, Liver Transplant Center, University of Udine, Italy
| | - Amedeo Carraro
- Liver Transplant Unit, University and Hospital Trust of Verona, Italy
| | - Matteo Cescon
- Hepatobiliary Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Vivarelli
- HPB Surgery and Transplantation Unit, United Hospital of Ancona, Department of Experimental and Clinical Medicine Polytechnic University of Marche, Ancona, Italy
| | - Vincenzo Mazaferro
- Department of Oncology and Onco-Hematology, University of Milan, Italy; Department of Surgery, Istituto Nazionale Tumori Fondazione IRCCS Milan, Italy
| | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Massimo Rossi
- General Surgery and Organ Transplantation, Sapienza University of Rome, Umberto I Polyclinic of Rome, Rome, Italy
| | - Giovanni Vennarecci
- Division of Hepatobiliary Surgery and Liver Transplant Center, AORN Cardarelli, Naples, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation AOU Pisana, Pisa, Italy
| | - Roberta Angelico
- Department of Surgical Sciences, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Salvatore Agnes
- Department of Surgery, Transplantation Service, Catholic University of the Sacred Heart, Foundation A. Gemelli Hospital, Rome, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit Azienda Ospedaliera Policlinico, University of Modena and Reggio Emilia Modena, Italy
| | - Luigi Giovanni Lupo
- General Surgery and Liver Transplantation Unit, University of Bari, Bari, Italy
| | - Fausto Zamboni
- Department of Surgery, General and Hepatic Transplantation Surgery Unit, A.O.B. Brotzu, Cagliari, Italy
| | - Arianna Zefelippo
- Division of General Surgery and Liver Transplantation, Fondazione Cà Granda IRCCS, Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Damiano Patrono
- Liver Transplant Center, General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Pietro Diviacco
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Zoe Larghi Laureiro
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padova, Italy
| | - Fabrizio Di Francesco
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Alessandro Lucianetti
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Maria Grazia Valsecchi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Centre-B4, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy; Department of Surgery and Medical and Surgical Specialties, University of Catania, 95124, Catania, Italy
| | - Tullia De Feo
- North Italy Transplant Program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cardillo
- Italian National Transplant Center-Istituto Superiore Di Sanità, Rome, Italy
| | - Luciano De Carlis
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Colledan
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Department of Organ Failure and Transplantation, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Enzo Andorno
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
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Affiliation(s)
- Michael R Lucey
- From the Department of Medicine, Division of Gastroenterology and Hepatology (M.R.L.), the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition (K.N.F.), and the Department of Surgery, Division of Transplantation (D.P.F.), University of Wisconsin, Madison
| | - Katryn N Furuya
- From the Department of Medicine, Division of Gastroenterology and Hepatology (M.R.L.), the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition (K.N.F.), and the Department of Surgery, Division of Transplantation (D.P.F.), University of Wisconsin, Madison
| | - David P Foley
- From the Department of Medicine, Division of Gastroenterology and Hepatology (M.R.L.), the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition (K.N.F.), and the Department of Surgery, Division of Transplantation (D.P.F.), University of Wisconsin, Madison
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19
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Aoki H, Ito T, Hirata M, Kadohisa M, Yamamoto M, Uebayashi EY, Shirai H, Okumura S, Masano Y, Ogawa E, Okamoto T, Okajima H, Hatano E. Effects of Adding Congested Segment IV to the Left Lateral Graft on Short-term Outcomes in Pediatric Living-donor Liver-transplant Recipients. Transplant Direct 2023; 9:e1551. [PMID: 37876916 PMCID: PMC10593261 DOI: 10.1097/txd.0000000000001551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/11/2023] [Indexed: 10/26/2023] Open
Abstract
Background In some pediatric patients undergoing living-donor liver transplantation, segment IV without the middle hepatic vein can be added to a left lateral segment graft to obtain larger graft volume. Because no clear consensus on this technique exists, this study investigated the effects of congested areas on postoperative outcomes in pediatric patients with biliary atresia undergoing living-donor liver transplantation. Methods We retrospectively reviewed data of recipients with biliary atresia aged ≤15 y who had undergone living-donor liver transplantation at Kyoto University Hospital between 2006 and 2021 and with graft-to-recipient weight ratios (GRWR) of ≤2%. Based on the percentage of congested area in the graft, patients were classified into the noncongestion (n = 40; ≤10%) and congestion (n = 13; >10%) groups. To compare the differences between groups with similar nooncongestive GRWRs and investigate the effect of adding congested areas, patients in the noncongestion group with GRWRs of ≤1.5% were categorized into the small noncongestion group (n = 24). Results GRWRs and backgrounds were similar between the noncongestion and congestion groups; however, patients in the congestion group demonstrated significantly longer prothrombin times, higher ascites volumes, and longer hospitalization. Further, compared with the small noncongestion group, the congestion group had significantly greater GRWR and similar noncongestive GRWR; however, the congestion group had significantly longer prothrombin time recovery (P = 0.020, postoperative d 14), higher volume of ascites (P < 0.05, consistently), and longer hospitalization (P = 0.045), requiring significantly higher albumin and gamma-globulin transfusion volumes than the small noncongestion group (P = 0.027 and P = 0.0083, respectively). Reoperation for wound dehiscence was significantly more frequent in the congestion group (P = 0.048). Conclusions In pediatric liver-transplant recipients, adding a congested segment IV to the left lateral segment to obtain larger graft volume may negatively impact short-term postoperative outcomes.
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Affiliation(s)
- Hikaru Aoki
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Ito
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masaaki Hirata
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masashi Kadohisa
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Miki Yamamoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Hisaya Shirai
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinya Okumura
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuki Masano
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Eri Ogawa
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tatsuya Okamoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Pediatric Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Etsuro Hatano
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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20
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Lopez-Verdugo F, Sanchez-Garcia J, Baraki S, Kastenberg ZJ, Sanchez-Garavito JE, Zendejas I, Alonso D, Jensen MK, Fujita S, Meyers RL, Book L, Rodriguez-Davalos MI. Utilization of Segmental Grafts Is Associated With Higher Transplant Rates in Pediatric Patients. J Surg Res 2023; 290:28-35. [PMID: 37178557 DOI: 10.1016/j.jss.2023.03.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 03/03/2023] [Accepted: 03/26/2023] [Indexed: 05/15/2023]
Abstract
INTRODUCTION In July 2017, a policy to increase the use of segmental grafts (SGs) was implemented at our institution. The aim was to compare changes in waitlist activity after implementation of this policy. METHODS A single-center, retrospective study. Pediatric patients on the liver waiting list between January 2015 and December 2019 were screened. Patients were classified as receiving a liver transplant (LT) before (Period 1) or after (Period 2) policy changes. Primary end points were transplant rates and time to transplant. RESULTS Sixty five first LT performed on 65 patients were included. Twenty nine LT were performed during Period 1 and 36 during Period 2. More than half (55%) of LT in Period 2 were SG, compared to 10.3% in Period 1 (P < 0.001). Forty nine and 56 pediatric candidates on the waiting list accounted for 38.78 and 24.48 person-years during Period 1 and Period 2, respectively. Transplant rates per 100 person-years on the waiting list increased from 85.09 during Period 1 to 187.87 in Period 2 (Rate ratio: 2.20; P < 0.001). Median time to receive a LT decreased from 229 d in Period 1 to 75 d during Period 2 (P = 0.013). One-year patient survival rates were 96.6% in Period 1 and 95.7% in Period 2. One-year graft survival rates were 89.7% and 88% in Period 1 and Period 2, respectively. CONCLUSIONS A policy to increase the use of SG was associated with significantly higher transplant rates and lower waiting times. Implementation of this policy can be done successfully with no observed negative impact on patient and graft survival.
