Graft-recipient Body Weight Ratio Research Articles

Minimum absolute graft weight of 650g predicts a good outcome in living donor liver transplant despite a graft recipient body weight ratio of less than 0.8.

In living donor liver transplant (LDLT), it is recommended to have a minimum graft recipient body weight ratio (GRBWR) 0.8 for good outcomes. Recent reports have, however, shown that good outcomes can be obtained even with GRBWR less than 0.8. We hypothesized that in patients receiving a graft with GRWR less than 0.8 absolute graft weight rather than GRBWR may be more relevant for predicting good outcome. Early post-transplant outcomes were assessed in adult patients undergoing elective right lobe LDLT. Patients were categorized as having good (survival) or poor (mortality) outcome. A ROC curve was drawn based on their graft weights and a cutoff value that provided the highest sensitivity and specificity for a good outcome was chosen. 147 patients received right lobe grafts with GRBWR less than 0.8. The 90-day mortality rate was 13.6% (n=20). AUROC was 67.7%. Graft weight cutoff of 643g gave the best combination of sensitivity (51.2%) and specificity (77.8%). There were 15 (19.4%) deaths in group with graft weight less than 643g compared to 5 (7.1%) patients with graft weight 643g or above. This cutoff value of 643g (rounded of to 650g) gave a positive predictive value (PPV) of 94%.

Application of three-dimensional visualization technique in pediatric living donor liver transplantation

To investigate the value of three-dimensional(3D) visualization technology for donor evaluation in pediatric living donor liver transplantation(LDLT). The clinical data of 348 familial donors who underwent LDLT from January 2013 to December 2015 in Renji Hospital, Shanghai Jiaotong University School of Medicine were reviewed retrospectively.3D visualize-vascular type and liver grafts volume were analyzed and compared to the actual volume and anatomy. Paired t-test was used to compared the liver volume between 3D visualization estimated-liver grafts and actual volume. Among the LDLT recipients, 168 were male and 180 were female aged from 5 to 176 months(median age 8 months), and average body weight was(9.4±5.4)kg, average abdominal circumference was (56.3±13.3)cm.Among the LDLT candidates, 131 were male and 217 were female aged from 19 to 59 years(average age (32.0±13.0)years, median age 30 years). The type of liver grafts from 348 donors included: 308 left lateral lobe(88.5%)(5 were reduced-size grafts(1.4%) and 2 were hyper reduced-size grafts (0.6%)), 32 left lobe donor(9.2%), 7 right lobe donor(2.0%) and 1 right posterior lobe donor(0.3%). The difference between the mean volume of 3D visualization estimated-liver grafts and the mean actual volume was not significant((300.3±80.7)ml vs.(287.6±71.5)ml)(P=0.15), the average weight was (291.9±75.6)g and mean graft recipient body weight ratio was (3.2±0.1)%.The mean operation time was (205±59)minutes, the mean blood loss was (153±49)ml, and the mean postoperative hospital stay was (7±3)days. 3D visualization reconstruction technique can accurately assess the donor condition and ensure the safety both donors and recipients.

Serial volumetric assessment of large for size liver grafts after whole cadaveric liver transplant in adults: do large liver grafts shrink in size?

BackgroundAfter whole graft orthotopic liver transplantation (OLT), adaptation of the large grafts' volume to recipient weight is widely accepted despite the paucity of evidence on this subject. MethodsThirty nine patients with GRWR > 2.5% were included in this study and subsequently divided into two groups with 3 ≥ GRWR > 3%. Patients had CT scans at three predetermined time points after OLT used for measuring the liver volume. The objective of this study is to evaluate the volumetric changes of whole large liver grafts after adult OLT. ResultsAt LT, the mean graft recipient body weight ratio (GRWR) was 3.1 ± 0.4%. The mean liver weight was 1881 ± 68 g at LT, 2014 ± 99 ml at one week, 1725 ± 126 ml at 3 months, and 1632 ± 117 (ml) at >6 months. There is an initial increase at 1 week after LT and a subsequent decrease of liver volume on later measurements. None of the late volume measurements were significantly different from the initial graft volume at liver transplant in pair wise comparisons ANOVA repeated measures (p > 0.05). Similarly, the mean GRWR did not change significantly between the initial calculation at transplantation date and the subsequent measurements during the different study time points (F = 0.04, p = 0.96) with a mean of 3.1% (95% CI = 2.2–4.2). AUC ROC discriminated a cutoff of 3% for the initial GRWR above which grafts tend to decrease in size over time (c statistics = 0.74, p = 0.036). In a Clustered ANOVA repeated measures, there was no significant difference in the changes of liver volume between both groups. However, patients with GRWR > 3 showed a trend towards a latent reduction in volume over the tracing period. There was a tendency, but none significant; towards a higher bilirubin, AST, ALT levels over the first postoperative days in recipients with GRWR > 3. ConclusionLarge grafts do not significantly decrease in size. Nonetheless, grafts weighing >3% of the GRWR show a different trend towards decrease in size over time.

