Adult-to-adult Living Donor Liver Transplantation Research Articles

Development of a model to predict the risk of early graft failure after adult-to-adult living donor liver transplantation: An ELTR study.

Graft survival is a critical end point in adult-to-adult living donor liver transplantation (ALDLT), where graft procurement endangers the lives of healthy individuals. Therefore, ALDLT must be responsibly performed in the perspective of a positive harm-to-benefit ratio. This study aimed to develop a risk prediction model for early (3 months) graft failure (EGF) following ALDLT. Donor and recipient factors associated with EGF in ALDLT were studied using data from the European Liver Transplant Registry. An artificial neural network classification algorithm was trained on a set of 2073 ALDLTs, validated using cross-validation, tested on an independent random-split sample (n=518), and externally validated on United Network for Organ Sharing Standard Transplant Analysis and Research data. Model performance was assessed using the AUC, calibration plots, and decision curve analysis. Graft type, graft weight, level of hospitalization, and the severity of liver disease were associated with EGF. The model ( http://ldlt.shinyapps.io/eltr_app ) presented AUC values at cross-validation, in the independent test set, and at external validation of 0.69, 0.70, and 0.68, respectively. Model calibration was fair. The decision curve analysis indicated a positive net benefit of the model, with an estimated net reduction of 5-15 EGF per 100 ALDLTs. Estimated risks>40% and<5% had a specificity of 0.96 and sensitivity of 0.99 in predicting and excluding EGF, respectively. The model also stratified long-term graft survival ( p <0.001), which ranged from 87% in the low-risk group to 60% in the high-risk group. In conclusion, based on a panel of donor and recipient variables, an artificial neural network can contribute to decision-making in ALDLT by predicting EGF risk.

Analysis of Outcome in Recipients with Different Graft-Recipient-Weight-Ratio (GRWR) Post Adult to Adult Living Donor Liver Transplant (LDLTx)

Abstract Background The problem of graft size is one of the critical factors limiting the expansion of adultto-adult living donor liver transplantation (LDLT). Graft-to-recipient weight ratio (GRWR) &amp;gt; 0.8% is perceived as the critical graft size to meet the metabolic demand of the recipient. Small-for-size graft (SFSG) is the graft with GRWR &amp;lt; 0.8 and when its unable to meet the recipients metabolic demands, small-for-size syndrome (SFSS) occurs which is a life-threatening condition with rapidly progressive liver failure. This lower limit of GRWR (0.8%) has been challenged over the last decade perhaps due to better understanding of the pathophysiology, coupled with technical refinements, particularly related to venous outflow reconstruction. Aim of Work Our aim was to analyse the different outcomes of patients undergoing Living donor liver transplantation using grafts with GRWR ≤ 0.8% with those &amp;gt;0.8% to evaluate the factors that affect the post-operative outcome and the overall one year Graft survival. Methods This is a retrospective cohort study on 100 adult patients with ESLD or HCC (mean age 54.16 ± 10.53 years old) who underwent adult LDLT in the period between 2018 and 2020 and follow up the patients for one year post transplant, Patients were divided into two groups, patients who received Graft with GRWR ≤ 0.8 (N = 22 patients with lower limit of GRWR = 0.58 and there is 7 patients with GRWR ≤ 0.7) and those with GRWR &amp;gt;0.8 (N = 78 patients). We compared the the Donor factors, preoperative patient factors, intraoperative factors, development of small for size syndrome and graft survival in patients received small-for-size grafts (GRWR ≤ 0.8) with patients received GRWR &amp;lt;0.8. Results We retrospectively evaluated the donor factors, recipient factors and operative factors through the medical records. Small-for-size syndrome (SFSS) occurred in 2 of 22 patients (9.1%) in patients with GRWR ≤ 0.8 and in 1 of 78 patients (1.3%) in patients with GRWR &amp;gt;0.8 which was statistically insignificant between two groups. There was No significant difference in the Donor age, Preoperative MELD, CHILD, Portal hypertension, cold and warm ischemia, operative time, presence of PVT and HCC in patients who received GRWR ≤ 0.8 and patients with GRWR &amp;gt;0.8. the mean overall survival for all the studied cases was found 43.35 months and the overall survival at 6 months and 1 year was 96.0% but there was statistically significant increase in the overall survival of cases with GRWR &amp;gt;0.8 than those with GRWR ≤ 0.8 with p-value = 0.009, as the overall 6 months and 1 year survival for patients with GRWR &amp;gt;0.8 was 98% and 98 % compared to 86 % and 86 % in thoses with GRWR ≤ 0.8 Conclusion There is no difference in the outcome in form of development of Small for size syndrome when we use Grafts with GRWR &amp;gt;0.8 or with GRWR ≤ 0.8, However the venous Outflow of SFSG (GRWR &amp;lt; 0.8) is very critical to maintain good graft function in the recipient.

