Living Donor Liver Transplantation Recipients Research Articles

Effect of the response to preoperative treatment for hepatorenal syndrome on the outcome of recipients of living-donor liver transplantation.

The effect of pretransplant hepatorenal syndrome (HRS) on the outcomes of living-donor liver transplantation (LDLT) recipients with special reference to the recovery of HRS before LDLT was investigated. The rate of HRS was 43.9% (125/285) among the cohort, and the subjects were divided into three groups: those without HRS (No-HRS group, n=160), those with HRS but recovered following pretransplant renal function restoration treatment (Responders group, n=55), and those with persistent HRS (Non-responders group, n=70). While the 1-, 3-, and 5-year patient survival rates were comparable between those with and without HRS (89.6%, 84.7%, and 84.7% vs 95.6%, 92.2%, and 87.5%), the cumulative incidence of the development of posttransplant chronic kidney disease (CKD) was significantly higher in those with HRS (P < .001). In addition, there was a significant difference between Responders and Non-responders in the development of CKD (P=.01). In the Cox regression model, Non-responders (P=.032, HR 1.79 [95% C.I. 1.05-3.03]) and recipient age (P=.014, HR 1.62 [95% C.I. 1.10-2.37]) were independent predictors for the development of CKD after LDLT. Living-donor liver transplantation is safe and effective for patients with HRS, and CKD progression could be reduced among those with HRS who responded to renal restoration treatment.

Small-for-Size versus Standard-Size Graft in Living Donor Liver Transplantation.

To compare the outcome of small-for-size grafts versus standard-size grafts regarding the frequency of postoperative complications, early graft dysfunction, and 1-year survival. Retrospective cohort study. Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences (PAQSJIMS) Hospital, Gambat, Sindh, Pakistan from March 2019 to April 2020. A total of 147 living donor liver transplant recipients' data were retrospectively evaluated. Study participants were divided into two groups; small-for-size graft (GRWR <0.8%) and standard-size graft (GRWR >0.8%). Recipients' demographics, graft characteristics, operative parameters, postoperative complications, and graft survival were compared in both groups. Out of 147 recipients, 21 were found to have small-for-size graft, while 126 patients had the standard-size graft. Mean GRWR in small-for-size graft group was 0.73 + 0.4 (0.63-0.79), while 0.93 + 0.82 (0.81-3.0) in standard-size graft group. A statistically significant difference was found while comparing body mass index (p <0.001), hepatic venous reconstruction (p = 0.013), and liver attenuation index (p <0.001) between both study groups. While all other recipient and donor characteristics, demographical data, operative variables, postoperative lab, and complications were comparable in both groups (p >0.05). Kaplan-Meier analysis showed that 1-year survival rate for small-for-size graft recipients was 90.5%, while the survival rate for the standard-size graft was 96.0% (p = 0.272). Frequency of post-op complications was comparable in both groups. The graft survival in small-for-size grafts was as good as for standard-size grafts. Key Words: Living donor liver transplantation, GRWR, Small-for-size graft, Standard-size graft.

Living donor liver transplantation versus donation after brain death and donation after circulatory death liver transplantation in the US

While previous research has compared outcomes between living donor liver transplantation (LDLT) and deceased donor liver transplantation, evidence is lacking regarding how donation after circulatory death (DCD) vs donation after brain death (DBD) affects this comparison. Using data from the Scientific Registry of Transplant Recipients for adults listed for liver transplant from 2012 to 2018, we compared 5-year patient and graft survival, readmissions, posttransplant chronic kidney disease (CKD), and return to work for 25,151 patients who underwent LDLT (1223 [4.9%]), DCD-LT (1431 [6.4%]), and DBD-LT (22,497 [89.4%]). LDLT recipients were significantly more likely to have a Model for End-Stage Liver Disease (MELD) score < 15 and to be working prior to transplant (P < 0.001 for both). At 5 years posttransplant, LDLT recipients had significantly more readmissions, but significantly less CKD and better survival than DBD-LT and DCD-LT recipients, as well as significantly better graft survival than DCD-LT recipients (P ≤ 0.01 for all). Significantly more LDLT recipients also returned to work for income (P < 0.01). This study shows a clear advantage of LDLT vs DCD-LT. This information should be weighed in transplantation decisions for patients such as those with low MELD scores who will realistically only be considered for DCD-LT.

Low-dose propofol as a solo agent for sedation in postoperative ventilated liver transplant recipients: A preliminary observational study.

