Expanding Living Donor Liver Transplantation

In the 1980s in the United States (US), young children in liver failure were at proportionately greater risk of dying on the deceased donor liver transplant (DDLT) waitlist than adults because of the lack of appropriately sized grafts. This led to the development of two deceased donor liver techniques—reduced-size (trimming the graft to decrease its size) and split-liver (where one liver could provide grafts to two candidates). These developments decreased but did not eliminate waitlist mortality for young children. Split-liver DDLT paved the way for living donor liver transplantation (LDLT) in children using the lateral segments of the left lobe. Pediatric LDLT began slowly at only a few centers with successful donor and recipient results. Adult-to-adult LDLT expanded quickly despite many US programs having limited experience, low volumes, and significant donor morbidity. The ethical issues raised by the rapid expansion of adult-to-adult LDLT in the US are discussed.

Candidate Criteria for Living Versus Deceased Donor Liver Grafts

This chapter explores whether living donor liver transplant (LDLT) is morally permissible when the candidate is ineligible for a deceased donor liver transplant (DDLT). Two cases are evaluated: a woman with metastatic colorectal cancer (CRC) and a young female liver transplant recipient with a history of multiple suicide attempts who is in acute liver failure due to another intentional drug overdose. Although both women could benefit (gain life years) from liver transplant, neither is deemed eligible for DDLT by their transplant teams because of a short post-transplant life expectancy in the first case and expected poor organ stewardship in the second case. This chapter argues that LDLT is morally permissible in candidates ineligible for DDLT if the living donor provides a voluntary informed consent, knows he or she can withdraw at any time, and understands that the recipient candidate will not be listed for a DDLT should the LDLT fail.

Reliable Estimation of Preoperative Graft Volume in Living Donor Liver Transplantation

Aims & Objectives: Corner stone in performing living donor liver transplant is to assess and predict the adequacy of the donated liver for recipient and remaining liver. Previously the conversion of liver volume to estimated weight is done by using unit to unit conversion with a factor of 1. We analyzed data of our institute to research the methodology and local applicability of the same. Place and duration of study: Shaikh Zayed Hospital, Lahore. January 2011 to June 2017 Material & Methods: Retrospective data was collected for the first 115 recipients and donors. Their preoperative liver volumes calculated by C.T scan and post-operative graft harvested with weights were compared. Results: The parameter of actual volume of right lobe averaged to 769.77 ± 12.73 gm varying with a quantum of 17.73% (426 – 1123 gm). Estimated volume of right lobe of liver varied 358 to 1218 ml (CV = 17.84%) with an average value of 798.96 ± 13.29 ml. Results of linear regression between estimated volume of right lobe and actual weight of the right lobe in gm was significantly linear (r = 0.830, r2 = 0.690, adj. r2 = 0.689 and F = 250.98, p < 0.0001), showing that volumetric assessment overestimated graft weight/volume. Following is equation generated from our data for graft weight estimation. Actual right lobe (g) = 134.004 + 0.796 (estimated right lobe volume (ml) ± 76.42. Conclusion: Using one to one principle for volume estimation of healthy liver can be misleading and therefore we propose an equation to reach more accurate estimation of graft weight. Keywords: living donor liver transplant, CT volumetry, graft to body weight ratio

Living donor liver transplantation for hepatocellular carcinoma beyond the Milan criteria: outcome of expanded criteria in tumor size

Background The Milan criteria are the universal standard of liver transplantation for hepatocellular carcinoma (HCC). Numerous expanded criteria have shown outcomes as good as the Milan criteria. In Taiwan, living donor liver transplant (LDLT) accounts for the majority of transplantations due to organ shortages. Methods We retrospectively enrolled 155 patients who underwent LDLT for HCC from July 2005 to June 2017 and were followed up for at least 2 years. Patients beyond the Milan criteria (n = 78) were grouped as recurrent or nonrecurrent, and we established new expanded criteria based on these data. Results Patients beyond the Milan criteria with recurrence (n = 31) had a significantly larger maximal tumor diameter (4.13 ± 1.96 cm versus 6.10 ± 3.41 cm, p = 0.006) and total tumor diameter (7.19 ± 4.13 cm versus 10.21 ± 5.01 cm, p = 0.005). Therefore, we established expanded criteria involving maximal tumor diameter ≤ 6 cm and total tumor diameter < 10 cm. The 5-year survival rate of patients who met these criteria (n = 134) was 77.3%, and the 5-year recurrence rate was 20.5%; both showed no significant differences from those of the Milan criteria. Under the expanded criteria, the pool of eligible recipients was 35% larger than that of the Milan criteria. Conclusion Currently, patients with HCC who undergo LDLT can achieve good outcomes even when they are beyond the Milan criteria. Under the new expanded criteria, patients can achieve outcomes as good as those with the Milan criteria and more patients can benefit.