Prevention and Management of Small-for-Size Syndrome of Liver Transplantation

Small-for-size syndrome (SFSS) is a critical complication of partial liver transplantation, particularly in adult-to-adult living donor liver transplantation (ALDLT) using a small graft. Minimally required liver graft size for a successful ALDLT is classically 40% of a standard recipient’s liver volume or 0.8% of recipient body weight. Recent progress in perioperative care and technical improvement push the lower limit of safe graft size to 25% of the recipient’s standard liver volume or 0.6% of the graft versus recipient weight ratio although this is an ongoing debate. The clinical manifestations of SFSS include various symptoms and signs related to graft dysfunction and portal hypertension in patients with small grafts. The risk factors for SFSS include poor preoperative patient condition, including portal pressure, surgical techniques to reduce portal pressure, and graft quality and size. Hence, various approaches have been explored to modulate inflow and pressure to a small graft and to decrease the outflow block to alleviate this SFSS as well as the selection of a patient and graft. Additionally, recent research and efforts to prevent and treat SFSS are reviewed. (Ewha Med J 2022;45(2):29-34)

Safe use of right lobe living donor livers with moderate steatosis in adult-to-adult living donor liver transplantation: a retrospective study.

Hepatic steatosis (HS) beyond a certain degree can jeopardize living donor (LD) safety, particularly in right lobe (RL) donors, making it a major obstacle for donor pool expansion in adult-to-adult living donor liver transplantation (ALDLT). From July 2004 to June 2016, 58 LDs donated their RLs despite having moderate HS (30%-50% steatosis) determined by intraoperative biopsy at a single center. We performed greedy matching to compare the outcomes of the donors and recipients of this group with those of LDs with no HS. The mean left lobe (LL) HS value in the 58 cases was 20.9±12.4%, which was significantly lower than the mean RL HS value (38.8±6.7%, P<0.001). The mean ratio of the remnant LL to the total liver volume was 37.8±2.2. No differences were observed in the postoperative liver function and donor and recipient morbidity and mortality rates. The liver regeneration rates in recipients and donors at 1month, 6months, and 1year postoperatively did not differ significantly. The patient and graft survival rates of the recipients showed no differences. The use of well-selected RL grafts with moderate steatosis does not impair graft function, recipient outcomes, or donor safety.

Older Donor Age Is a Risk Factor for Negative Outcomes After Adult Living Donor Liver Transplantation Using Small-for-Size Grafts.

Adult-to-adult living donor liver transplantation (ALDLT) using small-for-size grafts (SFSGs), ie, a graft with a graft-to-recipient weight ratio (GRWR) <0.8%, has been a challenge that should be carefully dealt with, and risk factors in this category are unclear. Therefore, we aimed to examine the risk factors and outcomes of ALDLT using SFSGs over a 13-year period in 121 patients who had undergone their first ALDLT using SFSGs. Small-for-size syndrome (SFSS), early graft loss, and 1-year mortality were encountered in 21.6%, 14.9%, and 18.4% of patients, respectively. By multivariate analysis, older donor age (≥45 years) was an independent risk factor for SFSS (odds ratio [OR], 4.46; P=0.004), early graft loss (OR, 4.11; P=0.02), and 1-year mortality (OR, 3.76; P=0.02). Child-Pugh C class recipients were associated with a higher risk of SFSS development (P=0.013; OR, 7.44). Despite no significant difference between GRWR categories in the multivariate outcome analysis of the whole population, in the survival analysis of the 2 donor age groups, GRWR <0.6% was associated with significantly lower 1-year survival than the other GRWR categories in the younger donor group. Moreover, in the high final portal venous pressure (PVP) group (>15mmHg), younger ABO-compatible donors showed 100% 1-year survival with a significant difference from the group of other donors. Older donor age was an independent risk factor for SFSS, early graft loss, and 1-year mortality after ALDLT using SFSGs. GRWR should not be <0.6%, and PVP modulation is indicated when grafts from older or ABO-incompatible donors are used.