Propofol is a commonly used sedative agent, in a dose of 1.5-4.5 mg.kg-1.h-1. Following liver transplantation (LT), drug metabolism may be altered due to liver mass, altered hepatic blood flow, reduced levels of serum proteins, and liver regeneration. Thus, we hypothesized that propofol requirements in this group of patients would be different as compared to the standard dose. This study evaluated the dose of propofol used for sedation in electively ventilated living donor liver transplantation (LDLT) recipients. After patients were shifted to the postoperative intensive care unit (ICU) following LDLT surgery, propofol infusion was started at a dose of 1 mg.kg-1.h-1 and titrated to maintain a bispectral index (BIS) value of 60-80. No other sedatives such as opioids or benzodiazepines were used. Dose of propofol, noradrenaline, and arterial lactate levels were noted 2 hourly. The mean propofol dose required in these patients was 1.02 ± 0.26 mg.kg-1.h-1. Noradrenaline was gradually tapered off and stopped within 14 h of shifting to ICU. The mean duration between the time of cessation of propofol infusion till extubation was 2.06 ± 1.44 h. Propofol dose did not correlate with respective lactate levels, ammonia levels, or graft-to-recipient weight ratio. The dose range of propofol required for postoperative sedation in LDLT recipients was lower than the conventional dose.

Superior Long-Term Outcomes of Adult Living Donor Liver Transplantation: A Cumulative Single-Center Cohort Study With 20 Years of Follow-Up.

Living donor liver transplantation (LDLT) is an attractive alternative to deceased donor liver transplantation (DDLT). Although both modalities have similar short-term outcomes, long-term outcomes are not well studied. We compared the 20-year outcomes of 668 adults who received LDLT with1596 DDLTs at the largest liver transplantation (LT) program in Canada. Recipients of LDLT were significantly younger and more often male than DDLT recipients (P<0.001). Autoimmune diseases were more frequent in LDLT, whereas viral hepatitis and alcohol-related liver disease were more frequent in DDLT. LDLT recipients had lower Model for End-Stage Liver Disease scores (P=0.008), spent less time on the waiting list (P<0.001), and were less often inpatients at the time of LT (P<0.001). In a nonadjusted analysis, 1-year, 10-year, and 20-year patient survival rates were significantly higher in LDLT (93%, 74%, and 56%, respectively) versus DDLT (91%, 67%, and 46%, respectively; log-rankP=0.02) as were graft survival rates LDLT (91%, 67%, and 50%, respectively) versus (90%, 65%, and 44.3%, respectively, for DDLT; log-rankP=0.31). After multivariable adjustment, LDLT and DDLT were associated with a similar hazard of patient and graft survival. Our data of 20 years of follow-up of LDLT from a single, large Western center demonstrates excellent long-term outcomes for recipients of LDLT.

Long-term outcome after living donor liver transplantation compared to donation after brain death in autoimmune liver diseases: Experience from the European Liver Transplant Registry

Knowledge of living donor liver transplantation (LDLT) for autoimmune liver diseases (AILDs) is scarce. This study analyzed survival in LDLT recipients registered in the European Liver Transplant Registry with autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis (PSC) and the non-autoimmune disorder alcohol-related cirrhosis. In total, 29902 individuals enrolled between 1998 and 2017 were analyzed, including 1003 with LDLT. Survival from >90days after LDLT for AILDs in adults was 85.5%, 74.2%, and 58.0% after 5, 10, and 15years. Adjusted for recipient age, sex, and liver transplantation era, adult PSC patients receiving LDLT showed increased mortality compared to donation after brain death (DBD) (hazard ratio [HR]=1.95, 95% confidence interval [CI]=1.36-2.80, p<.001). Pediatric PSC patients showed also increased mortality >90days after LDLT compared to DBD (HR=3.00, 95% CI 1.04-8.70, p=.043). Multivariate analysis identified several risk factors for death in adult PSC patients receiving LDLT including a male donor (HR=2.49, p=.025). Adult PSC patients with LDLT versus DBD conferred increased mortality from disease recurrence (subdistribution hazard ratio [subHR]=5.36, p=.001) and biliary complications (subHR=4.40, p=.006) in multivariate analysis. While long-term outcome following LDLT for AILD is generally favorable, PSC patients with LDLT compared to DBD might be at increased risk of death.

A comparative histological analysis of early and late graft dysfunction in different time zones following living donor liver transplantation.

