Adult Living Donor Liver Transplantation Research Articles

Propensity Score-Matched Analysis of Posttransplant Outcomes in Living Donor Liver Transplantation for Older Adult Recipients.

The impact of increasing recipient age on morbidity and mortality following living donor liver transplantation (LDLT) remains controversial. The study aims to analyze the impact of recipient age on outcomes following LDLT. Data on adult LDLTs performed between November 2009 and February 2020 were retrieved from a prospectively maintained database. Patients were stratified into 2 groups based on recipient age: 18 to 65years (younger adults) and >65years (older adults). Propensity score matching (PSM) using nearest-neighbor matching was used to match each older recipient with up to 2 younger adult recipients using multiple preoperative parameters. Outcomes evaluated were duration of ventilation, need for reintubation, tracheostomy, intensive care unit (ICU) readmission, length of ICU and hospital stays, postoperative complications, reoperation within 90days, and patient survival. A total of 801 adult LDLT recipients were included in the study; 751 (93.7%) were younger adults, and 50 (6.3%) were older adults. Older recipients were more likely to be diabetic (60.0% versus 39.7%) and hypertensive (44.0% versus 20.4%) with preexisting cardiac disease (28.0% versus 11.2%). However, their pretransplant Model for End-Stage Liver Disease score was significantly lower (14.5 versus 17.7), and they were more likely to receive a transplant because of hepatocellular carcinoma (38.0% versus 17.7%). Older recipients had longer durations of ventilation after LT both before (3.7 versus 1.9days) and after PSM (4.0 versus 1.5days). After PSM, the 30-day (13.0% versus 2.4%), 90-day (15.2% and 2.4%), and overall mortality rates (21.7% versus 7.1%) were significantly higher for older recipients when compared with younger recipients. There was no difference between the younger and older recipients with respect to other postoperative outcomes. This propensity score-matched study shows that the older LDLT recipients have higher 30-day, 90-day, 1-year, and 5-year mortality rates when compared with matched younger counterparts.

Role of percutaneous radiological treatment in biliary complications associated with adult left lobe living donor liver transplantation: a single-center experience.

Biliary complications develop at a higher rate in living donor liver transplantation (LDLT) compared with cadaveric liver transplantation. Almost all studies about biliary complications after LDLT were made with the right lobe. The aim of this study was to determine the frequency of biliary complications developing after adult left lobe LDLT and to evaluate the efficacy of the algorithm followed in diagnosis and treatment, particularly percutaneous radiological treatment. A total of 2185 LDLT operations performed in our center between May 2009 and December 2019 were retrospectively reviewed and patients receiving left lobe LDLT were analyzed regarding biliary complications and treatments. Biliary complications were treated via percutaneous drainage under ultrasound (US) guidance, endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous transhepatic cholangiography (PTC)/ percutaneous transhepatic biliary drainage (PTBD). Patient demographics, ERCP procedures before percutaneous treatment, and percutaneous treatment indications were analyzed. A total of 69 adult patients received left lobe LDLT. Biliary complications requiring endoscopic and/or percutaneous treatment developed in 28 patients (40%). Of these patients, 4 had bile leakage (14%), 20 had anastomosis stricture (72%), and 4 had both leakage and anastomosis stricture (14%). External drainage treatment under ultrasound guidance was sufficient for 2 of 4 patients with bile leakage, and these cases were accepted as minor bile leakage (7%). Overall, 26 patients underwent ERCP; of these, 8 were referred for PTC/PTBD because the guidewire and/or balloon-stent could not pass the anastomosis stricture (n=7) and common bile duct cannulation could not be obtained because of duodenal diverticulum (n=1). Diagnostic PTC was performed in 10 patients, 8 were referred after inadequate/failed ERCP procedure and two were referred directly without ERCP. Anastomosis stricture was found in 7 patients and anastomosis stricture and bile leakage in 3. In 7 patients determined to have stricture, balloon dilatation was applied and then biliary drainage was performed. In 3 patients who had leakage and anastomosis stricture, balloon dilatation was applied for stricture; after dilatation, an IEBD catheter was placed through the leakage region in 2 patients, while a covered metallic stent passing through the leakage region was placed in one patient. Generally, ERCP is the first preferred method in biliary complications of LDLT; however, in cases where a response cannot be obtained by endoscopic treatment or require complex and/or aggressive treatment, percutaneous radiological treatment should be the treatment of choice before surgery in left lobe LDLT.

