Sharing of split livers between centers is easily feasible

A national mandatory-split liver policy: A report from the Italian experience

To implement split liver transplantation (SLT) a mandatory-split policy has been adopted in Italy since August 2015: donors aged 18-50 years at standard risk are offered for SLT, resulting in a left-lateral segment (LLS) graft for children and an extended-right graft (ERG) for adults. We aim to analyze the impact of the new mandatory-split policy on liver transplantation (LT)-waiting list and SLT outcomes, compared to old allocation policy. Between August 2015 and December 2016 out of 413 potentially "splittable" donors, 252 (61%) were proposed for SLT, of whom 53 (21%) donors were accepted for SLT whereas 101 (40.1%) were excluded because of donor characteristics and 98 (38.9%) for absence of suitable pediatric recipients. The SLT rate augmented from 6% to 8.4%. Children undergoing SLT increased from 49.3% to 65.8% (P = .009) and the pediatric LT-waiting list time dropped (229 [10-2121] vs 80 [12-2503] days [P = .045]). The pediatric (4.5% vs 2.5% [P = .398]) and adult (9.7% to 5.2% [P < .001]) LT-waiting list mortality reduced; SLT outcomes remained stable. Retransplantation (HR = 2.641, P = .035) and recipient weight >20 kg (HR = 5.113, P = .048) in LLS, and ischemic time >8 hours (HR = 2.475, P = .048) in ERG were identified as predictors of graft failure. A national mandatory-split policy maximizes the SLT donor resources, whose selection criteria can be safely expanded, providing favorable impact on the pediatric LT-waiting list and priority for adult sick LT candidates.

Modified pediatric end-stage liver disease scoring system and pediatric liver transplantation in Brazil

The Pediatric End-Stage Liver Disease (PELD) scoring system is a formula developed to provide a continuous numerical assessment of the risk of death in order to allocate livers to children in need of transplantation. The PELD scoring system was introduced in Brazil in July 2006. An important change was made in the system: the final number for listing patients less than 12 years old for transplantation was the calculated PELD score multiplied by 3. The consequences of this allocation policy were analyzed in 2 ways in this research: nationally and in the state of São Paulo (SP State). In the analysis of the national data, a comparison of the pre-PELD era (July 2003 to July 2006) and the post-PELD era (August 2006 to April 2009) showed that the total number of pediatric transplants for children under 12 years of age decreased 7%. Regionally, in SP State, there was a 62% increase in the number of deceased donor liver transplantation procedures for the pediatric population after the introduction of the modified PELD system. There was also a 6.1-fold increase in split liver transplantation as well as a statistically significant decrease in the time on the waiting list (P < 0.001). In conclusion, changing the allocation policy in Brazil in order to benefit pediatric patients on the waiting list had different results according to analyses of national and regional data. A significant increase in deceased donor liver transplantation/split liver transplantation and a shorter time on the waiting list were observed in SP State. The modified PELD scoring system is simple and optimizes the utilization of deceased donor liver grafts in centers performing pediatric transplants.

Long-term outcome of split liver transplantation using right extended grafts in adulthood: A matched pair analysis

OBJECTIVE

Shortage of suitable organs led to the development of alternative techniques in liver transplantation. Split liver transplantation (SLT) is well established in pediatric patients. SLT is not completely accepted in adult recipients due to potential increased risk of complications. Despite satisfying results of short-term outcome, there is a leak on information of the long-term outcome. Therefore, we compared the outcome after transplantation of the right extended liver lobe with whole liver transplantation (WLT) using a matched pair's analysis.

PATIENTS AND METHODS

From the period of January 1993 to February 2005, 70 SLT recipients were matched with 70 WLT recipients of whole livers. Matching criteria were: 1) indication for transplantation, 2) United Network for Organ Sharing (UNOS) status, 3) recipient age, 4) donor age, 5) cold ischemic time, and 6) year of transplantation. The outcome was analyzed retrospectively.

RESULTS

Mean follow-up was 36 months. The 2- and 5-year patient survival rates after SLT and WLT were 86.3% and 82.6%, and 78.4% and 75.6%, respectively (log rank, P = 0.2127). Two- and 5-year graft survival rates were 77.3% and 77.3% after SLT and 71.9% and 65.8% after WLT, respectively (log rank, P = 0.3822). The total biliary complication rate was 11.4% in the SLT group versus 10.0% in the WLT group in the short-term course, while it was 8.5% after SLT and 10.0% after WLT in the long-term course. We did not observe significant differences between the groups in term of short- and long-term morbidity.

CONCLUSION

Transplantation of the right extended lobe deriving from left lateral splitting of deceased donor livers is followed by the same long-term patient and graft survival, which is known from WLT. There were no differences in the complication rates even in long-term outcome implementing that SLT does not put the adult recipient to an increased early and late risk. Transplantation of the extended right liver lobe provides a safe and efficient procedure in adult patients to expand the number of available grafts.

