Potential Living Liver Donors Research Articles

Multiple Swaps Tested: Rehearsal for Triple and Five Liver Paired Exchanges

Despite several advances in living donor liver transplant (LDLT), many potential living liver donors cannot donate their organs to their relatives because of blood group incompatibility and unsuitable anatomy. Liver paired exchange (LPE) can be used to overcome incompatibilities between living donor-recipient pairs. In this study, we report the early and late results of three and five LDLTs performed simultaneously to initiate the more complex LPE program. By demonstrating that our center is capable of performing up to five LDLTs, we have taken an essential step for establishing a complex LPE program.

Contrast-Enhanced T1-Weighted Magnetic Resonance Cholangiography Using Gadoxetate Disodium in Potential Living Liver Donors: Qualitative and Quantitative Improvement with 3-hour Delayed Imaging

BackgroundContrast-enhanced T1-weighted magnetic resonance cholangiography (CE-T1-MRC) after gadoxetate disodium administration can be used for preoperative evaluation of the bile ducts in live liver donors. This study aimed to determine whether CE-T1-MRC with 3-hour delayed imaging improves bile duct visualization both qualitatively and quantitatively compared with 20-minute delayed imaging in potential living liver donors. MethodsWe retrospectively identified 33 potential living liver donors (mean age, 30.1 years; 18 men and 15 women) who underwent preoperative CE-T1-MRC with both 20-minute delayed and 3-hour delayed imaging in a single session. The radiologist scored biliary visualization for right and left hepatic ducts (RHD and LHD), their secondary confluences and segmental bile ducts, common hepatic duct (CHD), and cystic duct (CD), and measured relative contrast ratio (rC) and relative signal intensity (rS) for RHD, LHD, and CHD. The data were analyzed using Wilcoxon's signed-rank test and paired t-test. ResultsIn qualitative analysis, duct visualization scores for RHD and LHD, their secondary confluences and segmental bile ducts, CHD, and CD were significantly higher on CE-T1-MRC with 3-hour delayed imaging than with 20-minute delayed imaging (all, P ≤ .046). In quantitative analysis, both rC and rS of RHD, LHD, and CHD were significantly higher on CE-T1-MRC with 3-hour delayed imaging than with 20-minute delayed imaging (all, P < .001). ConclusionsCE-T1-MRC with 3-hour delay imaging improves bile duct visualization both qualitatively and quantitatively in potential living liver donors.

The Consequences of HLA Screening in the Prevention of Graft-Versus-Host Disease in Living Donor Liver Transplantation.

To study the effects of routine HLA screening and the policy of avoiding donor-dominant one-way HLA match to prevent graft-versus-host disease (GVHD) after living donor liver transplantation (LDLT). The records of potential living liver donors and recipients who attended our center between 2007 and 2018 were reviewed retrospectively. Of the 149 patients who underwent LDLT and survived longer than 3 months, two developed GVHD despite our strict policy. The first patient presented with grade II GVHD limited to the skin. She was treated successfully by briefly discontinuing immunosuppression and switching to everolimus. In the second case, the policy had been relaxed due to the availability of a single donor for ABO-incompatible transplantation without any intervention to decrease anti-A antibody levels (special case: A2 to O). Nevertheless, the patient presented with grade I GVHD limited to skin and was treated successfully by adding oral methylprednisolone to tacrolimus and mycophenolate mofetil. To the best of our information, this is the second reported case who recovered from GVHD after LDLT from a donor, homozygous at HLA A, B and DR and a recipient, heterozygous for all. Sixteen potential donors (1.2% of all candidates) of 14 recipients were disqualified solely on the basis of the HLA results; five of these patients died due to unavailability of another donor. The results support the policy of avoiding HLA combinations that preclude immune recognition of graft lymphocytes as foreign to decrease the risk of GVHD after LDLT.

