Graft Living Donor Liver Transplantation Research Articles

Outcomes of Adult Right Graft Living Donor Liver Transplantation Utilizing the Robotic Platform Integrated Real-time Indocyanine Green Fluorescence Cholangiography Compared to the Open Approach.

This study aimed to assess short-term biliary outcomes in adult living donor liver transplants using right grafts, comparing robotic surgery with real-time indocyanine green fluorescence cholangiography (ICG-CA) for optimal hilar plate transection, against the conventional open approach. Determining the optimal transection plane through the hilar plate is crucial in donor hepatectomies, impacting outcomes significantly. From 2011 to 2023, a total of 839 right graft living donor hepatectomies were performed, with 414 (49%) performed via the open approach and 425 (51%) utilizing the robotic platform. The MRCP predictions correlated moderately with the actual count of graft ducts (r=0.57,P<0.001) Out of all 839 right donor hepatectomies, 321 (44%) were single duct grafts, of which 193/425 (49%) were retrieved with the robotic while 128/414 (38%) were with the open approach (OR 1.58, 95% CI 1.16-2.14),P=0.003). Overall, 50 (6%) of the donors developed a biliary complication during hospital stay, of whom 38 (9%) were grafts retrieved with the open, while 13 (3%) with the robotic approach (OR 0.31, 95% CI 0.15-0.61,P<0.001). Similarly, 63 (15%) of the adult recipients developed a biliary complication of any severity when grafts were retrieved with the open approach compared to 35 (8%) with the robotic approach (OR 0.50, 95% CI 0.31-0.79),P=0.002). The robotic platform with integrated real-time ICG-CA during right donor hepatectomy offers improved safety for the donor by accurately addressing the right hilar corridor, resulting in fewer graft ducts, and fewer complications of the donor and recipient when compared to the standard open approach.

Effectiveness of anatomic reconstruction of the middle hepatic vein in right lobe graft living donor liver transplantation using natural portal vein graft and synthetic graft

Effectiveness of anatomic reconstruction of the middle hepatic vein in right lobe graft living donor liver transplantation using natural portal vein graft and synthetic graft

Adult-to-adult right lobe graft living donor liver transplantation for acute-on-chronic liver failure: a single-centre retrospective study in Vietnam.

Acute-on-chronic liver failure (ACLF) has a high mortality rate, and liver transplantation is considered a definite treatment for patients with this condition. This study aims to evaluate the outcomes of living donor liver transplantation (LDLT) in ACLF patients in a single centre in a lower middle-income country, Vietnam. This was a retrospective study at the 108 Military Central Hospital (Hanoi, Vietnam), enroling 51 patients diagnosed with ACLF based on Asian Pacific Association for the Study of the Liver (APASL) criteria who underwent LDLT with a right lobe graft from December 2019 to December 2022. The authors utilize the model for end-stage liver disease (MELD) and APASL ACLF Research Consortium (AARC) scores to evaluate and stratify the severity of ACLF. The average age of all patients was 47.27±13.61, with 88.24% being male. The average BMI was 22.78±2.61. The most common underlying liver disease was chronic viral hepatitis B (88.2%). The average MELD score of the patients was 34.90±5.61, with 33.3% having MELD score greater than or equal to 40. In terms of ACLF severity, five patients (9.8%) had grade I ACLF, 35 patients (68.6%) had grade II ACLF, and 11 patients (21.6%) had grade III ACLF. The average AARC score was 9.43±1.68. The duration of treatment in the ICU was 8.59±7.27 days, and the length of hospital stay was 28.02±13.45 days. The most common post-transplant complication was biliary complication (19.61%). Death occurred in 7 patients (13.7%). The survival rates at 6 months, 1 year, and 3 years were 84%, 81.7%, and 81.7%, respectively. Living donor liver transplantation for ACLF patients is safe and has a high post-transplant survival rate. Multidisciplinary care before, during, and after surgery, and the decision to do a liver transplant early, is essential in saving the lives of ACLF patients.