The Concept of Functional Graft Size: An Eternal Theme of Maximizing Donor Safety and Recipient Survival in Living Donor Liver Transplantation.

The Concept of Functional Graft Size: An Eternal Theme of Maximizing Donor Safety and Recipient Survival in Living Donor Liver Transplantation.

HPi: A Novel Parameter to Predict Graft-related Outcome in Adult Living Donor Liver Transplant.

Portal hyperperfusion is frequently associated with early allograft dysfunction (EAD). It is imperative to identify patients who would require portal inflow modulation. We aimed to identify factors associated with hyperperfusion-related graft injury and develop a predictive index for the same. Prospectively maintained database was queried to identify 135 adult living donor liver transplant recipients between September 2016 and July 2020. According to the calculated sample size, 96 patients were randomly selected for "test cohort". The remaining 39 patients made the "validation cohort." EAD was defined according to the A2ALL study. "Hyperperfusion index (HPi)," defined as posttransplant portal pressure gradient (ΔPpost)/graft-to-recipient splenic volume ratio (GRSVR), was devised on the basis of laws of flow dynamics and regression analysis. Overall, 40 patients (29.6%) had EAD, six 90-d mortalities (4.4%) were attributable to EAD. In the test cohort, EAD patients (n = 29, 30.2%) had lower GRSVR (1.00 versus 2.22, P < 0.001), higher ΔPpost (14.8 versus 11.9, P = 0.004), and HPi (20.89 versus 8.67, P < 0.001). Multivariate analysis revealed GRSVR, ΔPpost, and HPi as significant factors to predict EAD. Receiver operating characteristic determined cutoff of HPi ≥9.97 could predict EAD with sensitivity of 90% and specificity of 73% (F-score = 0.712). HPi ≥16.25 predicted 90-d mortality with sensitivity of 100% and specificity of 78.9%. Patients with higher HPi had delayed graft-related recovery. Non-EAD patients had a higher 1-y (96% versus 79%) and 2-y (88% versus 79%) survival. The cutoff of HPi was validated well in the validation cohort (F-score = 0.645) (Hosmer-Lemeshow test, P = 0.89). While predicted GRSVR may help identify at-risk patients preoperatively, intraoperatively calculated HPi is more accurate in identifying patients who would require portal inflow modulation. Achieving an HPi below target cutoff significantly decreases the risk of EAD even in low-GRSVR patients.

Intraoperative hepatic artery thrombosis in living donor liver transplantation despite immediate reconstruction increases risk of graft failure

Post-transplant hepatic artery thrombosis (HAT) can lead serious complications of are derived from long arterial ischemic time. However, there has been few reports regarding fate of intraoperative HAT during adult living donor liver transplantation (ALDLT). From 2000 to 2019, 1,355 recipients underwent ALDLT in Seoul National University Hospital. All patients with no intraoperative arterial flow were managed by redoing hepatic artery anastomosis. Survival outcomes and the rates of biliary complication of patients with intraoperative HAT were compared with others without HAT and with postoperative HAT. Median follow-up period was 89 months. Intraoperative HAT was developed in 45 cases (3.3%). Hepatic artery reanastomosis was performed once in 33 cases (73.3%), for more than 2 times in 12 cases (26.6%). Among 45 patients with intraoperative HAT, postoperative HAT was detected in 6 cases (13.3%). All patients underwent redo arterial reconstruction, but technical success rate was 50.0%. Overall graft survival rates were lower in patients with intraoperative HAT (93.3%) than others without HAT (98.0%) (p = 0.026), but higher than in patients with postoperative HAT (88.9%) (p = 0.001). However, patient survival rates were similar among three groups (p = 0.269). There was no difference in biliary complication between patients with intraoperative HAT (33.3%) and the others without HAT (32.1%) (p = 0.945), lower than patients with postoperative HAT (55.5%, p = 0.011). Intraoperative HAT after ALDLT did not affect biliary complication and patient survival, but is significantly associated with recurrent postoperative HAT and graft failure. Patients with intraoperative HAT in ALDLT should be intensively monitored for HAT and graft dysfunction.

