Living Donor Liver Research Articles

Frequency of Living Donors with Comorbidity for Liver Transplantation: Analysis of 337 Cases

Introduction: Living donors for liver transplantation (LT) need to be physically and mentally healthy, but donor candidates sometimes have comorbidities and are forced to evaluate the suitability as donors. We examined the frequency of comorbidities in living liver donors. Patients and methods: Of 337 living donors for LT, except 67 cases with fatty liver, we investigated the preoperative comorbidities and perioperative management in living liver donors. Results: The number of donors with comorbidity was 95 (28%: 95/337), with a median age of 35 (23-57) years, 33 males, and 62 females. Relationships with recipients were 58 mothers, 28 fathers, 2 grandmothers, 2 sons, 5 others. The graft types were 62 lateral segments, 15 left lobes, 6 left lobes with caudate, 6 monosegments, 4 right lobes, and 2 posterior segments. A total of 107 comorbidities was recognized in 95 donors. Twenty-two cases with hepatic comorbidity were positive HBc antibodies, hepatic hemangiomas, drug-induced liver injuries, liver hamartoma, and congenital portosystemic shunt. Extrahepatic comorbidities were plasminogen disorder, obstructive respiratory disorder, lipid metabolism disorder, coagulation factor deficiency, iron deficiency anemia, hypertension, pollinosis, thyroid disease, menstrual abnormalities, postoperative gastrointestinal cancer, metabolic disease, benign ovarian tumor, arrhythmia, pregnancy, and others. We consulted with the department specializing in the comorbidity and closely performed preoperative evaluation and perioperative management according to each comorbidity. No case of complications due to each comorbidity was found. Conclusion: It is important to fully evaluate and determine the suitability of living donor candidates with comorbidities in collaboration with other departments.

Fibroprogression and cirrhosis in living liver donors

Background and Aim: Living liver donation has served to bridge the gap between transplant waitlist and dead donation rate. The current study is done to assess the prevalence of non alcoholic fatty liver disease and to non invasively assess liver health in living liver donors using sonologic evaluation for steatosis, inflammation and fibrosis.

Variations in the Origin of Middle Hepatic Artery in Living Liver Donors using CT Angiography in South Indian Population: A Retrospective Study

Variations in the Origin of Middle Hepatic Artery in Living Liver Donors using CT Angiography in South Indian Population: A Retrospective Study

Is Remnant Liver Volume Ratio Less than 30% Still Contraindication to Right Hepatectomy for Living Liver Donor?

Introduction: The evidence for defining a safe remnant/total volume ratio(RTVR) for in living donor ight hepatectomy (LDRH) for living donor liver transplantation (LDLT) is still not clear. The current practice of arbitrarily requiring an RTVR of at least 30% is based on the experience of early studies to keep donor safety. Herein, we describe our center’s experience for LDRH with RTVR < 30% and evaluate the outcomes of living donors with RTVR < 30%.

Assessment of Hepatic Steatosis Using Clinical and Laboratory Parameters with Computed Tomography Comparison in Living Liver Donor Candidates

Assessment of Hepatic Steatosis Using Clinical and Laboratory Parameters with Computed Tomography Comparison in Living Liver Donor Candidates

Left Lateral and Left Lobe Living Related Liver Donor Recovery Is a Safe Procedure with a Low Complication Rate

Introduction: Living donor liver transplantation (LDLT) is accepted worldwide. Living liver donors comprise of a super-selection of healthy individuals. Surgery remains complex and the technique is very demanding. Surgeons highest priority is to minimize operational risk and complication rate. It is believed that donors following left lateral or left lobe liver recovery for LDLT should be free of peri-operative complications.

Role of saroglitazar in potential live liver donors with mild to moderate hepatic steatosis on initial non-enhanced computed tomography of liver

Background and Aim: Live donor liver transplantations account for more than 95% of liver transplantations in our institute. A population-based study in Kerala showed the prevalence of NAFLD in the general population to be 49.8%. Its reflected in our transplant program, with > 10% hepatic steatosis being the most common reason for rejection as liver donors. We aimed to assess the efficacy and safety of Saroglitazar (PPAR agonist) in potential live liver donors with >10% hepatic steatosis as evidenced by a non-enhanced CT liver.

