Liver regeneration after living donor transplantation: Adult-to-adult living donor liver transplantation cohort study (original) (raw)
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Liver Transplantation, 2009
Many centers require a minimal graft to body weight ratio (GBWR) Ն 0.8 as an arbitrary threshold to proceed with right-lobe living donor liver transplantation (RL-LDLT), and there is often hesitancy about transplanting lower volume living donor (LD) liver grafts into sicker patients. The data supporting this dogma, based on the early experience with RL-LDLT at Asian centers, are weak. To determine the effect of LD liver volume in the modern era, we investigated the impact of GBWR on the outcome of RL-LDLT with a GBWR as low as 0.6 at the University of Toronto. Between April 2000 and September 2008, 271 adult-to-adult RL-LDLT procedures and 614 deceased donor liver transplants were performed. Twenty-two living donor liver transplantation (LDLT) cases with a GBWR of 0.59 to 0.79 (group A) were compared with 249 LDLT cases with a GBWR Ն 0.8 (group B) and with 66 full-graft deceased donor liver transplants (group C), who were matched 3:1 according to donor and recipient age, Model for End-Stage Liver Disease score, and presence of hepatitis C and hepatocellular carcinoma with the low-GBWR group. Portal vein shunts were not used. Markers of reperfusion injury [aspartate aminotransferase (AST) and alanine aminotransferase (ALT)], graft function (international normalized ratio and bilirubin), complications graded by the Clavien score, and graft and patient survival were compared. As expected, LD recipients had a significantly shorter cold ischemia time (94 Ϯ 43 minutes for A, 96 Ϯ 57 minutes for B, and 453 Ϯ 152 minutes for C, P ϭ 0.0001). However, the peak AST, peak ALT, absolute decrease in the international normalized ratio, day 7 bilirubin level, postoperative creatinine clearance, complication rate graded by the Clavien score, and median hospital stay were similar in all groups. The rate of biliary complications was higher with LD grafts than deceased donor grafts (19% for A versus 10% for B and 0% for C, P ϭ 0.2). Patient survival was similar in all groups at 1, 3, and 5 years (91% for A versus 89% for B and 93% for C at 1 year, 87% for A versus 81% for B and 89% for C at 3 years, and 83% for A versus 81% for B and 87% for C at 5 years, P ϭ 0.63). A Cox proportional regression analysis revealed only hepatitis C virus as a risk factor for poorer graft survival and not GBWR as a continuous or categorical variable. In conclusion, we found no evidence of inferior outcomes with smaller size grafts versus larger size LD grafts or full-size deceased donor grafts. Further studies are warranted to examine the factors affecting the function of smaller grafts for living liver donation and thereby define the safe lower limits for transplantation. Liver Transpl 15: [1776][1777][1778][1779][1780][1781][1782] 2009.
Analysis of Long-term Outcomes of 3200 Liver Transplantations Over Two Decades
Annals of Surgery, 2005
Objective: Few studies have evaluated long-term outcomes after orthotopic liver transplantation (OLT). This work analyzes the experience of nearly 2 decades by the same team in a single center. Outcomes of OLT and factors affecting survival were analyzed. Methods: Retrospective analysis of 3200 consecutive OLTs that were performed at our institution, between February 1984 and December 31, 2001. Results: Of 2662 recipients, 578 (21.7%) and 659 (24.7%) were pediatric and urgent patients, respectively. Overall 1-, 5-, 10-, and 15-year patient and graft survival estimates were 81%, 72%, 68%, 64% and 73%, 64%, 59%, 55%, respectively. Patient survival significantly improved in the second (1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001) versus the era I (1984 -1991) of transplantation (P Ͻ 0.001). Similarly, graft survival was better in the era II of transplantation (P Ͻ 0.02). However, biliary and infectious complications increased in era II. When OLT indications were considered, best recipient survival was obtained in children with biliary atresia (82%, 79%, and 78% at 1, 5, and 10 years, respectively), while malignant disease in adult patients resulted in the worst outcomes of 68% and 43% at 1 and 5 years, post-OLT. Further, patients Ͻ18 years and nonurgent recipients exhibited superior survival when compared with recipients Ͼ18 years (P Ͻ 0.001) or urgent patients (P Ͻ 0.001). Of 13 donor and recipient variables, era of OLT, recipient age, urgent status, donor age, donor length of hospital stay, etiology of liver disease, retrans-plantation, warm and cold ischemia, but not graft type (whole, split, living-donor), significantly impacted patient survival. Conclusions: Long-term benefits of OLT are greatest in pediatric and nonurgent patients. Multiple factors involving the recipient, etiology of liver disease, donor characteristics, operative variables, and surgical experience influence long-term survival outcomes. By balancing and matching these factors with a given recipient, optimum results can be achieved. (Ann Surg 2005;241: 905-918) Survival curves were computed using Kaplan-Meier methods and compared using log-rank tests. Medians were Busuttil et al