Older donor age is the risk factor for negative outcomes after adult living donor liver transplantation using small-for-size grafts

Introduction: Adult-to-adult living donor liver transplantation (ALDLT) using small for size grafts (SFSGs) (graft-to-recipient weight ratio (GRWR) < 0.8%) has been a challenge that should be carefully dealt with and risk factors in this category are unclear. Method: We aimed to examine the risk factors and outcomes of ALDLT using SFSGs in 121 patients who had undergone their first ALDLT using SFSGs over a 13-year-period. Result: Small-for-size syndrome (SFSS), early graft loss and 1-year mortality were encountered in 21.6%, 15.1% and 18.4% of patients, respectively. By multivariate analysis, older donor age (≥ 45 years) was an independent risk factor for SFSS, with early graft loss and 1-year mortality P values of 0.004, 0.02 and 0.02 and odds ratios (OR) of 4.46, 4.11 and 3.76, respectively. Child-Pugh C-class recipients were associated with a higher risk of SFSS development (P=0.013, OR 7.44). Despite no significant difference between GRWR% categories in the multivariate outcome analysis of the whole population, in the survival analysis of the two donor age groups, GRWR < 0.6% was associated with significantly lower 1-year survival than the other GRWR% categories in the younger donor group. Moreover, in the high final portal venous pressure (PVP) group (> 15 mmHg), younger ABO compatible donors showed 100% 1-year survival with a significant difference from the group of other donors. Conclusion: Older donor age was an independent risk factor for SFSS, early graft loss and 1-year mortality after ALDLT using SFSGs. GRWR should not be lower than 0.6% and PVP modulation is indicated when grafts from older or ABO incompatible donors are used.

Pure laparoscopic donor right hepatectomy in donor with severe portal vein anomaly

Summary Donor operation in adult-to-adult living donor liver transplantation(AALDLT) is still associated with postoperative morbidity. But, laparoscopic donor hepatectomy is sporadically reported in a few center with substantial experience and pure laparoscopic donor right hepatectomy(PLRH) has been gradually increased because of cosmetic satisfaction and rapid recovery, despite the controversial issues. We present PLRH in donor with severe portal vein anomaly. A 57 year old man volunteered to living liver donation for his wife who suffered from hepatic encephalopathy related with cirrhosis. Donor’s portal vein was unusual type on preoperative computed tomography; Nakamura type - single non-bifurcating portal vein variation. Right hepatic artery and hepatic duct were single. Right posterior portal vein and S5 branching portal vein were meticulously dissected and encircled with vessel loops before liver parenchymal transection, and S8 branching portal vein was identified after right hepatic duct transection. Three portal veins were reconstructed to one orifice during bench work procedure. Donor’s and recipient’s portal vein were patent, postoperatively. PLRH seems to be a feasible procedure when performed by a highly experienced surgeon, but careful preoperative evaluation and preparations are essential. Laparoscopic donor hepatectomy is being tried consistently and PLRH can be cautiously expanded to donors with hepatic anatomic variations.

