From living related to in-situ split liver transplantation: how to reduce waiting-list mortality

Is there an ethical obligation to split every donor liver? Scarce resources, medical factors, and ethical reasoning

SLT has the potential to counter the worldwide shortage of donor organs. Although the preferred recipients of SLT are usually pediatric patients, a more stringent ethical argument than the fundamental prioritization of children is to demonstrate that SLT of deceased donor organs could increase access to this potentially lifesaving resource for all patients, including children. Several empirical studies show that SLT also makes it possible to achieve similar outcomes to WLT in adults if several factors are observed. In general, it can be regarded as ethically permissible to insist on splitting a donor liver if, in an individual case, SLT is expected to have a similar outcome to that of WLT. The question is therefore no longer whether, but under what conditions SLT is able to achieve similar results to WLT. One of the main challenges of the current debate is the restricted comparability of the available data. We therefore have an ethical obligation to improve the available empirical data by implementing prospective clinical studies, SLT programs, and national registries. The introduction of 2 modes of allocation-one for patients willing to accept both SLT and WLT, and a second for patients only willing to accept WLT-would help to resolve the issue of patient autonomy in the case of mandatory splitting policy.

Living liver donation improves patient and graft survival in the pediatric population

BACKGROUND

The utilization of living donor grafts resulted in an increased availability of liver for pediatric recipients, and accordingly, this was associated with a significantly decreased waiting time before liver transplantation as well as reduced pre-transplant mortality. We hypothesized that the use of living donors in pediatric LT may lead to improved graft and patient survival, when compared to LT using deceased donors.

METHODS

Retrospective cohort analysis of pediatric recipients (aged <18 years) registered in the UNOS database who received a primary liver transplant between February 2002 and December 2016. Covariates predictive of survival by multivariable analyses were included in the Cox proportional hazards regression models to determine predictors of patient and graft survival.

RESULTS

A total of 6312 children received a primary LT from a LD (n = 800) or a deceased donor (n = 5517; partial graft n = 1784 and whole graft n = 3733). Vascular and biliary complications were similar. Kaplan-Meier graft and patient survival rates were superior in LD recipients compared with recipients of deceased whole and reduced graft (Figures 1 and 2). In the multivariable analysis, LD were an independent predictor of improved patient and graft survival.

CONCLUSION

The use of LD in children is associated with improved patient and graft survival. The option of LD should be introduced early on in the evaluation of every pediatric patient being evaluated for liver transplant.

Fighting Mortality in the Waiting List: Liver Transplantation in North America, Europe, and Asia

Liver disease is a major cause of mortality worldwide. Liver transplantation (LT) is the most effective treatment for end stage liver disease. Available resources and social circumstances have led to different ways of implementing LT around the world. The experience with pediatric LT corroborates the hypothesis that a combination of surgical strategies can be beneficial. The goal of this manuscript is to describe the strategies used by LT centers in North America, Europe and Asia and how these strategies can be applied to reduce waitlist mortality and increase access to LT.

Impaired intention-to-treat survival after listing for liver transplantation in children with biliary atresia compared to other chronic liver diseases: 20 years' experience from the Nordic countries

Biliary atresia (BA) is the most common indication for LT in children. We investigated whether this diagnosis per se, compared to other chronic liver diseases (OCLD), had an influence on patient survival. Data from 421 Scandinavian children, 194 with BA and 227 with OCLD, listed for LT between 1990 and 2010 were analyzed. The intention-to-treat survival and influencing risk factors were studied. Patients with BA had higher risk of death after listing than patients with OCLD. The youngest (<1 year) and smallest (<10 kg) children with the highest bilirubin (>510 μmol/L), highest INR (>1.6), and highest PELD score (>20) listed during 1990s had the worst outcome. Given the same PELD score, patients with BA had higher risk of death than patients with OCLD. For adolescents, low weight/BMI was the only prognostic marker. Impaired intention-to-treat survival in patients with BA was mainly explained by more advanced liver disease in younger ages and higher proportion of young children in the BA group rather than diagnosis per se. PELD score predicted death, but seemed to underestimate the severity of liver disease in patients with BA. Poor nutritional status and severe cholestasis had negative impact on survival, supporting the "sickest children first" allocation policy and correction of malnutrition before surgery.