Practices and Perceptions of Living Donor Liver Transplantation, Nondirected Donation, and Liver Paired Exchange: A National Survey.

Living donor liver transplantation (LDLT) remains underutilized in the United States. Barriers to LDLT and acceptance of nondirected living liver donation (ND-LLD) and liver paired exchange (LPE) are unclear. The medical and surgical directors of 99 unique transplantation programs (56 LDLT programs and 43 non-LDLT programs) were surveyed to gain insight into perceptions and practices of LDLT and types of donors utilized. The response rate was 84%. Most LDLT programs (65%) reported performing ND-LLD, though opinions regarding allocation and the need for additional evaluation of these donors were mixed. Only a minority of LDLT programs reported performing LPE (12%), but most programs (78%) would be open to cross-institutional LPE barring logistical barriers. There were significant differences between LDLT and non-LDLT programs with regard to perceived barriers to LDLT, with LDLT programs reporting mainly donor and recipient factors and non-LDLT programs reporting institutional factors (P<0.001). Understanding perceptions and practices of LDLT, ND-LLD, and LPE is important to aid in the growth of LDLT.

Anonymous Nondirected Living Liver Donation in the United States.

Anonymous Nondirected Living Liver Donation in the United States.

Anonymous living liver donor perspectives on the role of family in their donation experience.

Anonymous living organ donation is an understudied but rapidly expanding sector in organ transplantation, in which donors choose to donate anonymously to a recipient in need. The family members and close support network of living donors often play a crucial role in the donation process, and their influence likely has a large impact on the decision to donate as well as the donor's physical and psychosocial state. However, there is limited data examining the impact donor families have on the anonymous donor, and in turn, the impact donation has on donors' families. To assess this, we analyzed a semi-structured qualitative interview on living donor experiences with 26 anonymous living liver donors for common themes concerning donor families. Responses surrounding donor families were grouped into three major categories: (1) family reactions to donation, ranging from (a) pride/support, (b) fear/worry, and (c) jealousy/anger; (2) the impact of donation on donor-family relationships, including (a) positive impacts, (b) negative impacts, (c) a positive ripple effect; (3) gaps in institutional support for donor families. This study provides unique information on anonymous living liver donor perceptions related to their families and will help improve existing programs to accommodate donor family needs and cater to donor relationships.

Noninvasive Risk Stratification for Nonalcoholic Fatty Liver Disease Among Living Liver Donor Candidates: A Proposed Algorithm.

To reduce waitlist mortality, living donor liver transplantation (LDLT) has increased over the past decade in the United States, but not at a rate sufficient to completely mitigate organ shortage. As a result, there are ongoing efforts to expand the living liver donor pool. Simultaneously, the prevalence of nonalcoholic fatty liver disease (NAFLD) in the general population has increased, which has significant implications on the pool of potential living liver donors. As such, a clinical assessment algorithm that exhaustively evaluates for NAFLD and fibrosis is critical to the safe expansion of LDLT. An ideal algorithm would employ safe and noninvasive methods, relying on liver biopsy only when necessary. While exclusion of NAFLD and fibrosis by noninvasive means is widely studied within the general population, there are no well-accepted guidelines for evaluation of living donors using these modalities. Here we review the current literature regarding noninvasive NALFD and fibrosis evaluation and propose a potential algorithm to apply these modalities for the selection of living liver donors.

The Audiovisual Creation in Educational Proposals on Organ Donation: Attitude Towards Organ Donation and Transplantation of Secondary School Teachers

Audiovisual creation allows teachers and students to become consumers and producers of information, creating collaborative environments. In the field of organ donation and transplantation (ODT), most of the educational proposals analyzed to date consist of presentations. The teacher does not usually have a decisive role in this type of methodologies, in addition to not having the appropriate training to be able to participate actively. To analyze the change in teachers' attitudes towards ODT after participating in an educational proposal based on the creation of short films. Teachers of secondary education in ten schools in southeastern Spain. The proposal consisted in the creation of short films based on topics related to ODT by the students. A validated ODT attitude form was administered to teachers at the beginning of the proposal and at the end of the proposal. A descriptive analysis was carried out together with McNemar test was used to compare the pre and post test results of the teacher. P < .05 was considered statiscally significant. The favorable attitude towards organ donation at death increased after the proposal (64% vs 88%; P = .008). Favorable attitude towards organ donation from a relative also improved (52% vs 76%; P = .008), as did favorable attitude towards living kidney donation (52% vs 88%; P < .001), living liver donation (36% vs 85%; P = .008) and xenotransplantation (45% vs 82%; P < .001). The teachers improves after an educational proposal based on the creation of short films related to ODT.

