Paired exchange Living Donor Liver Transplantation: A Nine-Year Experience from North India

Abstract

Introduction: Liver paired exchange donation (LPD) or swap transplantation is an evolving strategy to overcome ABO incompatibility and other barriers like small for size syndrome that confront patients with end-stage Liver disease undergoing Living donor liver transplantation (LDLT). At the same time, for the transplant team to carry out 4 major operations simultaneously is a Herculean effort. Herein, we analyze our experience with LPD program over the past 9 years. Methods: This prospective study includes a total of 2340 LDLTs performed from May 2012 to April 2021. We started the Paired exchange LDLT program in May 2012. LPDs constituted approximately 1.45% (34 of 2340) of the total LDLT procedures. The reasons for LPD were ABO incompatibility in all (n=34) patients. The first and second recipient of each swap pair were divided into R1 and R2 groups for comparative analysis. Results: All patients included in paired exchange LDLT program were Indian citizens and donors were “near” relatives. After donor reassignment through 2-by-2 paired exchange with directed donors, the ABO matching status changed to A to A (n=17) and B to B (n=17) and this made all matches ABO-identical. Donor survival was 100%. The recipient’s (n=34, age 45.5 [11 -59] years; 31 men), UNOS status were 2b (n=5) and C (n=29) and they all underwent elective LDLT surgery with 4 OTs running simultaneously on the same day. The baseline clinical, peri-operative parameters, post-operative complications, median ICU/hospital stay, early deaths were comparable (P>0.1) between the R1 and R2 groups (Table 1). The overall recipient survival was 85.3 % (n=29) over the median follow up period of 20 (0-108) months. Conclusion: Our experience suggests that with careful attention to ethical and logistical issues, LPD program can expand the living donor liver pool and can facilitate a greater number of LDLTs. Keywords: Donor Exchange, Swap Liver Transplantation, Living Donor Liver Transplantation; ABO incompatibilityTable 1Comparative data between R1 and R2 groups of swap liver transplant recipients (n = 34).Parameters (Mean±SD)R1 (n=17)R2 (n=17)P valueAge (years)44.0 (±10.1)47.0 (±5.3)0.296MELD score21.8 (±11.1)19.4 (±6.3)0.445CTP score9.5 (±2.3)10.3 (±2.1)0.294Graft weight (grams)711 (±141.2)796 (±119.8)0.067GRWR1.01 (±0.34)1.18 (±0.26)0.136Warm ischemia time (minutes)32.7 (±7.8)36.1 (±7.1)0.257Cold ischemia time (minutes)109.7 (±61.2)112.6 (±40.9)0.870ICU stay (days)12.4 (±4.6)14.4 (±10.5)0.654Hospital stays (days)16.7 (±4.6)21.6 (±4.7)0.197Complications n (%)Bleeding01 (5.9%)1.00Bile leak02 (11.8%)0.485Acute rejection1 (5.9 %)1 (5.9 %)1.00Hepatic artery thrombosis01(5.9%)1.00Hepatic vein thrombosis2 (11.8%)1(5.9%)0.542Sepsis2 (11.8%)5 (29.4%)0.398Early mortality (Within 1 month)1 (5.8%)3(17.6%)0.6011 year survival16 (100 %)13 (92.8%)0.335Median follow up in months (IQR)27 (8-39)27 (8-43)1.00CTP, Child-Turcot-Pugh; GRWR, graft to recipient weight ratio; ICU, intensive care unit; IQR, inter quartile range; MELD, model for end stage liver disease. Open table in a new tab CTP, Child-Turcot-Pugh; GRWR, graft to recipient weight ratio; ICU, intensive care unit; IQR, inter quartile range; MELD, model for end stage liver disease.