Hepatic Arterial Buffer Response Maintains the Homeostasis of Graft Hemodynamics in Patient Receiving Living Donor Liver Transplantation

BACKGROUND

In living donor liver transplantation (LDLT), the hepatic hemodynamics plays important roles in graft regeneration, and the hepatic blood inflows are associated with graft size. However, the data of interplay between the hepatic arterial buffer response (HABR) and graft-to-recipient weight ratio (GRWR) in clinical LDLT are lacking.

AIMS

To identify the effect of the HABR on the hepatic hemodynamics and recovery of graft function and to evaluate the safe lower limit of the GRWR in carefully selected recipients.

METHODS

Portal venous and hepatic arterial blood flow was measured in recipients with ultrasonography, and the graft functional recovery, various complications, and survive states after LDLT were compared.

RESULTS

In total, 246 consecutive patients underwent LDLT with right lobe grafts. In total, 26 had a GRWR < 0.7 % (A), 29 had a GRWR between 0.7 and 0.8 % (B), and 181 had a GRWR > 0.8 % (C). For small-for-size syndrome, there was no significant difference (P = 0.176). Graft survival rates at 1, 3, and 5 year were not different (P = 0.710). The portal vein flow and portal vein flow per 100 g graft weight peaks were significantly higher in the A. Hepatic arterial velocity and hepatic arterial flow decreased in all the three groups on postoperative day 1; however, the hepatic arterial flow per 100 g graft weight was close to healthy controls.

CONCLUSIONS

HABR played important roles not only in the homeostasis of hepatic afferent blood supply but also in maintaining enough hepatic perfusion to the graft.

Significance of postoperative changes in hemodynamics and biochemical indices in pediatric recipients of live-donor liver transplants

OBJECTIVE

The aim of this study was to evaluate the postoperative changes in hemodynamics and biochemical indices in pediatric recipients of live-donor liver transplants (LDLT).

METHODS

Hemodynamics and biochemical indices (coagulation function, electrolytes, kidney function, liver function, and blood analysis) were monitored on the day before and the 1st, 3rd, 5th, and 7th days after the procedure in 20 children who underwent LDLT from June 2006 to January 2009.

RESULTS

Compared with preoperative measurements, systolic and diastolic blood pressure and mean arterial pressure increased and prothrombin time was prolonged significantly during the first 7 days after LDLT (P < .05). Fibrinogen, platelet count, total protein, globulin, and blood magnesium decreased significantly (P < .05). Liver enzymes (aspartate transaminase [AST], alanine transaminase [ALT]) and blood sodium increased significantly; serum potassium and calcium declined on the first postoperative day (P < .05). On the 7th day, AST returned to nearly normal (P < .05) and ALT returned to the preoperative levels. Blood urea nitrogen fluctuated within the normal range (P < .05). Total and direct bilirubin decreased on the 1st day but returned to near normal levels on the 7th day (P <.001).

CONCLUSIONS

Our data demonstrated postoperative changes in hemodynamics, electrolytes, and biochemical indices in pediatric LDLT recipients. The changes in clotting factors and platelet count did not result in severe coagulation function disorder; kidney function was normal. Changes in liver enzymes and bilirubin compared with the preoperation indices were within the regulatory scope of liver and did not result in severe complications. These preliminary postoperative trends suggest that further prospective evaluation is needed.

