UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Living donor liver transplantation

Author
Scott J Cotler, MD
Section Editor
Robert S Brown, Jr, MD, MPH
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF

INTRODUCTION

The scarcity of donor organs is the limiting factor in liver transplantation. While over 6000 transplants are performed annually in the United States, more than 2000 candidates die each year on the liver transplant waiting list. Living donor liver transplantation (LDLT) provides one means to expand organ availability. Living-donation of the lateral segment of the left lobe of the liver has become highly successful in pediatric transplantation. Some transplant centers perform adult-to-adult right lobe and, less commonly, left lobe LDLT.

Advantages of LDLT include thorough donor screening, optimization of timing for transplantation, and minimal cold ischemia time [1]. LDLT has also been associated with lower recipient mortality compared with waiting for a deceased donor [2]. A decision analysis concluded that the addition of LDLT to a standard waiting list for deceased donor liver transplantation was effective at improving recipient survival and preventing waiting list deaths, but at greater cost [3]. By contrast, a later cohort study found that the costs were similar to deceased donor transplantation when LDLT was performed in highly experienced transplant centers [4].

However, LDLT poses a risk to the donor. The number of LDLT procedures performed in the United States peaked at 519 in 2001 and then decreased to approximately 320 per year starting in 2003 as enthusiasm for the procedure was tempered by concerns about complications [5].

This topic will review living donor liver transplantation. Other issues regarding liver transplantation, such as patient selection, medical care of the post-transplantation patient, selection of organs from deceased donors, and complications are discussed elsewhere. (See "Liver transplantation in adults: Patient selection and pretransplantation evaluation" and "Liver transplantation in adults: Long-term management of transplant recipients" and "Liver transplantation in adults: Overview of immunosuppression" and "Liver transplantation: Donor selection" and "Infectious complications in liver transplantation".)

ETHICS

Ethical concerns regarding living donor liver transplantation (LDLT) are related to the potential for donor morbidity and mortality. Opponents argue that it is unacceptable to place a healthy donor at risk of long-term debility or death. Donation of the left lateral segment or left lobe, used primarily in pediatric transplantation, is associated with a 5 to 10 percent chance of surgical complications and a mortality rate of less than 1 percent [6,7]. The estimated mortality for right lobe donation, used in adult-to-adult LDLT, is around 0.5 percent. (See 'Donor outcomes' below.)

           