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Affiliation(s)
- Fidel Lopez-Verdugo
- Liver Center, Primary Children's Hospital, Salt Lake City, Utah; Transplant Services, Intermountain Medical Center, Salt Lake City, Utah
| | - Jorge Sanchez-Garcia
- Liver Center, Primary Children's Hospital, Salt Lake City, Utah; Transplant Services, Intermountain Medical Center, Salt Lake City, Utah
| | - Shanni Baraki
- Liver Center, Primary Children's Hospital, Salt Lake City, Utah
| | - Zachary J Kastenberg
- Division of Pediatric Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Ivan Zendejas
- Liver Center, Primary Children's Hospital, Salt Lake City, Utah; Transplant Services, Intermountain Medical Center, Salt Lake City, Utah
| | - Diane Alonso
- Liver Center, Primary Children's Hospital, Salt Lake City, Utah; Transplant Services, Intermountain Medical Center, Salt Lake City, Utah
| | - M Kyle Jensen
- Liver Center, Primary Children's Hospital, Salt Lake City, Utah; Department of Pediatrics, Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, Utah
| | - Shiro Fujita
- Liver Center, Primary Children's Hospital, Salt Lake City, Utah; Transplant Services, Intermountain Medical Center, Salt Lake City, Utah
| | - Rebecka L Meyers
- Division of Pediatric Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Linda Book
- Liver Center, Primary Children's Hospital, Salt Lake City, Utah; Department of Pediatrics, Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, Utah
| | - Manuel I Rodriguez-Davalos
- Liver Center, Primary Children's Hospital, Salt Lake City, Utah; Transplant Services, Intermountain Medical Center, Salt Lake City, Utah.
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21
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Mazariegos GV, Perito ER, Squires JE, Soltys KA, Griesemer AD, Taylor SA, Pahl E. Center use of technical variant grafts varies widely and impacts pediatric liver transplant waitlist and recipient outcomes in the United States. Liver Transpl 2023; 29:671-682. [PMID: 36746117 PMCID: PMC10270279 DOI: 10.1097/lvt.0000000000000091] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/06/2023] [Indexed: 02/07/2023]
Abstract
To assess the impact of technical variant grafts (TVGs) [including living donor (LD) and deceased donor split/partial grafts] on waitlist (WL) and transplant outcomes for pediatric liver transplant (LT) candidates, we performed a retrospective analysis of Organ Procurement and Transplantation Network (OPTN) data on first-time LT or liver-kidney pediatric candidates listed at centers that performed >10 LTs during the study period, 2004-2020. Center variance was plotted for LT volume, TVG usage, and survival. A composite center metric of TVG usage and WL mortality was developed to demonstrate the existing variation and potential for improvement. Sixty-four centers performed 7842 LTs; 657 children died on the WL. Proportions of WL mortality by center ranged from 0% to 31% and those of TVG usage from 0% to 76%. Higher TVG usage, from deceased donor or LD, independently or in combination, significantly correlated with lower WL mortality. In multivariable analyses, death from listing was significantly lower with increased center TVG usage (HR = 0.611, CI: 0.40-0.92) and LT volume (HR = 0.995, CI: 0.99-1.0). Recipients of LD transplants (HR = 0.637, CI: 0.51-0.79) had significantly increased survival from transplant compared with other graft types, and recipients of deceased donor TVGs (HR = 1.066, CI: 0.93-1.22) had statistically similar outcomes compared with whole graft recipients. Increased TVG utilization may decrease WL mortality in the US. Hence, policy and training to increase TVG usage, availability, and expertise are critical.
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Affiliation(s)
- George V. Mazariegos
- Hillman Center for Pediatric Transplantation, Thomas E. Starzl Transplantation Institute, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Emily R. Perito
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - James E. Squires
- Hillman Center for Pediatric Transplantation, Thomas E. Starzl Transplantation Institute, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kyle A. Soltys
- Hillman Center for Pediatric Transplantation, Thomas E. Starzl Transplantation Institute, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Sarah A. Taylor
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Eric Pahl
- Health Informatics, University of Iowa, Iowa City, Iowa, USA
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22
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McElroy LM, Martin AE, Feldman AG, Ng VL, Kato T, Reichman T, Valentino PL, Anand R, Anderson SG, Sudan DL. An appraisal of technical variant grafts compared to whole liver grafts in pediatric liver transplant recipients: Multicenter analysis from the SPLIT registry. Pediatr Transplant 2023; 27:e14415. [PMID: 36303260 PMCID: PMC10184704 DOI: 10.1111/petr.14415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Shortages of liver allografts for children awaiting transplantation have led to high LT waitlist mortality. Prior studies have shown that usage of TVG can reduce waiting time and waitlist mortality, but their use is not universal. We sought to compare patient and graft survival between WLG and TVG and to identify potential associated risk factors in a contemporary pediatric LT cohort. METHODS We performed a retrospective analysis of patient survival, graft survival, and biliary and vascular complications for LT recipients <18 years old entered into the Society of Pediatric Liver Transplantation prospective multicenter database. RESULTS Of 1839 LT recipients, 1029 received a WLG and 810 received a TVG from either a LD or a DD. There was no difference in patient survival or graft survival by graft type. Three-year patient survival and graft survival were 96%, 93%, and 96%, and 95%, 89%, and 92% for TVG-LD, TVG-DD, and WLG, respectively. Biliary complications were more frequent in TVG. Hepatic artery thrombosis was more frequent in WLG. Multivariate analysis revealed primary diagnosis was the only significant predictor of patient survival. Predictors for graft survival included time-dependent development of biliary and vascular complications. CONCLUSIONS There were no significant differences in patient and graft survival based on graft types in this North American multi-center pediatric cohort. Widespread routine use of TVG should be strongly encouraged to decrease mortality on the waitlist for pediatric LT candidates.
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Affiliation(s)
- Lisa M McElroy
- Division of Abdominal Transplant Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Abigail E Martin
- Division of Solid Organ Transplantation, Department of Surgery, Nemours Children's Hospital Delaware, Wilmington, Delaware, USA
| | - Amy G Feldman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Vicky L Ng
- Division of Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Tomoaki Kato
- Division of Abdominal Organ Transplantation, Department of Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University, New York, New York, USA
| | - Trevor Reichman
- Multi Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Pamela L Valentino
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | | | | | - Debra L Sudan
- Division of Abdominal Transplant Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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23
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Mazariegos GV, Soltys KA, Perito ER. Waitlist mortality in pediatric liver transplantation: The goal is zero. Liver Transpl 2023; 29:130-131. [PMID: 37160059 DOI: 10.1002/lt.26549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 01/25/2023]
Affiliation(s)
- George V Mazariegos
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Hillman Center for Pediatric Transplantation , University of Pittsburgh , Pittsburgh , Pennsylvania , USA
| | - Kyle A Soltys
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Hillman Center for Pediatric Transplantation , University of Pittsburgh , Pittsburgh , Pennsylvania , USA
| | - Emily R Perito
- Department of Pediatrics, Benioff Children's Hospital , University of California, San Francisco , San Francisco , California , USA
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24
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Wang Z, Gao W, Dong C, Sun C, Wang K, Zhang W, Song Z, Qin H, Han C, Yang Y, Zhang F, Xu M, Zheng W, Shen Z. Outcome of split-liver transplantation from pediatric donors weighing 25 kg or less. Liver Transpl 2023; 29:58-66. [PMID: 35715984 DOI: 10.1002/lt.26530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 05/28/2022] [Accepted: 06/11/2022] [Indexed: 01/14/2023]
Abstract
The lower limit of body weight for "splitable" liver grafts remains unknown. To examine the outcome of split-liver transplantation (SLT) from pediatric donors ≤25 kg relative to conventional graft-type liver transplantation from deceased donors under corresponding conditions, a total of 158 patients who received primary liver transplantation, including 22 SLTs from donors ≤25 kg, 46 SLTs from donors >25 kg, 76 whole-liver transplantations, and 14 reduced-liver transplantations in donors ≤25 kg between January 2018 and December 2019, were included in the study. There was no significant difference in the complications, patient survival, and graft survival between each of the latter three groups and the SLT ≤25 kg group. Pediatric End-Stage Liver Disease (PELD) score was the independent predictor of graft loss (death or retransplantation). Graft weight was the independent predictor of hepatic artery thrombosis. SLT using well-selected pediatric donors ≤25 kg is an effective strategy to increase organ availability, especially for low-body-weight recipients, compared with conventional graft type from deceased donors under the condition of corresponding donor weight without increasing morbidity and mortality.
