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2
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Improvement in survival associated with adult-to-adult living donor liver transplantation.
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Berg CL; Gillespie BW; Merion RM; Brown RS Jr; Abecassis MM; Trotter JF; Fisher RA; Freise CE; Ghobrial RM; Shaked A; Fair JH; Everhart JE
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Gastroenterology. 2007 Dec;133(6):1806-13. Epub 2007 Sep 14.
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BACKGROUND&AIMS: More than 2000 adult-to-adult living donor liver transplantations (LDLT) have been performed in the United States, yet the potential benefit to liver transplant candidates of undergoing LDLT compared with waiting for deceased donor liver transplantation (DDLT) is unknown. The aim of this study was to determine whether there is a survival benefit of adult LDLT. METHODS: Adults with chronic liver disease who had a potential living donor evaluated from January 1998 to February 2003 at 9 university-based hospitals were analyzed. Starting at the time of a potential donor's evaluation, we compared mortality after LDLT to mortality among those who remained on the waiting list or received DDLT. Median follow-up was 4.4 years. Comparisons were made by hazard ratios (HR) adjusted for LDLT candidate characteristics at the time of donor evaluation. RESULTS: Among 807 potential living donor recipients, 389 underwent LDLT, 249 underwent DDLT, 99 died without transplantation, and 70 were awaiting transplantation at last follow-up. Receipt of LDLT was associated with an adjusted mortality HR of 0.56 (95% confidence interval [CI]: 0.42-0.74; P<.001) relative to candidates who did not undergo LDLT. As centers gained greater experience (>20 LDLT), LDLT benefit was magnified, with a mortality HR of 0.35 (95% CI: 0.23-0.53; P<.001). CONCLUSIONS: Adult LDLT was associated with lower mortality than the alternative of waiting for DDLT. This reduction in mortality was magnified as centers gained experience with LDLT. This reduction in transplant candidate mortality must be balanced against the risks undertaken by the living donors themselves.
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Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA. CLB7D@hscmail.mcc.virginia.edu
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| PMID |
18054553
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31
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Pediatric liver transplantation with cadaveric or living related donors: comparative results in 90 elective recipients of primary grafts.
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Reding R; de Goyet Jde V; Delbeke I; Sokal E; Jamart J; Janssen M; Otte JB
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J Pediatr 1999 Mar;134(3):280-6.
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STUDY DESIGN: Between July 1993 and March 1997, 110 children were listed for primary elective liver transplantation with cadaveric (Cad: n = 68) or living-related (LR: n = 42) donors. Pregraft mortality, post-transplant survival, and surgical and immunologic complications were retrospectively compared in both groups. RESULTS: The pregraft mortality rate was 10 (15%) of 68 versus 1 (2%) of 42 in the Cad and LR groups, respectively (P =.049). Postliver transplantation 1-year patient and graft survival rates were 87% and 75% in the Cad group (n = 49) versus 92% and 90% in the LR group (n = 41), respectively (NS). The incidence of post-transplant complications was as follows: hepatic artery thrombosis (Cad: 16%; LR: 0%, P =.020), portal vein thrombosis (Cad: 8%; LR: 2%, NS), and biliary complications (Cad: 14%; LR: 34%, P =.044). The overall incidence of acute rejection was similar in both groups; however, a lower incidence of acute rejection occurred in LR graft recipients treated with tacrolimus. CONCLUSIONS: The introduction of an LR donor liver transplantation program allowed a significant decrease in the pretransplant mortality rate, with a consequent overall improvement in patient survival compared with the Cad series. The incidence of biliary complications was higher in the LR series, whereas better human leukocyte antigen matching in this subgroup did not result in a lower rejection incidence.
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Pediatric Liver Transplant Program, Saint-Luc University Clinics, University of Louvain Medical School, Brussels, Belgium.
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| PMID |
10064662
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32
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Single-center analysis of the first 40 adult-to-adult living donor liver transplants using the right lobe.
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Marcos A; Ham JM; Fisher RA; Olzinski AT; Posner MP
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Liver Transpl. 2000 May;6(3):296-301.