Split and whole liver transplantation outcomes: a comparative cohort study

A specific split liver transplantation (SLT) program has been pursued in the North Italian Transplant program (NITp) since November 1997. After 5 yr, 1,449 liver transplants were performed in 7 transplant centers, using 1,304 cadaveric donors. Whole liver transplantation (WLT) and SLT were performed in 1,126 and 323 cases, respectively. SLTs were performed in situ as 147 left lateral segments (LLS), 154 right trisegment liver (RTL) grafts, and 22 modified split livers (MSL), used for couples of adult recipients. After a median posttransplant follow-up of 22 months, SLTs achieved a 3-yr patient and graft survival not significantly different from the entire series of transplants (79.4 and 72.2% vs. 80.6 and 74.9%, respectively). Recipients receiving a WLT or a LLS showed significantly better outcomes than patients receiving RTL and MSL (P < 0.03 for patients and P < 0.04 for graft survival). At the multivariate analysis, donor age of >60 yr, RTL transplant, <50 annual transplants volume, urgent transplantation (United Network for Organ Sharing (UNOS) status I and IIA), ischemia time of >7 hours, and retransplantation were factors independently related to graft failure and to significantly worst patient survival. Right grafts procured from RTL and either split procured as MSL had a similar outcome of marginal whole livers. In conclusion, in 5 yr, the increased number of pediatric transplants due to split liver donation reduced to 3% the in-list children mortality, and a decrease in the adult patient dropout rate from 27.2 to 16.2% was observed. Such results justify a more widespread adoption of SLT protocols, organizational difficulties not being a limit for the application of such technique.

Outcomes of split versus reduced-size grafts in pediatric liver transplantation

BACKGROUND

Split-liver transplantation, where two grafts are created from a single donor organ, is a means of overcoming donor organ scarcity. There are few data comparing outcomes of split with reduced-size liver grafts, which is the most common type of cadaveric graft in pediatric liver transplantation. The aims of the present paper were to compare survival and complication rates between split and reduced-size cadaveric grafts in pediatric patients receiving a liver transplant in Brisbane.

METHODS

Review of the Queensland Liver Transplant Service database was undertaken. All pediatric patients who received either a cadaveric split or reduced-size graft between 1985 and 2000 were examined. The incidence of patient and graft survival, vascular complications and biliary complications were identified.

RESULTS

A total of 251 liver transplants were performed of which 138 were reduced-size grafts and 30 were split grafts. There were no differences in etiology of liver disease, mean age, weight, and urgency of transplant between the two groups. One-year patient and graft survivals were comparable at 73% and 67%, respectively, in both groups. There was no difference in the incidence of vascular complications between groups. Biliary complications were significantly more common after split grafts when compared with reduced-size grafts (21%vs 4%, P < 0.0001) but did not affect patient or graft survival.

CONCLUSIONS

Survival and vascular complications after split-liver grafts were comparable to outcomes after reduced-size grafts. Biliary complications occur more commonly with split-liver grafts but did not affect patient or graft survival. It is recommended that every pediatric recipient be considered for a split-liver graft.

Comparative Study Between Living and Cadaveric Donors in Pediatric Liver Transplantation

We examined whether the results in living-related hepatic transplantation (LRLT) are better than those from a cadaveric donor (CDLT).

MATERIAL AND METHODS

The last 27 consecutive LRLT, performed from 1998 to 2005, were compared with 27 CDLT matched for age, weight, date, and diagnosis. Grafts in LRLT group were left lateral segment (n = 22), left lobe (n = 3), and right lobe (n = 2). In the CDLT group, the grafts were split in situ (n = 10), hepatic reduction (n = 9) and whole liver (n = 8). We analyzed the actuarial survivals (grafts and children), retransplantation, primary nonfunction, initial graft malfunction (liver enzymes >2000 U/L), surgical complications, rejection, and resource consumption.

RESULTS

Patient survivals at 6 months, 1 year, and 5 years were 100%, 96%, and 96% in LRLT and 100%, 100%, and 100% in CDLT (P = NS). Graft survivals were 93%, 89%, and 89% versus 96%, 96%, and 96%, respectively (P = NS). Complications were biliary complications (LRLT, 25% vs CDLT, 3%; P = .021); portal vein thrombosis (LRLT, 7% vs CDLT, 3%; NS), and hepatic artery thrombosis (LRLT, 0% vs CDLT, 3%; NS). The overall incidence of acute rejection was slightly higher (NS) in LRLT (LRLT, 18% vs CDLT, 11%; NS). Liver enzyme levels were higher in the CDLT group, but initial malfunction rate was not statistically different. Regarding resource consumption: blood product needs were higher in LRLT (P < .05) and hospital stay and ICU stay were longer, although not significantly, among LRLT.