Academic contribution of Masatoshi Makuuchi: a master of hepatobiliary surgery, an example to learn from

The famous professor, Masatoshi Makuuchi was known as the king of the liver surgery. Authors concluded main contributions of Masatoshi Makuuchi by reviewing literatures. (1) He was the first to use intraoperative ultrasonography during liver operations. Furthermore, he pioneered anatomical hepatectomy and ultrasound guided transhepatic cholangiography and cholangial drainage. (2) He was the first to adopted pre-operative selective portal vein embolization (PVE) and hemihepatic blood flow occlusion. (3) He performed the first adult-to-adult living donor liver transplantation (A-ALDLT) worldwide and established the well-known formula to predict standard liver volume. (4) The more laudable achievement is promoting these advanced concepts and techniques to the world, training a large group of contemporary hepatobiliary surgeons and benefiting a great number of patients. Masatoshi Makuuchi is a well-deserved master and a good example for contemporary hepatobiliary surgeons to follow. Key words: Hepatobiliary surgery; Masatoshi Makuuchi; Contributions; Learning

A portal pressure cut-off of 15 versus a cut-off of 20 for prevention of small-for-size syndrome in liver transplantation: A comparative study.

Portal hypertension has recently been implicated in the pathogenesis of small-for-size syndrome (SFSS) in adult-to-adult living-donor liver transplantation (A-LDLT). The aim of our study is to compare the portal venous pressure (PVP) cut-off values of 15mmHg and 20mmHg in terms of prevention of SFSS in A-LDLT. Seventy-six patients underwent A-LDLT. A PVP <20mmHg at the end of the operation was targeted using graft inflow modulation. Patients were divided into two groups: group A, final PVP <15mmHg; and group B, final PVP 15-19mmHg. Peak serum bilirubin and peak international normalized ratio in the first month after A-LDLT, as well as hepatic encephalopathy, SFSS, 90-day morbidity, and mortality were observed in both groups. Final PVP was well controlled below 20mmHg in all patients (group A, n = 39; group B, n = 37). Six patients suffered SFSS in group B (16.2%) compared to one patient (2.6%) in group A (P = 0.04). Nine patients died in group B (24.3%), four of whom died of SFSS, compared to three patients in group A (7.7%) (P = 0.047). A PVP cut-off of 15mmHg seems to be a more appropriate target level than a cut-off of 20mmHg for prevention of postoperative SFSS in A-LDLT.

Living donor liver transplantation in Egypt.

In Egypt there is no doubt that chronic liver diseases are a major health concern. Hepatitis C virus (HCV) prevalence among the 15-59 years age group is estimated to be 14.7%. The high prevalence of chronic liver diseases has led to increasing numbers of Egyptian patients suffering from end stage liver disease (ESLD), necessitating liver transplantation (LT). We reviewed the evolution of LT in Egypt and the current status. A single center was chosen as an example to review the survival and mortality rates. To date, deceased donor liver transplantation (DDLT) has not been implemented in any program though Egyptian Parliament approved the law in 2010. Living donor liver transplantation (LDLT) seemed to be the only logical choice to save many patients who are in desperate need for LT. By that time, there was increase in number of centers doing LDLT (13 centers) and increase in number of LDLT cases [2,400] with improvement of the results. Donor mortality rate is 1.66 per 1,000 donors; this comprised four donors in the Egyptian series. The exact recipient survival is not accurately known however, and the one-year, three-year and five-year survival were 73.17%, 70.83% and 64.16% respectively in the International Medical Center (IMC) in a series of 145 adult to adult living donor liver transplantation (AALDLT) cases. There was no donor mortality in this series. LDLT are now routinely and successfully performed in Egypt with reasonable donor and recipient outcomes. Organ shortage remains the biggest hurdle facing the increasing need for LT. Although LDLT had reasonable outcomes, it carries considerable risks to healthy donors. For example, it lacks cadaveric back up, and is not feasible for all patients. The initial success in LDLT should drive efforts to increase the people awareness about deceased organ donation in Egypt.

Factors influencing donor and recipient decision making in adult-to-adult living donor liver transplantation: a survey of a non-transplant population.

