Successful living donor liver transplantation between septuagenarians

Donor safety of remnant liver volumes of less than 30% in living donor liver transplantation: A systematic review and meta-analysis

PURPOSE

This meta-analysis aimed to investigate the acceptability of donor remnant liver volume (RLV) to total liver volume (TLV) ratio (RLV/TLV) being <30% as safe in living donor liver transplantations (LDLTs).

METHODS

Online databases were searched from January 2000 to June 2022. Pooled odds ratios (ORs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using fixed- or random-effects model.

RESULTS

One prospective and seven retrospective studies comprising 1935 patients (164 RLV/TLV <30% vs. 1771 RLV/TLV ≥30%) were included. Overall (OR = 1.82; 95% CI [1.24, 2.67]; p = .002) and minor (OR = 1.88; 95% CI [1.23, 2.88]; p = .004) morbidities were significantly lower in the RLV/TLV ≥30% group than in the RLV/TLV <30% group (OR = 1.82; 95% CI [1.24, 2.67]; p = .002). No significant differences were noted in the major morbidity, biliary complications, and hepatic dysfunction. Peak levels of bilirubin (SMD = .50; 95% CI [.07, .93]; p = .02) and international normalized ratio (SMD = .68; 95% CI [.04, 1.32]; p = .04) were significantly lower in the RLV/TLV ≥ 30% group than in the RLV/TLV <30% group. No significant differences were noted in the peak alanine transferase and aspartate transaminase levels and hospital stay.

CONCLUSIONS

Considering the safety of the donor as the top priority, the eligibility of a potential liver donor in LDLT whose RLV/TLV is expected to be <30% should not be accepted.

Specific issues concerning the management of patients on the waiting list and after liver transplantation

The present document is a second contribution collecting the recommendations of an expert panel of transplant hepatologists appointed by the Italian Association for the Study of the Liver (AISF) concerning the management of certain aspects of liver transplantation, including: the issue of prompt referral; the management of difficult candidates; malnutrition; living related liver transplants; hepatocellular carcinoma; and the role of direct acting antiviral agents before and after transplantation. The statements on each topic were approved by participants at the AISF Transplant Hepatology Expert Meeting organized by the Permanent Liver Transplant Commission in Mondello on 12-13 May 2017. They are graded according to the GRADE grading system.

A comparison of desensitization methods: Rituximab with/without plasmapheresis in ABO-incompatible living donor liver transplantation

BACKGROUND

Plasmapheresis is a desensitization method used prior to ABO-incompatible (ABO-I) living donor liver transplantation. However, studies on its usefulness in the rituximab era are lacking.

METHODS

Fifty-six adult patients underwent ABO-I living donor liver transplantation between January 2012 and October 2015. A single dose of rituximab (300 mg/m²) was administered 2 weeks before surgery with plasmapheresis in all patients until February 2014 (RP group, n = 26). Patients were administered rituximab only, without plasmapheresis between March 2014 and October 2015 (RO group, n = 30).

RESULTS

The 6-, 12- and 18-month overall survival rates were 92.3%, 80.8% and 76.9% in the RP group and 96.6%, 85.4% and 85.4% in the RO group, respectively (P = 0.574). When the initial isoagglutinin titers < 16, neither group showed a rebound rise of isoagglutinin titers. For patients with initial isoagglutinin titers ≥ 16, the rebound rise of isoagglutinin titers was more prominent in the RP group. There was no difference in time-dependent changes in B cell subpopulations and ABO-I-related complications.

CONCLUSIONS

Sufficient desensitization for ABO-I living donor liver transplantation can be achieved using rituximab alone. This desensitization strategy does not affect the isoagglutinin titers, ABO-I-related complications and patient survival.