Early Graft Failure After Living-Donor Liver Transplant.

Living-donor liver transplantation (LDLT) has been increasing in the USA. While data exist on longer-term patient and graft outcomes, a contemporary analysis of short-term outcomes is needed. Evaluate short-term (30-day) graft failure rates and identify predictors associated with these outcomes. Adult (≥ 18) LDLT recipients from 01/2004 to 12/2021 were analyzed from the United States Scientific Registry of Transplant Recipients. Graft status at 30 days was assessed with graft failure defined as retransplantation or death. Comparison of continuous and categorical variables was performed and a multivariable logistic regression was used to identify risk factors of early graft failure. During the study period, 4544 LDLTs were performed with a graft failure rate of 3.4% (155) at 30 days. Grafts from male donors (aOR: 0.63, CI 0.44-0.89), right lobe grafts (aOR: 0.40, CI 0.27-0.61), recipients aged > 60years (aOR: 0.52, CI 0.32-0.86), and higher recipient albumin (aOR: 0.73, CI 0.57-0.93) were associated with superior early graft outcomes, whereas Asian recipient race (vs. White; aOR: 3.75, CI 1.98-7.10) and a history of recipient PVT (aOR: 2.7, CI 1.52-4.78) were associated with inferior outcomes. LDLTs performed during the most recent 2016-2021 period (compared to 2004-2009 and 2010-2015) resulted in significantly superior outcomes (aOR: 0.45, p < 0.001). Our study demonstrates that while short-term adult LDLT graft failure is uncommon, there are opportunities for optimizing outcomes by prioritizing right lobe donation, improving candidate nutritional status, and careful pre-transplant risk assessment of candidates with known PVT. Notably, a period effect exists whereby increased LDLT experience in the most recent era correlated with improved outcomes.

Feasibility of venous cuff using an open round ligament or inferior mesenteric vein around the hepatic vein for a left lobe graft in living-donor liver transplantation.

Living-donor liver transplantation (LDLT) is an established treatment for patients with end-stage liver disease or acute liver failure, and outflow reconstruction is considered one of the most vital techniques in LDLT. To date, many strategies have been reported to prevent outflow obstruction, which can be refractory to liver dysfunction and can cause life-threatening graft loss or mortality. In addition, in this era of laparoscopic hepatectomy in donor surgery, especially LDLT using a left liver graft, it has been predicted that cutting the hepatic vein with automatic linear staplers will lead to more outflow-related problems than with conventional open hepatectomy because of the short neck of the anastomosis orifice. We herein review 10 cases of venoplasty performed with a novel venous cuff system using a donor's round ligament around the hepatic vein in LDLT with a left lobe graft, which makes anastomosis of the hepatic vein sterically easy for postoperative venous patency.

Adult-to-adult right lobe graft living donor liver transplantation for acute-on-chronic liver failure: a single-center experience in Vietnam

Adult-to-adult right lobe graft living donor liver transplantation for acute-on-chronic liver failure: a single-center experience in Vietnam

Outcomes and Risk Factors for Liver Transplantation Using Graft-to-Recipient Weight Ratio Less Than 0.8 Graft From Living Donors: Multicentric Cohort Study.