Liver biopsy plays a crucial role in evaluating allograft dysfunction. Comprehensive analysis of the histological spectrum of complications, particularly rejection, in different time zones is lacking. To evaluate the histological spectrum of rejection, in four time zones, in a large Living donor liver transplant series. Retrospective analysis of 313 biopsies for the last 10 years of living donor liver transplantation (LDLT) recipients. 123 of which had rejection as diagnosis, were redistributed in four time zones [1-early (<3), 2-intermediate (3-6), 3 and 4-late (6-12 and > 12) months] and were assessed for sixteen histological parameters. Biopsies in time zone 1 (26.5%), 2 (20.7%), 3 (24.6%), and 4 (28.1%)] were nearly equal. Multiple coexistent complications existed in 12% of the cases. Rejection diagnosed in time zone groups: 1 = 22 (17.9%), 2 = 27 (22%), 3 = 36 (29.3%), and 4 = 38 (30.9%). Portal inflammation mixed type (P < 0.000), portal vein (P = 0.001) and hepatic vein endothelialitis (P < 0.000), portal eosinophils (P = 0.001), and lymphocytic bile duct damage (P = 0.01) were most pronounced in group 1. Perivenulitis without hepatic vein endothelialitis was observed (P = 0.03) in groups 3, whereas bile duct atypia (P = 0.01) and duct loss (P < 0.000) were observed in group 4. Multiple episodes of rejection displayed significant association with central perivenulitis (P = 0.002) and bile duct loss (P < 0.001). Histological analysis in large series of LDLT recipients highlights the spectrum of complications in different time zones. Late acute and chronic rejection occurred as early as 3 months posttransplant. Central perivenulitis and bile duct atrophy were associated with repeated episodes of rejection and deterioration.

The impact of preformed donor-specific antibodies in living donor liver transplantation according to graft volume.

IntroductionThe roles of preformed anti‐HLA donor‐specific antibodies (DSAs) in liver transplantation remain controversial. We evaluated the impact of preformed DSAs in living donor liver transplantation.MethodsAdults who underwent living donor liver transplantation (n = 175) in our institute were included in this study. Lymphocyte cytotoxicity test (LCT), flow cytometric crossmatch (FCXM), and single‐antigen bead assays were performed.ResultsAmong adult living donor liver transplantation recipients, 27 (16.5%) and 14 (8.5%) had pretransplant FCXM‐positive findings and LCT‐positive findings, respectively. FCXM‐positive patients displayed a significantly worse 5‐year graft survival rate (77.3%; vs. DSA‐negative, 91.6%). Six of 14 LCT‐positive patients exhibited graft loss shortly after transplantation (5‐year survival rate: 57.1%). All LCT‐positive patients with graft loss underwent left lobe living donor liver transplantation. Significantly lower ratio of graft volume relative to standard liver volume (32.9 ± 5.7%) and smaller graft size (365.3 ± 57.9 g) were observed in patients with graft loss (p < .03, vs. surviving grafts). Significantly higher DSA‐mean fluorescence intensity (MFI) values were present in patients with graft loss (p = .0012, vs. surviving grafts).ConclusionsPatients with preformed DSAs exhibited worse graft outcomes in living donor liver transplantation. Higher DSA‐MFI values and smaller graft size were associated with worse outcomes in LCT‐positive patients. High‐risk patients with preformed DSAs should be considered for appropriate graft selection and application of a desensitization protocol.

Experience of living donor liver transplantation for hepatocellular carcinoma in the University of Hong Kong Hospital

Aim: To describe the current practise of living donor liver transplantation (LDLT) for hepatocellular carcinoma (HCC), including the patient selection criteria, surgical techniques, management of small-for-size syndrome, postoperative complications, and the results of our units, in the Liver Transplant Centre of Queen Mary Hospital, Hong Kong, one of the high-volume centres for LDLT in Asia. Methods: Our centre practises careful selection for HCC patients using the University of California, San Francisco (UCSF) criteria, supplemented by alpha-fetoprotein level and the model for end-stage liver disease score. Slight flexibility is offered to enthusiastic donors and recipients in LDLT while balancing the risks and benefits. We pioneered in using the extended right lobe graft and the novel hepatic venoplasty technique, which lessen the risk of hyperperfusion and small-for-size syndrome with improved overall recipient survival. Data were collected prospectively and presented as the mean values and ranges, or the number of patients in proportion of total patient population. Results: Of our patients, 74.9% met the UCSF criteria, and 64.5% met the Milan criteria. A 5-year overall and disease-free survival rate of 78.9% and 76.3% were achieved. Conclusion: LDLT is an ideal treatment for HCC in Hong Kong with regard to the critical organ shortage and high demand for transplantation. The current surgical techniques and post-transplant surveillance contribute to the positive outcome.