The Efficiency of Volumetry in Graft Weight Assessment in Living Donor Liver Transplant

Abstract Background Liver transplantation is the treatment of choice for end-stage hepatic diseases. The most important factor responsible for the success of the transplant is the size of the graft and the remnant liver volume in the donor. A small graft may not meet the metabolic demands of the recipient resulting in impaired liver functions such as hyperbilirubinemia, prolonged prothrombin time (PT), ascites and portal hypertension. Patient and Methods This comparative study was conducted on manual contrast enhanced hepatic CT scans of 40 potential living liver donors (29) male and (11) female Age range from (18 to 50 ) in Ain shams specialized hospital and some private centers during the period from May 2021 till July 2022. The potential donors were investigated using 16 channel multi-detector row CT scanner (Alexion; Toshiba medical systems). All potential donors underwent 1st step laboratory investigations to enter the 2nd step investigations for living donor liver transplantation operations. All potential donors were of average weight and physically fit for operation with no history of any medical diseases. Results We correlated the results of CT volumetry of right lobe graft weight with the intra-operative weight of liver graft in patients undergoing Living Donor Liver Transplantation(LDLT). CT Volumetry is an efficient and a reliable tool for assessing potential donors undergoing liver transplant, and this information is essential for donor selection and pre operative surgical planning as well as it ensure that the liver remnant volume is at least 30 % which guarantee the safety of the donor. Conclusion The size of the right lobe graft for LDLT can be precisely calculated from pre-operative CT Volumetry with confidence and accuracy up to 95%.

Assessing hepatic steatosis by magnetic resonance in potential living liver donors

To determine the accuracy of magnetic resonance imaging-proton density fat fraction (MRI-PDFF) measurements for detecting liver fat content in potential living liver donors and to compare these results using liver biopsy findings. A total of 139 living liver donors (men/women: 83/56) who underwent MRI between January 2017 and September 2021 were included in this analysis retrospectively. The PDFFs were measured using both MR spectroscopy (MRS) and chemical shift-based MRI (CS-MRI) for each donor in a blinded manner. Significant positive correlations were found between liver biopsy and MRS-PDFF and CS-MRI PDFF in terms of hepatic steatosis detection [r = 0.701, 95% confidence interval (CI): 0.604–0.798, r = 0.654, 95% CI: 0.544–0.765, P < 0.001, respectively). A weak level correlation was observed between liver biopsy, MRI methods, and vibration-controlled transient elastography attenuation parameters in 42 available donors. Based on receiver operating characteristic (ROC) analysis, MRS-PDFF and CS-MRI PDFF significantly distinguished >5% of histopathologically detected hepatic steatosis with an area under the ROC curve (AUC) of 0.837 ± 0.036 (P < 0.001, 95% CI: 0.766–0.907) and 0.810 ± 0.036 (P < 0.001, 95% CI: 0.739–0.881), respectively. The negative predictive values (NPVs) of MRS-PDFF and CS-MRI PDFF were 88.3% and 81.3%, respectively. In terms of distinguishing between clinically significant hepatic steatosis (≥10% on histopathology), the AUC of MRS-PDFF and CS-MRI were 0.871 ± 0.034 (P < 0.001 95% CI: 0.804–0.937) and 0.855 ± 0.036 (P < 0.001, 95% CI: 0.784–0.925), respectively. The NPVs of MRS-PDFF and CS-MRI were 99% and 92%, respectively. The methods of MRS-PDFF and CS-MRI PDFF provide a non-invasive and accurate approach for assessing hepatic steatosis in potential living liver donor candidates. These MRI PDFF techniques present a promising clinical advantage in the preoperative evaluation of living liver donors by eliminating the requirement for invasive procedures like liver biopsy.