Over 500 liver transplants including more than 400 living-donor liver transplants in 2019 at Asan Medical Center

More than 400 liver transplants were performed at Asan Medical Center (AMC) in 2011, and over 500 liver transplants including 420 living-donor liver transplants (LDLTs) were performed in 2019. Herein, we report the methodology of these procedures. Since the first adult LDLTs at AMC using the left and right lobes were successfully performed, various innovative techniques and approaches have been developed: modified right lobe, dual graft, donor exchange for ABO incompatibility, expansion of indications and no-touch techniques for hepatocellular carcinoma, intraoperative cine-portogram and additional intervention for large collaterals, management of portal vein thrombosis (PVT) and stenosis, salvage LDLT after major hepatectomy, and timely LDLT for patients with acute-on-chronic liver failure. Four hundred twenty LDLTs in 403 adult and 17 pediatric patients and 85 deceased-donor liver transplants in 74 adult and 11 pediatric patients were performed. The number of deceased-donor liver transplants remained constant since 2011, but the number of LDLTs increased steadily. One hundred thirty patients (25.7%) required urgent liver transplantations and 24 patients with acute-on-chronic liver failure underwent LDLT. PVT including grade 1, 2, 3, and 4 was reported in 91 patients (18.0%), and Yerdel's grade 2, 3, and 4 PVT was reported in 47 patients (51.6%); all patients with PVT were successfully treated. Adult LDLTs for hepatocellular carcinoma and ABO incompatibility accounted for 52.6% and 24.3% of the cases, respectively. In-hospital mortality in 2019 was 2.97%. Continual efforts to overcome challenging problems in LDLT with various innovations and dedication of the team members during the perioperative period to.

Impact of graft weight change during perfusion on hepatocellular carcinoma recurrence after living donor liver transplantation

Inadequate liver volume and weight is a major source of morbidity and mortality after adult living donor liver transplantation (LDLT). The purpose of our study was to investigate HCC recurrence, graft failure, and patient survival according to change in right liver graft weight after histidine-tryptophan-ketoglutarate (HTK) solution perfusion in LDLT. Two hundred twenty-eight patients underwent LDLT between 2013 and 2017. We calculated the change in graft weight by subtracting pre-perfusion graft weight from post-perfusion graft weight. Patients with increased graft weight were defined as the positive group, and patients with decreased graft weight were defined as the negative group. After excluding patients who did not meet study criteria, 148 patients underwent right or extended right hepatectomy. The negative group included 89 patients (60.1%), and the positive group included 59 patients (39.9%). Median graft weight change was -28 g (range, -132-0 g) in the negative group and 21 g (range, 1-63 g) in the positive group (p < 0.001). Median hospitalization time was longer for the positive group than the negative group (27 days vs. 23 days; p = 0.048). There were no statistical differences in tumor characteristics, postoperative complications, early allograft dysfunction, or acute rejection between the two groups. Disease-free survival, death-censored graft survival, and patient survival were lower in the positive group than the negative group. Additionally, the positive group showed strong association with HCC recurrence, death-censored graft survival, and patient survival in multivariate analysis. This study suggests that positive graft weight change during HTK solution perfusion indicates poor prognosis in LDLT.

Renoportal anastomosis in adult-to-adult living donor liver transplantation for patients with portal vein thrombosis in single center experience

The anastomosis between the left renal vein and graft portal vein is one of the crucial options in patients with end-stage liver disease with portal venous thrombosis and a previous splenorenal shunt. However, especially in living donor liver transplantation (LDLT) practice, limited cases are published in the literature. Between January 2006 and December 2019, a total of 14 patients underwent adult LDLTs with renoportal anastomosis (RPA). The long-term outcomes were evaluated by reviewing the medical records of the 14 patients. Of the 14 patients who received adult LDLTs with RPA, 2 patients underwent end-to-end (E-to-E) RPA using left renal vein (LRV), 5 patients underwent side-to-end (S-to-E) RPA, and the rest underwent E-to-E RPA using LRV connected IVC cuff. Except two patients who died from cerebral hemorrhage and graft failure came from acute cellular rejection, twelve patients has maintained normal graft function and a patent RPA at a median follow-up of 42 months (range, 1-155 months). RPA can be performed safely and effectively in LDLT as an acceptable and life-saving procedure for patients with end-stage liver disease with portal venous thrombosis and a previous splenorenal shunt. According to our experience, E-to-E RPA using LRV connected IVC cuff is the best option considering feasibility and safety.