Initial Outcome of External Biliary Drainage Tube Insertion in Living Donor Liver Transplantation: Pure Laparoscopic Donor Hepatectomy Dominant Center Experience

Introduction: Surgical technique advancements and enhanced perioperative management improved outcome in living donor liver transplantation (LDLT) recipients. However, biliary complication(BC) including biliary leakage(BL) and biliary stricture(BS) continues to be the most common and intractable complication due to surgical/non-surgical factors. This study compared the incidence of biliary complication (BC) in adult living donor liver transplant recipients who underwent right-lobe duct-to-duct anastomosis (DDA) with or without external biliary drainage (EBD). Methods: This study compares the incidence of biliary complication after LDLT between EBD group (n = 40) and non-EBD group (n = 150) retrospectively. Total 190 patients who received LDLT with duct-to-duct anastomosis in SNUH from July 2017 to October 2020 were included in the analysis. Donor operation was pure laparoscopic surgery. Biliary complication included all short-term and long-term biliary leakage or biliary stricture of Clavien-Dindo grade III or higher. Results: The incidence of overall biliary complication(BC) was 16/40(40.0%) in EBD group and 76/150(50.7%) in non-EBD group (p = 0.230). The incidence of biliary leakage(BL) was 2.5% in EBD group and 14.6% in non-EBD group (p = 0.036). The EBD related complication(Clavien-Dindo grade III or higher) rate was 5.0%. Conclusion: This study shows that EBD insertion is effective in decreasing the rate of biliary leakage in LDLT recipients with duct-to-duct anastomosis. While the overall EBD related complication rate was high, most were minor complications such as self-removal or EBD retraction. Further research is needed to determine the optimal time of EBD clamping and removal.

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.

Clinical Outcomes of Adult Living Donor Liver Transplantation in High MELD Recipients: A Systematic Review and Meta-Analysis

Introduction: There is a clear survival advantage of living donor liver transplantation (LDLT) over waiting for deceased donor liver transplantation (DDLT) for patients with low Model for End-Stage Liver Disease (MELD) score. Results from several centers suggest that the outcomes following LDLT in patients with high-MELD(HM) and low-MELD(LM) are comparable. The aim of study was to verify this observation by performing a meta-analysis of available literature to determine patient survival and graft survival and postoperative outcomes. Methods: Following PROSPERO registration CRD-42021261501, a systematic database search was conducted for literature published between 1990-2021. Ten studies with 2,183 LDLT recipients were identified (N=490 HM group and N=1,693 LM group) and meta-analysis was performed using RevMan 5.3 and STATA/SE-16. Results: Patients in the HM group had comparable mortality at 1, 3 and 5 years post-transplant compared to patients LM group (5-year Hazard Ratio(HR)1.19; 95%CI 0.79-1.79; P-value 0.40). Graft survival was also comparable (5-year HR1.08; 95%CI 0.72-1.63; P-value 0.71.) No statistically significant difference was observed in terms of major morbidity, hepatic artery thrombosis, biliary complications, intraabdominal bleeding, wound infection and rejection. However, HM group had statistically significant higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay(Figure 1, Table 1). Conclusions: HM patients submitted to LDLT had overall comparable survival, graft survival and major morbidity rate compared to LM group despite higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay.Tabled 1FP13-4Table1 Post transplant outcomesA. OutcomesOdds ratio95%CIP-valueI2 (%)Major morbidity1.530.92-2.540.10$41%Hepatic artery thrombosis1.180.52-2.670.70$0%Biliary complications1.060.72-1.570.75$14%Wound infections1.460.51-4.240.48$0%Intraabdominal bleeding1.870.98-3.540.06$0%Pulmonary infections2.071.05-4.080.04**40%Abdominal fluid collections2.261.21-4.240.01**0%B. OutcomesMean difference95%CIP-valueI2 (%)Length of ICU stay1.140.43-1.840.00∗∗29%Strength: I2 --Mild to moderate heterogeneity, $: non-significant difference or comparable outcomes, *: significant difference Open table in a new tab Strength: I2 --Mild to moderate heterogeneity, $: non-significant difference or comparable outcomes, *: significant difference

Covid-19 in recipients of living donor liver transplantation: a worse or an equivalent outcome?

