Applicability of adult-to-adult living donor liver transplantation (original) (raw)
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Adult Living Donor Liver Transplantation
American Journal of Transplantation, 2004
Adult living donor liver transplantation (LDLT) begun in response to deceased donor organ shortage and waiting list mortality, grew rapidly after its first general application in the United States in 1998. There are significant risks to the living donor, including the risk of death and substantial morbidity, and two highly publicized donor deaths have led to decreased LDLT since 2001. Significant improvements in outcomes have been seen over recent years that have not been reported in single center studies; however, LDLT still comprises less than 5% of adult liver transplants, significantly less than in kidney transplantation where living donors now comprise the majority. The ethics, optimal utility and application of LDLT remain to be defined. In addition, studies to date have focused on post-transplant outcomes and not included the potential impact of LDLT on waiting time mortality. Future analyses should include appropriate control or comparison groups that capture the effect of LDLT on overall mortality from the time of listing. Further growth of LDLT will depend on defining the optimal recipient and donor characteristics for this procedure as well as broader acceptance and experience in the public and in transplant centers.
Living related liver transplantation in adults: first year experience at the University of Liège
Acta chirurgica Belgica, 2004
Living related liver transplantation (LRLT) in adult recipients has been recently developed to overcome the organ donor shortage, but LRLT leaves the healthy donors at risk of serious post-operative complications, or even death. The aim of this paper is to report the prospective evaluation of the initial experience of adult LRLT at the University of Liège. From March 2002 till March 2003, in a consecutive series of 35 adult liver transplantations, five recipients (mean age: 51 years) underwent LRLT, including one retransplantation. Indications for transplantation were autoimmune hepatitis, hepatitis B virus related cirrhosis with hepatocarcinoma (two cases), hepatitis C virus related cirrhosis with hepatocarcinoma, and ischemic intrahepatic bile duct necrosis 10 years after primary liver transplantation. Mean age of the donors was 34 years (range: 21-53 years). All donation cases were intra familial at first degree. The right lobe was used as a graft in four cases and the left lobe ...
Donor Selection for Adult-to-Adult Living Donor Liver Transplantation
Transplantation, 2013
Background-Donor selection criteria for adult-to-adult living donor liver transplantation vary with the medical center of evaluation. Living donor evaluation utilizes considerable resources and the non-maturation of potential into actual donors may sometimes prove fatal for patients with end stage liver disease. On the contrary, a thorough donor evaluation process is mandatory to ensure safe outcomes in otherwise healthy donors. We aimed to study the reasons for non-maturation of potential right lobe liver donors at our transplant center. Methods-A retrospective data analysis of all potential living liver donors evaluated at our center from 1998 to 2010 was done. Results-Overall 324 donors were evaluated for 219 potential recipients and 171 (52.7%) donors were disqualified. Common reasons for donor non-maturation included: (1) Donor reluctance, 21% (2) >10% macro-vesicular steatosis, 16% (3) assisted donor withdrawal, 14% (4) inadequate remnant liver volume, 13% (5) psychosocial issues, 7% and thrombophilia, 7%. Ten donors (6%) were turned down due to anatomical variations (8 biliary and 2 arterial anomalies). Donors older than 50 years and those with BMI over 25 were less likely to be accepted for donation. Conclusions-We conclude that donor reluctance, hepatic steatosis and assisted donor withdrawal are major reasons for non-maturation of potential into actual donors. Anatomical variations and underlying medical conditions were not a major cause of donor rejection. A system in practice to recognize these factors early in the course of donor evaluation to improve the efficiency of the selection process and ensure donor safety is proposed.
Adult–adult living donor liver transplantation
Journal of Gastrointestinal Surgery, 2004
After the first report from Denver in 1998 of a successful liver transplant in an adult using the right lobe from a living donor, the procedure was rapidly adopted by many transplant centers as a potential solution to the critical shortage of donor livers. By the end of 2000, when the National Institutes of Health held a Consensus Conference on Adult-Adult Living Donor Transplantation (AALDT), a substantial body of literature had already developed and many of the associated technical and medical pitfalls had been defined. The exponential expansion of the procedure came to a dramatic halt in January 2002 when the death of a donor occurred at Mount Sinai Hospital-the busiest AALDT center in the United States. This led to a widespread reassessment of the risks inherent in right lobe donation. Yet, the problem that drove the development of this controversial technique-the dire shortage of organs for transplantationstill persists. After a 50% drop in the number of AALDT procedures performed in the United States in 2002 compared with 2001, centers are regrouping and approaching AALDT with renewed interest, albeit with heightened awareness of the attendant risks. On November 2, 2002, a state-of-the-art symposium on AALDT was held in Boston, MA, under the combined auspices of the American Hepatico-Pancreato-Biliary Association and the American Association for the Study of Liver Diseases. This article comprises the presentations at the symposium on three subjects of critical importance concerning AALDT. These include advances in surgical technique, candidate selection, and hepatic regeneration; each subject is acknowledged by an expert in the field.