To compare graft survival after living donor liver transplantation (LDLT) in patients receiving graft-to-recipient weight ratio (GRWR) <0.8 versus GRWR≥0.8 grafts and identify risk factors for graft loss using GRWR<0.8 grafts. Favorable outcomes after LDLT using GRWR<0.8 grafts were recently reported; however, these results have not been validated using multicenter data. This multicentric cohort study included 3450 LDLT patients. Graft survival was compared between 1:3 propensity score-matched groups and evaluated using various Cox models in the entire population. Risk factors for graft loss with GRWR<0.8 versus GRWR≥0.8 grafts were explored within various subgroups using interaction analyses, and outcomes were stratified according to the number of risk factors. In total, 368 patients (10.7%) received GRWR<0.8 grafts (GRWR<0.8 group), whereas 3082 (89.3%) received GRWR≥0.8 grafts (GRWR≥0.8 group). The 5-year graft survival rate was significantly lower with GRWR<0.8 grafts than with GRWR≥0.8 grafts (85.2% vs 90.1%, P =0.013). Adjusted hazard ratio for graft loss using GRWR<0.8 grafts in the entire population was 1.66 (95% CI: 1.17-2.35, P =0.004). Risk factors exhibiting significant interactions with GRWR<0.8 for graft survival were age ≥60 years, Model for End-stage Liver Disease score ≥15, and male donor. When ≥2 risk factors were present, GRWR<0.8 grafts showed a higher risk of graft loss compared with GRWR≥0.8 graft in LDLT (hazard ratio 2.98, 95% CI: 1.79-4.88, P <0.001). GRWR<0.8 graft showed inferior graft survival than controls (85.2% vs 90.1%), especially when ≥2 risk factors for graft loss (among age 60 years or above, Model for End-stage Liver Disease score ≥15, or male donor) were present.

Sarcopenic obesity may predict worse liver regeneration after right graft living donor liver transplantation.

Sarcopenic obesity impairs the outcome after liver transplantation. The effect of this on liver regeneration has not yet been studied. The aim of this study was to evaluate the potential effect of body composition changes on liver volume gain after living donor liver transplantation. We observed liver regeneration in 100 patients who underwent living donor liver transplantation using right lobe grafts (Segments V-VIII). Liver volumetry and body composition analysis were performed based on CT images with special software. The gain of liver volume was calculated between 2 points in time considering the absolute and percentage values: before surgery and early after surgery, with a median time of 10 days. Pearson's correlation and multivariate analysis using stepwise multiple regression were used to examine the potential correlation between body composition and liver volume gain. The liver volume increase was significantly negatively correlated with adipose tissue in the body stem ( r = -0.4, p < 0.001) and positively correlated with psoas mass ( r = 0.24, p = 0.02). These results correspond with those of the multiple regression analysis, which indicated adipose tissue (ß = -1.0, p < 0.001) and psoas mass (ß = 0.12, p < 0.001). The presence of malignancy as an indication for liver transplantation was another significant independent factor negatively affecting liver growth (ß = -13.1, p = 0.046). Sarcopenic obesity predicts an impaired liver volume increase after living donation. This could worsen the postoperative outcome. The role of alimentary interventions and exercises in improving body composition and thus postoperative outcome should be evaluated through prospective interventional studies.

Single orifice outflow reconstruction in right lobe graft living donor liver transplantation: A single-center study in Vietnam

Single orifice outflow reconstruction in right lobe graft living donor liver transplantation: A single-center study in Vietnam

Dual Graft Living Donor Liver Transplantation for High Acuity Patients: A Single-Center Experience

The outcomes of dual graft living donor liver transplantation (DGLDLT) in high acuity patients remain underreported. The objective of this study was to report long-term outcomes from a single center in this select group of patients. This was a retrospective review of patients who underwent DGLDLT between 2012 and 2017 (n= 10). High acuity patients were defined as patients with model for end stage liver disease (MELD) ≥30 or Child Pugh score ≥11. We looked at 90-day morbidity and mortality and 5-year overall survival (OS). The median MELD score and Child Pugh score were 30 (26.7-35) and 11 (11-11.2). The median recipient weight was 105 (95.2-113.7) and ranged from 82 to 132kg. Out of 10 patients, 4 (40%) required perioperative renal replacement therapy, and 8 (80%) required hospital admission for optimization. The estimated graft to recipient weight ratio (GRWR) with right lobe graft alone was <0.8 in all patients, between 0.75 and 0.65 in 5 (50%) patients, and <0.65 in 5 (50%) patients. The 90-day mortality was 3/10 (30%), and there were 3/10 (30%) deaths during long-term follow-up. Among 155 high acuity patients, the 1-year OS with standard LDLT, standard LDLT with GRWR <0.8, and DGLDLT was 82%, 76%, and 58%, respectively (P= 0.123). With a median follow-up of 40.6 (1.9-74.4) months, the 5-year OS for DGLDLT was 50%. The use of DGLDLT in high acuity patients should be prudent and low GRWR grafts should be considered a viable alternative in selected patients.