Effect of Graft Type on Postoperative Liver Function Recovery in Living Liver Donors
Transplantation Proceedings, 2009
Background. Donor safety is the primary focus in living-donor liver transplantation. Although, the procedure carries a significant risk of morbidity and even death, the use of marginal living donors is a current issue of discussion. Patients and Methods. Between September 2001 and October 2008, we performed 203 liver transplantation procedures using organs from living donors. Of 203 donors, 115 were men and 88 were women, with a mean (SD; range) age of 34.5 (9; 19-66) years. One hundred fifty donors were first-degree relatives of the recipients, 36 were second-degree relatives, and 17 were spouses. We did not accept grafts with remnant volume less than 40% or from donors with impaired liver function. We performed 96 right-lobe 38 left-lobe, and 69 left-lateral segmentectomies. For the right-lobe grafts, the median hepatic vein was always left in the remnant liver. The mean ratios of remnant to total donor liver volume were 42.0%, 66.8%, and 74.6% for the right-, left-, and left lateral segmentectomies, respectively. Mean hospitalization time was 7.0, 6.2, and 9.7 days, respectively. Mean operative time was 330, 324, and 324 minutes, respectively. Only 15 donors (7.8%) received autologous blood transfusions during surgery. Liver function tests including alanine aminotransferase, aspartate aminotransferase and bilirubin concentrations and prothrombin time were assessed postoperative days 1, 3, and 5 at outpatient follow-up, usually at week 3. Results. There were no deaths; however, 26 complications occurred in 20 of 203 donors (5.2%), most of which were treated with radiologic interventions. Conclusion. Larger grafts produce impaired function in the early postoperative period; however, they do not have a negative effect in the long term. The remnant volume should be measured fastidiously, and surgeons must avoid taking large volumes of liver, especially in right-lobe donors.
Annals of …, 2005
Objective:Few studies have evaluated long-term outcomes after orthotopic liver transplantation (OLT). This work analyzes the experience of nearly 2 decades by the same team in a single center. Outcomes of OLT and factors affecting survival were analyzed.Methods:Retrospective analysis of 3200 consecutive OLTs that were performed at our institution, between February 1984 and December 31, 2001.Results:Of 2662 recipients, 578 (21.7%) and 659 (24.7%) were pediatric and urgent patients, respectively. Overall 1-, 5-, 10-, and 15-year patient and graft survival estimates were 81%, 72%, 68%, 64% and 73%, 64%, 59%, 55%, respectively. Patient survival significantly improved in the second (1992–2001) versus the era I (1984–1991) of transplantation (P < 0.001). Similarly, graft survival was better in the era II of transplantation (P < 0.02). However, biliary and infectious complications increased in era II. When OLT indications were considered, best recipient survival was obtained in children with biliary atresia (82%, 79%, and 78% at 1, 5, and 10 years, respectively), while malignant disease in adult patients resulted in the worst outcomes of 68% and 43% at 1 and 5 years, post-OLT. Further, patients <18 years and nonurgent recipients exhibited superior survival when compared with recipients >18 years (P < 0.001) or urgent patients (P < 0.001). Of 13 donor and recipient variables, era of OLT, recipient age, urgent status, donor age, donor length of hospital stay, etiology of liver disease, retransplantation, warm and cold ischemia, but not graft type (whole, split, living-donor), significantly impacted patient survival.Conclusions:Long-term benefits of OLT are greatest in pediatric and nonurgent patients. Multiple factors involving the recipient, etiology of liver disease, donor characteristics, operative variables, and surgical experience influence long-term survival outcomes. By balancing and matching these factors with a given recipient, optimum results can be achieved.