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Fri Jun 03 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Malagó M, Rogiers X, Broelsch CE. Liver splitting and living donor techniques. Br Med Bull 1997; 53:860.
  2. Berg CL, Gillespie BW, Merion RM, et al. Improvement in survival associated with adult-to-adult living donor liver transplantation. Gastroenterology 2007; 133:1806.
  3. Northup PG, Abecassis MM, Englesbe MJ, et al. Addition of adult-to-adult living donation to liver transplant programs improves survival but at an increased cost. Liver Transpl 2009; 15:148.
  4. Lai JC, Pichardo EM, Emond JC, Brown RS Jr. Resource utilization of living donor versus deceased donor liver transplantation is similar at an experienced transplant center. Am J Transplant 2009; 9:586.
  5. Pomfret EA, Fryer JP, Sima CS, et al. Liver and intestine transplantation in the United States, 1996-2005. Am J Transplant 2007; 7:1376.
  6. Grewal HP, Thistlewaite JR Jr, Loss GE, et al. Complications in 100 living-liver donors. Ann Surg 1998; 228:214.
  7. Whitington PF. Living donor liver transplantation: ethical considerations. J Hepatol 1996; 24:625.
  8. Cotler SJ, McNutt R, Patil R, et al. Adult living donor liver transplantation: Preferences about donation outside the medical community. Liver Transpl 2001; 7:335.
  9. Vila G, Nollet-Clémençon C, de Blic J, et al. Assessment of anxiety disorders in asthmatic children. Psychosomatics 1999; 40:404.
  10. American Society of Transplant Surgeons' position paper on adult-to-adult living donor liver transplantation. Liver Transpl 2000; 6:815.
  11. Hashikura Y, Kawasaki S, Miyagawa S, et al. Donor selection for living-related liver transplantation. Transplant Proc 1997; 29:3410.
  12. Dayangac M, Taner CB, Yaprak O, et al. Utilization of elderly donors in living donor liver transplantation: when more is less? Liver Transpl 2011; 17:548.
  13. Goldaracena N, Sapisochin G, Spetzler V, et al. Live Donor Liver Transplantation With Older (≥50 Years) Versus Younger (<50 Years) Donors: Does Age Matter? Ann Surg 2016; 263:979.
  14. Chan SC, Lo CM, Yong BH, et al. Paired donor interchange to avoid ABO-incompatible living donor liver transplantation. Liver Transpl 2010; 16:478.
  15. Hwang S, Lee SG, Moon DB, et al. Exchange living donor liver transplantation to overcome ABO incompatibility in adult patients. Liver Transpl 2010; 16:482.
  16. Song GW, Lee SG, Hwang S, et al. Dual living donor liver transplantation with ABO-incompatible and ABO-compatible grafts to overcome small-for-size graft and ABO blood group barrier. Liver Transpl 2010; 16:491.
  17. Song GW, Lee SG, Hwang S, et al. Biliary stricture is the only concern in ABO-incompatible adult living donor liver transplantation in the rituximab era. J Hepatol 2014; 61:575.
  18. Kim JM, Kwon CH, Joh JW, et al. Case-matched comparison of ABO-incompatible and ABO-compatible living donor liver transplantation. Br J Surg 2016; 103:276.
  19. Emond JC. Clinical application of liver-related liver transplantation. Gastroenterol Clin North Am 1993; 22:301.
  20. Savas N, Coskun M, Bilezikci B, et al. Value of an individual liver biopsy in the preoperative evaluation of apparently healthy potential liver donors. Liver Transpl 2008; 14:541.
  21. Valentín-Gamazo C, Malagó M, Karliova M, et al. Experience after the evaluation of 700 potential donors for living donor liver transplantation in a single center. Liver Transpl 2004; 10:1087.
  22. Trotter JF, Wisniewski KA, Terrault NA, et al. Outcomes of donor evaluation in adult-to-adult living donor liver transplantation. Hepatology 2007; 46:1476.
  23. Piper JB. Living related liver transplantation. Adv Exp Med Biol 1997; 420:257.
  24. Broelsch CE, Whitington PF, Emond JC, et al. Liver transplantation in children from living related donors. Surgical techniques and results. Ann Surg 1991; 214:428.
  25. Yamaoka Y, Ozawa K, Tanaka A, et al. New devices for harvesting a hepatic graft from a living donor. Transplantation 1991; 52:157.
  26. Inomoto T, Nishizawa F, Sasaki H, et al. Experiences of 120 microsurgical reconstructions of hepatic artery in living related liver transplantation. Surgery 1996; 119:20.
  27. Marwan IK, Fawzy AT, Egawa H, et al. Innovative techniques for and results of portal vein reconstruction in living-related liver transplantation. Surgery 1999; 125:265.
