Expanding Donor Selection and Recipient Indications for Living Donor Liver Transplantation

Outcomes of 6000 living donor liver transplantation procedures: a pioneering experience at ASAN Medical Center

Living donor liver transplantation (LDLT) has emerged as a favorable alternative to deceased donor liver transplantation, significantly reducing waitlist mortality, particularly in Asian countries with very low deceased organ donation rates. Asan Medical Center (AMC) in South Korea has pioneered innovative LDLT surgical techniques and become established as an extremely high-volume center for LDLT. This retrospective study analyzed 6000 consecutive LDLT procedures, including 510 dual-graft procedures, performed at AMC between December 1994 and January 2021. Of these, 312 LDLT procedures were performed in children aged < 18 years. In adult recipients, liver cirrhosis (LC) related to viral hepatitis was the most common indication, occurring in 69.8% of cases. Biliary atresia (46.8%) was the most common indication for pediatric LDLT. This study demonstrated outstanding long-term outcomes, with patient survival rates at 1, 5, 10, and 20 years of 92.7%, 85.9%, 82.1%, and 70.9%, respectively, in LDLT group for adults aged 50 and under at the time of LDLT, and 92.9%, 89.0%, 88.1%, and 81.9%, respectively, in the pediatric group. The in-hospital mortality rate of adult recipients was 3.8% (n = 214/5688). This study demonstrates the importance of refined surgical techniques, selection of grafts tailored to the recipient, and comprehensive multidisciplinary perioperative patient care in expanding the scope of LDLT and improving recipient outcomes.

Living donor liver transplantation: A multi-disciplinary collaboration towards growth, consensus, and a change in culture

INTRODUCTION

Living donor liver transplantation (LDLT) reduces liver transplant waitlist mortality and provides excellent long-term outcomes for persons with end stage liver disease. Yet, utilization of LDLT has been limited in the United States (US).

METHODS

In October 2021, the American Society of Transplantation held a consensus conference to identify important barriers to broader expansion of LDLT in the US, including data gaps, and make recommendations for impactful and feasible mitigation strategies to overcome these barriers. Domains addressed encompassed the entirety of the LDLT process. Representation from international centers and living donor kidney transplantation were included for their perspective/experience in addition to members across disciplines within the US liver transplantation community. A modified Delphi approach was employed as the consensus methodology.

RESULTS

The predominant theme permeating discussion and polling results centered on culture; the beliefs and behaviors of a group of people perpetuated over time.

CONCLUSIONS

Creating a culture of support for LDLT in the US is key for expansion and includes engagement and education of stakeholders across the spectrum of the process of LDLT. A shift from awareness of LDLT to acknowledgement of benefit of LDLT is the primary goal. Propagation of the maxim "LDLT is the best option" is pivotal.

Current Approaches in the Allocation of Liver Transplantation

In recent decades, important advances have been made in the field of liver transplantation. One of the major problems remaining in this area is the small number of donors. Thus, recent data bring multiple updates of the indications and contraindications of this therapeutic method. The main goal is to increase the number of patients who can benefit from liver transplantation, a therapeutic method that can improve life expectancy and the quality of life of patients with end-stage liver disease. Another goal in the management of these patients is represented by the optimal care of those on the waiting list during that period. A multidisciplinary team approach is necessary to obtain the best results for both the donor and the recipient.

Comparative long-term outcomes of laparoscopic hepatectomy and radiofrequency ablation for hepatocellular carcinoma located in the anterolateral segments of the liver

BACKGROUND

Laparoscopic liver resection (LLR) is considered the standard surgical approach for resecting small hepatocellular carcinomas (HCC) located in the anterolateral segments of the liver. However, few studies have compared LLR and radiofrequency ablation (RFA) in such cases.

METHODS

We retrospectively compared the short- and long-term outcomes of 101 patients who underwent LLR and 264 patients who underwent RFA because of a newly diagnosed single, small (≤4 cm) HCC located in the anterolateral segments of the liver. By applying 1:1 propensity score matching, we matched 61 patients in both groups.

RESULTS

Although the 5-year overall survival rates were similar (83.6% vs 84.5%; P = .913), the 5-year disease-free survival rate was greater in the LLR group (56.4% vs 41.8%; P = .009). In patients with an α-fetoprotein level of ≥100 ng/mL, the 5-year overall (100% vs 80.0%; P = .022) and disease-free survival (76.6% vs 45.5%; P = .006) rates were greater in the LCC group.

CONCLUSIONS

For patients with a single, small HCC located in the anterolateral segments of the liver, LLR was associated with similar complication and overall survival rates, but better disease-free survival compared with RFA. LLR may be recommended for patients with higher α-fetoprotein levels.