Updated Reference Intervals for Alanine Aminotransferase in a Metabolically and Histologically Normal Population

Background and AimsThis study aims to reevaluate upper reference limit (URL) for alanine aminotransferase (ALT) by considering the changing epidemiology of major liver diseases. We employed histological and metabolic parameters in Asian living liver donors. MethodsWe performed a retrospective analysis of 5,455 potential living liver donors from 2005 to 2019. Participants were screened for hepatitis B, C, HIV, and alcohol use. Histologically and metabolically healthy participants were assessed using the Prati criteria (body mass index <23 kg/m2, triglyceride ≤200 mg/dL, fasting glucose ≤105 mg/dL, total cholesterol ≤220 mg/dL). The updated ALT-URL was determined as the 95th percentile among participants without hepatic steatosis and who met the Prati criteria. ResultsThe median age was 30 years, with a male predominance (66.2%). Among 5,455 participants, 3,162 (58.0%) showed no hepatic steatosis, with 1,553 (49.1%) meeting both the criteria for no steatosis and the Prati criteria for metabolic health. The updated URL for ALT in these participants was 34 U/L for males and 22 U/L for females, which was significantly lower than conventionally accepted values. Using this revised ALT-URL, 72.8% of males with ALT levels ≥34 U/L and 55.0% of females with ALT levels ≥22 U/L showed signs of steatosis, while 32.7% of males and 22.2% of females met the criteria for metabolic syndrome. ConclusionsOur study provided the newly established reference intervals for ALT levels in a metabolically and histologically verified Asian population. The proposed URL for ALT are 34 U/L and 22 U/L for males and females, respectively.

Financial toxicity in living donor liver transplantation: A call to action for financial neutrality

After 2 decades of limited growth, living donor liver transplant (LDLT) has been increasingly accepted as a promising solution to the growing organ shortage in the US. With experience, LDLT offers superior graft and patient survival with low rates of rejection. However, not all waitlisted patients have equal access to LDLT, with financial toxicity representing a substantial barrier. Potential living liver donors face indirect, direct, and opportunity costs associated with donation as well as insurance-based discrimination and variable employer leave policies. There are multiple potential national, local, and patient-centered solutions to address some of the cost-related issues associated with living LDLT. These include standardization of employer leave policies, creation of federal and state-led tax relief programs, optimization of National Living Donor Assistance Center use, engagement of independent living donor advocates, creation of financial toolkits, and encouragement of recipient or donor-led fundraising. In this piece, members of the North American Living Liver Donation Group, a consortium of 37 LDLT programs, explore these financial challenges and discuss solutions to achieve financial neutrality, where individuals can donate free from financial constraints or gains. As a community, it is imperative that we confront factors driving financial toxicity to improve equity and access to LDLT.

Utilizing fully-automated 3D organ segmentation for hepatic steatosis assessment with CT attenuation-based parameters

ObjectivesTo investigate the clinical utility of fully-automated 3D organ segmentation in assessing hepatic steatosis on pre-contrast and post-contrast CT images using magnetic resonance spectroscopy (MRS)-proton density fat fraction (PDFF) as reference standard.Materials and methodsThis retrospective study analyzed 362 adult potential living liver donors with abdominal CT scans and MRS-PDFF. Using a deep learning-based tool, mean volumetric CT attenuation of the liver and spleen were measured on pre-contrast (liver(L)_pre and spleen(S)_pre) and post-contrast (L_post and S_post) images. Agreements between volumetric and manual region-of-interest (ROI)-based measurements were assessed using the intraclass correlation coefficient (ICC) and Bland–Altman analysis. Diagnostic performances of volumetric parameters (L_pre, liver-minus-spleen (L-S)_pre, L_post, and L-S_post) were evaluated for detecting MRS-PDFF ≥ 5% and ≥ 10% using receiver operating characteristic (ROC) curve analysis and compared with those of ROI-based parameters.ResultsAmong the 362 subjects, 105 and 35 had hepatic steatosis with MRS-PDFF ≥ 5% and ≥ 10%, respectively. Volumetric and ROI-based measurements revealed ICCs of 0.974, 0.825, 0.992, and 0.962, with mean differences of −4.2 HU, −3.4 HU, −1.2 HU, and −7.7 HU for L_pre, S_pre, L_post, and S_post, respectively. Volumetric L_pre, L-S_pre, L_post, and L-S_post yielded areas under the ROC curve of 0.813, 0.813, 0.734, and 0.817 for MRS-PDFF ≥ 5%; and 0.901, 0.915, 0.818, and 0.868 for MRS-PDFF ≥ 10%, comparable with those of ROI-based parameters (0.735–0.818; and 0.816–0.895, Ps = 0.228–0.911).ConclusionAutomated 3D segmentation of the liver and spleen in CT scans can provide volumetric CT attenuation-based parameters to detect and grade hepatic steatosis, applicable to pre-contrast and post-contrast images.Clinical relevance statementVolumetric CT attenuation-based parameters of the liver and spleen, obtained through automated segmentation tools from pre-contrast or post-contrast CT scans, can efficiently detect and grade hepatic steatosis, making them applicable for large population data collection.Key Points• Automated organ segmentation enables the extraction of CT attenuation-based parameters for the target organ.• Volumetric liver and spleen CT attenuation-based parameters are highly accurate in hepatic steatosis assessment.• Automated CT measurements from pre- or post-contrast imaging show promise for hepatic steatosis screening in large cohorts.Graphical abstract