Pure Laparoscopic vs. Open Right Hepatectomy in Living Liver Donors: Bench-Surgery Time.

Background: Recently, there have been several reports on pure laparoscopic donor right hepatectomy (PLDRH), but the effect of pure laparoscopy on bench surgery has not been evaluated. This study aimed to compare bench-surgery time between PLDRH and conventional donor right hepatectomy (CDRH).Methods: We retrospectively reviewed the medical records of 758 live liver donors between January 2012 and December 2019. We divided the patients into two groups: between January 2012 and September 2015, when we exclusively performed CDRH, and between March 2016 and December 2019, when PLDRH was standardized. We excluded all other types of graft donor hepatectomy, laparoscopic assisted donor hepatectomy, and cases with no recorded data.Results: In total, 267 donors were included in the PLDRH group and were compared with 247 donors in the CDRH group. Similar proportions of graft vascular variations were observed between the two groups. The mean bench-surgery time was longer in the PLDRH group than in the CDRH group (49.3 ± 19.9 vs. 39.5 ± 17.5 min; P < 0.001).Conclusion: The bench-surgery time was longer in the PLDRH group than the CDRH group, regardless of whether the vascular network was reconstructed. Expertise in bench-surgery as well as donor surgery and recipient surgery is mandatory for PLDRH to be safe and feasible.

Artificial intelligence enhances the accuracy of portal and hepatic vein extraction in computed tomography for virtual hepatectomy.

Current conventional algorithms used for 3-dimensional simulation in virtual hepatectomy still have difficulties distinguishing the portal vein (PV) and hepatic vein (HV). The accuracy of these algorithms was compared with a new deep-learning based algorithm (DLA) using artificial intelligence. A total of 110 living liver donor candidates until 2017, and 46 donor candidates until 2019 were allocated to the training group and validation groups for the DLA, respectively. All PV or HV branches were labeled based on Couinaud's segment classification and the Brisbane 2000 Terminology by hepato-biliary surgeons. Misclassified and missing branches were compared between a conventional tracking-based algorithm (TA) and DLA in the validation group. The sensitivity, specificity, and Dice coefficient for the PV were 0.58, 0.98, and 0.69 using the TA; and 0.84, 0.97, and 0.90 using the DLA (P<.001, excluding specificity); and for the HV, 0.81, 087, and 0.83 using the TA; and 0.93, 0.94 and 0.94 using the DLA (P<.001 to P=.001). The DLA exhibited greater accuracy than the TA. Compared with the TA, artificial intelligence enhanced the accuracy of extraction of the PV and HVs in computed tomography.

Immunologic benefits of maternal living donor allografts in pediatric liver transplantation: fewer rejection episodes and no evidence of de novo allosensitization.

Pediatric liver transplant (LT) recipients of maternal living liver donor (LLD) grafts have been reported to experience fewer rejection episodes. However, it is unclear whether this benefit translates to reduction in developing donor-specific antibody (DSA) among maternal-LLD recipients. The aim of this study was to compare immunologic outcomes among maternal-LLD, non-maternal-LLD, and deceased donor liver transplant (DDLT) recipients. Children (≤18years) who underwent LT between 1/1998 and 12/2019 at two high-volume LT centers in North America were evaluated. Patients were divided into three groups by type of graft received (maternal-LLD, non-maternal LLD, and DDLT). Clinical variables and outcomes were compared according to each graft type. A total of 450 pediatric primary LT were analyzed: 275 (61.1%) DDLT, 73 (16.2%) maternal-LLD, and 102 (22.6%) non-maternal-LLD. Children receiving LLD grafts were less likely to develop rejection when compared to the DDLT group (DDLT 46.9% vs. maternal-LLD 31.5% vs. non-maternal-LLD 28.4%, p=0.001). There was no difference in rejection rates between maternal and non-maternal-LLD recipients. A higher percentage of maternal-LLD recipients were on immunosuppression monotherapy compared to non-maternal-LLD and DDLT recipients (6.7% vs. 1.2 vs. 2.4%, respectively). A subgroup of 68 patients were tested for DSA post-LT. Maternal-LLD recipients were less likely to develop de novo DSA (maternal-LLD 11.8% vs. non-maternal-LLD 19.3% vs. DDLT 43%, p=0.018). None of the maternal-LLD recipients developed antibody-mediated rejection. These data support the concept of immunologic benefit of maternal-LLD in pediatric LT, with lower rates of rejection and allosensitization post-LT when compared to DDLT recipients.