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Affiliation(s)
- Zhen Wang
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Wei Gao
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
- Tianjin Key Laboratory of Organ Transplantation , Tianjin , China
| | - Chong Dong
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Chao Sun
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Kai Wang
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Wei Zhang
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Zhuolun Song
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Hong Qin
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Chao Han
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Yang Yang
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Fubo Zhang
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Min Xu
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Weiping Zheng
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Zhongyang Shen
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
- Tianjin Key Laboratory of Organ Transplantation , Tianjin , China
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25
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Xu M, Dong C, Sun C, Wang K, Zhang W, Qin H, Han C, Yang Y, Zhang F, Wang Z, Zheng W, Wei X, Gao W, Shen Z. Impact of donor age on short-term outcomes after pediatric split liver transplantation. Front Pediatr 2023; 11:1131629. [PMID: 37114006 PMCID: PMC10126406 DOI: 10.3389/fped.2023.1131629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 03/28/2023] [Indexed: 04/29/2023] Open
Abstract
Background Donor shortage is an important limitation of liver transplantation (LT). Split liver transplantation (SLT) may increase the sources of donors and reduce the problem of organ shortage. However, there are no standard criteria of the selection of SLT donor, especially regarding the donor age. Methods We retrospectively analyzed the clinical data of children who received initial SLT between January 2015 and December 2021. Based on the age of donors, the patients were divided into groups A (1-10 years old; n = 26), B (10-45 years old; n = 87), and C (45-55 years old; n = 27). The short-term (<1 year after SLT) outcomes of the recipients were analyzed. Results A total of 140 patients received SLT from 122 donors. The 1-, 3- and 12-month patient survival rates in group A were 100.0%, and the graft survival rates were 92.3%. The 1-, 3- and 12-month survival rates of patient and graft in group B were 97.7%, 96.6%, and 95.0%, respectively, and in group C were 85.2%, 85.2%, and 81.1%, respectively. The patient survival rate was significantly lower in group C than in groups A and B (p = 0.0082). There was no significant difference in graft survival between the three groups (p = 0.0545). Conclusions Similar results were obtained for pediatric SLT with donors <10 years old and 10-45 years old. Pediatric SLT can be performed with older donors (45-55 years) after strict donor selection and selection of appropriate recipients.
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Affiliation(s)
- Min Xu
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Chong Dong
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Chao Sun
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Kai Wang
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Wei Zhang
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Hong Qin
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Chao Han
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Yang Yang
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Fubo Zhang
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Zhen Wang
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Weiping Zheng
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Xinzhe Wei
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Wei Gao
- Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
- Correspondence: Wei Gao
| | - Zhongyang Shen
- Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China
- Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, China
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26
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Vargas PA, Dalzell C, Robinson T, Cunningham M, Henry Z, Stotts MJ, Su F, Argo C, Pelletier S, Oberholzer J, Goldaracena N. Split liver transplantation with extended right grafts on adult recipients: A propensity score matching analysis. Clin Transplant 2022; 36:e14801. [PMID: 35997030 DOI: 10.1111/ctr.14801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/24/2022] [Accepted: 08/14/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Split liver transplantation (SLT) emerged due to its potential to contribute to the organ pool and reduce organ shortage. However, SLT is technically challenging and has been associated with higher rates of postoperative complications leading to concerns about graft and patient survival. Moreover, there are few studies on matched-pair adult recipients of SLT and whole-liver transplant (WLT), with conflicting results. METHODS This retrospective study analyze outcomes among adults who underwent SLT at our institution from 2010 to 2019. A 1:1 propensity score matching analysis was performed based on important donor and recipient variables. Baseline characteristics and postoperative outcomes were analyzed and compared between groups. Actuarial graft and patient survival were analyzed by KM curves. RESULTS Out of 592 adults receiving a LT in our institution, 21 SLT adult recipients were identified and matched with 21 adults undergoing WLT. As expected donor age was significantly lower in SLT recipients (16 (15-22) vs. 32 (17-47), P = .012). Additional donor characteristics, including anthropometrics, and ischemic times were similar between groups. Baseline recipient characteristics and postoperative outcomes, including length of stay, vascular complications, biliary complications, and re-transplantation were comparable between SLT and WLT recipients. Graft (95/95/95 vs. 100/94/94, P = .98) and patient (100/100/100 vs. 100/94/94, P = .30) survival at 1-, 3-, 5-years, were similar between the SLT- and WLT group, respectively. CONCLUSION Split liver transplantation has the potential to increase the availability of organs for adult recipients without compromising individual outcomes.
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Affiliation(s)
- Paola A Vargas
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Christina Dalzell
- School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Todd Robinson
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michaela Cunningham
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Zachary Henry
- Department of Medicine, Division of Gastroenterology, University of Virginia, Charlottesville, Virginia, USA
| | - Matthew J Stotts
- Department of Medicine, Division of Gastroenterology, University of Virginia, Charlottesville, Virginia, USA
| | - Feng Su
- Department of Medicine, Division of Gastroenterology, University of Virginia, Charlottesville, Virginia, USA
| | - Curtis Argo
- Department of Medicine, Division of Gastroenterology, University of Virginia, Charlottesville, Virginia, USA
| | - Shawn Pelletier
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jose Oberholzer
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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27
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Wang D, Fan N, Wang X, Sun Y, Guan G, Wang J, Zhu X, Zang Y, Cai J, Guo Y. IV segment portal vein reconstruction in split-liver transplantation with extended right grafts. BMC Surg 2022; 22:311. [PMID: 35953816 PMCID: PMC9367133 DOI: 10.1186/s12893-022-01761-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Liver transplantation is one of the most effective treatments for end-stage liver disease. Split liver transplantation (SLT) can effectively improve the utilization efficiency of grafts. However, split liver transplantation still faces shortcomings and is not widely used in surgery. How to improve the effective transplantation volume of split liver transplantation and promote the postoperative recovery of patients has important clinical significance. Methods In our study, the donor’s liver was split into the extended right graft and left lateral sector, and the IV segment occur ischemia. To guarantee the functional graft size, and avoid complications, we reconstructed the IV segment portal vein and left portal vein. And we analyzed the operation time, intraoperative bleeding, liver function, and postoperative complications. Results In our research, 14 patients underwent IV segment portal vein reconstruction, and 8 patients did not undergo vascular reconstruction. We found that the ischemic area of the IV segment decreased significantly after IV segment portal vein reconstruction. We found that there was no significant difference in operation time and postoperative complications between the patients of the groups. There were significant differences in ALT on the 1st day and albumin on the 6th day after the operation. Conclusion It indicates that IV segment reconstruction in SLT surgery can alleviate the graft ischemic and promote the recovery of liver function after the operation. And, IV segment reconstruction as a novel operating procedure may be widely used in SLT.
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Affiliation(s)
- Dong Wang
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Ning Fan
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Xin Wang
- Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Yandong Sun
- Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Ge Guan
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Jianhong Wang
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.,Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Xiaodan Zhu
- Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Yunjin Zang
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.,Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Jinzhen Cai
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China. .,Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.
| | - Yuan Guo
- Department of Liver Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China. .,Department of Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.