Summary BackgroundCoronavirus disease 2019 (Covid-19) pandemic is representing a massive burden to the community with the new virus. There is few data regarding Covid-19 in liver transplant patients. Concerns were raised regarding the course of the disease in transplanted patients due to immunosuppression and risk of hepatic injuries.AimTo describe the outcomes of Covid-19 infection in recipients of living-donor liver transplantation (LDLT).MethodsRetrospective analysis of 41 recipients of LDLT diagnosed with Covid-19 by real-time PCR or CT chest criteria of Covid-19 between April 2020 and April 2021. This Cohort was derived from Ain Shams Center for Organ Transplantation database, Ain Shams Specialized Hospital, Cairo, Egypt, which is considered one of the largest centers of LDLT in the Middle East. Patients were classified to mild, moderate, severe and critics according to clinical classification released by the National Health Commission of China.ResultsA total of 41 patients and 2 patients with reinfection were included in this cohort with mean age 54 years with 74% male and 26% female. The body mass index ranged from 19.3 to 37. About 30% were described as a mild case, 46.5% were moderate, 14% were severe and 9% were critical cases. Two cases developed infection twice. Total of 20 patients (46.5%) were managed in home isolation setting, 17 patients (39.5%) needed admission to ward, 4 patients (9%) in intermediate care unit and 2 patients (4%) admitted to intensive care unit. About 60% of cases were on room air, only 3 patients needed invasive methods, 2 patients needed face mask and 1 case needed invasive CPAP. In total, 41 patients recovered (95%) and 2 patients (5%) died; 1 was Covid related and the other one was non-Covid related. Female gender, higher BMI and hypertension were associated with severe course of the disease.ConclusionIn the setting of LDLT, the possibilities of catching Covid-19 infection are high due to chronic immunosuppression use. Yet, the outcome of infection in term of morbidity and the needs for hospital admission or intensive care is generally matched to general population.

Impact of older age on the long-term survival in living-donor liver transplantation: A propensity score matching analysis

BackgroundPrevalence of the end-stage liver disease in the elderly patients indicating a liver transplantation (LT) has been increasing. There is no universally accepted upper age limit for LT candidates but the functional status of older patients is important in pre-LT evaluation. This study aimed to examine the impact of older age on survival after living donor liver transplantation (LDLT). MethodA total of 171 LDLT recipients were assessed in two groups: age ≥65 and < 65. To eliminate selection bias propensity score matching (PSM) was performed, and 56 of 171 recipients were included in this study. ResultsThere were 20 recipients in the older group and 36 in the younger. The 1-, 3-, and 5-year survival rates were 65.0%, 60.0%, and 60.0% in group 1; 88.9%, 84.7%, and 71.4% in group 2, respectively. The 1-year survival was significantly lower in the older recipients; however, overall survival rates were similar between the groups. Of the 56 recipients, 15 (27%) deaths were observed in overall, and 11 (20%) in 1-year follow-up. The univariate regression analysis after PSM revealed that MELD score affected 1- year survival and the multivariate analysis revealed that age ≥65 years and MELD score were the predictors of 1-year survival. ConclusionAt first sight, before PSM, survival appeared to be worse for older recipients. However, we have shown that there were confounding effects of clinical variables in the preliminary evaluation. After the elimination of this bias with PSM, This study highlights that older recipients have similar outcomes as youngers in LDLT for long-term survival.

Expedited evaluation for liver transplantation: A critical look at processes and outcomes.

Most patients are listed for liver transplant (LT) following extensive workup as outpatients ("conventional evaluation"). Some patients undergo urgent evaluation as inpatients after being transferred to a transplant center ("expedited evaluation"). We hypothesized that expedited patients would have inferior survival due to disease severity at the time of transplant and shorter workup time. Patients who underwent evaluation for LT at our institution between 2012 and 2016 were retrospectively reviewed. The expedited and conventional cohorts were defined as above. Living donor LT recipients, combined liver-kidney recipients, acute liver failure patients, and re-transplant patients were excluded. We compared patient characteristics and overall survival between patients who received a transplant following expedited evaluation and those who did not, and between LT recipients based on expedited or conventional evaluation. Five-hundred and nine patients were included (110 expedited, 399 conventional). There was no difference in graft or patient survival at 1year for expedited versus conventional LT recipients. In multivariable analysis of overall survival, only Donor Risk Index (HR 1.97, CI 1.04-3.73, P=.037, per unit increase) was associated with increased risk of death. Patients who underwent expedited evaluation for LT had significant demographic and clinical differences from patients who underwent conventional evaluation, but comparable post-transplant survival.