This study aimed to (i) investigate the factors that influence donor and recipient decision making in adult-to-adult living donor liver transplantation (AALDLT); (ii) quantify the level of risk that would be acceptable to potential donors; and (iii) determine from whom an individual would be willing to receive a donation. A self-administered questionnaire using hypothetical scenarios centred on AALDLT was created and administered to participants recruited from the waiting room of an orthopaedic outpatient clinic at a teaching hospital in Sydney (n = 105). The questionnaire asked participants to consider scenarios in which they either (i) were a potential donor for a family member or close friend or (ii) themselves required a liver transplant. Ninety-five (90%) participants expressed an in-principal willingness to consider living organ donation. The factors most important in deciding to be living liver donors were the probability of a good outcome for the recipient, the likelihood of the potential recipient's survival until a deceased donor liver became available and the risk of donor death. Donor death was also rated as the least acceptable donor outcome. Participants expressed a willingness to receive a donation from all proposed donor groups equally. The acceptability of hypothetical living organ donation was very high in the population group studied. Participants were also willing to accept significantly higher risks of complications from organ donation than they would actually be exposed to. Clinicians should feel encouraged to discuss the risks and benefits of living donation frankly with patients and their families.

Portal Venous Pressure in Adult Living Donor Liver Transplantation

ObjectiveThe relationship between portal pressure and small-for-size syndrome (SFSS) is unsettled. The purpose of this study was to evaluate the role of portal pressure in predicting SFSS. MethodsThirty-four patients with end-stage liver disease who received adult-to-adult living-donor liver transplantation (ALDLT) were included. Recipients were grouped based on whether they received portal flow modulation or not. The intraoperative portal vein flow volume (PVFV) and portal venous pressure (PVP) between the 2 groups were compared. The relationship of PVP to PVFV, graft weight-to-recipient weight ratio (GRWR), and graft weight-to-recipient spleen size ratio (GRSSR) were analyzed. ResultsPersistent portal hypertension was found after ALDLT. The PVP was linearly correlated with PVFV but not with GRWR or GRSSR. With the use of the following criteria, (1) PVFV >250 mL/min/100 g graft weight, (2) GRWR <0.8%, and (3) GRSSR <0.6, modulation of the portal flow was performed in 3 cases. The receiver operating characteristic analysis showed that 23 mm Hg was the cutoff point for PVP, with a sensitivity of 83% and specificity of 43%. ConclusionsPVP is a weak parameter to use for portal flow modulation after ALDLT. It is sensitive but not specific to predict SFSS.

Outcome of Using Small-For-Size Grafts in Living Donor Liver Transplantation Recipients with High Model for End-Stage Liver Disease Scores: A Single Center Experience

AimsTo evaluate the impact of small-for-size grafts (SFSG) in adult-to-adult living donor liver transplantation (AALDLT) on outcomes of recipients with different model for end-stage liver disease (MELD) score in a single liver transplant center.Materials and MethodsClinical data of 118 patients underwent right-lobe AALDLT from January 2004 to December 2011 were retrospectively analyzed, Patients were divided into Group L (MELD score≤25) and Group H (MELD score > 25) according to MELD score. The patients were further stratified into Group LS (MELD score≤25, GBWR<0.8%), Group LN (MELD score≤25, GBWR≥0.8%), Group HS (MELD score > 25, GBWR<0.8%), and Group HN (MELD score > 25, GBWR≥0.8%) to investigate the impact of graft size on recipients’ complications and outcomes. Pre-operative characteristics, post-operative complications graded by the Clavien score and patient survival were analyzed.ResultsMELD scores between the two groups were significant different (12.4±4.9 vs 34.5±7.5, P=0.026). There was no significant difference in preoperative demographic data as well as postoperative liver function. Complication rate, length of ICU and hospital stay, graft loss, and mortality were similar in both groups. The 1- and 3- year survival were similar between group H and group L. When recipients were further stratified into group LS, LN, HS, and HN, no significant difference was found among groups in 1- and 3- year survival rate. In multivariate analysis, HCC was not a predictor for long term survival.ConclusionOur single institution experience demonstrates that it is safe to use SFSGs in high pre-MELD score recipients with the improvement of intensive care and the selection of listing criteria.