Regeneration Rate of Left Liver Grafts in Adult Living Donor Liver Transplant

ObjectiveAppropriate graft weight is important in liver transplant to provide better graft regeneration and to avoid small-for-size syndrome with graft failure. Generally, to protect the donor, the left liver is always selected as the graft. The aim of this study is to evaluate the regeneration rate of the left lobe liver graft in adult living donor liver transplantation (ALDLT). Patients and MethodsThe records and preoperative and postoperative images within 6 months after liver transplantation were reviewed for 9 left and 145 right liver grafts ALDLT enrolled in this study. We calculated the graft volume at 6 months after transplantation divided by the standard liver volume as the regeneration ratio. The regeneration rate of the group with a left liver graft ALDLT was compared with our right liver graft group. ResultsThe liver graft regeneration ratio of the left lobe was 85.3 ± 11.0 (range, 61–97), slightly lower than the right liver graft (91.2 ± 12.6%; range, 58–151). In the graft-recipient body weight ratio (GRWR) > 1, the regenerative rate was slightly higher than the group of GRWR < 1. The regeneration ratio was proportional to spleen volume and portal inflow (P = .039). ConclusionEither the right or left liver graft can achieve sufficient regeneration in ALDLT. However, there was a slightly lower regeneration rate among the left liver graft and GRWR < 1 groups. Spleen size, a major factor contributing to portal inflow, may directly trigger graft regeneration after transplantation with a linear correlation in growth.

Tacrolimus dosage requirements in living donor liver transplant recipients with small-for-size grafts

To investigate the tacrolimus dosage requirements and blood concentrations in adult-to-adult right lobe living donor liver transplantation (AALDLT) recipients with small-for-size (SFS) grafts. During January 2007 and October 2008, a total of 54 cases of AALDLT with an observation period of 6 mo were enrolled in this study. The 54 patients were divided into two groups according to graft-recipient body weight ratio (GRBW): SFS grafts group (Group S, GRBW < 0.8%, n = 8) and non-SFS grafts group (Group N, GRBW > or = 0.8%, n = 46). Tacrolimus 12-hour blood levels and doses were recorded during weeks 1, 2, 3 and 4 and months 2, 3, 4, 5 and 6 in group S and group N. Meanwhile, acute rejection rates, liver and renal function test results, and the number of potentially interacting medications were determined at each interval in the two groups. A comparison of tacrolimus dosage requirements and blood levels were made weekly in the first month post-surgery, and monthly from months 2 to 6. There were no differences in the demographic characteristics, acute rejection rates, liver and renal function test results, or the number of potentially interacting medications administered between the two groups. The tacrolimus dosage requirements in group S were significantly lower than group N at 2 wk (2.8 +/- 0.4 mg/d vs 3.6 +/- 0.7 mg/d, P = 0.006), 3 wk (2.9 +/- 0.7 mg/d vs 3.9 +/- 0.8 mg/d, P = 0.008), 4 wk (2.9 +/- 0.8 mg/d vs 3.9 +/- 1.0 mg/d, P = 0.023) and 2 mo (2.8 +/- 0.7 mg/d vs 3.8 +/- 1.1 mg/d, P = 0.033). Tacrolimus 12-h trough concentrations were similar between the two groups at all times except for 2 wk post-transplantation, when the concentrations were significantly greater in group S recipients than in group N recipients (11.3 +/- 4.8 ng/mL vs 7.0 +/- 3.8 ng/mL, P = 0.026). SFS grafts recipients have significantly decreased tacrolimus dosage requirements compared with non-SFS grafts recipients in AALDLT during the first 2 mo post-surgery.