Laparoscopic living donor hepatectomy using the left liver - pushing the limits further

With the accumulation of experience in both living donor liver transplantation (LDLT) and laparoscopic liver surgery, efforts have been made to minimize the surgical trauma to the donor and many institutions are now using minimally invasive approach for donor surgery. Nevertheless, the overwhelming majority of the grafts used for adult LDLT are right lobe grafts. Right lobe, which usually consist of 2/3 of the liver, provides a larger size grafts, facilitating the recovery of the recipient but this comes at the price of the increase risk of the donor. It is known that utilization of right lobe has a higher complication and mortality rate compared to the left, but the utilization of the left lobe has not been practiced widely. In this talk, I'll provide the early results of our program using laparoscopic approach for left lobe and describe the detailed techniques through video presentation.

The effect of intraductal transanastomotic stent in reducing biliary complication after duct-to-duct biliary reconstruction in living donor liver transplantation: Single center experience

Despite of the innovations in surgical and postoperative surgical treatment of donors and recipients, biliary complication is still considered to be a technical "Achilles' heel" of living donor liver transplantation (LDLT) due to the high incidence, requiring long-term interventional treatment, and potential risk for graft failure. The purpose of this study was to evaluate the effect of intraductal transanastomotic stent in reducing biliary complications after LDLT. From August 2015 to February 2020, 201 adult LDLTs using right liver were enrolled. The intraductal transanastomotic stent was a silicone tube of various diameters considering the duct size. By dividing biliary complication into bile leakage and stricture, the risk factor and effect of stent were analyzed. In all patients with LDLT, biliary complications occurred in 54 (26.9%) patients and anastomosis site leakage occurred in 9 (9.5%) patients. Of the 201 patients, non-stent group was 101 (50.2%) patients and stent group was 100 (49.8%) patients. Anastomosis site leakage was higher in the non-stent group (n = 15, 14.9%) than in the stent group (n = 4, 4.0%, p = 0.005). Biliary stricture was also higher in the non-stent group (n = 30, 29.7%) than in the stent group (n = 17, 17.0%, p = 0.03). In multivariate analysis, hepatic artery thrombosis (p < 0.001) and intraductal stent (p = 0.01). Intraductal transanastomotic stent can reduces biliary complications including anastomosis leakage and stricture. Further large-scale analyses of clinical data or randomized controlled trial are required to support this study.

Eversion technique: A safe anastomosis method of bile duct in living donor liver transplantation without internal or external biliary stent

Biliary stricture (BS) is still a major concern after bile duct anastomosis in living donor liver transplantation (LDLT), even after the technical refinements using a microscope. This study aims to describe our eversion technique without stent insertion of biliary anastomosis and its effects on the incidence of biliary complications. This was a single-center retrospective study of 52 adult LDLT recipients between December 2011 and June 2020. Group 1 consisted of the first 20 patients for whom the standard technique of biliary anastomosis (minimal hilar dissection during donor duct division, high hilar division of the recipient bile duct, and preservation of the recipient duct periductal tissue) was used. Group 2 consisted of 32 patients for whom biliary anastomosis was done with the addition of corner-sparing sutures and mucosal eversion of the recipient duct to the standard technique. Primary outcome measures included biliary complications (biliary leaks and strictures). Biliary complications occurred in 4/20 patients in group 1 (20.0%) and 2/32 patients in group 2 (6.25%). The technical factors mentioned above are aimed at preserving the blood supply of the donor and recipient ducts and hold the key for minimizing biliary complications in adult-to-adult LDLT. The application of eversion technique could be a key for preventing BAS in duct-to-duct biliary reconstruction in LDLT.