Review of the surgical approach to prevent small-for-size syndrome in recipients after left lobe adult LDLT

Left lobe liver grafts increase the donor safety in adult-to-adult living-donor liver transplantation (ALDLT). However, the left lobe graft provides about 30-50 % of the required liver volume to adult recipients, which is insufficient to sustain their metabolic demands, which can lead to small-for-size syndrome (SFSS). Transient portal hypertension and microcirculatory hemodynamic derangement, apart from outflow obstruction, during the first week after reperfusion are the critical events associated with small-for-size graft transplantation. The incidence of SFSS in left lobe ALDLT can be decreased by increasing the left lobe graft volume by effective utilization of the caudate lobe with preserved vascular supply, by modulating the portal pressure with splenectomy or a porto-systemic shunt or by hepatic venous outflow reconstruction to prevent the development of venous congestion. In this review, we discuss the pathophysiology of SFSS and the various surgical strategies that can be performed to prevent SFSS in an effort to enhance the donor safety during living-donor liver transplantation.

Using a Small-For-Size Graft Might Attribute to the Future Use of Left-Lobe Living Graft in Adult to Adult Living Donor Liver Transplantation

Adult to adult living donor liver transplantation (AALDLT) is performed worldwide. The aim of this study was to evaluate using a graft with graft to body weight ratio (GBWR) less than 0.8 in right-lobe AALDLT recipients. Clinical data of 127 patients who had right-lobe AALDLT from January 2002 to November 2009 were retrospectively analyzed. Patients were divided into two groups according to GBWR (group A: 0.6 ≤ GBWR < 0.8, group B: GBWR ≥ 0.8). Preoperative characteristics, postoperative complications graded by the Clavien score and patient survival time were recorded and analyzed. GBWR between the two groups were significantly different (0.67 ± 0.05 vs. 0.97 ± 0.17, p = 0.000). There was no significant difference in preoperative demographic data as well as postoperative liver function data. Complication rate, median ICU stay and small-for-size syndrome incidence were similar in both groups. In univariate analysis, only MELD emerged as independent risk factor for small-for-size syndrome (p = 0.045). Patient survival was similar in both groups at 1, 3 and 5 years as well. Using a GBWR of less than 0.8 is safe in selected recipients. To some extent, this result may attribute to the wide use of left-lobe living graft in AALDLT in future.

Strategies to optimize donor safety with smaller grafts for adult-to-adult living donor liver transplantation

To describe our current understanding of adult-to-adult living donor liver transplantation (AA-LDLT) in terms of graft size. Improved outcomes of small liver graft with the use of portal vein pressure (PVP) modulation. AA-LDLT is viewed as a viable alternative to whole liver transplantation on the treatment of end-stage liver disease. Over the past two decades, right lobe AA-LDLT has been the standard because of concerns related to graft size. Small-for-size syndrome (SFSS) is an entity that presents in recipients of small grafts. It negatively affects patient and graft survival and recipients of grafts with a graft weight-to-recipient weight ratio (GW/RW) lower than 1.0 are at the highest risk. Over the last decade, our understanding of SFSS has identified PVP as a major determinant in the development of SFSS. Direct or indirect surgical PVP modulation has demonstrated a way to prevent the development of SFSS in recipients of small grafts and has improved the survival outcomes of small grafts. These improved outcomes coupled with concerns for donor safety have led to the renaissance of the use of left lobe grafts. Based on the current clinical data, the use of small grafts GW/RW greater than 0.6 is viewed as well tolerated when PVP is modulated to achieve a target PVP less than 15 mmHg after reperfusion and the left lobe is currently viewed as the ideal graft for AA-LDLT.

“Inherent Limitations” in Donors

The aim of this study was to identify "inherent limitations" in healthy donors who are responsible for donor morbidity after right hepatectomy (RH) for adult-to-adult living donor liver transplantation (ALDLT). Right hepatectomy for ALDLT remains a challenging procedure without significant improvement in morbidity over time. This suggests some "inherent limitations" in healthy individuals, which are beyond the recent improvements in the donor evaluation and selection process and refinements in surgical technique during the learning curve. To identify response of RH in ALDLT, we prospectively studied 32 patients requiring an RH for benign liver lesions (BL), matched with 32 living donors (LD) operated by same team. All patients underwent liver volume evaluation by computed tomographic (CT) volumetry preoperatively and 1 week after RH, postoperative complications graded with Clavien's system. The comparison (LD vs BL) showed that remnant liver volume (RLV) on preoperative CT volumetry was higher in the BL group (450 ± 150 vs 646 ± 200 mL, P < 0.001) representing 31% ± 7% in LD group versus 36% ± 7% of the total liver volume in BL group (P = 0.03). On postoperative day 7, the RLV was similar in the 2 groups (866 ± 162 vs 941 ± 153 mL) resulting from a significantly higher regeneration rate in the LD group (89% vs 55%, P = 0.009). Overall complications rate was lower in the BL group (46% vs 21%, P = 0.035). Right hepatectomy in LDLT induces a more severe deprivation of liver volume than in BL, which induce an accelerated regeneration. Accelerated regeneration could represent "inherent limitation" in healthy donors that makes them more vulnerable for postoperative complications.

