Living Donor Liver Transplantation Program Research Articles

Exploring Anesthesiology Management of Living Donor Liver Transplantation: Survey From the Society for the Advancement of Transplant Anesthesia and the Korean Society for Transplantation Anesthesiologists.

While living donor liver transplantation (LDLT) serves as the predominant method of adult liver transplant (LT) in the Republic of Korea (ROK), it represents a minority of LT in the United States (US). A survey was conducted to gain insight into these nations' anesthetic management. An electronic questionnaire was distributed to directors of LT anesthesiology overseeing LDLT programs in both countries between May 2021 and October 2021. The response rate was 93.0% (100% [37/37] in the US and 80% [16/20] in the ROK). Both countries mainly adhered to deceased donor LT recipient management practices, including the frequency of routine pulmonary artery catheter use, transesophageal echocardiography, and point-of-care coagulation monitoring. Differences were observed in early extubation of recipients (US vs. ROK: 39.7%vs. 14.7% of all cases), participation in donor selection meetings (88.9% [32/36] vs. 6.3% [1/16], p < 0.0001), application of the Enhanced Recovery After Surgery donor protocol (69.4% [25/36] vs. 12.5% [2/16], p < 0.0001), and cell saver usage for donors (94.4% [34/36] vs. 18.8% [3/16], p < 0.0001). More ROK programs implemented simultaneous donor/recipient anesthesia supervision by a single anesthesiologist. Several important differences were identified between the US and the ROK in adult LDLT anesthetic management.

Benefits of liver transplant in critically ill patients with acute-on-chronic liver failure: Implementation of an urgent living-donor program

We evaluated the liver transplantation (LT) criteria in acute-on-chronic liver failure (ACLF), incorporating an urgent living-donor LT (LDLT) program. Critically ill patients with a Chronic Liver Failure Consortium (CLIF-C) ACLF score (CLIF-C_ACLF_score) ≥65, previously considered unsuitable for LT, were included to explore the excess mortality threshold of the CLIF-C_ACLF_score (CLIF-C_ACLF_score_threshold). We followed 854 consecutive patients with ACLF (276 ACLF grade 2 and 215 ACLF grade 3) over 10 years among 4432 LT recipients between 2008 and 2019. For advanced ACLF patients without immediate deceased-donor (DD) allocation, an urgent LDLT program was expedited. The CLIF-C_ACLF_score_threshold was determined by the metrics of transplant survival benefit: >60% 1-year and >50% 5-year survival rate. In predicting post-LT mortality, the CLIF-C_ACLF_score outperformed the (model for end-stage liver disease-sodium) MELD-Na and (model for end-stage liver disease) MELD-3.0 scores but was comparable to the Sundaram ACLF-LT-mortality score. A CLIF-C_ACLF_score ≥65 (n = 54) demonstrated posttransplant survival benefits, with 1-year and 5-year survival rates of 66.7% and 50.4% (P < .001), respectively. Novel CLIF-C_ACLF_score_threshold for 1-year and 5-year mortalities was 70 and 69, respectively. A CLIF-C_ACLF_score-based nomogram for predicting survival probabilities, integrating cardiovascular disease, diabetes, and donor type (LDLT vs DDLT), was generated. This study suggests reconsidering the criteria for unsuitable LT with a CLIF-C_ACLF_score ≥65. Implementing a timely salvage LT strategy, and incorporating urgent LDLT, can enhance survival rates.

Implementation of a living donor liver transplantation program in the Republic of Uzbekistan: a report of the first 40 cases.

Living donor liver transplantation (LDLT) is an effective treatment for patients with end-stage liver disease. This study was performed to evaluate the outcomes of the initial series of LDLT procedures performed in the Republic of Uzbekistan and to demonstrate that liver transplantation is viable under the conditions in this country. Between October 2021 and December 2023, we performed 40 LDLTs. We evaluated both immediate and long-term outcomes. Thrombosis of the hepatic artery developed in one case (2.5%). Arterial anastomotic stenoses were diagnosed in three cases (7.5%) and were successfully treated with endovascular balloon vasodilation. Splenic artery steal syndrome arose in three patients (7.5%) and was managed with endovascular embolization of the splenic artery. One patient (2.5%) developed portal vein thrombosis. Portal vein stenosis occurred in two patients (5%) at 10 months posttransplantation and was addressed with endovascular balloon angioplasty, yielding good clinical outcomes. Biliary complications were observed in 45% of the cases, with bile leakages accounting for 89% of these issues and strictures of the biliary anastomoses for 11%. The in-hospital mortality rate was 12.5%. Our research findings and analysis of complications align with the international literature, and the results are deemed acceptable during this implementation phase of the liver transplantation program. Accordingly, liver transplantation is feasible in the Republic of Uzbekistan; however, improvements in surgical and therapeutic methods are necessary to minimize the development of both early and late postoperative complications.