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28
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George M, Thomas G, Karpelowsky J. Pediatric transplantation: An international perspective. Semin Pediatr Surg 2022; 31:151192. [PMID: 35725047 DOI: 10.1016/j.sempedsurg.2022.151192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The international practice of transplant in the pediatric population is heterogenous. Global trends in pediatric transplant activity are increasing, with diffusion of transplant activities into developing and emerging economies. There have been impacts of the COVID-19 pandemic which have in the earlier part of the pandemic caused a decrease in the number of transplants. While deceased donor programs are well established in advanced economies, emerging and developing countries rely heavily on live donor programs. Prioritization of organs for children exists in different forms throughout the world. Pediatric transplantation as a sub-specialty is young but growing around the world with a need to train surgeons and physicians in this discipline. Outreach efforts with multi-national and multi-institutional partnerships have enabled resource poor countries to establish new transplant programs for children. Further international collaboration, good quality data collection and audit, prospective research and ongoing mentorship and education are needed to further improve outcomes of all children receiving solid organ transplants.
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Affiliation(s)
- Mathew George
- Department of Surgery, Children's Hospital at Westmead, Australia
| | - Gordon Thomas
- Department of Surgery, Children's Hospital at Westmead, Division of Child and Adolescent Health, Sydney Medical School, University of Sydney, Australia
| | - Jonathan Karpelowsky
- Department of Surgery, Children's Hospital at Westmead, Children's Cancer Research Unit, Kids Research Institute, Division of Child and Adolescent Health, Sydney Medical School, University of Sydney, Westmead, NSW, Australia.
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29
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Mouch CA, Alexopoulos SP. Declining a Split-Liver Offer Can Be Hazardous to Your Health. Liver Transpl 2022; 28:923-924. [PMID: 35182105 DOI: 10.1002/lt.26434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Charles A Mouch
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - Sophoclis P Alexopoulos
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN
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30
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Primary Liver Transplantation vs. Transplant after Kasai Portoenterostomy for Infants with Biliary Atresia. J Clin Med 2022; 11:jcm11113012. [PMID: 35683401 PMCID: PMC9181323 DOI: 10.3390/jcm11113012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/04/2022] [Accepted: 05/23/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction: Primary liver transplants (pLT) in patients with biliary atresia (BA) are infrequent, since most babies with BA undergo a prior Kasai portoenterostomy (KPE). This study compared transplant outcomes in children with BA with or without a prior KPE. We hypothesized that pLT have less morbidity and better outcomes compared to those done after a failed KPE. Methods: A retrospective review of patients with BA transplanted at our institution was performed. Patients were included if they received a pLT or if they were transplanted less than 2 years from KPE. Outcomes were compared between those groups. Comparisons were also made based on era (early: 1997−2008 vs. modern: 2009−2020). p < 0.05 was considered significant. Results: Patients who received a pLT were older at diagnosis (141.5 ± 46.0 vs. KPE 67.1 ± 25.5 days, p < 0.001). The time between diagnosis and listing for transplant was shorter in the pLT group (44.5 ± 44.7 vs. KPE 140.8 ± 102.8 days, p < 0.001). In the modern era, the calculated PELD score for the pLT was significantly higher (23 ± 8 vs. KPE 16 ± 8, p = 0.022). Two waitlist deaths occurred in the KPE group (none in pLT, p = 0.14). Both the duration of transplant surgery and transfusion requirements were similar in both groups. There was a significant improvement in graft survival in transplants after KPE between eras (early era 84.3% vs. modern era 97.8%, p = 0.025). The 1-year patient and graft survival after pLT was 100%. Conclusions: Patient and graft survival after pLT are comparable to transplants after a failed KPE but pLT avoids a prior intervention. There was no significant difference in pre- or peri-transplant morbidity between groups other than wait list mortality. A multicenter collaboration with more patients may help demonstrate the potential benefits of pLT in patients predicted to have early failure of KPE.
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31
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Ngee-Soon L, Mark L, Ken L, Avik M, SimoneI S, Raaj K B, Geoffrey W M, Michael C, Carlo P. Is it safe to expand the indications for split liver transplantation in adults? A single-centre analysis of 155 in-situ splits. Clin Transplant 2022; 36:e14673. [PMID: 35441379 PMCID: PMC9541812 DOI: 10.1111/ctr.14673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/21/2022] [Accepted: 04/09/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Split liver transplantation (SLT) enables two recipients to be transplanted using a single donor liver; typically, an adult and a child. Despite equivalent long-term outcomes to whole grafts in selected adults, the use of these grafts in high-risk adult recipients with high model for end-stage liver disease (MELD) scores (≥30), a poor pre-transplant clinical status (ICU or hospital-bound), acute liver failure or retransplantation remains controversial. METHODS We retrospectively analysed all deceased donor adult liver transplants performed between July 2002 and November 2019 at a single high-volume centre and performed a propensity score-matched analysis. A subgroup analysis was performed to assess utility of these grafts for high-risk recipients. RESULTS A total of 1090 adult liver transplants were performed, including 155 SLT (14%). Graft survival at 1-, 3- and 5-years were comparable between recipients of split and whole liver grafts (82%, 79% and 74% vs 86%, 81% and 77% respectively, log rank p = 0.537), as was patient survival at 1-, 3- and 5-years. Recipients of split grafts were more likely to have biliary complications and hepatic artery thrombosis, but equivalent long-term survival. Recipients with high MELD scores or a poor pre-transplant clinical status had similar patient and graft survival and complication profiles irrespective of whether they received split or whole grafts. CONCLUSIONS SLT is an important method for addressing donor shortages and provides comparable long-term outcomes in adult recipients despite an increase in short-term complications. SLT use in high-risk recipients should be considered to allow for sickest-first allocation policies. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Lau Ngee-Soon
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, 2050, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
| | - Ly Mark
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, 2050, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
| | - Liu Ken
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, 2050, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
| | - Majumdar Avik
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, 2050, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
| | - Strasser SimoneI
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, 2050, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
| | - Biswas Raaj K
- Sydney Local Health District Clinical Research Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, 2050, Australia
| | - McCaughan Geoffrey W
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, 2050, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
| | - Crawford Michael
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, 2050, Australia
| | - Pulitano Carlo
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, 2050, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
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32
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Variability of Care and Access to Transplantation for Children with Biliary Atresia Who Need a Liver Replacement. J Clin Med 2022; 11:jcm11082142. [PMID: 35456234 PMCID: PMC9032543 DOI: 10.3390/jcm11082142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/24/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
Background & Aims: Biliary atresia (BA) is the commonest single etiology indication for liver replacement in children. As timely access to liver transplantation (LT) remains challenging for small BA children (with prolonged waiting time being associated with clinical deterioration leading to both preventable pre- and post-transplant morbidity and mortality), the care pathway of BA children in need of LT was analyzed—from diagnosis to LT—with particular attention to referral patterns, timing of referral, waiting list dynamics and need for medical assistance before LT. Methods: International multicentric retrospective study. Intent-to-transplant study analyzing BA children who had indication for LT early in life (aged < 3 years at the time of assessment), over the last 5 years (2016−2020). Clinical and laboratory data of 219 BA children were collected from 8 transplant centers (6 in Europe and 2 in USA). Results: 39 patients underwent primary transplants. Children who underwent Kasai in a specialist -but not transplant- center were older at time of referral and at transplant. At assessment for LT, the vast majority of children already were experiencing complication of cirrhosis, and the majority of children needed medical assistance (nutritional support, hospitalization, transfusion of albumin or blood) while waiting for transplantation. Severe worsening of the clinical condition led to the need for requesting a priority status (i.e., Peld Score exception or similar) for timely graft allocation for 76 children, overall (35%). Conclusions: As LT currently results in BA patient survival exceeding 95% in many expert LT centers, the paradigm for BA management optimization and survival have currently shifted to the pre-LT management. The creation of networks dedicated to the timely referral to a pediatric transplant center and possibly centralization of care should be considered, in combination with implementing all different graft type surgeries in specialist centers (including split and living donor LTs) to achieve timely LT in this vulnerable population.
