Living Donor Liver Retransplantation Research Articles

Liver Retransplantation Using Living Donor Grafts: A Feasible Approach for Chronic Allograft Failure.

The indication of living donor liver retransplantation (re-LDLT) for retransplant candidates with chronic allograft failure (CAF) is increasing because of the high mortality rate of patients on the waiting list. However, evidence supporting re-LDLT for CAF remains scarce because of technical difficulties. We aimed to examine the feasibility based on our significant case experience. A total of 95 retransplant cases (adult: 53, pediatric: 42) between 2000 and 2020 were retrospectively reviewed. Graft survival after re-LDLT and deceased donor liver retransplantation (re-DDLT) was compared among recipients with CAF and acute allograft failure (AAF). Re-LDLTs for CAF were performed in 58 (61.1%) cases, re-DDLTs for CAF in 16 (16.8%) cases, re-LDLTs for AAF in 13 (13.7%) cases, and re-DDLTs for AAF in 8 (8.4%) cases. Re-DDLTs have become increasingly prevalent over time. Retransplantation for AAF results in lower graft survival than that for CAF in both adult and pediatric cases. All adult recipients who underwent re-LDLT for AAF died within 1 y after retransplantation. The 5-y graft survival between re-LDLT and re-DDLT for CAF was not significantly different (73.8% versus 75.0%, P = 0.84). Operation time and blood loss were not significantly different. The survival rate of re-LDLT for recipients with CAF is permissible. Re-LDLT may be another treatment option for recipients with CAF.

A single center analysis of long-term outcomes and survival related risk factors in liver retransplantation.

Liver retransplant is the only option to save a patient with liver graft failure. However, it is controversial due to its poor survival outcome compared to primary transplantation. Insufficient deceased organ donation in Taiwan leads to high waitlist mortality. Hence, living-donor grafts offer a valuable alternative for retransplantation. This study aims to analyze the single center's outcome in living donor liver retransplantation (re-LDLT) and deceased donor liver retransplantation (re-DDLT) as well as the survival related confounding risk factors. This is a single center retrospective study including 32 adults who underwent liver retransplantation (re-LT) from June 2002 to April 2020. The cohort was divided into a re-LDLT and a re-DDLT group and survival outcomes were analyzed. Patient outcomes over different periods, the effect of timing on survival, and multivariate analysis for risk factors were also demonstrated. Of the 32 retransplantations, the re-LDLT group (n=11) received grafts from younger donors (31.3 vs. 43.75 years, P=0.016), with lower graft weights (688 vs. 1,457.2 g, P<0.001) and shorter cold ischemia time (CIT) (45 vs. 313 min, P<0.001). The 5-year survival was significantly better in the re-LDLT group than in the re-DDLT group (100% vs. 70.8%, P=0.02). This difference was adjusted when only retransplantation after 2010 was analyzed. Further analysis showed that the timing of retransplantation (early vs. late) did not affect patient survival. Multivariate analysis revealed that prolonged warm ischemia time (WIT) and intraoperative blood transfusion were related to poor long-term survival. Retransplantation with living donor graft demonstrated good long-term outcomes with acceptable complications to both recipient and donor. It may serve as a choice in areas lacking deceased donors. The timing of retransplantation did not affect the long-term survival. Further effort should be made to reduce WIT and massive blood transfusion as they contributed to poor survival after retransplantation.

Comparing the Outcomes of Deceased-Donor and Living-Donor Liver Re-Transplantation In Adult Patients

Patients with liver graft failures have an extremely low chance of finding a cadaveric graft in countries with a scarcity of deceased donors. We compared the outcomes of liver re-transplantation with living-donor liver grafts (re-LDLT) and deceased-donor liver grafts (re-DDLT) in adult patients (>18 years). The medical records of 1513 (1417 [93.6%] LDLT and 96 [6.3%] DDLT) patients who underwent liver transplantation at Memorial Hospital between January 2011 and October 2022 were reviewed. Forty patients (24 adults and 16 pediatric) were re-transplanted (2.84%); 24 adult patients (2.72%: 25 re-LDLT, 1 patient with second re-LDLT) were divided into 2 groups: re-DDLT (n=6) and re-LDLT (n=18). The groups were compared in demographics, pre-, peri-, postoperative characteristics, and outcomes. The overall survival rates were 91.7%, 79.2%, 75.0%, and 75% for <30 days, 31 to 90 days, 1, and 3 years, respectively. The LDLT group was significantly younger (P=.022), had smaller graft weight (P=.03), shorter mechanical ventilation (P=.036) but longer operation time (P=.019), and hospitalization period (P=.003). The groups were otherwise comparable. There was no statistically significant difference in survival rates between the groups (P=.058), although the re-LDLT group had an evidently higher survival rate (88.9% and 83.3 % vs 50.0%). Re-LDLT has shown comparable outcomes to re-DDLT, if not better (even not far from significance P=.058). These results may encourage performing re-LDLTs in patients with indications for re-LT without worrying about low chances of survival, especially in countries with limited sources of deceased donors.