226.5: The devil is in the details: investigating ineligibility of potential living liver donors for transplantation in Pakistan.

226.5: The devil is in the details: investigating ineligibility of potential living liver donors for transplantation in Pakistan.

Investigating Ineligibility of Potential Living Liver Donors for Transplantation: Experience from a Large Liver Transplant Center in Pakistan

BackgroundLiving Donor Liver Transplantation (LDLT) is common in Pakistan, where the deceased organ donation is lacking. However, not all potential living donors are suitable for the procedure due to various medical, technical, psychosocial, and ethical reasons. This study aims to investigate the reasons for the ineligibility of potential living liver donors in Pakistan. MethodsBetween June 2022 and March 2023, 530 potential living liver donors were assessed for liver transplant recipients at the Pakistan Kidney and Liver Institute & Research center (PKLI&RC). Potential donors were evaluated in three steps, including laboratory tests imaging, and consultations. Prospectively maintained data on all potential donors were examined and retrospectively assessed to identify the causes of donor rejection. ResultsOf the 530 potential living donors evaluated, 364 of the potential donors were considered ineligible (68.67% of donors were rejected). From these rejected donors, 193 (53%) were males, and 171 (47%) were females. The mean age of the rejected donors was 26 years old. The most common reason for disqualifying potential living liver donors was a withdrawal of consent (65 cases, 17.9%). Other factors contributing to ineligibility included fatty liver infiltration reflected by a liver attenuation index (LAI) < 0, future liver remnant (FLR) < 28%, and a graft-to-recipient weight ratio (GRWR) < 0.6. Medical issues, such as abnormal liver function tests and positive hepatitis serology, also resulted in disqualification. ConclusionThis study highlights the importance of meticulous assessment of potential living liver donors to ensure their safety and the success of the transplant. The high rate of withdrawal of consent and the prevalence of medical issues indicates the need for addressing ethical concerns and improving public education on the donation process. This study also emphasizes the importance of a deceased organ donation in developing countries like Pakistan to ensure the availability of organs for transplantation.

WITHDRAWN: Multiple Swaps Tested: Rehearsal for Triple and Five-Liver Paired Exchanges

Despite several advances in living donor liver transplant (LDLT), many potential living liver donors cannot donate their organs to their relatives because of blood group incompatibility and unsuitable anatomy. Liver paired exchange (LPE) can be used to overcome incompatibilities between living donor-recipient pairs. In this study, we report the early and late results of 3 and 5 LDLTs performed simultaneously to initiate the more complex LPE program. By demonstrating that our center is capable of performing up to 5 LDLTs, we have taken an essential step for establishing a complex LPE program.

High-resolution MR imaging with gadoxetate disodium for the comprehensive evaluation of potential living liver donors.