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33
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Azoulay D, Feray C, Lim C, Salloum C, Conticchio M, Cherqui D, Sa Cunha A, Adam R, Vibert E, Samuel D, Allard MA, Golse N. A systematic review of auxiliary liver transplantation of small for size grafts in patients with chronic liver disease. JHEP Rep 2022; 4:100447. [PMID: 35310820 PMCID: PMC8927838 DOI: 10.1016/j.jhepr.2022.100447] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 12/14/2022] Open
Abstract
Background & Aims The shortage of liver grafts continues to worsen. Because the expanded use of small-for-size grafts (SFSGs) would substantially alleviate this shortage, we aimed to analyse the available knowledge on auxiliary liver transplantation (ALT) with SFSGs in patients with chronic liver disease (CLD) to identify opportunities to develop ALT with SFSGs in patients with CLD. Methods This is a systematic review on ALT using SFSGs in patients with CLD. The review was completed by updates obtained from the authors of the retained reports. Results Heterotopic ALT was performed in 26 cases between 1980 and 2017, none for SFGS stricto sensu, and auxiliary partial orthotopic liver transplantation (APOLT) in 27 cases (from 1999 to 2021), all for SFSG. In APOLT cases, partial native liver resection was performed in most of cases, whereas the second-stage remnant native liver hepatectomy was performed in 9 cases only. The median graft-to-body weight ratio was 0.55, requiring perioperative or intraoperative portal modulation in 16 cases. At least 1 complication occurred in 24 patients following the transplant procedure (morbidity rate, 89%). Four patients (4/27, 15%) died after the APOLT procedure. At the long term, 19 (70%) patients were alive and well at 13 months to 24 years (median, 4.5 years) including 18 with the APOLT graft in place and 1 following retransplantation. Conclusions Despite high postoperative morbidity, and highly reported technical variability, the APOLT technique is a promising technique to use SFSGs in patients with CLD, achieving satisfactory long-term results. The results need to be confirmed on a larger scale, and a standardised technique could lead to even better results. Lay summary At the cost of a high postoperative morbidity, the long-term results of APOLT for small-for-size grafts are good. Standardisation of the procedure and of portal modulation remain needed.
Using a small-for-size graft is a risk factor of small-for-size syndrome. Auxiliary liver transplantation can be orthotopic or heterotopic. In auxiliary transplantation, the remnant native liver prevents small-for-size syndrome. Transplantation with a small-for-size graft requires individually tailored portal modulation. Auxiliary liver transplantation might substantially increase the number of available grafts.
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34
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Lau NS, Liu K, McCaughan G, Crawford M, Pulitano C. Are split liver grafts a suitable option in high-risk liver transplant recipients? Curr Opin Organ Transplant 2021; 26:675-680. [PMID: 34653087 DOI: 10.1097/mot.0000000000000938] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To assess the outcomes of split liver transplantation (SLT) in adults and children and evaluate its role in high-risk recipients with a high model for end-stage liver disease (MELD) score, an urgent indication or requiring retransplantation. RECENT FINDINGS Split liver grafts in general have equivalent long-term survival outcomes to whole grafts despite an increase in biliary complications. Recent success and technical advances have encouraged use of these grafts in high-risk recipients. Split liver grafts can be used successfully in recipients with a high MELD score if there is adequate weight-matching. There are mixed results in urgent indication recipients and for retransplantation such that use in this group of patients remains controversial. SUMMARY SLT addresses donor shortages by facilitating the transplant of two recipients from the same donor liver. By using careful donor and recipient selection criteria, SLT can achieve equivalent long-term outcomes to whole grafts. These grafts have been used successfully in recipients with a high MELD score, but should be used selectively in urgent indication recipients and for retransplantation.
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Affiliation(s)
- Ngee-Soon Lau
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ken Liu
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Geoffrey McCaughan
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael Crawford
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital
| | - Carlo Pulitano
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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35
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Sneiders D, van Dijk ABRM, Polak WG, Mirza DF, Perera MTPR, Hartog H. Full-left-full-right split liver transplantation for adult recipients: a systematic review and meta-analysis. Transpl Int 2021; 34:2534-2546. [PMID: 34773303 PMCID: PMC9300103 DOI: 10.1111/tri.14160] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/24/2021] [Accepted: 11/07/2021] [Indexed: 12/14/2022]
Abstract
Full-left-full-right split liver transplantation (FSLT) for adult recipients, may increase the availability of liver grafts, reduce waitlist time, and benefit recipients with below-average body weight. However, FSLT may lead to impaired graft and patient survival. This study aims to assess outcomes after FSLT. Five databases were searched to identify studies concerning FSLT. Incidences of complications, graft- and patient survival were assessed. Discrete data were pooled with random-effect models. Graft and patient survival after FSLT were compared with whole liver transplantation (WLT) according to the inverse variance method. Vascular complications were reported in 25/273 patients after FSLT (Pooled proportion: 6.9%, 95%CI: 3.1-10.7%, I2 : 36%). Biliary complications were reported in 84/308 patients after FSLT (Pooled proportion: 25.6%, 95%CI: 19-32%, I2 : 44%). Pooled proportions of graft and patient survival after 3 years follow-up were 72.8% (95%CI: 67.2-78.5, n = 231) and 77.3% (95%CI: 66.7-85.8, n = 331), respectively. Compared with WLT, FSLT was associated with increased graft loss (pooled HR: 2.12, 95%CI: 1.24-3.61, P = 0.006, n = 189) and patient mortality (pooled HR: 1.81, 95%CI: 1.17-2.81, P = 0.008, n = 289). FSLT was associated with high incidences of vascular and biliary complications. Nevertheless, long-term patient and graft survival appear acceptable and justify transplant benefit in selected patients.
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Affiliation(s)
- Dimitri Sneiders
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.,Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | - Anne-Baue R M van Dijk
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wojciech G Polak
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | | | - Hermien Hartog
- Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
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36
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Yoeli D, Jackson WE, Adams MA, Wachs ME, Sundaram SS, Sater A, Cisek JR, Choudhury RA, Nydam TL, Pomposelli JJ, Conzen KD, Kriss MS, Burton JR, Pomfret EA. Challenging the Traditional Paradigm of Supply and Demand in Pediatric Liver Transplantation Through Nondirected Living Donation: A Case Series. Liver Transpl 2021; 27:1392-1400. [PMID: 34048131 DOI: 10.1002/lt.26108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/20/2021] [Accepted: 05/12/2021] [Indexed: 12/13/2022]
Abstract
A gap exists between the demand for pediatric liver transplantation and the supply of appropriate size-matched donors. We describe our center's experience with pediatric liver transplantation using anonymous nondirected living liver donors (ND-LLD). First-time pediatric liver transplant candidates listed at our center between January 2012 and June 2020 were retrospectively reviewed and categorized by donor graft type, and recipients of ND-LLD grafts were described. A total of 13 ND-LLD pediatric liver transplantations were performed, including 8 left lateral segments, 4 left lobes, and 1 right lobe. Of the ND-LLD recipients, 5 had no directed living donor evaluated, whereas the remaining 8 (62%) had all potential directed donors ruled out during the evaluation process. Recipient and graft survival were 100% during a median follow-up time of 445 (range, 70-986) days. Of ND-LLDs, 69% were previous living kidney donors, and 1 ND-LLD went on to donate a kidney after liver donation. Of the ND-LLDs, 46% were approved prior to the recipient being listed. Over time, the proportion of living donor transplants performed, specifically from ND-LLDs, increased, and the number of children on the waiting list decreased. The introduction of ND-LLDs to a pediatric liver transplant program can expand the benefit of living donor liver transplantation to children without a suitable directed living donor while achieving excellent outcomes for both the recipients and donors.