Clinical Relevance of Isoagglutinin Rebound in Adult ABO-Incompatible Living Donor Liver Transplantation.

ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) can be performed successfully. However, anti-ABO isoagglutinin rebound may cause antibody-mediated rejection (AMR) and graft loss. The risk threshold of isoagglutinin rebound is still not defined. 76 ABO-I LDLT recipients were divided into group A (n = 56) with low isoagglutinin titers (<1:256), and group B (n = 20) with high isoagglutinin titers (≥1:256), at initial assessment for liver transplantation. The last 12 patients in group B received a modified desensitization regimen by adding bortezomib to deplete plasma cells. Six (10.7%) patients in group A and 10 (50.0%) patients in group B had postoperative isoagglutinin rebound (p < 0.001). Three patients (5.54%) in group A and two patients (10%) in group B developed clinical AMR (p = 0.602). The cutoff value of postoperative isoagglutinin rebound to cause clinical AMR was ≥1:1024. Among the 12 patients in group B with bortezomib administration, isoagglutinin rebounded up to 1:128 only, and no clinical AMR occurred. In conclusion, the patients with high isoagglutinin titers had a higher rate of postoperative isoagglutinin rebound. Isoagglutinin rebound ≥1:1024 is risky for developing clinical AMR. Adding bortezomib into the desensitization regimen may mitigate isoagglutinin rebound, and avoid clinical AMR.

Resuming post living donor liver transplantation in the COVID-19 pandemic: real-life experience, single-center experience

BackgroundSolid organ transplantation (SOT) service has been disrupted during the current coronavirus disease 2019 (COVID-19) pandemic, which deferred the service in most centers worldwide. As the pandemic persists, there will be an urgency to identify the best and safest practices for resuming activities as areas re-open. Resuming activity is a difficult issue, in particular, the decision of reopening after a period of slowing down or complete cessation of activities.ObjectivesTo share our experience in resuming living donor liver transplantation (LDLT) in the context of the COVID-19 pandemic in the Liver Transplantation Unit of El-Manial Specialized Hospital, Cairo University, Egypt, and to review the obstacles that we have faced.Material and methodsThis study is a single-center study. We resumed LDLT by the 26th of August 2020 after a period of closure from the 1st of March 2020. We have taken a lot of steps in order to prevent COVID-19 transmission among transplant patients and healthcare workers (HCWs).ResultsIn our study, we reported three LDLT recipients, once resuming the transplantation till now. All our recipients and donors tested negative for SARS-CoV-2 by nasopharyngeal RT-PCR a day before the transplantation. Unfortunately, one of them developed COVID-19 infection. We managed rapidly to isolate him in a single room, restricting one team of HCWs to deal with him with strict personal protective measures. Finally, the patient improved and was discharged in a good condition. The second patient ran a smooth course apart from FK neurotoxicity which improved with proper management. The third patient experienced a sharp rise in bilirubin and transaminases on day 14 that was attributed to drug toxicity vs. rejection and managed by discontinuing the offending drugs and pulse steroids. In addition, one of our head nurses tested positive for SARS-CoV-2 that was manageable with self-isolation.ConclusionCareful patient, donor, personnel screening is mandatory. Adequate supply of personal protective equipments, effective infection control policies, and appropriate administrative modifications are needed for a safe return of LDLT practice.

Impact of Advanced Renal Dysfunction on Posttransplant Outcomes After Living Donor Liver Transplantation in the United States.