Up-regulated LRRN2 expression as a marker for graft quality in living donor liver transplantation.

The quality and size of liver grafts are critical factors that influence living‐donor liver transplantation (LDLT) function and safety. However, the biomarkers used for predicting graft quality are lacking. In this study, we sought to identify unique graft quality markers, aside from donor age, by using the livers of non‐human primates. Hepatic gene microarray expression data from young and elderly cynomolgus macaques revealed a total of 271 genes with significantly increased expression in the elderly. These candidate genes were then narrowed down to six through bioinformatics analyses. The expression patterns of these candidate genes in human donor liver tissues were subsequently examined. Importantly, we found that grafts exhibiting up‐regulated expression of these six candidate genes were associated with an increased incidence of liver graft failure. Multivariable analysis further revealed that up‐regulated expression of LRRN2 (encoding leucine‐rich repeat protein, neuronal 2) in donor liver tissue served as an independent risk factor for graft failure (odds ratio 4.50, confidence interval 2.08–9.72). Stratification based on graft expression of LRRN2 and donor age was also significantly associated with 6‐month graft survival rates. Conclusion: Up‐regulated LRRN2 expression of liver graft is significantly correlated with graft failure in LDLT. In addition, combination of graft LRRN2 expression and donor age may represent a promising marker for predicting LDLT graft quality.

Living Donor Liver Transplant Center Volume Influences Waiting List Survival Among Children Listed for Liver Transplantation.

Pediatric living donor liver transplantation (LDLT) remains infrequently performed in the United States and localized to a few centers. This study aimed to compare pediatric waiting list and posttransplant outcomes by LDLT center volume. The Scientific Registry of Transplant Recipients/Organ Procurement and Transplantation Network database was retrospectively reviewed for all pediatric (age <18 y) liver transplant candidates listed between January 1, 2009, and December 31, 2019. The average annual number of LDLT, deceased donor partial liver transplant (DDPLT), and overall (ie, LDLT + DDPLT + whole liver transplants) pediatric liver transplants performed by each transplant center during the study period was calculated. Of 88 transplant centers, only 44 (50%) performed at least 1 pediatric LDLT during the study period. LDLT, DDPLT, and overall transplant center volume were all positively correlated. LDLT center volume was protective against waiting list dropout after adjusting for confounding variables (adjusted hazard ratio, 0.92; 95% confidence interval, 0.86-0.97; P = 0.004), whereas DDPLT and overall center volume were not ( P > 0.05); however, DDPLT center volume was significantly protective against both recipient death and graft loss, whereas overall volume was only protective against graft loss and LDLT volume was not protective for either. High-volume pediatric LDLT center can improve waiting list survival, whereas DDPLT and overall volume are associated with posttransplant survival. Expertise in all types of pediatric liver transplant options is important to optimize outcomes.

Size Is Not Everything: "Small" Living Donor Liver Transplantation Grafts Can Have Good Outcomes.

Size Is Not Everything: "Small" Living Donor Liver Transplantation Grafts Can Have Good Outcomes.

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.