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Affiliation(s)
- Dor Yoeli
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO.,Division of Abdominal Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, CO
| | - Whitney E Jackson
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Megan A Adams
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO.,Division of Abdominal Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, CO
| | - Michael E Wachs
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO.,Division of Abdominal Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, CO
| | - Shikha S Sundaram
- Division of Gastroenterology, Hepatology and Nutrition, The Digestive Health Institute, Department of Pediatric Medicine, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Anna Sater
- Division of Abdominal Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, CO
| | - Jaime R Cisek
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Rashikh A Choudhury
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Trevor L Nydam
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - James J Pomposelli
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Kendra D Conzen
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Michael S Kriss
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - James R Burton
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Elizabeth A Pomfret
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
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Lemoine CP, Wall A, Testa G, Superina R. Ethical considerations in pediatric solid organ transplantation. Semin Pediatr Surg 2021; 30:151104. [PMID: 34635280 DOI: 10.1016/j.sempedsurg.2021.151104] [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] [Indexed: 10/20/2022]
Abstract
Solid organ transplantation is now an accepted therapeutic modality for children and teenagers suffering from a wide variety of complex medical conditions. Unfortunately, patients continue to die while on the organ waiting list as there remains an imbalance between the number of recipients listed for transplantation and the number of donors available. The organ allocation process continues to generate ethical questions and debates. In this publication, we discuss some of the most frequently reported ethical matters in the field of pediatric solid organ transplantation.
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Affiliation(s)
- Caroline P Lemoine
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago avenue Box 57, Chicago, IL 60611, United States
| | - Anji Wall
- Annette C. And Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Giuliano Testa
- Annette C. And Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Riccardo Superina
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago avenue Box 57, Chicago, IL 60611, United States.
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38
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Gallagher TK. Opportunity in a Crisis: We Can Do Better. Transplantation 2021; 105:2140-2141. [PMID: 33065724 DOI: 10.1097/tp.0000000000003492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Tom K Gallagher
- St. Vincent's University Hospital, Elm Park, Dublin, Ireland
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The Surge in Deceased Liver Donors Due to the Opioid Epidemic: Is It Time to Split the Difference? Transplantation 2021; 105:2239-2244. [PMID: 33065726 DOI: 10.1097/tp.0000000000003491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND This study aimed to compare trends in use of drug overdose (DO) donors in adult versus pediatric liver transplants and the utilization of split liver transplantation in this donor population. METHODS The United Network for Organ Sharing database was reviewed for deceased donor liver transplants from March 2002 to December 2017. Recipients were categorized by donor mechanism of death. Donor splitting criteria was defined as age <40 y, single vasopressor or less, transaminases no >3 times the normal limit, and body mass index ≤ 28 kg/m2. RESULTS Adult liver transplants from DO donors increased from 2% in 2002 to 15% in 2017, while pediatric liver transplants from DO donors only increased from <1% to 3% in the same time. While 28% of DO donors met splitting criteria, only 3% of those meeting splitting criteria were used as a split graft. Both pediatric and adult recipients of DO donor livers achieved excellent patient and graft survival. CONCLUSIONS DO donors are underutilized in pediatric liver transplantation. Increased splitting of DO donor livers could significantly decrease, if not eliminate, the pediatric liver waiting list.
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Lau NS, Jacques A, McCaughan G, Crawford M, Liu K, Pulitano C. Addressing the challenges of split liver transplantation through technical advances. A systematic review. Transplant Rev (Orlando) 2021; 35:100627. [PMID: 34052472 DOI: 10.1016/j.trre.2021.100627] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/08/2021] [Accepted: 05/17/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Split liver transplantation addresses donor shortages by facilitating the transplant of two recipients using one donor liver. Some still consider these grafts inferior due to prolonged cold ischaemia time and at times difficult vascular reconstruction. Techniques such as in-situ splitting, machine perfusion and interposition grafts may address these challenges and thereby address these concerns. The aim of this review is to assess these technical advances in split liver transplantation, their utility and outcomes. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Keywords included 'split liver transplantation', 'arterial reconstruction', and 'machine perfusion'. Data found was synthesised into sections including: methods of splitting, full-left full-right splitting, donor cholangiography, machine perfusion and arterial reconstruction. RESULTS A total of 78 articles met inclusion criteria after screening of 151 eligible articles. These were subdivided into the following categories: in-situ (25), ex-vivo (25), full-left full-right splitting (15), donor cholangiography (2), machine perfusion (6), and arterial reconstruction (5). The in-situ splitting technique reduces the cold ischaemia time compared to the ex-vivo technique which may improve graft quality and liver splitting during normothermic machine perfusion is a novel technique with the potential to incorporate the best aspects of both techniques. Interposition grafts are often required during split liver transplantation but have an increased risk of hepatic artery thrombosis. CONCLUSION Advancements in technique have allowed many of the unique challenges of split liver transplantation to be overcome. Overall, this supports the use of split liver transplantation in broader and riskier settings and we advocate for liver transplant surgeons to not hesitate in using these grafts liberally and expanding their recipient selection criteria.
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Affiliation(s)
- Ngee-Soon Lau
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales 2050, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Andrew Jacques
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales 2050, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Geoffrey McCaughan
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales 2050, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Michael Crawford
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales 2050, Australia
| | - Ken Liu
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales 2050, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Carlo Pulitano
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales 2050, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia.
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41
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Lembach Jahnsen H, Mergental H, Perera MTPR, Mirza DF. Ex-situ liver preservation with machine preservation. Curr Opin Organ Transplant 2021; 26:121-132. [PMID: 33650995 DOI: 10.1097/mot.0000000000000864] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW To summarize key studies in liver preservation published over the last 3 years and evaluate benefits and limitations of the different perfusion techniques. Selected experimental applications that may be translated to the clinical use will be also discussed. RECENT FINDINGS Normothermic machine perfusion (NMP) has transitioned into clinical practice. Viability assessment is a reliable tool for clinical decision-making, and safety of the back-to-base approach has facilitated adoption of the technology. Data supporting well tolerated use of declined livers after NMP and new protocols selecting complex recipients aim to improve access to suitable organs. Hypothermic machine perfusion (HMP) is showing promising clinical results by decreasing biliary complications in recipients' receiving organs donated after circulatory death (DCD) and improving early graft function in extended criteria organs. Long-term data of HMP on DCD livers shows improved graft survival over standard SCS. Novel approaches utilizing sequential HMP--NMP or ischaemia-free preservation aim to improve outcomes of extended criteria organs. SUMMARY Machine perfusion for organ transplantation has become an established technique but the field is rapidly evolving. Ongoing research focuses on evaluation of the intervention efficacy and finding optimal indications to use each perfusion strategy according to graft type and clinical scenario.
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Affiliation(s)
- Hanns Lembach Jahnsen
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
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Lemoine C, Brandt K, Carlos Caicedo J, Superina R. Internal split liver transplants reduce the waiting list time for teenagers with a low calculated Model for End-stage Liver Disease score. Pediatr Transplant 2021; 25:e13874. [PMID: 33245634 DOI: 10.1111/petr.13874] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/14/2020] [Accepted: 08/12/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Split liver transplantation allows for the simultaneous transplantation of two patients, typically a child and an adult, with a single organ. We report our experience with "internal splits" in which 10 pediatric patients from our institution were transplanted with five organs. We hypothesized that this would reduce the WL time for teenagers with a low calculated MELD score. METHODS A retrospective chart review of those 10 patients was done. Their WL time was compared with local, regional, and national data. P < .05 was considered significant. RESULTS The median age of the five primary recipients to whom the liver was first allocated was 2.3 years (0.7-7.4) (median weight 10.4 kg (8.4-17.7)). They received a segment 2-3 graft. Five "secondary" recipients (median age 17.4 years (16.6-18.9); median weight 66.2 kg (53.7-70.0)) were identified on our WL to receive the trisector graft. At transplant, their median calculated MELD score was 11 (8-20). Their mean WL time (241.6 ± 218.9 days) was significantly shorter than local (480.6 ± 833.6 days), regional (370.4 ± 563.4 days), and national patients (245.6 ± 465.4 days) with MELD ≤ 20 (P = .047). There was no significant difference between their WL time and that of patients with a MELD 8 ≤ x≤31 (equivalent to their median exception score, P = .63). Patient and graft survival was 100% for all 10 patients. CONCLUSION In our experience, simultaneous internal split liver transplantation allowed teenagers with a low calculated MELD score to be transplanted faster than patients with a similar score. Promoting the use of internal split liver transplantation could help reduce the pediatric waitlist mortality.