Ethical considerations and rationale of adult-to-adult living donor liver transplantation
Liver Transplantation, 2001
Adult-to-adult living donor liver transplantation (ALDLT) is a reality; shortly after its introduction into clinical practice, it is being performed in approximately 50 centers throughout the United States and Europe. The quick development of ALDLT and some deaths among donors repropose old ethical dilemmas and confront the transplant community with new urgent problems. To minimize risks for recipients and, especially, donors, two key questions are addressed: (1) who can or should perform the procedure, and (2) what patient should undergo the procedure. The high risks taken by live donors undergoing a hemihepatectomy seem to be justified by the steadily increasing mortality of adult recipients waiting for transplantation. A comprehensive consent procedure is at the base of responsible decision making for both donors and recipients. In adherence to basic medical criteria, the autonomy of decision of donors and recipients may allow the extension of indications to patients not suitable to undergo transplantation with cadaveric grafts. The broadening of indications is appropriate only in centers with adequate experience and proven expertise in ALDLT. The medical community faces the duty of regulating ALDLT before external influences force undesired policy changes, particularly if not based on medical grounds. Individual centers and patients are ultimately responsible for the correct use of LDLT. (Liver Transpl 2001;7:921-927.)
Annals of Surgery, 2007
To determine outcomes for both donors and recipients of adult-to-adult living donor liver transplantation (AALDLT) and independent factors impacting those outcomes. Summary Background Data: Deceased donors for organ transplantation remain extremely rare, making living donor liver transplantation (LDLT) practically the sole therapeutic modality for patients with end-stage liver disease in Japan. Methods: Retrospective analysis of initial LDLT for 335 consecutive adult (Ն18 years) patients performed between November 1994 and December 2003. Results: Of the 335 recipients, 275 received right-liver grafts and the remaining 60 recipients received non-right-liver grafts. Three of the 335 liver grafts were domino-splitting livers. Sixty of the 332 donors other than the domino-donors showed major postoperative complications. Multivariate analysis indicated that accumulation of case experience significantly and advantageously affected the surgical outcomes of these living liver donors, and right-liver donation and prolonged donor operation time were shown to be independent risk factors of major complications in the donors. Post-transplant patient and graft survival estimates were 73.1% and 72.5% at 1 year, 67.7% and 66.3% at 4 years, and 64.7% and 61.9% at 7 years, respectively. Obvious pretransplant encephalopathy, a higher (Ն31) modified Model for End-stage Liver Disease score (including points for persistent ascites and low serum sodium) and higher donor age (Ն50 years) were indicated as independent factors predictive of graft failure (graft loss or death) in the multivariate analysis. Conclusions: Graft type and degree of experience exerted a significant impact on the surgical outcomes of AALDLT donors but did not significantly affect the survival outcomes of AALDLT recipients. Better pretransplant conditions and younger age (Ͻ50 years) among the living donors appeared to be advantageous in terms of gaining better survival outcomes of patients undergoing AALDLT. (Ann Surg 2007;245: 315-325) From the *Organ Transplant Unit and the †Department
Liver Transplantation, 2011
The study objectives were to determine whether the findings of the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) reflect the U.S. national experience and to define risk factors for patient mortality and graft loss in living donor liver transplantation (LDLT). A2ALL previously identified risk factors for mortality after LDLT, which included early center experience, older recipient age, and longer cold ischemia time. LDLT procedures at 9 A2ALL centers (n ¼ 702) and 67 non-A2ALL centers (n ¼ 1664) from January 1998 through December 2007 in the Scientific Registry of Transplant Recipients database were analyzed. Potential predictors of time from transplantation to death or graft failure were tested using Cox regression. No significant difference in overall mortality between A2ALL and non-A2ALL centers was found. Higher hazard ratios (HRs) were associated with donor age (HR ¼ 1.13 per 10 years, P ¼ 0.0002), recipient age (HR ¼ 1.20 per 10 years, P ¼ 0.0003), serum creatinine levels (HR ¼ 1.52 per loge unit increase, P < 0.0001), hepatocellular carcinoma (HR ¼ 2.12, P<0.0001) or hepatitis C virus (HR ¼ 1.18, P ¼ 0.026), intensive care unit stay (HR ¼ 2.52, P< 0.0001) or hospitalization (HR ¼ 1.62, P < 0.0001) versus home, earlier center experience (LDLT case number 15: HR ¼ 1.61, P < 0.0001, and a cold ischemia time >4.5 hours (HR ¼ 1.79, P ¼ 0.0006). Except for center experience, risk factor effects between A2ALL and non-A2ALL centers were not significantly different. Variables associated with graft loss were identified and showed similar trends. In conclusion, mortality and graft loss risk factors were similar in A2ALL and non-A2ALL centers.
Live donor adult liver transplantation
Current Opinion in Organ Transplantation, 2008
Purpose of review Because the gap between liver organ supply and demand continues to increase, adult living-donor liver transplantation continues to represent a significant pool of organs. Recent findings With this in mind, we discuss recent issues in adult living-donor liver transplantation, including issues with donor evaluation and selection, donor liver biopsy, orphan organ allocation, donor morbidity and mortality, outcomes compared with deceased donor liver transplant from time of evaluation, death on the waiting list, and evolving recipient indications for living-donor liver transplantation. Summary Increasing the number of living-donor liver transplants would allow us to expedite transplant, avoid death on the waitlist, and possibly save more lives by expanding the criteria for transplant. These benefits must always be weighed against the potential risks and complications to the donor, which can be significant.