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The first adult-to-adult living donor liver transplant using the right hepatic lobe in the United States was performed only 2 years ago. Although initial reports were encouraging, continuous review of the results and appropriate modifications in patient management will be necessary to minimize donor risk and optimize recipient outcome. The results of 40 such transplantations were analyzed and are summarized. Recipients were listed for transplantation according to the usual criteria. Living donors were not considered for United Network for Organ Sharing status IIA patients after the initial 22 patients. Donor evaluation followed a rigid protocol. A graft-to-recipient body weight ratio of at least 0.8% was the minimum required throughout most of the study. The surgical procedures were similar, except the plane of transection was modified to better accommodate donor biliary anatomy, and uniform stenting of bile ducts was practiced after the first 10 transplants. Immunosuppression consisted of tacrolimus, mycophenolate mofetil, and a prednisone taper. The target tacrolimus level was decreased and mycophenolate was withdrawn more rapidly in the second half of the study because of the absence of acute cellular rejection. Donor morbidity has been limited to minor complications, and transplant recipient biliary complications decreased from 35% to 0%. Acute cellular rejection has not been observed despite less aggressive immunosuppression, and septic complications decreased dramatically. There have been no recipient deaths since these changes were instituted. Right lobectomy can be performed safely in the donor population. Recipient biliary complications can be minimized with stenting. Less aggressive immunosuppression is well tolerated and minimizes septic complications and attributable mortality.
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Department of Surgery, Division of Transplantation, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA 23219, USA. amarcos@hsc.vcu.edu
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| PMID |
10827229
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33
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One hundred nine living donor liver transplants in adults and children: a single-center experience.
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Miller CM; Gondolesi GE; Florman S; Matsumoto C; Munoz L; Yoshizumi T; Artis T; Fishbein TM; Sheiner PA; Kim-Schluger L; Schiano T; Shneider BL; Emre S; Schwartz ME
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Ann Surg 2001 Sep;234(3):301-11; discussion 311-2.
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OBJECTIVE: To summarize the evolution of a living donor liver transplant program and the authors' experience with 109 cases. SUMMARY BACKGROUND DATA: The authors' institution began to offer living donor liver transplants to children in 1993 and to adults in 1998. METHODS: Donors were healthy, ages 18 to 60 years, related or unrelated, and ABO-compatible (except in one case). Donor evaluation was thorough. Liver biopsy was performed for abnormal lipid profiles or a history of significant alcohol use, a body mass index more than 28, or suspected steatosis. Imaging studies included angiography, computed tomography, endoscopic retrograde cholangiopancreatography, and magnetic resonance imaging. Recipient evaluation and management were the same as for cadaveric transplant. RESULTS: After ABO screening, 136 potential donors were evaluated for 113 recipients; 23 donors withdrew for medical or personal reasons. Four donor surgeries were aborted; 109 transplants were performed. Fifty children (18 years or younger) received 47 left lateral segments and 3 left lobes; 59 adults received 50 right lobes and 9 left lobes. The average donor hospital stay was 6 days. Two donors each required one unit of banked blood. Right lobe donors had three bile leaks from the cut surface of the liver; all resolved. Another right lobe donor had prolonged hyperbilirubinemia. Three donors had small bowel obstructions; two required operation. All donors are alive and well. The most common indications for transplant werebiliary atresia in children (56%) and hepatitis C in adults (40%); 35.6% of adults had hepatocellular carcinoma. Biliary reconstructions in all children and 44 adults were with a Roux-en-Y hepaticojejunostomy; 15 adults had duct-to-duct anastomoses. The incidence of major vascular complications was 12% in children and 11.8% in adult recipients. Children had three bile leaks (6%) and six (12%) biliary strictures. Adult patients had 14 (23.7%) bile leaks and 4 (6.8%) biliary strictures. Patient and graft survival rates were 87.6% and 81%, respectively, at 1 year and 75.1% and 69.6% at 5 years. In children, patient and graft survival rates were 89.9% and 85.8%, respectively, at 1 year and 80.9% and 78% at 5 years. In adults, patient and graft survival rates were 85.6% and 77%, respectively, at 1 year. CONCLUSION: Living donor liver transplantation has become an important option for our patients and has dramatically changed our approach to patients with liver failure. The donor surgery is safe and can be done with minimal complications. We expect that living donor liver transplants will represent more than 50% of our transplants within 3 years.
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Recanati/Miller Transplantation Institute, Mount Sinai Hospital, Mount Sinai School of Medicine, New York, New York 10029, USA. charles.miller@mountsinai.org
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| PMID |
11524583
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34
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Lessons learned from one hundred right lobe living donor liver transplants.
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Lo CM; Fan ST; Liu CL; Yong BH; Wong Y; Lau GK; Lai CL; Ng IO; Wong J
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Ann Surg. 2004 Jul;240(1):151-8.