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Affiliation(s)
- Caroline Lemoine
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katherine Brandt
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Juan Carlos Caicedo
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Riccardo Superina
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Expert consensus on split-liver transplantation. LIVER RESEARCH 2021; 5:1-6. [PMID: 39958927 PMCID: PMC11791845 DOI: 10.1016/j.livres.2020.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/21/2022]
Abstract
With the dawn of organ donation after a citizen's death in China, the use of split-liver transplantation (SLT) can effectively increase the source of donor liver, reduce the waiting time for organ transplantation in patients, and particularly solve the problem of organ shortage in children. In recent years, many transplantation centers have been performing SLT to varying degrees and efficacy. At the current stage, the experiences of countries with advanced transplantation techniques should be used to establish an SLT consensus that is suitable for China to further increase the ratio and efficacy of SLT. In this paper, we combined expert experiences to generate an SLT expert consensus that included donor and donor liver evaluation, recipient selection criteria, donor and recipient matching, selection of splitting form and tools, blood vessels and bile ducts dissection and allocation, perioperative management of SLT, and organ allocation.
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A Novel Surgical Technique to Assure Donor and Recipient Safety: Pyloric to Segment 4 Arterial Reconstruction. Transplant Direct 2020; 7:e639. [PMID: 33335979 PMCID: PMC7738044 DOI: 10.1097/txd.0000000000001095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/07/2020] [Accepted: 10/09/2020] [Indexed: 12/03/2022] Open
Abstract
Background. Strategies to extend the pool of organs include and promote the use of segmental liver grafts. While performing a living donor left lateral segment (LLS) liver transplant and in split procedures, the hepatic artery´s division becomes critical when a dominant segment 4 artery (S4A) emerges from the left hepatic artery (LHA). We aim to describe a novel technique that consists of performing microsurgical reconstruction from the pyloric artery (PA) to S4A. Case Reports. A 45-y-old living donor was evaluated to use his LLS as a graft for a pediatric recipient. During the procedure, a dominant S4A born from the LHA was dissected. To obtain an appropriate LHA length and diameter for the recipient, it was necessary to transect it. An extended right lobe split graft was used in a 61-y-old patient. The S4A born from LHA had to be sectioned during the split procedure. In both cases, segment 4 remained incompletely perfused. The PA was dissected with enough length to be rotated, to perform a microsurgical anastomosis to the S4A, recovering parenchyma’s color and Doppler signal while vascular permeability was demonstrated using CT scan. There was no biliary or cut surface complication. Conclusions. PA to S4A reconstruction is a simple and novel technique that can be used for LLS and extended right lobe split graft and might contribute to increase donor selection and reduce living donor and recipient S4A-related complications.
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45
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Sakamoto S, Uchida H, Shimizu S, Yanagi Y, Takeda M, Kubota T, Nakazato Y, Fukuda A, Kasahara M. Current status of pediatric deceased donor liver transplantation: Lessons learned from a high-volume center in Japan where living donation remains predominant. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:1014-1022. [PMID: 33315309 DOI: 10.1002/jhbp.886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/27/2020] [Accepted: 12/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND In Japan, a recent gradual increase in deceased donor donation has expanded opportunities for pediatric patients to obtain deceased grafts. METHODS Forty-three children underwent deceased donor liver transplantation (DDLT) at our institute before February 2020. Twenty-five patients received a split or reduced graft and 18 patients received a whole graft. The clinical outcomes of DDLT were retrospectively analyzed. RESULTS The main organ resource was split/reduced grafts retrieved from adult donors; however, the number of whole grafts retrieved from pediatric donors has increased. The rates of major complications were similar in the two groups. The 5-year graft survival rate of patients who received a split/reduced graft (78.0%) was lower than that of patients who received a whole graft (88.9%; P = .40). The 3-year graft survival rates of patients who recently received a split/reduced graft and a whole graft improved to 92.3% and 91.7%, respectively. CONCLUSIONS The recent amendment of the organ allocation system, especially the introduction of pediatric prioritization, can effectively increase the chance to obtain deceased donor grafts for pediatric DDLT in Japan. The recent refinements in donor and recipient selection and in the surgical technique of split DDLT can improve the outcomes of pediatric DDLT in Japan.
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Affiliation(s)
- Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Seiichi Shimizu
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Yusuke Yanagi
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Masahiro Takeda
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Tomomi Kubota
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Yayoi Nakazato
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
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METİN O, ŞİMŞEK C, GÜRAKAR A. Update on liver transplantation-newer aspects. Turk J Med Sci 2020; 50:1642-1650. [PMID: 32222125 PMCID: PMC7672347 DOI: 10.3906/sag-2002-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 03/22/2020] [Indexed: 12/12/2022] Open
Abstract
Liver transplantation (LT) remains the only therapeutic option offering gold standard treatment for end-stage liver disease (ESLD) and acute liver failure (ALF), as well as for certain early-stage liver tumors. Currently, the greatest challenge facing LT is the simple fact that there are not enough adequate livers for all the potential patients that could benefit from LT. Despite efforts to expand the donor pool to include living and deceased donors, organ shortage is still a major problem in many countries. To solve this problem, the use of marginal liver grafts has become an inevitable choice. Although the definition of marginal grafts or criteria for expanded donor selection has not been clarified yet, they are usually defined as grafts that may potentially cause primary nonfunction, impaired function, or late loss of function. These include steatotic livers, older donors, donors with positive viral serology, split livers, and donation after cardiac death (DCD). Therefore, to get the best outcome from these liver grafts, donor-recipient selection should be vigilant. Alcohol- related liver disease (ALD) is one of the most common indications for LT in Europe and North America. Traditionally, LT for alcoholic liver disease was kept limited for patients who have achieved 6 months of abstinence, in part due to social and ethical concerns regarding the use of a limited resource. However, the majority of patients with severe alcoholic hepatitis who fail medical therapy will not live long enough to meet this requirement. Besides, the initial results of early liver transplantation (ELT) without waiting for 6 months of abstinence period are satisfactory in severe alcoholic hepatitis (SAH). It will be important to take care of these patients from a newer perspective.