Adult to adult living related liver transplantation: Where do we currently stand?

Adult to adult living donor liver transplantation (AALDLT) was first preformed in the United States in 1997. The procedure was rapidly integrated into clinical practice, but in 2002, possibly due to the first widely publicized donor death, the number of living liver donors plummeted. The number of donors has since reached a steady plateau far below its initial peak. In this review we evaluate the current climate of AALDLT. Specifically, we focus on several issues key to the success of AALDLT: determining the optimal indications for AALDLT, balancing graft size and donor safety, assuring adequate outflow, minimizing biliary complications, and maintaining ethical practices. We conclude by offering suggestions for the future of AALDLT in United States transplantation centers.

Adult-to-adult living donor liver transplantation for acute liver failure in China

To investigate the long-term outcome of recipients and donors of adult-to-adult living-donor liver transplantation (AALDLT) for acute liver failure (ALF). Between January 2005 and March 2010, 170 living donor liver transplantations were performed at West China Hospital of Sichuan University. All living liver donor was voluntary and provided informed consent. Twenty ALF patients underwent AALDLT for rapid deterioration of liver function. ALF was defined based on the criteria of the American Association for the Study of Liver Diseases, including evidence of coagulation abnormality [international normalized ratio (INR) ≥ 1.5] and degree of mental alteration without pre-existing cirrhosis and with an illness of < 26 wk duration. We reviewed the clinical indications, operative procedure and prognosis of AALDTL performed on patients with ALF and corresponding living donors. The potential factors of recipient with ALF and corresponding donor outcome were respectively investigated using multivariate analysis. Survival rates after operation were analyzed using the Kaplan-Meier method. Receiver operator characteristic (ROC) curve analysis was undertaken to identify the threshold of potential risk factors. The causes of ALF were hepatitis B (n = 18), drug-induced (n = 1) and indeterminate (n = 1). The score of the model for end-stage liver disease was 37.1 ± 8.6, and the waiting duration of recipients was 5 ± 4 d. The graft types included right lobe (n = 17) and dual graft (n = 3). The mean graft weight was 623.3 ± 111.3 g, which corresponded to graft-to-recipient weight ratio of 0.95% ± 0.14%. The segment Vor VIII hepatic vein was reconstructed in 11 right-lobe grafts. The 1-year and 3-year recipient's survival and graft survival rates were 65% (13 of 20). Postoperative results of total bilirubin, INR and creatinine showed obvious improvements in the survived patients. However, the creatinine level of the deaths was increased postoperatively and became more aggravated compared with the level of the survived recipients. Multivariate analysis showed that waiting duration was independently correlated with increased mortality (P = 0.014). Furthermore, ROC curve revealed the cut-off value of waiting time was 5 d (P = 0.011, area under the curve = 0.791) for determining the mortality. The short-term creatinine level with different recipient's waiting duration was described. The recipients with waiting duration ≥ 5 d showed the worse renal function and higher mortality than those with waiting duration < 5 d (66.7% vs 9.1%, P = 0.017). In addition, all donors had no residual morbidity. Furthermore, univariate analysis did not show that short assessment time induced the high morbidity (P = 0.573). Timely AALDLT for patients with ALF greatly improves the recipient survival. However, further systemic review is needed to investigate the optimal treatment strategy for ALF.

Fifteen millimeters of mercury

Fifteen millimeters of mercury