Analysis of donor morbidity in 177 donor hepatectomies for living donor liver transplant: Experience from a high-volume centre in western India.

Living donor liver transplant (LDLT) is based on the principle of double equipoise. Organ shortage in Asian countries has led to development of high-volume LDLT programs with good outcomes. Safety of live liver donor is the Achilles heel of LDLT program and every effort should be made to achieve low morbidity and near zero mortality rates. We retrospectively analyzed our prospectively maintained donor morbidity data (outcomes) of 177 donors in a new transplant program setup in western India by an experienced surgeon. The primary end point was to analyze the morbidity rates and the factors associated with it. None of the donors in our cohort of 177 donors developed grade IV or V complication (Clavien-Dindo classification). One-fourth (1/4th) of the donors developed complications ranging from grade I to grade III(b). The rate of complications according to modified Clavien-Dindo classification is as follows: (1) grade I in 5.6% (n = 10), (2) grade II in 14.6% (n = 26), (3) grade III(a) in 3.9% (n = 7), (4) grade III(b) in 2.2% (n = 4). Three donors (1.6%) developed post-hepatectomy intra-abdominal bleeding and required re-exploration (grade IIIb). All of them recovered well post-surgery and are doing well in follow-up. The mean follow-up of the entire cohort was 2871 ± 521days (range 1926-3736days). Donor safety (outcome) is determined by meticulous donor surgery and good-quality remnant.

The new “Living Donor Liver Transplantation Program” Created by the Scientific Cooperation Between Malatya and Bishkek

The new “Living Donor Liver Transplantation Program” Created by the Scientific Cooperation Between Malatya and Bishkek

Donor Safety First: Postoperative Hepatectomy Outcomes in Living Liver Donors

Living donor liver transplantation (LDLT) has become a popular treatment option because some countries lack a deceased organ program and the growing demand for liver transplants. Although postoperative outcomes are similar to deceased donor liver transplants, there is still an element of risk to the donor. The Clavien-Dindo classification system has been used to standardize reporting across different institutions and surgeons to categorize surgical outcomes. Between January 1, 2022, and December 31, 2022, 207 living donors underwent hepatectomies at our center. All donors underwent a 3-step process of mandatory screening. Postsurgical complications were classified using the Clavien-Dindo classification. A total of 207 donor hepatectomies for LDLT were performed during our study period. Most donors (92.8%) were aged between 18 and 39 years. The most common type of graft used was a right lobe without the middle hepatic vein (82.6%). Most donors (91.7%) experienced an intraoperative blood loss of ≤500 mL. A total of 140 patients had an ordinary postoperative course. Grade 1 complications were observed in 16.9%, grade 2 in 12.1%, and grade 3 in 3.4% of the remaining patients. No grade 4 or grade 5 (patient death) complications were observed in this cohort. Living donor liver transplantation remains the most practiced liver transplant surgery in Pakistan. Our findings highlight the safety of the LDLT program with minimal risk of significant complications. The study also underscores the importance of careful screening and monitoring of living donors and the need for standardized reporting of surgical outcomes using the Clavien-Dindo classification system.

Safely Implementing a Program of Pure Laparoscopic Donor Right Hepatectomy: The Experience From a Southeast Asian Center.

Our center systematically introduced a laparoscopic hepatectomy program in 2006. We started with minor wedge resections followed by major hepatectomies with increasing complexities. In 2017, we performed our first laparoscopic living donor left lateral sectionectomy. Since 2018, we have performed 8 cases of right lobe living donor hepatectomy (laparoscopy-assisted: 4 and pure laparoscopic: 4). The median operative time was 418 (298-540) min, whereas the median blood loss was 300 (150-900) mL. Two patients (25%) had surgical drain placed intraoperatively. The median length of stay was 5 (3-8) d, and the median time to return to work was 55 (24-90) d. None of the donors sustained any long-term morbidity or mortality. Small- to medium-sized transplant programs face unique challenges in adopting LDRH. Progressive introduction of complex laparoscopic surgery, a mature living donor liver transplantation program, appropriate patient selection, and the invitation of an expert to proctor the LDRH are necessary to ensure success.