Several major transplantation centers have used composite multimodality evaluation for the preoperative evaluation of potential living liver donors. This approach can be time-consuming and, although rare, can cause complications. We aimed to demonstrate the clinical feasibility of our comprehensive preoperative MR protocol for the preoperative assessment of living liver donor candidates instead of composite multimodality evaluation. Thirty-five consecutive living liver donor candidates underwent multiphasic liver CT and comprehensive donor protocol MR examinations for preoperative evaluation in a single large-volume liver transplantation (LT) center. Three blinded abdominal radiologists reviewed the CT and MR images for vascular and biliary variations. The strength of agreement between CT and MR angiography was assessed using the kappa index. The detection rate of biliary anatomical variations was calculated. The sensitivity and specificity for detecting significant steatosis (>5%) were calculated. The estimated total volume and right lobe volumes measured by MR volumetry were compared with the corresponding CT volumetry measurements using the intraclass correlation coefficient (ICC). Among the 35 patients, 26 underwent LT. The measurement of agreement showed a moderate to substantial agreement between CT and MR angiography interpretations (kappa values, 0.47-0.79; p < 0.001). Combining T2-weighted and T1-weighted MR cholangiography techniques detected all biliary anatomical variations in 9 of the 26 patients. MR-proton density fat fraction showed a sensitivity of 100% (3/3) and a specificity of 91.3% (21/23) for detecting pathologically determined steatosis (>5%). MR volumetry reached an excellent agreement with CT volumetry (reviewers 1 and 2: ICC, 0.92; 95% CI, 0.84-0.96). Our one-stop comprehensive liver donor MR imaging protocol can provide complete information regarding hepatic vascular and biliary anatomies, hepatic parenchymal quality, and liver volume for living liver donor candidates and can replace composite multimodality evaluation.

Quality of life, depression and anxiety in potential living liver donors for pediatric recipients: A retrospective single center experience.

Living donor liver transplantation is a safe alternative for patients on a liver transplant list. Donor evaluation goes beyond physical variables to include social, emotional, and ethical aspects. The role of pre-donation sociopsychological evaluation of the donor candidate is as important to the success of the procedure as is the medical assessment. Success implies recovery from the operation and prompt engagement in pre-transplant professional and social activities, without leading to psychological or physical distress. Psychological profiling of potential living liver donors (PLLD) and evaluation of quality of life (QOL) can influence outcomes. To evaluate the socio-demographics and psychological aspects (QOL, depression, and anxiety) of PLLD for pediatric liver transplantation in a cohort of 250 patients. This was a retrospective cohort study of 250 PLLD who underwent psychological pre-donation evaluation between 2015 and 2019. All the recipients were children. The Beck anxiety inventory, Beck depression inventory, and 36-item short-form health survey (SF-36) scores were used to evaluate anxiety (Beck anxiety inventory), depression (Beck depression inventory), and QOL, respectively. A total of 250 PLLD were evaluated. Most of them were women (54.4%), and the mean age was 29.2 ± 7.2 years. A total of 120 (48.8%) PLLD were employed at the time of evaluation for donation; however, most had low income (57% earned < 2 times the minimum wage). A total of 110 patients (44%) did not finish the donation process, and 247 PLLD answered a questionnaire to evaluate depression, anxiety, and QOL (SF-36). Prevalence of depression was of 5.2% and anxiety 3.6%. Although most of the PLLD were optimistic regarding the donation process and never had doubts about becoming a donor, some traces of ambivalence were observed: 46% of the respondents said they would feel relieved if a deceased donor became available. PLLD had a low prevalence of anxiety and depression. The foundation for effective and satisfactory results can be found in the pre-transplantation process, during which evaluations must follow rigorous criteria to mitigate potential harm in the future. Pre-donation psychological evaluation plays a predictive role in post-donation emotional responses and mental health issues. The impact of such findings on the donation process and outcomes needs to be further investigated.