Right lobe living donors ages 55 years old and older in liver transplantation

The evidence is insufficient for safe use of elderly donors in adult-to-adult living donor liver transplantation (LDLT). The aim of this study was to evaluate the outcomes of right lobe LDLT by donor age (≥55 versus < 55 years). All living donors who underwent right hepatectomy at the authors' institution between March 2008 and December 2015 were divided into 2 groups: group A with an age ≥ 55 years and group B with an age of <55 years. The selection criteria for elderly donor were preservation of middle hepatic vein, remnant liver volume ≥30%, and no or mild fatty liver. The matching criteria of recipients for the elderly donor grafts were Model for End-Stage Liver Disease score of <25, graft-to-recipient weight ratio of >0.8%, and body mass index of <25 kg/m² . Perioperative data, complications by the Clavien classification, and the outcomes with at least 12 months follow-up were compared. A total of 42 donors were enrolled in group A and 498 in group B. No significant differences in operative parameters were observed between the 2 groups. The peak postoperative aspartate aminotransferase, alanine aminotransferase, and total bilirubin levels made no difference between the 2 groups. The peak international normalized ratio level was significantly lower in group A than in group B (P = 0.001). All donors recovered completely with no significant differences in overall complications between the 2 groups. All recipients of grafts from donors in group A showed good initial function with no significant differences in 1-year graft and patient survival or biliary complications between 2 groups. These results provide clinical evidence for feasibility of right hepatectomy in living donors aged ≥ 55 years without compromising donor safety or recipient outcomes. Liver Transplantation 23 1305-1311 2017 AASLD.

Living donor liver transplantation: eliminating the wait for death in end-stage liver disease?

Adult-to-adult living donor liver transplantation (A2ALDLT), outside of Asia, remains an important yet underutilized gift of life. For patients with end-stage liver disease, A2ALDLT is a proven transplantation option, with lower waiting list mortality and suffering, and equivalent or better allograft and patient survival than deceased-donor liver transplantation (DDLT). The risks to living donors and the benefit to their recipients have been carefully defined with long-term level 1 and 2 evidence-based study. An overview of the development and practice of living donor liver transplant (LDLT), including donor and recipient surgical allograft innovation, is provided. The issues of recipient selection, outcomes and morbidity, including disease-variable study and challenges past and present are presented in comparison with DDLT cohorts, and future insights are described. Central to practice is the careful and concise review of donor evaluation and selection and donor outcome, morbidity, quality of life and present and future strategies for donor advocacy and growth of the technique.

Right hepatectomy in living donors with previous abdominal surgery

BACKGROUND

Few studies have evaluated the impact of previous abdominal surgery (PAS) on living donor right hepatectomy (LDRH). The aim of this study was to investigate the outcomes of liver transplantation using right lobe grafts of living donors with PAS.

METHODS

Data were reviewed from LDRH patients at the authors' institution between March 2008 and November 2014. LDRH patients with PAS were divided into two groups according to upper PAS (group 1) or lower PAS (group 2), and they were compared to those without PAS (group 3) who were matched 1:1 based on age, gender, and body mass index. Perioperative data, complications by the Clavien classification, and the outcomes with more than 14 months follow-up were compared.

RESULTS

Twenty-three (4.9%) of a total of 471 LDRH donors had PAS. Eleven donors were assigned to group 1, 12 to group 2, and 23 to group 3. Intraperitoneal adhesions were found in 20 (87.0%) of 23 donors with PAS, of whom 5 (21.7%) had adhesiolysis-related injuries that happened more commonly in group 1 than in group 2 (P=0.025). LDRH was successfully completed under upper midline laparotomy in all donors. No donors received perioperative blood transfusion. The peak postoperative AST, ALT, INR, and total bilirubin levels made no difference between the three groups. Compared with group 3, groups 1 and 2 had a longer operative time (P=0.012) and a higher grade I complication rate (P=0.047). All donors recovered fully to their routine activities. The 23 recipients of grafts from donors with PAS showed good liver function with 1-year graft and patient survivals of 100%.

CONCLUSION

A history of PAS is not a contraindication to LDRH in the current era of advanced surgical techniques.