Feasibility of external biliary drainage in living donor liver transplantation: Lessons learned from initial experiences in single center

Biliary complication is the most common and unmanageable complication of living donor liver transplantation (LDLT). External biliary drainage (EBD) is one of the strategies to decrease the incidence of biliary complication. Herein, we examined the LDLT cases with EBD application and evaluated the outcome of patients to assess whether EBD is a practicable surgical method to reduce biliary problem. This study was a single-center case series study performed at Seoul National University Hospital. All adult LDLT patients with EBD application during bile duct anastomosis were included from April 2019 to May 2020. Demographic data and the rates of biliary complication and EBD-related complication were demonstrated. Median follow-up period was 15 months. EBD techniques were applied during bile duct anastomosis in 45 cases of adult LDLT patients during study period. In most cases (95.6%), duct-to-duct anastomosis was performed. Median diameter of bile duct opening was 4 mm (range 1.5-16 mm). More than 2 bile duct openings were observed in 26 cases (57.8%). With application of EBD, incidence of biliary complications was 35.6% (n = 16); concretely, leakage in 2 cases (4.4%) and stricture in 14 cases (31.1%). EBD-related complications, such as retraction, accidental removal, and dislocation, were found in 19 cases (42.2%). EBD is worthwhile in selected patients with a high risk of anastomotic bile leakage, such as multiple and/or small openings of bile duct. However, efforts should be exerted regarding EBD-related complications. Further study is needed to establish appropriate selection criteria for EBD.

Living Donor Liver Transplantation in the United States: Evolution of Frequency, Outcomes, Center Volumes, and Factors Associated With Outcomes.

Recent modifications in organ allocation policies and increases in chronic liver diseases may have resulted in important changes in living donor liver transplantation (LDLT) in the United States. We examined the trends, outcomes, and factors associated with outcomes in adult LDLT. United Network for Organ Sharing data on 2566 adult LDLT recipients who received transplants from January 1, 2010, through December 31, 2019, were analyzed. LDLT graft and patient survival rates were compared with propensity score-matched deceased donor liver transplantation recipients by the Kaplan-Meier curve estimator. The association between preceding LDLT frequency and subsequent outcomes were assessed by Cox proportional hazards mixed effects modeling. After a stable annual frequency of LDLTs from 2010 to 2014 (~200 per year), the number of LDLTs doubled to 440 in 2019. The 1-year and 5-year graft survival rates for LDLT recipients were 88.4% and 78.1%, respectively, compared with 92.5% and 80.7% in the propensity score-matched donation after brain death recipients (P=0.005), respectively. Older donor age and recipient diabetes mellitus and life support requirement were significantly associated with graft failure among LDLT recipients (P values <0.05). Average preceding LDLT frequencies of <3 per year, 3 to 20 per year, and >20 per year resulted in 1-year graft survival rates of 82%, 88% to 89%, and 93%, respectively (P values <0.05). There were 3 living donor deaths (0.12%). The frequency of LDLTs has doubled during the past decade, with good outcomes and acceptable donor safety profiles. However, there appear to be varying threshold transplant frequencies (volume/unit time) associated with acceptable (88%-89%) and aspirational (93%) 1-year graft survival rates. These data should be reassuring and encourage LDLT practice as efforts continue to expand the donor pool.

Predictors of success of immediate tracheal extubation in living donor liver transplantation recipients

BackgroundEarly tracheal extubation of recipients following liver transplantation (LT) has been gradually replacing the standard postoperative prolonged mechanical ventilation, contributing to better patient and graft survival and reduced costs. There are no universally accepted predictors of the success of immediate extubation in LT recipients. We hypothesized several potential predictors of successful immediate tracheal extubation in living donor liver transplantation (LDLT) recipients. AimEvaluation of the validity of the following hypothesized factors: model for end-stage liver disease (MELD) score, duration of surgery, number of intraoperatively transfused packed red blood cells (RBCs) units, and end of surgery (EOS) serum lactate, as predictors of success of immediate tracheal extubation in living donor liver transplantation (LDLT) recipients. MethodsIn this prospective clinical investigation, perioperative data of adult living donor liver transplantation (LDLT) recipients were recorded. “Immediate extubation” was defined as tracheal extubation immediately and up to 1 hour post-transplant in the operating room. Patients were divided into the extubated group who were successfully extubated with no need for reintubation, and the non-extubated group who failed to meet the criteria of extubation, or were re-intubated within 4 hours of extubation. ResultsWe enrolled 64 patients candidates for LDLT; 50 patients (76.9%) in group 1 were extubated early after LDLT while 14 patients (23.07%) in group 2 were transferred to the intensive care unit intubated. After data analysis, we found that EOS serum lactate, duration of surgery and number of packed RBCs units transfused intraoperatively were good predictors of success of immediate extubation (p < 0.001). MELD scores did not show any significant impact on the results (p = 0.54). Other factors such as EOS urine output and blood gases indices were shown to have a significant effect on the decision of extubation (p = 0.03 and 0.006, respectively). ConclusionsEOS serum lactate, duration of surgery and number of packed RBCs units transfused were potential predictors of post-transplant early extubation.