S1347 Comparison of Quantification of Hepatic Steatosis Between Liver MRI and Biopsy in Obese Patients in Pre-Transplant Setting

Introduction: Liver biopsy is a gold standard for assessing steatosis in non-alcoholic fatty liver disease (NAFLD). However, it carries risks including bleeding, discomfort, sampling error bias, inter-, and intra-observer variability. Magnetic resonance imaging with proton density fat-fraction (MRI-PDFF) has been explored to quantify steatosis to characterize NAFLD with accuracy and reproducibility. Our study assesses if MRI quantification of hepatic steatosis is consistent with that performed by liver biopsy for obese patients. Methods: In this study, a bivariate correlation was performed to calculate a Pearson’s correlation coefficient for patients with BMI≥30 who underwent screening with liver biopsy and liver MRI to quantify steatosis prior to living donation hepatectomy at Cleveland Clinic between 2019 and 2022. We excluded non-obese patients as well as patients who had contraindications to MRI, high alcohol use, pre-existing liver disease, or bleeding disorders. Results: We included 28 patients (median [standard deviation]) aged 41.0 [9.89] with BMI 32.3 [2.99] (Table). Patients were predominantly female (n=16, 57.1%), Caucasians (n=24, 85.7%), and with Class 1 Obesity (n=23, 23.2%). Mean MRI steatosis was 3.48 [2.53] while mean biopsy steatosis was 1.79 [3.45]. Bivariate correlation analysis showed that liver MRI and biopsy steatosis quantification to be positively correlated with moderate strength, R = 0.60, p < 0.001 for patients with BMI≥30. Conclusion: Our data highlight that liver MRI quantification of hepatic steatosis is consistent with biopsy for obese patients. These findings indicate that a liver MRI could be an accurate alternative for potential living liver donors. Further work is needed to evaluate if a liver MRI is a suitable alternative for individuals across different classes of obesity (Figure).Figure 1.: Correlation between liver biopsy steatosis and MRI steatosis Table 1. - Baseline characteristics of potential liver donors with obesity prior to hepatectomy Baseline characteristics n % Sex Female 16 57.1 Male 12 42.9 Race/Ethnicity Caucasian 24 85.7 African American 2 7.14 Hispanic 1 3.57 Other 2 7.14 Obesity classification Class I (30-34.9) 23 23.2 Class II (35-39.9) 3 3.03 Class III (>40) 2 2.02

Changes in Indices of Steatosis and Fibrosis in Liver Grafts of Living Donors After Weight Reduction.

BackgroundA short-term weight reduction program for potential living donors was introduced to reduce the extent of hepatic steatosis prior to liver transplantation. We aimed to investigate changes in non-invasive hepatic steatosis and fibrosis indices among those who completed the program.MethodsAmong 1,950 potential living liver donors between January 2011 and May 2019, 160 living donors joined the weight reduction program. The prospectively collected clinical data of these potential liver donors were analyzed retrospectively. Hepatic steatosis and fibrosis scores were determined using the fatty liver index (FLI), hepatic steatosis index (HSI), and NAFLD fibrosis score (NFS) and compared to MR spectroscopy (MRS) fat fraction results before and after weight reduction.ResultsThirty-nine potential living donors who had undergone MRS both before and after weight reduction were included in the analysis. Their body weight decreased from 78.02 ± 10.89 kg to 72.36 ± 10.38 kg over a mean of 71.74 ± 58.11 days. FLI, HSI, and MRS values decreased significantly from 41.52 ± 19.05 to 24.53 ± 15.93, 39.64 ± 3.74 to 35.06 ± 3.82, and 12.20 ± 4.05 to 6.24 ± 3.36, respectively. No significant decreases in NFS were observed. There was a significant correlation between the extent of HSI change and the extent of MRS change (R2 value = 0.69, P < 0.001), although there was no correlation between MRS and FLI.ConclusionThe weight reduction program significantly improved non-invasive indices of hepatic steatosis over a short period. HSI may allow for prediction of simple decreases in hepatic steatosis.