Survival after living donor liver transplantation (LDLT) in the United States is excellent. However, the significance of pretransplant kidney disease on outcomes in this population is poorly understood. This was a retrospective cohort study of 2806 LDLT recipients nationally between January 2010 and June 2020. Recipients with estimated glomerular filtration rate <40 mL/min/1.73 m2 (eGFR-low) or requiring dialysis were compared. Multivariable survival analyses evaluated (1) eGFR-low as a predictor of post-LDLT survival and (2) the survival of LDLT versus deceased donor liver transplant (DDLT) alone with eGFR-low. From 2010 to 2020, 140 (5.0%) patients had eGFR-low and 18 (0.6%) required dialysis pre-LDLT. The number of LDLTs requiring dialysis between 2017 and 2020 outnumbered the prior 7 y. Overall LDLT experience was greater at centers performing LDLT in recipients with renal dysfunction (P < 0.001). LDLT recipients with eGFR-low had longstanding renal dysfunction: mean eGFR 3-6 mo before LDLT 42.7 (±15.1) mL/min/1.73 m2. Nearly half (5/12) of eGFR-low recipients with active kidney transplant (KT) listing at LDLT experienced renal recovery. Five patients underwent early KT after LDLT via the new "safety net" policy. Unadjusted survival after LDLT was worse with eGFR-low (hazard ratio 2.12 versus eGFR ≥40 mL/min/1.73 m2; 95% confidence interval, 1.47-3.05; P < 0.001), but no longer so when accounting for mean eGFR 3-6 mo pre-LDLT (hazard ratio, 1.27; 95% confidence interval, 0.82-1.95; P = 0.3). The adjusted survival of patients with eGFR-low receiving LDLT versus deceased donor liver transplant alone was not different (P = 0.08). Overall, outcomes after LDLT with advanced renal dysfunction are acceptable. These findings are relevant given the recent "safety net" KT policy.

Impact of biliary complications on quality of life in live-donor liver transplant recipients.

BACKGROUNDDespite significant advancements in liver transplantation (LT) surgical procedures and perioperative care, post-LT biliary complications (BCs) remain a significant source of morbidity, mortality, and graft failure. In addition, data are conflicting regarding the health-related quality of life (HRQoL) of LT recipients. Thus, the success of LT should be considered in terms of both the survival and recovery of HRQoL. AIMTo assess the impact of BCs on the HRQoL of live-donor LT recipients (LDLT-Rs).METHODSWe retrospectively analysed data for 25 LDLT-Rs who developed BCs post-LT between January 2011 and December 2016 at our institution. The Short Form 12 version 2 (SF 12v2) health survey was used to assess their HRQoL. We also included 25 LDLT-Rs without any post-LT complications as a control group.RESULTSThe scores for HRQoL of LDLT-Rs who developed BCs were significantly higher than the norm-based scores in the domains of physical functioning (P = 0.003), role-physical (P < 0.001), bodily pain (P = 0.003), general health (P = 0.004), social functioning (P = 0.005), role-emotional (P < 0.001), and mental health (P < 0.001). No significant difference between the two groups regarding vitality was detected (P = 1.000). The LDLT-Rs with BCs had significantly lower scores than LDLT-Rs without BCs in all HRQoL domains (P < 0.001) and the mental (P < 0.001) and physical (P = 0.0002) component summary scores.CONCLUSIONThe development of BCs in LDLT-Rs causes a lower range of improvement in HRQoL.

Use of minor donors for living donor liver transplantation and associated ethical issues.

BackgroundLiving liver donation by minors is regarded as justifiable only if minors possess the capacity to consent to donation and the procedure is in their best interests. This study analyzed the incidence of and reasons for living donor liver transplantation (LDLT) by minor donors in Korea, and discussed ethical issues regarding liver donation by minors.MethodsThe databases of the Korean Network for Organ Sharing (KONOS) and Asan Medical Center (AMC) from 2010 to 2019 were retrospectively reviewed to determine the incidence of LDLT by minor donors.ResultsFrom 2010 to 2019, 590 (4.1%) of 14,243 liver donors in the KONOS database and 276 (7.5%) of 3,401 liver donors in the AMC database were minors. The proportions of minor donors in the KONOS and AMC databases were highest in 2012, at 4.1% and 12.6%, respectively, and lowest in 2019, at 1.1% and 3.0%, respectively. Because most LDLT recipients had relatively low model for end-stage liver disease scores and hepatocellular carcinoma, they were unlikely candidates for deceased-donor liver transplantation and were highly likely to drop out of LDLT if they waited for 1–2 years. The donor-recipient relationship of minor donors in the AMC database was first-degree in 256 (92.8%) and second- or third-degree in 20 (7.2%).ConclusionsLiver donation by minors is limitedly acceptable only when the minor proves informed, well‐considered, and autonomous consent to the procedure and the procedure is in the minor's best interests. We suggest that minors be allowed to donate only to first-degree family members.