  28. Lo CM, Fan ST, Liu CL, et al. Adult-to-adult living donor liver transplantation using extended right lobe grafts. Ann Surg 1997; 226:261.
  29. Marcos A, Fisher RA, Ham JM, et al. Right lobe living donor liver transplantation. Transplantation 1999; 68:798.
  30. Wachs ME, Bak TE, Karrer FM, et al. Adult living donor liver transplantation using a right hepatic lobe. Transplantation 1998; 66:1313.
  31. Emond JC, Whitington PF, Broelsch CE. Overview of reduced-size liver transplantation. Clin Transplant 1991; 5:168.
  32. Sindhi R, Rosendale J, Mundy D, et al. Impact of segmental grafts on pediatric liver transplantation--a review of the United Network for Organ Sharing Scientific Registry data (1990-1996). J Pediatr Surg 1999; 34:107.
  33. Miwa S, Hashikura Y, Mita A, et al. Living-related liver transplantation for patients with fulminant and subfulminant hepatic failure. Hepatology 1999; 30:1521.
  34. Roberts JP, Hulbert-Shearon TE, Merion RM, et al. Influence of graft type on outcomes after pediatric liver transplantation. Am J Transplant 2004; 4:373.
  35. Oh SH, Kim KM, Kim DY, et al. Long-term outcomes of pediatric living donor liver transplantation at a single institution. Pediatr Transplant 2010; 14:870.
  36. Feng S, Ekong UD, Lobritto SJ, et al. Complete immunosuppression withdrawal and subsequent allograft function among pediatric recipients of parental living donor liver transplants. JAMA 2012; 307:283.
  37. Ueda M, Oike F, Ogura Y, et al. Long-term outcomes of 600 living donor liver transplants for pediatric patients at a single center. Liver Transpl 2006; 12:1326.
  38. Drews D, Sturm E, Latta A, et al. Complications following living-related and cadaveric liver transplantation in 100 children. Transplant Proc 1997; 29:421.
  39. Egawa H, Uemoto S, Inomata Y, et al. Biliary complications in pediatric living related liver transplantation. Surgery 1998; 124:901.
  40. Reding R, de Goyet Jde V, Delbeke I, et al. Pediatric liver transplantation with cadaveric or living related donors: comparative results in 90 elective recipients of primary grafts. J Pediatr 1999; 134:280.
  41. Miller CM, Gondolesi GE, Florman S, et al. One hundred nine living donor liver transplants in adults and children: a single-center experience. Ann Surg 2001; 234:301.
  42. Lo CM, Fan ST, Liu CL, et al. Lessons learned from one hundred right lobe living donor liver transplants. Ann Surg 2004; 240:151.
  43. Malagó M, Testa G, Frilling A, et al. Right living donor liver transplantation: an option for adult patients: single institution experience with 74 patients. Ann Surg 2003; 238:853.
  44. Boillot O, Belghiti J, Azoulay D, et al. Initial French experience in adult-to-adult living donor liver transplantation. Transplant Proc 2003; 35:962.
  45. Bak T, Wachs M, Trotter J, et al. Adult-to-adult living donor liver transplantation using right-lobe grafts: results and lessons learned from a single-center experience. Liver Transpl 2001; 7:680.
  46. Kaido T, Egawa H, Tsuji H, et al. In-hospital mortality in adult recipients of living donor liver transplantation: experience of 576 consecutive cases at a single center. Liver Transpl 2009; 15:1420.
  47. Olthoff KM, Merion RM, Ghobrial RM, et al. Outcomes of 385 adult-to-adult living donor liver transplant recipients: a report from the A2ALL Consortium. Ann Surg 2005; 242:314.
  48. Olthoff KM, Abecassis MM, Emond JC, et al. Outcomes of adult living donor liver transplantation: comparison of the Adult-to-adult Living Donor Liver Transplantation Cohort Study and the national experience. Liver Transpl 2011; 17:789.
  49. Kilic M, Aydin U, Noyan A, et al. Live donor liver transplantation for acute liver failure. Transplantation 2007; 84:475.
  50. Shah SA, Levy GA, Greig PD, et al. Reduced mortality with right-lobe living donor compared to deceased-donor liver transplantation when analyzed from the time of listing. Am J Transplant 2007; 7:998.
  51. Freise CE, Gillespie BW, Koffron AJ, et al. Recipient morbidity after living and deceased donor liver transplantation: findings from the A2ALL Retrospective Cohort Study. Am J Transplant 2008; 8:2569.
  52. Wan P, Yu X, Xia Q. Operative outcomes of adult living donor liver transplantation and deceased donor liver transplantation: a systematic review and meta-analysis. Liver Transpl 2014; 20:425.
  53. Olthoff KM, Smith AR, Abecassis M, et al. Defining long-term outcomes with living donor liver transplantation in North America. Ann Surg 2015; 262:465.