Early Postoperative Renal Dysfunction in the Adult Living Donor Liver Transplantation

Living donor liver transplantation (LDLT) is a widely accepted treatment for end-stage liver diseases. Renal dysfunction, a frequent complication after liver transplantation, has an unfavorable effect on the prognosis. Despite special characteristics of LDLT, such as small-for-size graft syndrome (SFS), the relations between graft size and postoperative renal dysfunction have not been evaluated. So we described the relevance of previously known risk factors with SFS (graft-recipient body weight ratio [GRWR] < 0.8%) and early postoperative renal dysfunction in LDLT. The study population consisted of adults who received LDLT from May 1996 to November 2005. The 284 patients who were followed to 3 months after LDLT were classified as group I ( n = 201, creatinine < 1.5 mg/dL) versus group II ( n = 83, creatinine ≥ 1.5 mg/dL). Univariate analysis showed renal dysfunction in the early postoperative period was related to preoperative total bilirubin, blood urea nitrogen, creatinine, prothrombin time level, model for end-stage liver disease (MELD) score, GRWR, presence of preoperative renal dysfunction, transfusion of packed red blood cell, fresh frozen plasma, cryoprecipitate, reoperation, and the need for renal replacement therapy (RRT). Upon multivariate analysis, MELD score, GRWR, preoperative renal dysfunction, and need for RRT were related to early postoperative renal dysfunction. In conclusion, there was a significant relationship between SFS (GRWR < 0.8) and early postoperative renal dysfunction.

Evaluation of the donor liver for living donor liver transplantation.

Key points 1. Accurate assessment of the donor liver is an important component of the living donor liver evaluation and is critical to ensure a successful outcome for both donor and recipient. 2. Liver biochemistry tests, viral hepatitis serological tests, tests to exclude chronic liver disease, and volumetric computed tomographic or magnetic resonance (MR) imaging of the liver are performed routinely as part of the donor evaluation. 3. Liver biopsy should be a standard component of the donor evaluation in all donors, with the possible exception of those with a body mass index less than 25 who have normal liver test and abdominal imaging study results and no risk factors for chronic liver disease or hepatic steatosis. 4. The maximum acceptable percentage of steatosis in the donor liver is unknown, but most centers use an upper limit of 10% to 30%. 5. A graft-recipient body weight ratio of at least 0.8% provides the recipient with adequate hepatic mass in most situations. 6. Anatomic variants in donor biliary and hepatic vascular anatomy are common. 7. Evaluation of donor vascular anatomy varies among centers and includes MR or computed tomographic angiography and hepatic angiography. 8. Evaluation of biliary anatomy is performed most commonly using intraoperative cholangiography. Some centers use MR cholangiography or endoscopic retrograde cholangiopancreatography in selected situations.

The effect of liver graft-body weight ratio on the core temperature of pediatric patients during liver transplantation

The left lateral segment of the liver from an adult living donor sometimes is relatively too large for a small pediatric recipient. It currently is unknown whether a high graft-recipient body weight ratio (GRWR) has a significant effect on core temperature during the anhepatic and reperfusion phases of living donor liver transplantation (LDLT). Seventy-two pediatric patients undergoing LDLT were divided into two groups according to body weight. Group I (GI) consisted of patients with a body weight greater than 10 kg, and group II (GII), less than 10 kg. Core temperature, measured as nasopharyngeal temperature (NT), was compared between groups at induction of anesthesia, hourly during the following 6 hours, as the lowest core temperature at the anhepatic phase, 5 and 30 minutes after reperfusion, and the last 2 hours before the end of the operation. Mild hypothermia of 35.8°C ± 0.7°C and 35.9°C ± 0.4°C for GI and GII was noted after induction of anesthesia, respectively; this increased ± 1°C in the following 6 hours. In the anhepatic and reperfusion phases, a sudden and significant decrease in NT was observed in both groups. This decrease in NT was significantly greater in GII than GI. In conclusion, a sudden decrease in core temperature was observed during the anhepatic and reperfusion phases of LDLT in pediatric patients, likely caused by placement of the cold liver graft, which is flushed with 4°C lactated Ringer's solution during vessel reconstruction, in the anhepatic phase and return of venous blood through the cold preserved liver in the reperfusion phase. Core temperatures of pediatric patients with a body weight less than 10 kg in GII, who received grafts with a high GRWR, were more affected than those in GI. ( Liver Transpl 2003;9:760-763.)

Anaesthetic management and outcome in right-lobe living liver-donor surgery.