Split-liver transplantation using the left lateral segment: a collaborative sharing experience between two distant centers

Split-liver transplantation (SLT) increases the pool of organs for pediatric orthotopic liver transplantation (pOLT). With increased collaboration and organ sharing, transplant centers can fully maximize the use of all split donor allografts. Herein, we report the collaborative results between two distant centers involved in a sharing alliance. The current study consists of a retrospective review of 56 pediatric LLS transplants performed at two collaborating centers between 9/1997 and 10/2003. Fifty-three patients (41% Status 1) were transplanted using 56 left lateral segment (LLS) grafts. Sixteen percent of LLS grafts were shared between the two institutions. Overall patient survival at both 1 and 3 years was 90% and 90%, respectively. Overall graft survival at both 1 and 3 years was 82% and 82%, respectively. Shared patient and graft survival was 89% and 89%, respectively. There was an 11% biliary complication and 18% vascular complication rate. Five patients required retransplantation. In conclusion, SLT increases the number of available allografts for pOLT. While SLT is technically demanding, with a significant learning curve, patient and graft survival rates compare favorably with United Network Organ Sharing (UNOS) averages. Sharing of grafts between centers is a safe and effective way to maximize organ usage and should be actively pursued through collaborative networks.

Split-liver transplantation in the United States: outcomes of a national survey

OBJECTIVE

Assess application and outcomes of split-liver transplantation within the United States.

SUMMARY BACKGROUND DATA

While a theoretically attractive mechanism to increase cadaver organ supply, split-liver transplantation has been infrequently applied. The American Society of Transplant Surgeons, in an attempt to gather preliminary data on split-liver transplantation, performed a data protected survey of transplant centers participating in the U.S. Scientific Registry for Transplant Recipients.

METHODS

Between April 2000 and May 2001, 89 surgical teams were surveyed. Elicited data included graft type, recipient status, procurement method, graft sharing, graft outcomes, recipient outcomes, and experience with cadaver, whole-organ transplantation.

RESULTS

Eighty-three surgical teams reported data on 207 left lateral segment, 152 right trisegment, 15 left lobe, and 13 right lobe grafts. The split procedure was performed ex vivo in 54% and in situ in 46% of grafts. Complications were frequent in all graft types with biliary and vascular complications equally distributed between grafts procured by either technique. Primary nonfunction, graft failure, and recipient death correlated with transplant status.

CONCLUSIONS

Split-liver transplantation has been principally applied to adult-child pairs with at least one recipient critically ill. Biliary and vascular complications account for the majority of morbidity in grafts procured by either split technique with graft failure and recipient death observed more frequently in critically ill recipients. Enhanced utilization and improved results may be possible through improved information sharing and modification of allocation criteria.

Split-liver transplantation: a review

Split-liver transplantation (SLT), a procedure where one cadaver liver is divided to provide for two recipients, offers immediate expansion of the existing cadaver donor pool. To date, the principal beneficiaries of SLT have been adult/pediatric recipient pairs with excellent outcomes reported; however, the current scarcity of cadaver organs has renewed interest in expanding these techniques to include two adult recipients from one adult cadaver donor. Significant obstacles to the widespread application of SLT exist and must be resolved by the transplant community before greater utilization can be realized. This manuscript reviews the historic background, surgical techniques, current results, and obstacles impeding further application of SLT.

Split liver transplantation

Greater experience and improved outcomes in liver transplantation have necessarily led to longer waiting lists against a constantly limited donor pool. Split liver transplantation has been conceived as a means to increase the supply of liver grafts. The bipartition of a whole liver provides grafts for two recipients in a complex operation with equally complex manpower and logistical demands. The in situ technique of splitting offers advantages over the ex vivo technique, although after the time-dependent learning curve is overcome, they may theoretically be used interchangeably with acceptable outcomes. Aside from surgical expertise, donor characteristics and recipient pre-transplant status are risk factors for survival. This review will address the salient aspects of split liver transplantation, summarize the world experience with this procedure and describe the preliminary attempts in Asia.

Optimizing the use of donated cadaver livers: analysis and policy development to increase the application of split-liver transplantation

The American Society of Transplant Surgeons and the American Society of Transplantation jointly sponsored a conference in Crystal City, Virginia, on March 28th and 29th, 2001, to explore mechanisms for maximizing the cadaver-organ donor pool. Participants from transplantation medicine, surgery, organ procurement organizations, the general public, and government convened to address expanding utilization of each organ type. The committee assigned to review liver organ utilization identified multiple practices that could expand the potential donor pool including non-heart beating donors, marginal grafts, efficient allocation of cadaver organs, and wider application of split-liver transplantation. This article details the data reviewed by the liver committee and their recommendations on policy development for the expanded application of split-liver transplantation.