Surgical outcomes after donor hepatectomy for adult living-donor liver transplants: A single-center experience

AimMore than 3500 live donor liver transplants were performed in Egypt; however, data is scarce. So, we aimed to analyze the surgical outcomes of donor hepatectomy in our center and to compare it to other centers. MethodsA total of 120 donors were included and analyzed, 112 (93.3%) were males, and the mean age was 31 ± 5.4 years. The postoperative complications (within 90 days from surgery) were graded according to the Dindo-Clavien classification, and complications > grade II were considered major. ResultsA total of 116 (97%) donors underwent right hepatectomy, while left hepatectomy was performed in 4 (3%) donors. The remaining liver volume was 39.3 ± 4.7%. The mean operating time was 428 ± 50 min, and the estimated blood loss was 375 ± 149 ml. A total of 28 complications were reported in 23 (19%) donors with no donor mortality. Biliary complications were the most common and were detected in 11 patients. Most complications were grade I and contributed to 43.5%, and major complications were reported in 7 (5.8%) donors. ConclusionsThis study shows good surgical outcomes of donor hepatectomy. There is no mortality, and most of complications were minor and managed conservatively.

Application of Proximal Splenic Vein Embolization to Interrupt Complicated Large Splenorenal Shunts in Adult Living Donor Liver Transplantation.

The aim of the present study is to evaluate efficacy and safety of proximal splenic vein embolization (PSVE) for liver transplant recipients having complicated large splenorenal shunts (SRS). In adult living donor liver transplantation for a patient who has large splenorenal shunts (SRS), their interruption is utmost important to maintain adequate portal flow by avoidance of portal flow steal through the preexisting SRS. We effectively managed most of the recipients with surgical ligation and/or additional radiologic embolization using by intraoperative cine-portogram. However, when complete interruption is not achieved in a few recipients having complicated large SRS, it may leave a chance of lethal portal flow steal in the recipient afterward. PSVE was performed in 13 patients between April 2014 and November 2017. We performed a retrospective analysis of preoperative images, postoperative graft and recipient outcomes, and presence of isolated portal hypertension. Ten patients underwent PSVE as an additional secondary method because of portal steal syndrome through the remaining SRS after surgical interruption and/or embolization, and 3 patients underwent PSVE only as a primary method of SRS interruption. In all 13 patients, portal steal on the final intraoperative cine-portogram completely disappeared after PSVE. All patients recovered with satisfactory regeneration of the partial liver graft without the reappearance of portosystemic collaterals, and there were no procedure-related complications. PSVE is an effective and safe procedure to secure adequate portal flow without portal steal for patients with complicated large SRS arising from multiple sites of the splenic vein or escaping to multiple terminal ends.

Donor age (≥45years) and reduced immunosuppression are associated with the recurrent primary sclerosing cholangitis after liver transplantation - a multicenter retrospective study.

The present study investigated the possible risk factors, including relationship/HLA matching between donor and recipient, and immunosuppressive therapies on the recurrence of primary sclerosing cholangitis (PSC) after liver transplantation (LT). Subjects were 197 recipients of LT for PSC, among whom 180 surviving more than 1year after LT were further analyzed for risk factors of recurrence. The 5- and 10-year patient- and graft survival rates were 83% and 68%, and 71% and 62%, respectively. The overall PSC recurrence rate was 25% with a 5- and 10-year graft survival rate of 34% and 18%, which was significantly lower than the survival rate of those without recurrence (P<0.001). Univariate analysis identified the following as risk factors for recurrence: donor age (P<0.001), cyclosporine use (P=0.012), mono or no immunosuppressive agent (P<0.001), postoperative biliary complication (P<0.001), and active intestinal bowel disease after LT (P<0.001). Among these factors, donor age ≥45years [hazard ratio (HR), 1.65; 95% confidence interval (CI), 1.21-2.69; P=0.003] and mono or no immunosuppressive agent 1-year after LT (HR, 2.38; 95% CI, 1.23-3.45; P=0.011) were identified as independent risk factors in the final multivariate Cox regression model. The results were similar in sub-analysis for ABO-identical/compatible adult living donor LT cases.