  54. Kiuchi T, Kasahara M, Uryuhara K, et al. Impact of graft size mismatching on graft prognosis in liver transplantation from living donors. Transplantation 1999; 67:321.
  55. Emond JC, Renz JF, Ferrell LD, et al. Functional analysis of grafts from living donors. Implications for the treatment of older recipients. Ann Surg 1996; 224:544.
  56. Ogura Y, Hori T, El Moghazy WM, et al. Portal pressure <15 mm Hg is a key for successful adult living donor liver transplantation utilizing smaller grafts than before. Liver Transpl 2010; 16:718.
  57. Moon JI, Kwon CH, Joh JW, et al. Safety of small-for-size grafts in adult-to-adult living donor liver transplantation using the right lobe. Liver Transpl 2010; 16:864.
  58. Miyagawa S, Hashikura Y, Miwa S, et al. Concomitant caudate lobe resection as an option for donor hepatectomy in adult living related liver transplantation. Transplantation 1998; 66:661.
  59. Ikegami T, Bekki Y, Imai D, et al. Clinical outcomes of living donor liver transplantation for patients 65 years old or older with preserved performance status. Liver Transpl 2014; 20:408.
  60. Middleton PF, Duffield M, Lynch SV, et al. Living donor liver transplantation--adult donor outcomes: a systematic review. Liver Transpl 2006; 12:24.
  61. Ghobrial RM, Freise CE, Trotter JF, et al. Donor morbidity after living donation for liver transplantation. Gastroenterology 2008; 135:468.
  62. Muzaale AD, Dagher NN, Montgomery RA, et al. Estimates of early death, acute liver failure, and long-term mortality among live liver donors. Gastroenterology 2012; 142:273.
  63. Hwang S, Lee SG, Lee YJ, et al. Lessons learned from 1,000 living donor liver transplantations in a single center: how to make living donations safe. Liver Transpl 2006; 12:920.
  64. Taner CB, Dayangac M, Akin B, et al. Donor safety and remnant liver volume in living donor liver transplantation. Liver Transpl 2008; 14:1174.
  65. Beavers KL, Sandler RS, Fair JH, et al. The living donor experience: donor health assessment and outcomes after living donor liver transplantation. Liver Transpl 2001; 7:943.
  66. Trotter JF, Talamantes M, McClure M, et al. Right hepatic lobe donation for living donor liver transplantation: impact on donor quality of life. Liver Transpl 2001; 7:485.
  67. Pascher A, Sauer IM, Walter M, et al. Donor evaluation, donor risks, donor outcome, and donor quality of life in adult-to-adult living donor liver transplantation. Liver Transpl 2002; 8:829.
  68. Kim SH, Kim YK, Lee SD, Park SJ. Selection and outcomes of living donors with a remnant volume less than 30% after right hepatectomy. Liver Transpl 2013; 19:872.
  69. Simpson MA, Kendrick J, Verbesey JE, et al. Ambivalence in living liver donors. Liver Transpl 2011; 17:1226.
  70. Kawasaki S, Makuuchi M, Ishizone S, et al. Liver regeneration in recipients and donors after transplantation. Lancet 1992; 339:580.
  71. Nakagami M, Morimoto T, Itoh K, et al. Patterns of restoration of remnant liver volume after graft harvesting in donors for living related liver transplantation. Transplant Proc 1998; 30:195.
  72. Haga J, Shimazu M, Wakabayashi G, et al. Liver regeneration in donors and adult recipients after living donor liver transplantation. Liver Transpl 2008; 14:1718.
  73. Trotter JF, Gillespie BW, Terrault NA, et al. Laboratory test results after living liver donation in the adult-to-adult living donor liver transplantation cohort study. Liver Transpl 2011; 17:409.
  74. Markus BH, Duquesnoy RJ, Gordon RD, et al. Histocompatibility and liver transplant outcome. Does HLA exert a dualistic effect? Transplantation 1988; 46:372.
  75. Alonso EM, Piper JB, Echols G, et al. Allograft rejection in pediatric recipients of living related liver transplants. Hepatology 1996; 23:40.
  76. Jakab SS, Navarro VJ, Colombe BW, et al. Human leukocyte antigen and adult living-donor liver transplantation outcomes: an analysis of the organ procurement and transplantation network database. Liver Transpl 2007; 13:1405.
  77. Whitington PF, Rubin CM, Alonso EM, et al. Complete lymphoid chimerism and chronic graft-versus-host disease in an infant recipient of a hepatic allograft from an HLA-homozygous parental living donor. Transplantation 1996; 62:1516.
  78. Trotter JF, Mackenzie S, Wachs M, et al. Comprehensive cost comparison of adult-adult right hepatic lobe living-donor liver transplantation with cadaveric transplantation. Transplantation 2003; 75:473.