Clinical liver transplant tolerance: Recent topics.

Immunosuppression is essential after organ transplantation to prevent severe graft injury due to rejection, but in long-term, transplanted organs are generally accepted with minimal dose of immunosuppression, and adverse effects of it such as renal dysfunction, diabetes and development of malignancies might become to exceed over the benefits in majority of the cases. Accordingly, to achieve the immunologic tolerance has been the ultimate goal in organ transplantation, and the liver has been well recognized as the tolerogenic organ compared to other organs. We referred the reported studies showing the actual protocol to achieve the immunologic tolerance after clinical liver transplantation. Actually, two main procedures as "elective weaning of immunosuppression" and/or "cell therapy" using various immune-related cells have been introduced to induce the immunologic tolerance in clinical liver transplantation. The cell therapy, especially using regulatory T-cell has been reported to achieve definitive immunologic tolerance in living donor liver transplantation. Although it is still developing, the induction of immunologic tolerance in clinical liver transplantation is realistic. Herein, the current topics of immunologic tolerance in liver transplantation is described.

Outcomes of living liver donors are worse than those of matched healthy controls

Donor death is the most serious complication of living liver donation but is reported rarely. We investigated the actual mortality of living liver donors (LLDs) compared with matched control groups based on analysis of the Korean National Health Insurance Services (NHIS) database. This cohort study included 12,372 LLDs who donated a liver graft between 2002 and 2018, and were registered in the Korean Network for Organ Sharing. They were compared to 3 matched control groups selected from the Korean NHIS and comprising a total of 123,710 individuals: healthy population (Group I); general population without comorbidities (Group II); and general population with comorbidities (Group III). In this population, 78.5% of living liver donors were 20-39 years old, and 64.7% of all donors were male. Eighty-nine donors (0.7%) in the LLD group died (68 males and 21 females), a mortality rate (/1,000 person-years) of 0.91 (0.74-1.12). Mortality rate ratio and the adjusted hazard ratio of the LLD group was 2.03 (1.61-2.55) and 1.71 (1.31-2.25) compared to Control Group I, 0.75 (0.60-0.93) and 0.63 (0.49-0.82) compared to Control Group II, and 0.58 (0.46-0.71) and 0.49 (0.39-0.60) compared to Control Group III. LLD group, depression, and lower income were risk factors for adjusted mortality. The incidence of liver failure, depression, cancer, diabetes, hypertension, brain infarction, brain hemorrhage, and end-stage renal disease in the LLD group was significantly higher than in Control Group I. Outcomes of the LLD group were worse than those of the matched healthy control group despite the small number of deaths and medical morbidities in this group. LLDs should receive careful medical attention for an extended period after donation. The incidence of mortality, liver failure, depression, cancer, diabetes, hypertension, brain infarction, brain hemorrhage, and end-stage renal disease in the living liver donor group was significantly higher than in the matched healthy group. Careful donor evaluation and selection processes can improve donor safety and enable safe living donor liver transplantation.

Circuitous Path to Live Donor Liver Transplantation from the Coordinator's Perspective.