Impact of Intra-Abdominal Adhesion on Living Donor Right Hepatectomy

The impact of intra-abdominal adhesion (IAA) on living donor right hepatectomy (LDRH) remains to be clarified. The purpose of this study was to compare both the donor and recipient outcomes of right lobe living donor liver transplantation according to IAA detected intraoperatively. LDRH donors were identified through a prospectively maintained database at the authors' institution between March 2008 and February 2014. IAA was graded according to Beck et al (Dis Colon Rectum 2000; 43: 1749-1753). LDRH donors with IAA (group A) were matched 1:3 to those without IAA (group B) based on age, gender, and BMI. Perioperative data, complications by the Clavien classification, and the outcomes with at least 12 months follow-up were compared. Thirty-two (7.6%) of a total of 420 LDRH donors had IAA around the liver. Nineteen donors had previous abdominal surgery. LDRH was successfully completed under upper midline laparotomy in all donors. Compared with group B, group A had a longer operative time (270 vs. 172 min; p < 0.001), a higher wound complication rate (28.1% vs. 4.2%; p = 0.009), and a longer postoperative stay (10 vs. 7 days; p = 0.009). All donors recovered completely to their previous activities. The 1-year graft and recipient survivals of recipients were comparable between two groups. These findings support the feasibility and safety of LDRH in patients with IAA.

Living donor liver transplantation in India

Liver transplantation is currently in its golden period in India. The number of transplants being performed and the steady increase in the new programs that have emerged over the last decade is a testimony to it. The growth was not smooth, especially in the early years. But a multipronged approach in developing infrastructure and the involvement of multidisciplinary teams in the management of transplant patients has had a major positive impact on the outcome and as a result a positive impetus to the growth of this specialty in India. To date, the majority of transplants performed in India are live donor liver transplants. Deceased donation is more sporadic and concentrated in a couple of regions. With phenomenal increase in transplant activity in India, there is huge potential for streamlining data sharing among programs in India and with the rest of the world to ultimately benefit the transplant community.

The Impact of a Surgical Protocol for Enhanced Recovery on Living Donor Right Hepatectomy: A Single-Center Cohort Study

The concept of surgery for enhanced recovery (SFER) program has never been an issue in the context of living donor right hepatectomy (LDRH), much less its effects. The purpose of this study was to evaluate outcomes after the establishment of an SFER protocol for LDRH in a single center.A single-center cohort study was performed in 500 consecutive living donors who underwent right hepatectomy from January 2005 to June 2014 by analyzing the outcomes before and after an established SFER protocol that evolved with continuous refinements in surgical technique and management over 300 LDRHs, being in place on September 2011. Donor characteristics, operative outcomes, and postoperative complications divided into 2 groups (group 1, stepwise adjustment; group 2, complete adherence to the protocol) were compared.Donor characteristics were comparable in the 2 groups. Overall complication rate was 10.0% with no mortality. In group 2, operative time, hospital stay, and overall complication rate decreased significantly, and the morbidity was 1% and confined in grade I complication without reoperation, perioperative blood transfusion, or readmission. All donors in this series recovered fully and returned to the previous functional lifestyle.An SFER protocol on LDRH can be established by the gradual implementation of various refinements of surgical technique, and the recent outcomes achieved after the establishment of an SFER protocol could provide a current guidance on LDRH toward the ultimate goal of zero morbidity.

Kidney and liver transplantation in the elderly

BACKGROUND

Transplant surgery is facing a shortage of deceased donor organs. In response, the criteria for organ donation have been extended, and an increasing number of organs from older donors are being used. For recipients, the benefits of transplantation are great, and the growing ageing population has led to increasing numbers of elderly patients being accepted for transplantation.

METHODS

The literature was reviewed to investigate the impact of age of donors and recipients in abdominal organ transplantation, and to highlight aspects of the fine balance in donor and recipient selection and screening, as well as allocation policies fair to young and old alike.

RESULTS

Overall, kidney and liver transplantation from older deceased donors have good outcomes, but are not as good as those from younger donors. Careful donor selection based on risk indices, and potentially biomarkers, special allocation schemes to match elderly donors with elderly recipients, and vigorous recipient selection, allows good outcomes with increasing age of both donors and recipients. The results of live kidney donation have been excellent for donor and recipient, and there is a trend towards inclusion of older donors. Future strategies, including personalized immunosuppression for older recipients as well as machine preservation and reconditioning of donor organs, are promising ways to improve the outcome of transplantation between older donors and older recipients.

CONCLUSION

Kidney and liver transplantation in the elderly is a clinical reality. Outcomes are good, but can be optimized by using strategies that modify donor risk factors and recipient co-morbidities, and personalized approaches to organ allocation and immunosuppression.