Emergency, ABO-Incompatible Living Donor Liver Re-Transplantation for Graft Failure Complicated by Pneumonia-Associated Sepsis.

Although liver re-transplantation is the only therapeutic option for acute and chronic graft failure, few studies have addressed the use of ABO-incompatible living donors in the emergency setting. Here, based on our experience, we report a successful case of emergency, ABO-incompatible, adult-to-adult, living donor liver re-transplantation (LDLT) for late graft failure from chronic rejection complicated by pneumonia-related sepsis. A fifty-five-year-old man had undergone LDLT for hepatocellular carcinoma accompanied by hepatitis C virus (HCV)-related cirrhosis in 30 September 2013. The voluntary donor was his 56-year-old wife, who was also a carrier of HCV. The donor and recipient blood types were the same: O and Rh positive. She underwent a right hepatectomy and was discharged on postoperative day (POD) seven. The patient was also discharged without complications on POD eleven and was followed up with on an outpatient basis. Abdominal distension and jaundice were developed at 6 months after LDLT, when the serum total bilirubin level was 2.7 mg/dL. The serum total bilirubin levels increased rapidly to 22.9 mg/dL over the next 4 months. Chronic rejection was diagnosed via liver biopsy. On 3 October 2014, he developed pneumonia-related sepsis and showed the progressive deterioration of liver function. Liver re-transplantation using the right liver from his ABO-incompatible, 20-year-old nephew was performed as an emergency in 15 October 2014. The donor blood type was A and Rh positive. The resection of the failed graft and the implantation of a new graft was performed by the intragraft dissection technique to re-use previously transplanted graft vessels in order to cope with severe adhesions. The recipient went through a gradual recovery process and was finally discharged on POD 50 with normal liver function, while the donor had an uneventful recovery and was discharged on POD 7. Biloma due to bile leak was detected three months after re-transplantation and was cured by percutaneous interventional procedures. Since then, the postoperative course has been event-free at regular outpatient follow-ups. The patient has so far had normal laboratory findings and no signs of complications. It has been 98 months since the re-transplantation, and the recipient and two donors are still in good condition with normal liver function, having complete satisfaction with the results obtained from this re-transplantation. In conclusion, long-term, satisfactory outcomes can be achieved in emergency, ABO-incompatible, adult-to-adult, living donor liver re-transplantation for graft failure complicated by pneumonia-related sepsis in selected patients.

Living-donor Liver Retransplantation Using the Vessels of the Previous Allograft by Means of Intragraft Dissection

Retransplantation with the use of a living-donor graft can be the only therapeutic option for patients with irreversible graft failure, especially in regions with limited access to deceased donors, but it can be technically demanding because of severe adhesion around the hepatic hilum and inferior vena cava. We introduce an effective and safe technique to overcome this challenge for right-lobe living-donor liver retransplantation by using the vessels of the previous right liver allograft with the use of intragraft dissection. The technique was used in 2 critically ill patients undergoing the graft failure. The operative times were 360 and 410 minutes. The recipients were discharged on days 18 and 25 with normal liver function. One postoperative complication occurred 3 months after retransplantation: biliary leakage, corrected with the use of percutaneous transhepatic biliary drainage. Both patients were alive with a functioning allograft at last follow-up of >3 years. Intragraft dissection to use the vessels of the previous right-liver allograft can be a useful technique and should be considered for right-lobe living-donor liver retransplantation.

Comparable short- and long-term outcomes in deceased-donor and living-donor liver retransplantation.