Background: The live donor liver transplantation (LDLT) process is circuitous and requires a considerable amount of coordination and matching in multiple aspects that the literature does not completely address. From the coordinators’ perspective, we systematically analyzed the time and risk factors associated with interruptions in the LDLT process. Methods: In this retrospective single center study, we reviewed the medical records of wait-listed hospitalized patients and potential live donors who arrived for evaluation. We analyzed several characteristics of transplant candidates, including landmark time points of accompanied live donation evaluation processes, time of eventual LDLT, and root causes of not implementing LDLT. Results: From January 2014 to January 2021, 417 patients (342 adults and 75 pediatric patients) were enrolled, of which 331 (79.4%) patients completed the live donor evaluation process, and 205 (49.2%) received LDLT. The median time from being wait-listed to the appearance of a potential live donor was 19.0 (interquartile range 4.0–58.0) days, and the median time from the appearance of the donor to an LDLT or a deceased donor liver transplantation was 68.0 (28.0–188.0) days. The 1-year mortality rate for patients on the waiting list was 34.3%. Presence of hepatitis B virus, encephalopathy, and hypertension as well as increased total bilirubin were risk factors associated with not implementing LDLT, and biliary atresia was a positive predictor. The primary barriers to LDLT were a patient’s critical illness, donor’s physical conditions, motivation for live donation, and stable condition while on the waiting list. Conclusions: Transplant candidates with potential live liver donors do not necessarily receive LDLT. The process requires time, and the most common reason for LDLT failure was critical diseases. Aggressive medical support and tailored management policies for these transplantable patients might help reduce their loss during the process.

Randomized control trial on perioperative antibiotic prophylaxis in live liver donors: Are three doses enough?

The duration of perioperative antibiotic prophylaxis following live liver donor hepatectomy (LDH) is not known. This is a double-blind equivalence trial. All consecutive LDH were randomized into: group A (three doses) and group B (nine doses) of perioperative antibiotics (piperacillin+tazobactam-4.5g intravenous) at fixed 8hourly intervals. Primary end point was incidence of infective complications as per CDC (Centers for Disease Control and Prevention) criteria. Secondary end points were liver function tests, total leukocyte count, international normalized ratio, hospital stay, morbidity, and cost analysis. One hundred and twenty-six LDHs were enrolled. A total of 19.8% (n=25) experienced postoperative complications, 11 (17.7%) in group A and 14 (21.9%) in group B (P=.561). Infective complications were seen in 11 donors (8.1%), five in group A and six in group B (P=.79). A total of 8.1% of donors required continuation/up-gradation of antibiotics in group A and 9.4% in group B. Return to soft diet was delayed in group B (P=.039). Median hospital stay and cost were similar. Three doses of perioperative antibiotic are equally effective in preventing infective complications.

Long-term Outcomes of Pediatric Living Versus Deceased Donor Liver Transplantation Recipients: A Systematic Review and Meta-analysis.

Living donor liver transplantation (LDLT) emerged in the 1980s as a viable alternative to scarce cadaveric organs for pediatric patients. However, pediatric waitlist mortality remains high. Long-term outcomes of living and deceased donor liver transplantation (DDLT) are inconsistently described in the literature. Our aim was to systematically review the safety and efficacy of LDLT after 1 year of transplantation among pediatric patients with all causes of liver failure. We searched the MEDLINE, Medline-in-Process, MEDLINE Epub Ahead of Print, Embase + Embase Classic (OvidSP), and Cochrane (Wiley) from February 1, 1947 to February 26, 2020, without language restrictions. The primary outcomes were patient and graft survival beyond 1 year following transplantation. A meta-analysis of unadjusted and adjusted odds and hazard ratios was performed using a random-effects model. A total of 24 studies with 3677 patients who underwent LDLT and 9098 patients who underwent DDLT were included for analysis. In patients with chronic or combined chronic liver failure and acute liver failure (ALF), 1-year (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.53-0.88), 3-year (OR, 0.73; 95% CI, 0.61-0.89), 5-year (OR, 0.71; 95% CI, 0.57-0.89), and 10-year (OR, 0.42; 95% CI, 0.18-1.00) patient and 1-year (OR, 0.50; 95% CI, 0.35-0.70), 3-year (OR, 0.55; 95% CI, 0.37-0.83), 5-year (OR, 0.5; 95% CI, 0.32-0.76), and 10-year (OR, 0.26; 95% CI, 0.14-0.49) graft survival were consistently better in LDLT recipients compared with those in DDLT recipients. In patients with ALF, no difference was seen between the 2 groups except for 5-year patient survival (OR, 0.60; 95% CI, 0.38-0.95), which favored LDLT. Sensitivity analysis by era showed improved survival in the most recent cohort of patients, consistent with the well-described learning curve for the LDLT technique. LDLT provides superior patient and graft survival outcomes relative to DDLT in pediatric patients with chronic liver failure and ALF. More resources may be needed to develop infrastructures and health care systems to support living liver donation.