Toronto Management of Initially Unresectable Liver Metastases from Colorectal Cancer in a Living Donor Liver Transplant Program.

Living donor liver transplantation (LDLT) is an attractive option for patients with unresectable, bilobar colorectal liver metastases (CRLM). However, it is not available in most centres beyond study protocols. This study describes the interim experience with LDLT for CRLM at a large North American transplant and hepatobiliary centre. Adults with unresectable CRLM, receiving systemic chemotherapy were recruited into a prospective clinical trial. Data on demographics, referral patterns, and clinical characteristics were extracted from October 2016 to February 2023. Patients were divided into three groups: transplanted, resected, and control (excluded, with continuation of systemic chemotherapy). Overall survival (OS) and recurrence-free survival (RFS) were compared. 81 referred patients were assessed for LDLT. 7 received transplants, 22 underwent resection, and 48 control. All had similar pre-assessment baseline characteristics. Median time from initial assessment to transplantation was 15.4 months. The control population had significantly worse post-assessment OS than the transplanted population (p=0.002) and resected population (p<0.001). The median post-operative follow-up duration was 21.4 months (resection) and 14.8 months (LDLT). There was no difference in OS between the transplanted and resected populations (1-year 100% vs. 93.8%; 3-year 100% vs. 43.3%, p=0.17). However, RFS was superior in the LDLT group (1-year 85.7% vs. 11.4%; 3-year 68.6% vs. 11.4%, p=0.012). Most patients with unresectable CRLM referred for LDLT are deemed ineligible for trial inclusion. However, the excellent oncologic outcomes in patients who meet criteria for LDLT supports its role in highly selected populations. Future results after the trial's completion will inform long-term outcomes.

The current landscape of pediatric living donor liver transplantation in the United States: Benefits, challenges, and future directions.

The current landscape of pediatric living donor liver transplantation in the United States: Benefits, challenges, and future directions.

Living donor liver transplant: A strategy to increase transplant access

Living donor liver transplant: A strategy to increase transplant access

The toronto management of initially unresectable liver metastases from colorectal cancer in a living donor liver transplant program

Background: Living donor liver transplantation (LDLT) is an attractive option for patients with unresectable, bilobar, liver-only colorectal liver metastases (CRLM). However, it is not available in most centres beyond study protocols. This study describes the interim experience with LDLT for CRLM at a large transplant and hepatobiliary centre in North America.

Experience from Vietnam and lessons learned in setting up a living donor liver transplant program

Experience from Vietnam and lessons learned in setting up a living donor liver transplant program

Right Lobe Liver Donation After Bariatric Surgery. A Case Series of 4 Living Donors

The increasing prevalence of obesity and need for bariatric surgery as well as the expanding use of living donors for liver transplantation means that potential donors could present with this surgical history. We present 4 cases of liver donors with previous bariatric surgery in our living donor liver transplant program. A retrospective descriptive analysis of patients with a bariatric surgery history who underwent right hepatectomy in our living donor liver transplant program is presented. Case 1: A 53-year-old man with body mass index (BMI) of 33 who underwent laparoscopic sleeve gastrectomy (LSG). Pretransplant BMI was 21.5. Case 2: A 46-year-old woman with a BMI maximum of 40.8 who underwent LSG and required conversion to Roux-en-Y gastric bypass. Pretransplant BMI was 35.1. Case 3: A 53-year-old woman with a BMI maximum of 31.6 who underwent LSG. Pretransplant BMI was 24.2. Case 4: A 38-year-old man with a BMI maximum of 41.5 who underwent Roux-en-Y gastric bypass 6 years before the hepatectomy. Pretransplant BMI was 29.4. No complications were observed. Average operative time was 367.5 minutes, with a hospital stay of 5.8 days and 100% graft survival to date. Utilization of selected donors with previous bariatric surgery appears to be a safe option and increases the donor pool.