Living Donor Liver Transplant in patients with Hepatorenal Syndrome without the use of Intraoperative Renal Replacement Therapy, a single-center experience.

Continuous Renal Replacement Therapy (CRRT) is often used to support the intraoperative course during liver transplantation (LT) for patients with HRS. However, the use of intraoperative CRRT (IOCRRT) is not without its problems. Living donor liver transplantation (LDLT) is a planned operation and is possible without IOCRRT as the recipient can be optimized. To study the peritransplant outcomes of patients with CLD and HRS undergoing LT without IOCRRT. Analysis of LT program database for perioperative outcomes in patients with HRS from Feb 2017 to Dec 2018. 87/363 (23.9%) adult LDLT patients had HRS, of whom 31 (35.6%) did not respond (NR) to standard medical therapy (SMT) prior to LT. Modified perioperative protocol enabled the NR patients (who were sicker and in persistent renal failure) to undergo LT without IOCRRT. Postoperative renal dysfunction was similar (2 in NR and 2 in R) at 1year. Post-LT survival was also not different at one month (83.87% in NR and 87.5% in R [p=.640]) and at 1year (77% in NR vs 80.4% in non-responders [p=.709]). IOCRRT can be avoided in HRS patients undergoing LDLT without compromising their outcomes (post-LT survival and RD), even in patients who have not responded to SMT, preoperatively.

Doppler-derived renal resistive index helps predict acute kidney injury in patients undergoing living-related liver transplantation.

Acute kidney injury (AKI) is commonly associated with increased postoperative morbidity in liver transplant (LT) recipients. The aim of this study was to identify the role of renal resistive index (RRI) in predicting AKI and to study the factors associated with AKI in LT recipients. We performed a single-center, prospective study, including adult living donor LT recipients at our center between January 2018 and September 2019 with no preoperative renal dysfunction. RRI was calculated on ultrasound doppler once preoperatively, and once daily in the postoperative period through postoperative day (POD) six. Patients were grouped into AKI and non-AKI groups for comparison. Fifty patients were included in the study (mean age, 44years; 20% females). AKI developed in 25 patients (50%). Both groups were similar in baseline characteristics. RRI of≥0.69 on POD 2 predicted AKI (sensitivity 88%; specificity 92%). RRI on the day before AKI diagnosis (0.71 vs. 0.65) and on the day of diagnosis (0.72 vs. 0.65) were significantly increased relative to preoperative baseline. Doppler-derived RRI is a rapid, non-invasive, and bedside procedure capable of predicting the occurrence of postoperative AKI in LT recipients.

Impact of Graft Weight Change During Perfusion on Hepatocellular Carcinoma Recurrence After Living Donor Liver Transplantation.

BackgroundsInadequate liver volume and weight is a major source of morbidity and mortality after adult living donor liver transplantation (LDLT). The purpose of our study was to investigate HCC recurrence, graft failure, and patient survival according to change in right liver graft weight after histidine-tryptophan-ketoglutarate (HTK) solution perfusion in LDLT.MethodsTwo hundred twenty-eight patients underwent LDLT between 2013 and 2017. We calculated the change in graft weight by subtracting pre-perfusion graft weight from post-perfusion graft weight. Patients with increased graft weight were defined as the positive group, and patients with decreased graft weight were defined as the negative group.ResultsAfter excluding patients who did not meet study criteria, 148 patients underwent right or extended right hepatectomy. The negative group included 89 patients (60.1%), and the positive group included 59 patients (39.9%). Median graft weight change was -28 g (range; -132–0 g) in the negative group and 21 g (range; 1–63 g) in the positive group (P<0.001). Median hospitalization time was longer for the positive group than the negative group (27 days vs. 23 days; P=0.048). There were no statistical differences in tumor characteristics, postoperative complications, early allograft dysfunction, or acute rejection between the two groups. Disease-free survival, death-censored graft survival, and patient survival were lower in the positive group than the negative group. Additionally, the positive group showed strong association with HCC recurrence, death-censored graft survival, and patient survival in multivariate analysis.ConclusionThis study suggests that positive graft weight change during HTK solution perfusion indicates poor prognosis in LDLT.