Relationship of body mass index and abdominal fat with radiation dose received during preoperative liver CT in potential living liver donors: a cross-sectional study

Although contrast-enhanced computed tomography (CT) is currently the most widely-used imaging modality for the preoperative evaluation of potential living liver donors, radiation exposure remains a major concern. The present study aimed to determine the relationship of body mass index (BMI) and abdominal fat with the effective radiation dose received during liver CT scans as part of a pre-donation work-up in potential living donors. This retrospective cross-sectional study included 695 potential living donors (mean age, 30.5±9.7 years; 445 men and 250 women) who had undergone preoperative liver CT scans between 2017 and 2018. The following measures were evaluated: BMI, abdominal fat as measured at the level of the third lumbar vertebra, and effective dose based on the dose length product (DLP). Correlations between the effective dose and other variables were evaluated using Pearson's correlation coefficient. The mean BMI, total fat area (TFA), and effective dose were 23.6±3.3 kg/m2, 218.7±110.0 cm2, and 9.4±3.3 mSv, respectively. The effective dose during liver CT scans had a strong positive correlation with both BMI (r=0.715; P<0.001) and TFA (r=0.792; P<0.001). As BMI and TFA increased, so did the effective dose. Higher BMI and TFA significantly increased the radiation dose received during liver CT scans in potential living donors.

Visceral Fat Area Is an Independent Risk Factor for Overweight or Obese Nonalcoholic Fatty Liver Disease in Potential Living Liver Donors

The present study aimed to evaluate the correlation between hepatic steatosis (HS), determined by biopsy, and visceral adiposity, measured by computed tomography (CT), in overweight or obese potential living liver donors, and to investigate the risk factors for overweight or obese nonalcoholic fatty liver disease (NAFLD). This retrospective study included 375 overweight or obese (body mass index ≥23 kg/m2) potential living liver donors (mean age, 30.4 ± 9.5 years; 273 men) who underwent liver biopsies and abdominal CT examinations in 2017 and 2018. Anthropometry, laboratory parameters, body composition, and HS were assessed. Correlations were analyzed using Pearson's correlation coefficient, and logistic regression was used to identify independent predictors of overweight or obese NAFLD. Visceral fat area (VFA) was positively correlated with the degree of HS in men (r=0.307; P < .001) and women (r=0.387; P < .001). Multivariable logistic regression analysis showed that alanine aminotransferase (odds ratio [OR], 1.017; 95% confidence interval [CI], 1.001-1.033; P = .033) and VFA (OR, 1.015; 95% CI, 1.008-1.022; P < .001) were independent risk factors for overweight or obese NAFLD in men, and VFA (OR, 1.029; 95% CI, 1.011-1.047; P = .002) was an independent risk factor for overweight or obese NAFLD in women. Visceral adiposity was positively correlated with the degree of HS in overweight or obese potential living liver donors. Additionally, visceral adiposity may be an independent risk factor for overweight or obese NAFLD in potential living liver donors.

Expanding donor pool for live donor liver transplantation: utilization of donors with non-alcoholic steatohepatitis after optimization.

Potential live liver donors with non-alcoholic steatohepatitis (NASH) are rejected upfront for donation in live donor liver transplantation (LDLT). Herein, we share our experience of the feasibility of live liver donation in donors with NASH after successful donor optimization. Prospectively collected data of 410 consecutive donor hepatectomies from June 2011 to January 2018 were analyzed. During the study period, NASH was diagnosed histopathologically in 17 donors. Four donors were rejected in view of grade 2 fibrosis on histology. Out of remaining 13 donors, six became eligible for donation following lifestyle changes, dietary modifications, and target weight reduction of ≥5%. Reversal of NASH was confirmed on repeat liver biopsy in all the 6 donors. Five out of 6 underwent right lobe (without MHV) donor hepatectomies, while one had left lobe donation. These donors had significantly higher peak bilirubin levels in the immediate post-operative period as compared to other non-NASH donors (4.00 ± 0.32 vs. 2.57 ± 1.77mg/dL, p = 0.043). In addition, post-hepatectomy normalization of hyperbilirubinemia, if any, was slower in donors with NASH (7 ± 1.3 vs. 5 ± 1.7days, p = 0.016). However, none of these donors had post-hepatectomy liver failure. All these donors were discharged after an average hospital stay of 8 ± 1.7days. Their respective recipients had uneventful post-operative courses without complications. Both the recipients and donors are having satisfactory liver functions after 46.7 ± 10.2months of follow-up. Scrupulous selection of live liver donors with NASH can open a door for expanding the organ pool in LDLT after a successful donor optimization program.

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.

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.