We reviewed retrospectively the anaesthetic management and perioperative course of eight right hepatectomies for living liver donation. After preoperative psychiatric evaluation, eight ASA I-II individuals donated the right lobe of their liver to a family member. A graft-recipient body weight ratio of 0.8-1.0% was required for patient selection. Indications for liver transplantation were: hepatitis C viral-related cirrhosis in six patients; combined hepatitis C and B viral cirrhosis in one patient; multifocal hepatocellular carcinoma--four lesions, involving both liver lobes--of hepatitis C viral-related cirrhosis in another patient. Indication for adult-to-adult living-donor liver transplantation was retained in the latter because of rapid deterioration of liver disease, rare recipient's blood group and extended, unresectable hepatocellular carcinoma. Hepatitis C viral-related cirrhosis was casually the primary indication for adult-to-adult living-donor liver transplantation in this group. The condition of the donated hepatic lobe was optimized by appropriate drug and perfusion management. Preoperative investigations included: blood tests (full cell count and film, thyroid function tests, pregnancy tests, full virological tests and bacteriological cultures, and immunological typing), chest radiograph, electrocardiogram plus Doppler cardiac ultrasound, spirometry, aminopyrine breath test, liver Doppler examination, magnetic resonance imaging, angiography and cholangiography and a volumetric study of the whole liver and the right lobe. Haemoglobin and lactate concentrations, liver function tests and international normalized ratio were measured before and after operation. The volume and weight of the resected right lobe was calculated. Anaesthesia was induced with propofol 300 mL h(-1) and sufentanil 0.3 microg kg(-1) intravenously; cisatracurium, 0.15 mg kg(-1), was given to facilitate tracheal intubation. Anaesthesia was maintained during normocapnic ventilation of the lungs with oxygen 40% in air, isoflurane 1-1.5 MAC and sufentanil. Routine anaesthetic monitoring included electrocardiography, pulse oximetry, invasive blood pressure, central venous pressure, urine output, state of neuromuscular blockade and core temperature. Periods of hypotension (<80% of the preoperative blood pressure) or haemodynamic instability (requiring inotropic or vasoactive support) were registered. Total blood loss and transfusion (homologous, autologous or cell-saver blood) requirements were measured; volume replacements were derived. Data are presented as mean (range). There was no morbidity or mortality and no periods of intraoperative hypotension or haemodynamic instability. The operation time averaged 619 (525-780)min. Four donors were extubated in the operating room immediately after surgery; the others were extubated in the intensive care unit, where the mean extubation time was 16.3 (5-25)h after arrival. The estimated blood loss was 967 (550-1,600)mL. No homologous blood was administered; five donors received autologous blood, intraoperatively; three donors received a cell-saver blood transfusion. Intraoperative fluid replacement was with crystalloids, colloids and 4% albumin. Total urine output was 1,472 (700-3100)mL. Although intraoperative hypothermia occurred all subjects were normothermic at the end of operation. The pre- and immediately postoperative haemoglobin concentration averaged 13.6 (9.8-15.6) and 10.5 (6.9-13.0)gdL(-1), respectively. On the first postoperative day, the haemoglobin was 11.7 (8.4-15.1)gdL(-1). The donors' liver function tests were transiently elevated in the initial postoperative period. The intensive care unit discharge time was 2 (1-3) days. The hospital stay was 13 (7-17) days. There was no morbidity or mortality. The study demonstrates that right-lobe living-donor surgery was well tolerated, without intraoperative hypotension or haemodynamic instability, without perioperative anaesthetic or surgical complications, and with an excellent general outcome.