Increasing Living Liver Donor Pools: Liver Paired Exchange Versus ABO-incompatible Living Donor Liver Transplantation.

Increasing Living Liver Donor Pools: Liver Paired Exchange Versus ABO-incompatible Living Donor Liver Transplantation.

Anatomical characterization of potential liver donor in a living donor liver transplantation program in Latin America

Anatomical characterization of potential liver donor in a living donor liver transplantation program in Latin America

Preoperative Evaluation of Potential Liver Donor in a Living Donor Liver Transplantation Program in Latin America

Introduction: The living donor liver transplantation (LDLT) technique was developed to face the problem of low-rate donation. Living donor selection is crucial to minimize postoperative donor complications and to improve recipient outcomes This study evaluates the reasons for discarding potential donors in our LDLT program. Methods: Retrospective descriptive analysis from all potential donors evaluated in our LDLT program between April 2018 and July 2021. Selection criteria included age 18-60 years old, no significant medical or mental comorbidities, ABO and anatomical suitability. Results: A total of 231 patients were evaluated. Mean age was 37+11 years and male gender in 52%. 101 potential donors (43.7%) did not complete the evaluation because of the availability of a deceased donor (n=26; 11.3%), ABO incompatibility (n=13; 5.6%), progression or death of the recipient (n=14; 6.1%). Of the 130 who completed their radiological evaluation, the main causes of inadequate candidacy were small liver remnant size (SLRS) (n=17/130; 13.1%) and steatosis (n=15/130; 11.5%). Out of the 231 potential donors, 75 were accepted as adequate donors (32.4%) and 32 candidates underwent liver donation (13.8%). Conclusions: 43.7% of the potential donors didn’t complete the evaluation because of progression, death or deceased donor transplantation of the recipient. Steatosis, SRLS and anatomical variation are the main causes for dropout. Only 1/3 of potential donors are suitable for donation and half of them will undergo surgery. It is important to know main exclusion criteria met by potential donors, in order to make a more efficient use of time and financial resources.

In Light of a New Transplant Allocation Policy, Is a LDLT Program Still Justified in a High MELD Region?

Introduction: Living donor liver transplant (LDLT) has a unique role in providing life-saving organs for patients who do not have access to the deceased donor pool. The new liver allocation system expands availability of the national resource of donated organs to reduce waitlist mortality. Aim: To evaluate our LDLT program under the new allocation system and its justification in a high MELD region. Methods: We retrospectively reviewed outcomes of deceased donor LT (DDLT) and LDLT at our institution before (01/2018-01/2020) and after (02/2020-07/2021) allocation change. Results. A total of 247 transplants were included. The median OLTX MELD pre-allocation was 34 and 33 post-allocation. LDLT recipients had a non-significant decrease in MELD from 17 to 14. Only 4% of DDLT recipients were transplanted at a MELD within the LDLT IQR of 9-18 over both periods. The waiting time (WT) for DDLT pre-allocation was a median of 66 days (IQR 253) vs. 11 (213) (p=0.012) post. The WT for hepatocellular carcinoma (HCC) patients increased from 310 to 344 days after allocation change and the proportion of HCC transplants decreased from 28% to 13% (p=0.008) Discussion: Despite the positive impact of the allocation system on high MELD patients, lower MELD and HCC candidates seem to have less access to DDLT. In our institution, where a high MELD score at transplant is common, LDLT is an important option for these patients due to organ shortages.

Paired exchange Living Donor Liver Transplantation: A Nine-Year Experience from North India