Approach for outflow reconstruction and reperfusion in LDLT with a right lobe graft

Presenter: Nicolas Goldaracena MD | University of Virginia Health System Background: Living donor liver transplantation (LDLT) emerged to overcome the organ shortage and reduce waitlist mortality. However, is a technically demanding operation that requires careful preoperative preparation, as well as a meticulous surgery. To reduce the risk of small for size syndrome, a balance between a sufficient graft size, the degree of the recipient’s portal hypertension and adequate outflow reconstruction to avoid venous congestion of the graft are mandatory. Different approaches are being utilized to perform an optimal outflow reconstruction during LDLT. However, proper graft positioning, enlarged outflow openings and reconstruction of venous outflow of all liver sectors are crucial to achieve a congestion-free graft. Methods: A video abstract is presented illustrating the approach used for venous outflow reconstruction and graft reperfusion during LDLT with a right lobe graft. Results: The living donor graft consisted of a right lobe without the middle hepatic vein (MHV). As venous outflow, the graft had a dominant right hepatic vein (RHV), an accessory segment 6/7 vein and a segment 8 vein that needed reconstruction for optimal graft venous drainage. The approach used consists of performing a total caval clamping that facilitates a wide opening of the recipient’s vena cava, as anastomosis sites, while ensuring an optimal graft positioning and orientation. Once the RHV and segment 6/7 vein are reconstructed, the outflow of the anterior sector (segment 8 vein) is temporarily clamped to be reconstructed sequentially to the MHV following graft reperfusion. Therefore, portal vein anastomosis is then performed and following the release of the caval clamps the graft is reperfused via the portal vein. Once the graft is reperfused, the anastomoses of the graft segment 8 vein to the recipient’s MHV is performed with an interposition cadaveric iliac vein that was previously anastomosed to the segment 8 vein of the graft in the backtable. Conclusion: In our opinion, total caval clamping in LDLT ensures the possibility of providing enlarged outflow openings without compromising graft positioning and orientation. Therefore, this approach allows an optimal venous outflow and a congestion free graft in LDLT. In addition, in order to shorten the total caval clamping time, sequential reconstruction of the anterior sector veins of right lobe grafts can be safely performed following reperfusion of the graft.

Feasibility of Dual Living Donor Liver Transplantation From Donors With Complex Portal Vein Variations

Living donor liver transplantation (LDLT) from donors with complex portal vein anomalies has been considered a challenging procedure because vasculobiliary variations of the donor’s liver may lead to significant increases in donor and recipient complications. The use of donors with anatomic variations may be considered under the accurate preoperative planning if a more suitable donor is not available. We report a successful dual LDLT for 2 donors with portal vein anomaly to overcome the small-for-size graft syndrome and secure donor safety. A 62-year-old man was referred to our institution for liver transplant because of hepatitis B–related liver cirrhosis with hepatocellular carcinoma. The only available donors were his son and his daughter-in-law, one with type IV portal venous anatomic variation and the other with type III variation. Neither of the 2 available donors were suitable as a single donor because of the complexity of the portal vein reconstruction and the donor’s safety. Therefore, the decision was made to perform LDLT using dual graft, and we planned to harvest the right posterior sector graph from the first donor together with the left lobe graft of the second donor. Donor hepatectomy and recipient total hepatectomy were performed in the usual manner. He has recovered well with normal graft function, and there has been no tumor recurrence after dual LDLT. Dual graft LDLT using right posterior sector and left lobe graft could be undertaken successfully to overcome the small-for-size graft syndrome and secure the safety of donors in cases with the complex portal vein anomalies.

Outcome of Living-Donor Liver Transplantation Using Grafts from Donors Treated for Fatty Liver.