CONCLUSIONS

The results in LRLT among children are similar to those obtained in CDLT. We found a trend towards less initial graft malfunction in LRLT. Blood product needs were higher in LRLT. Hospital and ICU stay were longer, but not significantly different in LRLT. The benefits of LRLT are saving a scarce resource: a cadaveric donor liver graft.

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Combined living donor liver/small bowel transplantation

We are reporting the first known case of sequential combined living donor liver/small bowel transplantation (LDL/SBT). A 2-year-old boy born with gastroschisis and intestinal malrotation lost his entire small bowel and colon shortly after birth. He underwent a living donor small bowel transplant at 1 year of age that was lost 4 months after implantation for posttransplant lymphoproliferative disease (PTLD). He recovered from PTLD but developed total parenteral nutrition (TPN)-induced liver failure. He received a combined left lateral liver and terminal ileum transplant that we chose to perform sequentially due to the presence of preformed antibodies against his mother's tissues. The mother had no complications and a cumulative hospital stay of 7 days. At 9 months postsurgery, the patient is on full enteral nutrition and has suffered neither technical complications nor rejection. The technique described here is reproducible and makes combined living donor LDL/SBT an alternative to combined cadaveric liver-small bowel transplant.

Surgical advances in liver and bowel transplantation

Liver and intestinal transplantation are currently the treatments of choice for life-threatening hepatic and gastrointestinal failure. These technologies have evolved through contributions from the fields of immunology, anatomy, physiology, surgery, anesthesiology, critical care, ethics, epidemiology, and public health. Transplantation now accounts for the treatment of over 5,000 recipients per year who are in a state of organ failure. The available donor population, however, is not increasing to meet the demands of the faster growing recipient population. This discrepancy has led to the rapid development of novel strategies that require critical evaluation to build on the success rates in recent years. This article presents the most salient advances in liver and intestinal transplantation in the last 15 years.

Liver transplantation for children--the Red Cross Children's Hospital experience

Liver transplantation for infants and children has been available in South Africa at a single centre, the only established service in Sub-Saharan Africa, for more than a decade. Current concerns have shifted from an initial target of early post-transplant survival to quality of life in the long-term.

MATERIALS AND METHODS

Since 1985, 225 infants and children have been assessed, with 146 accepted for transplantation. Sixty-nine have had 71 orthotopic liver transplants (OLTx). Biliary atresia was the most frequent diagnosis (54%) followed by acute liver failure (ALF) (15%). Waiting list mortality has remained high (23%), particularly for the ALF group (50%). Forty-three were reduced size transplants with donor: recipient weight ratios ranging from 2:1 to 11:1. Twenty-seven were <10 kg.

RESULTS

Fifty (74%) survive 1 month-12 years post-transplant. Actuarial survival after 1996 since HBV core antibody positive donor livers were refused and prophylactic IV ganciclovir used has been >82%. Early post-OLTx mortality was low (5%), one primary non-function, one IVC thrombosis, one PV thrombosis, but late morbidity and mortality (20%) was mainly due to viral infection: de novo hepatitis B (five patients, three deaths), EBV-related post-transplantation lymphoproliferative disease (PTLPD) (eight patients, six deaths) and CMV disease (11 patients, five deaths). Tuberculosis prophylaxis, required in six cases, resulted in major morbidity in two and mortality in one. Poor compliance played a significant role in seven deaths. Hypertension requiring medication along with some compromise of renal function has been present in all but two patients. However, all those of school-going age (25) attend school normally and remain in good health and only three of the survivors have abnormal liver function tests.