Introduction: Liver paired exchange donation (LPD) or swap transplantation is an evolving strategy to overcome ABO incompatibility and other barriers like small for size syndrome that confront patients with end-stage Liver disease undergoing Living donor liver transplantation (LDLT). At the same time, for the transplant team to carry out 4 major operations simultaneously is a Herculean effort. Herein, we analyze our experience with LPD program over the past 9 years. Methods: This prospective study includes a total of 2340 LDLTs performed from May 2012 to April 2021. We started the Paired exchange LDLT program in May 2012. LPDs constituted approximately 1.45% (34 of 2340) of the total LDLT procedures. The reasons for LPD were ABO incompatibility in all (n=34) patients. The first and second recipient of each swap pair were divided into R1 and R2 groups for comparative analysis. Results: All patients included in paired exchange LDLT program were Indian citizens and donors were “near” relatives. After donor reassignment through 2-by-2 paired exchange with directed donors, the ABO matching status changed to A to A (n=17) and B to B (n=17) and this made all matches ABO-identical. Donor survival was 100%. The recipient’s (n=34, age 45.5 [11 -59] years; 31 men), UNOS status were 2b (n=5) and C (n=29) and they all underwent elective LDLT surgery with 4 OTs running simultaneously on the same day. The baseline clinical, peri-operative parameters, post-operative complications, median ICU/hospital stay, early deaths were comparable (P>0.1) between the R1 and R2 groups (Table 1). The overall recipient survival was 85.3 % (n=29) over the median follow up period of 20 (0-108) months. Conclusion: Our experience suggests that with careful attention to ethical and logistical issues, LPD program can expand the living donor liver pool and can facilitate a greater number of LDLTs. Keywords: Donor Exchange, Swap Liver Transplantation, Living Donor Liver Transplantation; ABO incompatibilityTable 1Comparative data between R1 and R2 groups of swap liver transplant recipients (n = 34).Parameters (Mean±SD)R1 (n=17)R2 (n=17)P valueAge (years)44.0 (±10.1)47.0 (±5.3)0.296MELD score21.8 (±11.1)19.4 (±6.3)0.445CTP score9.5 (±2.3)10.3 (±2.1)0.294Graft weight (grams)711 (±141.2)796 (±119.8)0.067GRWR1.01 (±0.34)1.18 (±0.26)0.136Warm ischemia time (minutes)32.7 (±7.8)36.1 (±7.1)0.257Cold ischemia time (minutes)109.7 (±61.2)112.6 (±40.9)0.870ICU stay (days)12.4 (±4.6)14.4 (±10.5)0.654Hospital stays (days)16.7 (±4.6)21.6 (±4.7)0.197Complications n (%)Bleeding01 (5.9%)1.00Bile leak02 (11.8%)0.485Acute rejection1 (5.9 %)1 (5.9 %)1.00Hepatic artery thrombosis01(5.9%)1.00Hepatic vein thrombosis2 (11.8%)1(5.9%)0.542Sepsis2 (11.8%)5 (29.4%)0.398Early mortality (Within 1 month)1 (5.8%)3(17.6%)0.6011 year survival16 (100 %)13 (92.8%)0.335Median follow up in months (IQR)27 (8-39)27 (8-43)1.00CTP, Child-Turcot-Pugh; GRWR, graft to recipient weight ratio; ICU, intensive care unit; IQR, inter quartile range; MELD, model for end stage liver disease. Open table in a new tab CTP, Child-Turcot-Pugh; GRWR, graft to recipient weight ratio; ICU, intensive care unit; IQR, inter quartile range; MELD, model for end stage liver disease.

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.

Evaluation of Adult Living Donor Liver Transplantation in Largest Southeast Asian Transplantation Center: Benchmarking With Adult-to-Adult Living Donor Liver Transplantation (A2ALL) Experience

The volume-outcome relation for complex surgical procedures such as living donor liver transplantation (LDLT) generally favors high volume (HV) centers. It is important for low to medium volume (MV) centers to evaluate their centers' performance against HV centers to allow early detection and correction of potential systemic issues. There is a dearth of national and international comprehensive registries for LDLT that may allow reasonable risk-adjusted comparisons for benchmarking. This study aims to evaluate the LDLT program by comparing our center's performance against HV centers of the Adult-to-Adult Living Donor Liver Transplantation cohort. Patient outcomes from a MV transplant center were compared with 11 HV transplant centers from the Adult-to-Adult Living Donor Liver Transplantation cohort. Outcomes evaluated included length of hospital stay, same admission mortality, 90-day mortality, and overall survival. A total of 1381 patients were analzyed. HV 1 to 4, 6, 8, 9, and 11 centers had a shorter median length of hospital stay compared with the MV center (All Dunnett corrected P values all less than .05). HV 9 and 11 centers had lower same admission mortality compared with the MV center (Dunnett corrected P=.023 and .015). After adjusting for other significant predictors, the MV center had comparable 90-day mortality rates and overall survival rates to all HV centers. This benchmarking exercise has demonstrated that the limitation of low institutional case volume can be overcome with a protocol-based framework to implement a safe LDLT program. This framework presented can be adopted for developing programs.