2451 Living Donation: A Liver Saved or a Liver Compromised

Abstract

INTRODUCTION: When compared to deceased donor liver transplants (DDLT), living donor liver transplants (LDLT) have been associated with longer operative times, higher rates of biliary and vascular complications, and higher rates of small-for-size syndrome (SFSS). We present a case in which multiple complications and related diagnostic dilemmas are manifested over the course of several months following LDLT. CASE DESCRIPTION/METHODS: A 55 year old woman with decompensated alcohol-related cirrhosis with MELD of 24 was admitted and underwent living donor liver transplantation. Donor anatomy limited R lobe hepatectomy. Intraoperatively, portocaval shunt was left intact due to concern for small graft size (graft to recipient weight ratio was 0.7) as left lobe graft appeared congested post-anastomosis. Postoperatively, her transaminases trended down slowly, but she developed a worsening direct hyperbilirubinemia, peaking at Tbili 16.2 on POD #9. She was subsequently taken back to the OR for portocaval shunt closure and liver biopsy which was complicated by large hematoma. Following closure of portocaval shunt, her total and direct bilirubin continued to fluctuate but stabilized at Tbili 5.3 at which point she was discharged. Her biopsy was consistent with moderate preservation injury. Following discharge, she continued to require periodic paracentesis and thoracentesis for her refractory ascites. The patient's postoperative course was further complicated by persistent cholestatic liver tests concerning for bile cast syndrome and an admission for cholangitis two months post-op. She had multiple ERCPs showing biliary anastomotic strictures requiring stent placement. She continued to have persistent cholestatic labs despite these interventions and subsequently underwent a percutaneous liver biopsy. A venogram done at time of biopsy was revealing for severe short segment narrowing of the infrahepatic IVC s/p stent placement. Her repeat liver biopsy was suggestive of acute cell mediated rejection. Following pulsed steroid therapy, her liver tests improved. DISCUSSION: This case demonstrates the complications that are more likely to arise in LDLT compared to DDLT. Despite this, LDLT outcomes remain superior when compared to those who received DDLT; however this observation is complicated by selection bias in that younger, less critically ill patients with lower MELD scores are usually chosen for LDLT.