BackgroundThe aim of this study was to determine the efficacy of treating donors’ fatty liver (FL) and to assess early graft function in recipients who received treated FL grafts in living-donor liver transplantation (LDLT).Material/MethodsData were collected for adult-to-adult LDLTs. Donors diagnosed with FL (FL group) received diet–exercise and pharmacological treatment. The perioperative findings and early transplanted graft function were compared with those of donors without FL (non-FL group) during the same period.ResultsOf 30 donors, 8 were determined to have FL. The median duration of treatment for FL was 58 days. The liver-to-spleen attenuation ratios on CT scan in the FL group were significantly improved after treatment: 0.95 (0.62–1.06) to 1.2 (1.12–1.46) (P=0.003). Liver biopsy prior to donor surgery showed ≤10% fatty infiltration. Postoperative laboratory findings of the donors in the FL group were comparable to those in the non-FL group: maximum alanine transaminase (189.6±94.7 IU/L vs. 196.8±57.4) and maximum total bilirubin (2.2±1.1 mg/dL vs. 1.7±0.5 mg/dL). No major complications were observed after donor hepatectomy in either group. There were no significant differences between the 2 groups in early graft function, as evaluated by laboratory data, ascites volume, and bile production 2 weeks postoperatively. Graft and patient survival were 100% in both groups at 3 months.ConclusionsPreoperative intentional treatment for FL was effective. Early graft function and donor postoperative course were comparable in the 2 groups. These results suggest that well-treated steatotic grafts can be used without jeopardizing donor safety.

Right posterior segment graft for living donor liver transplantation: A systematic review.

The clinical significance of the right posterior segment (RPS) graft in living donor liver transplantation (LDLT) is unknown because of its limited use and technical concerns. This study aimed to review published studies investigating outcomes of RPS grafts. The systematic literature search was conducted to retrieve data from Embase, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar. Among the 388 articles, six retrospective studies from Asian countries were included. The overall incidences of major and minor complications after RPS graft procurement were 5.6% and 34.6%, respectively and no donor deaths were reported. RPS graft recipients had the following postoperative complications: overall mortality rate, 14.5%; bile leakage, 8.7%, biliary stenosis, 18.8%, hepatic artery thrombosis, 8.7%, and liver re-transplantation, 2.9%. The RPS graft can be considered as an option for a living liver graft respecting donor safety under strict selection criteria and surgical strategy. The precise evaluation and understanding of anatomical variations and volumetric analyses is critical for selecting donors and planning the surgical strategy in the RPS grafts procurement. The RPS grafts procurement requires carefully dissection of the hepatic artery and portal vein, safely confirmation of the bile duct, and precisely parenchymal transection. However, further experience is needed to clarify the significance of the RPS graft in LDLT. The special technical requirements should limit this donor procedure to centers with a high level of experience in LDLT.

Dual-graft living donor liver transplantation

Shortage of donors is a major obstacle for liver transplantation. Lee innovated dual graft living donor liver transplantation in 2001, obtained graft from two donors, and it was conducted in various parts of the world. At present, South Korea has the biggest numbers in operation, China, Japan, and Germany. Turkey, Romania, and other countries are relatively less; current clinical liver donor liver transplantation is mainly based on single graft living donor liver transplantation, and in some complicated cases, single graft liver transplantation cannot be completed due to various factors, at this situation dual grafts living donor liver transplantation can complete the treatment. Although dual donor liver transplantation can only be carried out in a few areas due to complex surgical procedures, it can enrich the treatment of liver transplantation and promotes the development of liver transplantation. Key words: Liver transplantation; Dual graft living donor liver transplantation; Single graft living donor liver transplantation; Living donor liver transplantation

Living donor liver transplantation.

As experience grows, living donor liver transplantation (LDLT) has become an effective treatment option to overcome the deceased donor organ shortage. Donor safety is the highest priority in LDLT. Strict donor selection according to structured protocols and center experience are the main factors that determine donor safety. However, with increased experience, many centers have explored increasing organ availability within living donation by means of ABO incompatible LDLT, dual graft LDLT, and anonymous living donation. Also, this growing experience in LDLT has allowed the transplant community to cautiously explore the role of liver transplantation for hepatocellular carcinoma outside of Milan criteria and patients with unresectable colorectal liver metastases. LDLT has become established as a viable strategy to ameliorate the organ shortage experienced by centers around the world. Improved understanding of this technique has allowed the improved utilization of live donor graft resources, without compromising donor safety. Moreover, LDLT may offer some advantages over deceased donor liver transplantation and a unique opportunity to assess the broader applicability of liver transplantation.