Anaesthetic management and outcome in right-lobe living liver-donor surgery

Background and objective: We reviewed retrospectively the anaesthetic management and perioperative course of eight right hepatectomies for living liver donation. Methods: After preoperative psychiatric evaluation, eight ASA I-II individuals donated the right lobe of their liver to a family member. A graft-recipient body weight ratio of 0.8-1.0% was required for patient selection. Indications for liver transplantation were: hepatitis C viral-related cirrhosis in six patients; combined hepatitis C and B viral cirrhosis in one patient; multifocal hepatocellular carcinoma - four lesions, involving both liver lobes - of hepatitis C viral-related cirrhosis in another patient. Indication for adult-to-adult living-donor liver transplantation was retained in the latter because of rapid deterioration of liver disease, rare recipient's blood group and extended, unresectable hepatocellular carcinoma. Hepatitis C viral-related cirrhosis was casually the primary indication for adult-to-adult living-donor liver transplantation in this group. The condition of the donated hepatic lobe was optimized by appropriate drug and perfusion management. Preoperative investigations included: blood tests (full cell count and film, thyroid function tests, pregnancy tests, full virological tests and bacteriological cultures, and immunological typing), chest radiograph, electrocardiogram plus Doppler cardiac ultrasound, spirometry, aminopyrine breath test, liver Doppler examination, magnetic resonance imaging, angiography and cholangiography and a volumetric study of the whole liver and the right lobe. Haemoglobin and lactate concentrations, liver function tests and international normalized ratio were measured before and after operation. The volume and weight of the resected right lobe was calculated. Anaesthesia was induced with propofol 300 mL h−1 and sufentanil 0.3 μg kg−1 intravenously; cisatracurium, 0.15 mg kg−1, was given to facilitate tracheal intubation. Anaesthesia was maintained during normocapnic ventilation of the lungs with oxygen 40% in air, isoflurane 1-1.5 MAC and sufentanil. Routine anaesthetic monitoring included electrocardiography, pulse oximetry, invasive blood pressure, central venous pressure, urine output, state of neuromuscular blockade and core temperature. Periods of hypotension (<80% of the preoperative blood pressure) or haemodynamic instability (requiring inotropic or vasoactive support) were registered. Total blood loss and transfusion (homologous, autologous or cell-saver blood) requirements were measured; volume replacements were derived. Results: Data are presented as mean (range). There was no morbidity or mortality and no periods of intraoperative hypotension or haemodynamic instability. The operation time averaged 619 (525-780) min. Four donors were extubated in the operating room immediately after surgery; the others were extubated in the intensive care unit, where the mean extubation time was 16.3 (5-25) h after arrival. The estimated blood loss was 967 (550-1600) mL. No homologous blood was administered; five donors received autologous blood, intraoperatively; three donors received a cell-saver blood transfusion. Intraoperative fluid replacement was with crystalloids, colloids and 4% albumin. Total urine output was 1472 (700-3100) mL. Although intraoperative hypothermia occurred all subjects were normothermic at the end of operation. The pre- and immediately post-operative haemoglobin concentration averaged 13.6 (9.8-15.6) and 10.5 (6.9-13.0) g dL−1, respectively. On the first postoperative day, the haemoglobin was 11.7 (8.4-15.1) g dL−1. The donors' liver function tests were transiently elevated in the initial postoperative period. The intensive care unit discharge time was 2 (1-3) days. The hospital stay was 13 (7-17) days. There was no morbidity or mortality. Conclusions: The study demonstrates that right-lobe living-donor surgery was well tolerated, without intraoperative hypotension or haemodynamic instability, without perioperative anaesthetic or surgical complications, and with an excellent general outcome.

Auxiliary partial orthotopic living donor liver transplantation as an aid for small-for-size grafts in larger recipients.

In countries where living donors are the only source of liver grafts, restrictions on graft size are a serious obstacle for the expansion of indications for adult recipients. To overcome this problem, auxiliary partial orthotopic liver transplants (APOLT*) was performed on the basis of the concept that the residual native liver would support the graft function until the graft had grown enough to function by itself. APOLT as an aid for small-for-size (SFS) grafts was reviewed retrospectively to evaluate its feasibility. Between April 1995 and March 1998, 20 recipients underwent APOLT, which was indicated because of a SFS graft in 15 of them. The indication was based on the estimated graft/recipient's body weight ratio (GRWR). If the ratio was <0.8%, APOLT was performed. The other 5 patients had a graft with a GRWR >0.8% and underwent APOLT on the basis of the residual native liver supporting the graft function temporarily, 4 for supplementation of the defective enzyme in metabolic liver diseases and one for leaving the potential of the regeneration of the native liver in fulminant hepatic failure. The recipients who underwent APOLT because of a SFS graft were categorized as the SFS group, and the others were the second group. In the SFS group, the age of the recipients ranged from 13 to 48 (median 23). The original indications of this group were fulminant hepatic failure in 2 recipients, acute deterioration of chronic liver diseases in 3, Wilson's disease in 2, biliary atresia in 4, primary biliary cirrhosis in 3, and primary sclerosing cholangitis (PSC) in one. The actual GRWR ranged from 0.45 to 0.72 (median 0.55). The graft was implanted after resection of the left lateral segment of the native liver. Except in the first two patients, the portal vein to the residual native liver was completely transected so that all of the portal blood drained into the graft liver. This procedure was successful in 9 patients. The cause of death in the other 6 was mainly infection. The mortality rate among the recipients with signs of advanced liver failure, such as massive ascites or hepatic coma, was higher, even though APOLT was used to support the SFS graft. In the second group, in the other five recipients who underwent APOLT for other indications, one recipient with fulminant hepatic failure died of sepsis caused by the dehiscence of bilio-enteric anastomosis. APOLT as an aid for a SFS graft is technically viable. This procedure can thus expand the indication of living donor liver transplants for adult recipients when the native liver retains some functional capability to support the grafted liver during the immediate postoperative period.