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OBJECTIVE: To evaluate the first 100 adult right lobe living donor liver transplants (LDLT) in a single center to determine whether the results have improved with technical modifications and better experience. SUMMARY BACKGROUND DATA: Right lobe LDLT has been increasingly performed for adults with end-stage liver disease. Numerous modifications in technique have been introduced, and a learning curve is likely in view of its complexity. METHODS: One hundred consecutive adult right lobe LDLTs performed between May 1996 and May 2002 were retrospectively studied by comparing the first 50 (group 1) with the last 50 cases (group 2). The median follow-up was 37 (27 to 79) months for group 1 and 15 (7 to 27) months for group 2. RESULTS: The characteristics of donors and liver grafts were similar. In group 2, fewer recipients were intensive care unit (ICU)-bound or had hepatorenal syndrome before transplantation, and there was a lower disease severity as shown by a lower Child-Pugh score and Model for End-Stage Liver Disease (MELD) score. Significant improvements were found in the operation time, blood loss, ICU stay, and postoperative complication rate of the donors and in the operation time, transfusion requirements, number of reoperations, ICU stay, and hospital stay of the recipients in group 2. The hospital mortality rate of recipients was reduced from 16% to 0% (P = 0.006). Graft survival rates at 12 months and 24 months were improved from 80% and 74%, respectively, in group 1 to 100% and 96%, respectively, in group 2 (P = 0.002). After adjusting for differences in recipient risk factors (ICU-bound, hepatorenal syndrome, Child-Pugh score, and MELD score) in a multivariate Cox model, recipients in group 2 had significantly lower risk of graft loss (relative risk compared with group 1, 0.13; 95% CI, 0.03 to 0.66; P = 0.014). CONCLUSIONS: There is a learning curve in adult right lobe LDLT. The results have significantly improved with technical refinement and better experience.
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Centre for the Study of Liver Disease, and Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China. chungmlo@hkucc.hku.hk
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| PMID |
15213631
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35
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Right living donor liver transplantation: an option for adult patients: single institution experience with 74 patients.
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| AU |
Malago M; Testa G; Frilling A; Nadalin S; Valentin-Gamazo C; Paul A; Lang H; Treichel U; Cicinnati V; Gerken G; Broelsch CE
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| SO |
Ann Surg. 2003 Dec;238(6):853-62; discussion 862-3.
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OBJECTIVE: To present an institutional experience with the use of right liver grafts in adult patients and to assess the practicability and efficacy of this procedure by analyzing the results. SUMMARY BACKGROUND DATA: Living donor liver transplantation (LDLT) for the pediatric population has gained worldwide acceptance. In the past few years, LDLT has also become feasible for adult patients due to technical evolution in hepatobiliary surgery and increased experience with reduced-size and split-liver transplants. Nevertheless, some graft losses remain unexplained and are possibly due to unrecognized venous outflow problems. METHODS: From April 1998 to September 2002, we performed 74 right LDLTs (segments 5-8). The 74 donors were selected from 474 candidates according to standard protocol. The median age of the donors was 35 years (range 18-58 years) and 51 years (range 18-64 years) in recipients. Standard and extended indications for transplantation were considered. Over the period reported, technical modifications in the bile duct anastomosis (duct-to-duct, end-to-end, or end-to-side) and a new graft implantation technique that provides maximized venous outflow, leading to outcome improvement, were developed. RESULTS: 64.9% of patients had liver cirrhosis and 35.1% had malignancy. While 44 donors (59.5%) presented an uneventful postoperative course, 27% minor (pleural effusion, pneumonia, venous thrombosis, wound infection, incisional hernia) and 13.5% major (biliary leakage, death of a donor due to unrecognized hereditary liver disease, and consecutive liver insufficiency) complications were documented. In recipients, 23% biliary complications and 6.8% hepatic artery thrombosis occurred. The overall patient and graft survival rate after 1 year was 79.4% and 75.3%, respectively. In cases with extended indication, the patient survival rate was 74% and the graft survival rate 68% at 12 months. Using technical modifications in the last 10 recipients, including 2 critically decompensated cirrhotics, the survival rate was 100% at a median follow-up of 3.5 months. CONCLUSIONS: In our transplant program, living donor liver transplantation has become a standard option in the adult patient population. The critical issue of this procedure is donor morbidity. Technical improvements in the harvesting and implantation of right grafts can also offer hope to patients with challenging forms of end-stage liver disease or malignant liver tumors.
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| AD |
Department of General Surgery and Transplantation, University Hospital Essen, Essen, Germany.
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| PMID |
14631222
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