Short and Long-Term Outcomes After Living Donor Liver Transplantation
Transplantation Proceedings, 2005
Introduction. Living donor liver transplantation was first described as a way to alleviate the organ shortage. Extensive studies of both the prospective donor and the recipient are necessary to ensure successful outcome. In this paper we describe our results in 28 living donor liver transplantations from the perspective of the donor and the recipient. Methods. A prospective, longitudinal, observational, comparative study was conducted from April 1995 to October 2004, including 28 living donor liver transplantations. Results. After a mean follow-up time of 25.6 Ϯ 20.58 months, all donors are alive, showing normal liver function tests. All of them have been reincorporated into their normal lives. At the end of the study and after a mean follow-up time of 21.2 Ϯ 14.3 months, 86.3% of the adult recipients are alive. Actuarial recipient survivals at 6, 12, and 36 months were 86.36%. Actuarial mean survival time was 44 months (95% CI, 37 to 51). At the end of the study, 77.3% of the grafts are functioning. Actuarial graft survivals at 6, 12, and 36 months were 77.27%. Actuarial mean graft survival time was 32 months (95% CI, 25 to 39). The main complications were hepatic artery thrombosis (n ϭ 2) and small for-size syndrome (n ϭ 2). At a mean follow-up of 20.33 Ϯ 7.74 months, all pediatric recipients are alive. Actuarial recipient survivals at 12 and 36 months were 100% and actuarial graft survivals were 80%. Conclusions. Living donor liver transplantation may increase the liver graft pool, and therefore reduce waiting list mortality. Nevertheless caution must be deserved to avoid surgical morbidity and mortality in with the donor the recipient.
Long-Term Follow-up of Living Liver Donors
Transplantation Proceedings, 2010
Objectives. At our center living donor liver transplantation (LDLT) represents 4% of all transplantations. The aim of this cross-sectional study was to clarify the current well-being of the donors, their experiences of being a donor, as well as the regenerative capacity of the liver. Patients and Method. Thirty-six healthy subjects donated a part of their liver between 1996 and 2007. Thirty-four patients participated in the study and completed our questionnaire. We performed magnetic resonance imaging (MRI) of the liver, physical examination, and blood chemistry. Results. Twenty-three subjects had donated the left lateral segment and 11 the right lobe. Their hospital stay ranged from 5-15 days (median, 10). Mostly, the sick-leave period was 8 -12 weeks and time for recovery was 3-6 months. Long-term problems were heartburn, abdominal discomfort, incisional hernia, and fatigue. Twenty-six (76.5%) subjects viewed the donation experience as entirely positive; no one was regretful. Liver function tests were normal. The MRI data at follow-up of 13 left lateral segment and 11 right lobe grafts showed recovery of the total liver volume to almost preoperative values, mean 1522 Ϯ 241 mL versus 1552 Ϯ 219 mL, respectively. Conclusion. Living liver donors commonly recovered after 3-6 months, perceiving donation as a positive experience with no regret. Durable side effects were mainly heartburn and abdominal discomfort, but the symptoms were mostly mild. Liver function was normal. The MRI data showed a mean regeneration of liver volume to 98.6% of the preoperative values.
Who Fares Worse After Liver Transplantation? Impact of Donor and Recipient Variables on Outcome
Transplantation, 2013
Background. Numerous donor and recipient risk factors influence survival after liver transplantation (LT). Methods. The aim of this study was to prospectively evaluate the effect of donor and recipient variables on 12-month patient and graft survival after LT. Five hundred forty-six patients underwent LT in a single center (2000Y2010). Results. Bilirubin (P=0.006) and cold ischemia time (P =0.002) were predictive of graft loss at 12 months after LT. Model for End-Stage Liver Disease score Q25 was associated with a lower 12-month graft survival than Model for End-Stage Liver Disease score G15 (P =0.02). Hepatitis C virus (HCV)Ypositive patients showed a lower survival than HCV-negative patients 12 months after LT (P =0.04), with serum sodium concentration (P =0.01) predictive for graft survival. Donor age demonstrated a trend of prediction (P=0.05) for HCV-positive patient survival. In hepatocellular carcinoma patients, donor age (P=0.02 and 0.02) and use of partial graft (P =0.01 and 0.02) were predictive of patient and graft survival at 12 months after LT. Conclusions. Bilirubin and cold ischemia time are crucial for graft outcome post-LT. Survival in HCV-positive patients is lower than in HCV-negative recipients. Donor age and partial graft use are predictive of patient and graft survival in hepatocellular carcinoma patients.