CONCLUSIONS

Successful liver transplantation is possible in a developing country with limited resources. Scarcity of virus-free donors (HBV and HIV) leading to waiting list mortality and infrequent re-transplantation along with long-term consequences of immunosuppression (infection, lymphoma and renal toxicity) remain problems. Intense education of the caregiver and close follow-up, particularly of those living at long distances has partly addressed the compliance problem.

Influence of graft type on outcomes after pediatric liver transplantation

We sought to determine which type of donor graft provides children and young adults with the best outcomes following liver transplantation. Using the US Scientific Registry of Transplant Recipients database, we identified 6467 recipients of first liver transplants during 1989-2000 aged < 30 years. We used Cox models to examine adjusted patient and graft outcomes by age (< 2, 2-10, 11-16, 17-29) and donor graft type (deceased donor full size (DD-F), split (DD-S), living donor (LD)]. For patients aged < 2, LD grafts had a significantly lower risk of graft failure than DD-S (RR = 0.49, p < 0.0001) and DD-F (RR = 0.70, p = 0.02) and lower mortality risk than DD-S (RR = 0.71, p = 0.08) during the first year post-transplant. In contrast, older children exhibited a higher risk of graft loss and a trend toward higher mortality associated with LD transplants. In young adults, DD-S transplants were associated with poor outcomes. Three-year follow up yielded similar graft survival results but no significant differences in mortality risk by graft type within age group. For recipients aged < 2, LD transplants provide superior graft survival than DD-F or DD-S and trend toward better patient survival than DD-S. Living donor is the preferred donor source in the most common pediatric age group (< 2 years) undergoing liver transplantation.

Pediatric living donor liver transplantation

AIM

The aim of this study was to analyze the results of living donor in a pediatric liver transplantation program.

PATIENTS

Twenty-six living donor liver transplantations were performed in children from 0.5 to 14.8 years of age. The main indication was biliary atresia (72%) followed by tumors (2 hepatoblastomas and 1 hepatocarcinoma). Left lateral segments were used in 23 (1 transformed into a monosegment), 1 left lobe was used in 1, and right lobes were used in 2. Arterial reconstruction employed saphenous venous grafts in the first 3 cases and end-to-end anastomoses with a microsurgical technique in the following 22 cases.

RESULTS

There has been no major morbidity in the donors, with a median hospitalization of 6 days. Four grafts have been lost; 2 in the first 3 cases. In only 1 case, the graft loss was related to the procedure saphenous venous graft thrombosis). Early biliary complications were frequent (23%). Six month, 1 year, and 5 year graft and patient survival rates were 91%, 85%, and 85% and 100%, 96%, and 96%, respectively.

CONCLUSIONS

Living donor liver transplantation is an excellent option for transplantation in children.

Worth continuing doing ex situ liver graft splitting? A single-center analysis

Grafts for split liver transplantation can be prepared in situ during the retrieval operation, or ex situ on the back table. The in situ technique has theoretical advantages because it minimizes the cold ischemic time and allows excellent hemostasis at the cut surface. However, in situ liver division prolongs the retrieval procedure, may precipitate hemodynamic instability in the donor, and may cause logistical difficulties for some centers. This report is a single-center analysis comparing results of ex situ liver division (group I: 1992-97; and group II: 1998-2001) before and after a new protocol for liver graft division was introduced in our center. Eighty-nine split liver transplants (SLT) were reviewed retrospectively. Vascular complications were less common in group II (3.3% vs. 20%; p = 0.04), and 1-year graft survival increased from 59% to 78% (p = 0.03). Since 1998, 1-year graft survival of SLT has been similar to that of conventional liver graft transplantation in our center (78% and 74%, respectively). In conclusion, good results can be achieved from splitting livers ex situ and this procedure should be considered when the in situ technique is not feasible.

Complications following Split-Liver Transplantation: A Pediatric Case Study

Liver transplantation using split and reduced livers has helped to expand the donor pool for pediatric patients in the presence of a severe cadaveric organ donor shortage. However, this technique has been associated with an increased rate of postoperative complications. The purpose of this paper is to review a case report of postoperative complications experienced by a pediatric patient following split-liver transplantation for fulminant hepatic failure of unknown etiology.