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Affiliation(s)
- Olga METİN
- Department of Internal Medicine, Okmeydanı Training and Research Hospital, İstanbulTurkey
| | - Cem ŞİMŞEK
- Department of Gastroenterology, School of Medicine, Hacettepe University, AnkaraTurkey
| | - Ahmet GÜRAKAR
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine Liver Transplant Program Baltimore, MarylandUSA
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Jeffrey AW, Jeffrey GP, Stormon M, Thomas G, O'Loughlin E, Shun A, Hardikar W, Jones R, McCall J, Evans H, Starkey G, Hodgkinson P, Ee LC, Moore D, Mews C, McCaughan GW, Angus PW, Wigg AJ, Crawford M, Fawcett J. Outcomes for children after second liver transplantations are similar to those after first transplantations: a binational registry analysis. Med J Aust 2020; 213:464-470. [DOI: 10.5694/mja2.50802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 07/10/2020] [Indexed: 11/17/2022]
Affiliation(s)
| | - Gary P Jeffrey
- Sir Charles Gairdner Hospital Perth WA
- The University of Western Australia Perth WA
| | - Michael Stormon
- Australian National Liver Transplantation Service Children's Hospital at Westmead Sydney NSW
- The University of Sydney Sydney NSW
| | - Gordon Thomas
- Australian National Liver Transplantation Service Children's Hospital at Westmead Sydney NSW
- The University of Sydney Sydney NSW
| | - Edward O'Loughlin
- Australian National Liver Transplantation Service Children's Hospital at Westmead Sydney NSW
- The University of Sydney Sydney NSW
| | - Albert Shun
- Australian National Liver Transplantation Service Children's Hospital at Westmead Sydney NSW
- The University of Sydney Sydney NSW
| | | | - Robert Jones
- Victorian Liver Transplant Unit Austin Hospital Melbourne VIC
- Victorian Liver Transplant Unit Royal Children's Hospital Melbourne VIC
| | - John McCall
- New Zealand Liver Transplant Unit Auckland City Hospital Auckland New Zealand
- Starship Children's Health Auckland New Zealand
| | - Helen Evans
- Starship Children's Health Auckland New Zealand
| | - Graham Starkey
- Victorian Liver Transplant Unit Austin Hospital Melbourne VIC
- Victorian Liver Transplant Unit Royal Children's Hospital Melbourne VIC
| | - Peter Hodgkinson
- Queensland Liver Transplantation Service Princess Alexandra Hospital Brisbane QLD
- The University of Queensland Brisbane QLD
| | - Looi C Ee
- Lady Cilento Children's Hospital Brisbane QLD
| | | | | | - Geoff W McCaughan
- Australian National Liver Transplantation Unit Royal Prince Alfred Hospital Sydney NSW
- Sydney Medical School , the University of Sydney Sydney NSW
| | - Peter W Angus
- Victorian Liver Transplant Unit Austin Hospital Melbourne VIC
- Victorian Liver Transplant Unit Royal Children's Hospital Melbourne VIC
| | - Alan J Wigg
- South Australian Liver Transplantation Service Flinders Medical Centre Adelaide SA
| | - Michael Crawford
- The University of Sydney Sydney NSW
- Australian National Liver Transplantation Unit Royal Prince Alfred Hospital Sydney NSW
| | - Jonathan Fawcett
- Queensland Liver Transplantation Service Princess Alexandra Hospital Brisbane QLD
- The University of Queensland Brisbane QLD
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Terry LV, Oo YH. The Next Frontier of Regulatory T Cells: Promising Immunotherapy for Autoimmune Diseases and Organ Transplantations. Front Immunol 2020; 11:565518. [PMID: 33072105 PMCID: PMC7538686 DOI: 10.3389/fimmu.2020.565518] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/17/2020] [Indexed: 12/18/2022] Open
Abstract
Regulatory T cells (Tregs) are crucial in maintaining tolerance. Hence, Treg immunotherapy is an attractive therapeutic option in autoimmune diseases and organ transplantations. Currently, autoimmune diseases do not have a curative treatment and transplant recipients require life-long immunosuppression to prevent graft rejection. There has been significant progress in understanding polyclonal and antigen-specific Treg biology over the last decade. Clinical trials with good manufacturing practice (GMP) Treg cells have demonstrated safety and early efficacy of Treg therapy. GMP Treg cells can also be tracked following infusion. In order to improve efficacy of Tregs immunotherapy, it is necessary that Tregs migrate, survive and function at the specific target tissue. Application of antigen specific Tregs and maintaining cells' suppressive function and survival with low dose interleukin-2 (IL-2) will enhance the efficacy and longevity of infused GMP-grade Tregs. Notably, stability of Tregs in the local tissue can be manipulated by understanding the microenvironment. With the recent advances in GMP-grade Tregs isolation and antigen-specific chimeric antigen receptor (CAR)-Tregs development will allow functionally superior cells to migrate to the target organ. Thus, Tregs immunotherapy may be a promising option for patients with autoimmune diseases and organ transplantations in near future.
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Affiliation(s)
- Lauren V Terry
- Centre for Liver and Gastrointestinal Research, National Institute for Health Research Birmingham Biomedical Research Council, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Ye Htun Oo
- Centre for Liver and Gastrointestinal Research, National Institute for Health Research Birmingham Biomedical Research Council, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,European Reference Network (ERN) Centre-Rare Liver, Queen Elizabeth Hospital, Birmingham, United Kingdom.,Liver Transplant Unit, University Hospital of Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
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49
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van Dijk ABRM, Sneiders D, Murad SD, Polak WG, Hartog H. Disadvantage of Small (<60 kg) Adult Candidates on the Liver Transplantation Waitlist. Prog Transplant 2020; 30:349-354. [PMID: 32912082 DOI: 10.1177/1526924820958142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Small adult patients with lower bodyweight wait-listed for liver transplantation may face a shortage of size-matched whole-liver grafts. The objective of this study is to compare time to transplantation in adult patients with a bodyweight of <60 kg to patients with bodyweight ≥60 kg. METHODS A matched case-control study was conducted. Patients aged 18 years and older listed for liver transplantation at our transplant center, from 2007 to 2016 with a bodyweight <60 kg were manually matched 1:2 to control patients ≥ 60 kg. Matching was performed based on ABO blood type, model for end-stage liver disease score, (non)-standard exception status, and eligibility for donation after cardiac death. Time to transplantation was assessed with univariable Cox-regression. RESULTS In total, 23 cases with a bodyweight < 60 kg were matched to 46 average-sized control patients. Small adults were significantly disadvantaged for receiving a liver transplantation as compared to their average-sized counterpart (hazard ratio 0.47; 95% confidence interval 0.29-0.75, P = .002). At the end of follow-up, 14/23 (60.9%) of cases versus 35/46 of controls (76.1%) had received a liver transplantation. CONCLUSION Small adults with a bodyweight below 60 kg are disadvantaged on the waitlist for a size-matched whole liver graft.
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Affiliation(s)
- Anne-Baue R M van Dijk
- Division of Hepatopancreatobiliary and Transplant Surgery, Department of Surgery, 6993Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Dimitri Sneiders
- Division of Hepatopancreatobiliary and Transplant Surgery, Department of Surgery, 6993Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, 6993Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Wojciech G Polak
- Division of Hepatopancreatobiliary and Transplant Surgery, Department of Surgery, 6993Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hermien Hartog
- Division of Hepatopancreatobiliary and Transplant Surgery, Department of Surgery, 6993Erasmus MC University Medical Center, Rotterdam, the Netherlands
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50
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Ge J, Perito ER, Bucuvalas J, Gilroy R, Hsu EK, Roberts JP, Lai JC. Split liver transplantation is utilized infrequently and concentrated at few transplant centers in the United States. Am J Transplant 2020; 20:1116-1124. [PMID: 31705730 PMCID: PMC7103556 DOI: 10.1111/ajt.15696] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/19/2019] [Accepted: 11/01/2019] [Indexed: 01/25/2023]
Abstract
Split liver transplantation (SLT) is 1 strategy for maximizing the number of deceased donor liver transplants. Recent reports suggest that utilization of SLT in the United States remains low. We examined deceased donor offers that were ultimately split between 2010 and 2014. SLTs were categorized as "primary" and "secondary" transplants. We analyzed allocation patterns and used logistic regression to evaluate factors associated with secondary split discard. Four hundred eighteen livers were split: 54% from adult, 46% from pediatric donors. Of the 227 adult donor livers split, 61% met United Network for Organ Sharing "optimal" split criteria. A total of 770 recipients (418 primary and 352 secondary) were transplanted, indicating 16% discard. Ninety-two percent of the 418 primary recipients were children, and 47% were accepted on the first offer. Eighty-seven percent of the 352 secondary recipients were adults, and 7% were accepted on the first offer. Of the 352 pairs, 99% were transplanted in the same region, 36% at the same center. In logistic regression, shorter donor height was associated with secondary discard (odds ratio 0.97 per cm, 95% CI 0.94-1.00, P = .02). SLT volume by center was not predictive of secondary discard. Current policy proposals that incentivize SLT in the United States could increase the number of transplants to children and adults.
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Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | - Emily R. Perito
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of California – San Francisco, San Francisco, CA
| | - John Bucuvalas
- Mount Sinai Kravis Children’s Hospital and Recanati/Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Richard Gilroy
- Liver Transplant Program, Intermountain Medical Center, Murray, UT
| | - Evelyn K. Hsu
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital, Seattle, WA
| | - John P. Roberts
- Division of Transplant Surgery, Department of Surgery, University of California – San Francisco, San Francisco, CA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
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