There is a big controversy over liver retransplantation, the only life-saving treatment for patients with a failing or failed liver graft. This retrospective study tried to determine if living-donor liver retransplantation (re-LDLT) is a justifiable alternative to deceased-donor liver retransplantation (re-DDLT). Anonymous data of liver transplant patients from January 2000 to April 2016 were reviewed. Recipients of retransplantation were divided into the re-DDLT and re-LDLT groups. The groups were compared in demographic characteristics, pre-retransplant and intraoperative details, and short- and long-term outcomes. Risk for living donors was examined. Twenty-nine patients had 33 re-DDLTs and 15 patients received re-LDLT. The re-LDLT group had lighter grafts (525 vs. 1295g, p≤0.001), a smaller ratio of graft weight to recipient standard liver volume (56.98 vs. 107.7%, p≤0.001), and shorter cold ischemia (106 vs. 451min, p≤0.001). The groups were otherwise comparable. Two patients in the re-DDLT group had Grade-5 complication. The groups were similar in patient survival (p=0.326) and graft survival (p=0.102). No living donors died, but three of them developed Grade-1 complications. With the required expertise, re-LDLT can produce results comparable to those of re-DDLT while keeping donor risk at bay. In places where the demand for deceased-donor liver grafts far outstrips supply, re-LDLT can be considered as an alternative to re-DDLT if the expertise is available and if the potential recipient benefits can balance out the potential donor risks.

Successful living-donor liver retransplantation by retroperitoneal end-to-end portal vein grafting using recipient's internal jugular vein graft for a patient with portal vein thrombosis

Successful living-donor liver retransplantation by retroperitoneal end-to-end portal vein grafting using recipient's internal jugular vein graft for a patient with portal vein thrombosis

Pediatric liver retransplantation from living donors can be considered as a therapeutic option for patients with irreversible living donor graft failure

Liver retransplantation (re-LT) is required in patients with irreversible graft failure, but it is a significant issue that remains medically, ethically, and economically controversial, especially in living donor liver transplantation (LDLT). The aim of this study was to evaluate the outcome, morbidity, mortality, safety and prognostic factors to improve the outcome of pediatric living donor liver retransplantation (re-LDLT). Six of 172 children that underwent LDLT between January 2001 and March 2010 received a re-LDLT and one received a second re-LDLT. The overall re-LDLT rate was 3.5%. All candidates had re-LDLT after the initial LDLT. The overall actuarial survival of these patients was 83.3% and 83.3% at one and five yr, respectively. These rates are significantly worse than the rates of pediatric first LDLT. Vascular complications occurred in four patients and were successfully treated by interventional radiologic therapy. There were no post-operative biliary complications. One case expired because of hemophagocytic syndrome after re-LDLT. Although pediatric re-LDLT is medically, ethically, and economically controversial, it is a feasible option and should be offered to children with irreversible graft failure. Further investigations, including multicenter studies, are therefore essential to identify any prognostic factors that may improve the present poor outcome after re-LDLT.

Retransplantation for End-Stage Liver Disease: A Single-Center Asian Experience

Liver retransplantation carries a significantly higher morbidity and mortality compared with patients after single transplantations. The aim of this study was to review our outcomes in liver retransplantations. From February 1984 to February 2007, 409 liver transplantations were performed on 396 patients, including 13 retransplantations (3.2%) in 12 patients. The mean follow-up was 1.6 ± 0.4 years (range, 0.1–5.2). The mean duration between the first and the second transplantation was 2.8 ± 1.0 years (range, 15 days–11.6 years). The indications for the first liver transplantation included biliary atresia (n = 3), hepatitis B virus (HBV)–related cirrhosis with hepatoma (n = 3), fulminant hepatic failure (n = 2), HBV-related end-stage liver disease (n = 1), hepatitis C virus (HCV)–related end-stage liver disease (n = 1), neonatal hepatitis (n = 1), and glycogen storage disease (n = 1). The indications for retransplantations were secondary biliary cirrhosis (n = 3), veno-occlusive disease–related liver failure (n = 2), hepatic arterial occlusion and graft failure (n = 2), chronic rejection with hepatic graft failure (n = 2), recurrent HBV (n = 1) and de novo HBV-related decompensated cirrhosis (n = 1), and idiopathic graft failure (n = 1). There were 4 living donor and 9 deceased donor liver retransplantations. The cumulative survival rate was 71.4 ± 14.4%, with an estimated mean survival time of 3.9 ± 0.7 years. Our results showed that minimizing the rate of retransplantation was critical to enhance overall patient survival. Moreover, living donor liver retransplantation is another option within the short, yet critical, waiting period, after failure of the first graft. Provided that a suitable living donor is available, we recommend early retransplantation to minimize the risk of morbidity and mortality.