Acute-on-chronic liver failure (ACLF) is a fatal condition, and liver transplantation (LT) is a vital option for these patients. However, the result of living donor LT (LDLT) for ACLF is not well investigated. This study investigated the outcomes of LDLT in patients with ACLF compared with patients without ACLF. This was a single-center, retrospective, matched casecontrol study. From July 2002 to March 2017, a total of 112 patients with ACLF who underwent LDLT were enrolled according to the consensus of the Asian Pacific Association for the Study of the Liver. A total of 224 patients were selected for control comparison (non-ACLF) with demographic factors (sex, age, and body mass index) matched (1:2). Patients with ACLF were stratified into ACLF 1, 2, and 3 categories according to the number of organ failures based on the Chronic Liver Failure-Sequential Organ Failure Assessment score. Survival and surgical outcomes after LDLT were analyzed. The Model for End-Stage Liver Disease and Child-Turcotte-Pugh scores in the ACLF group were significantly higher than those in the non-ACLF group (P < 0.001). The 90-day, 3-year, and 5-year survival rates in the ACLF and non-ACLF groups were 97.3%, 95.5%, 92.9%, respectively, and 96.9%, 94.2%, and 91.1%, respectively (P = 0.58). There was more intraoperative blood loss in the ACLF group than in the non-ACLF group (P < 0.001). The other postoperative complications were not significantly different between the groups. A total of 20 patients (17.9%) in the ACLF group presented with 3 or more organ system dysfunctions (ACLF 3), and the 90-day, 3-year, and 5-year survival rates were comparable with those of ACLF 1 and ACLF 2 (P = 0.25). In carefully selected patients, LDLT gives excellent outcomes in patients with ACLF regardless of the number of organs involved. Comprehensive perioperative care and timely transplantation play crucial roles in saving the lives of patients with ACLF.

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Objective: Using non-invasive methods, such as BMI and CT LAIto suggest a prediction model for hepatic steatosis, examine the CT liver attenuation index and body mass index (BMI)association for pathological steatosis in living liver donors. Histological analysis remains the standard reference. Study Design: Retrospective study Place and Duration of Study: Liver Transplantation Department, Bahria International Hospital Orchard, Lahore from 1st June 2017 to 31st December 2018. Methodology: Fifty-nine donors were included with a median age of 23.00 years, as well as the potential donors for LDLT who experienced evaluation as a potential liver donor. Donors who underwent CT scan and histological liver evaluation were part of this study. Results: Of the donors, forty-eight (81.35%) had a CT LAI ≥1. The median BMI was 22.1 (range: 17.00–33.4). Twenty eight (47.5%) of the patients had undergone liver biopsy for screening in the pre-transplant period whereas 31 (52.5%) of the total evaluated donors underwent biopsy during the transplant. Thirty four (57.62%) out of 59 evaluated living liver donors underwent hepatectomy. Non-significant association (P=0.719) between different categories of BMI as the steatosis increases histologically, whereas significant association (P<.05) for CT LAI as the steatosis increases histologically. Conclusion: Body mass index alone is not a reliable factor for liver fat estimation non-enhanced CT liver-spleen attenuation index of ≤0 correspond to severe hepatic steatosis reserving histopathological liver evaluation via biopsy for selected cases and decreasing the need of liver biopsy while making sure both donor and recipient are safe. Keywords:Living donor liver transplantation, CT LAI, BMI, Liver biopsy

Introduction: Cryopreserved iliac vein, Polytetrafluoroethylene (PTFE) grafts, and cryopreserved aorta without endarterectomy have been used as middle hepatic vein (MHV) conduits for right liver graft in living donor liver transplantation, but each has advantages and disadvantages. In this study, we started to use aorta after endarterectomy (AoE) without any additional patches and checked patency after engraftment. Method: From January 2015 to June 2018, 111 cases of adult LDLT with modified right lobe grafts using aorta after endarterectomy were performed at Asan Medical Center. Retrospective analysis of patency in these recipients were carried out and compared with control group who received iliac vein (n=436) during the same study period. All vessels were stored and prepared as cryopreservation. Patency of reconstructed MHV was assessed by computed tomography (CT) which was routinely followed at every week during inhospital stay and at 1, 3, 6, and 12 months after LDLT. Result: Clinically significant stenosis of MHV requiring interventional stenting was occurred in three patients (2.7%) in AoE group, not significantly different from seventeen patients (3.9%) in iliac vein group (p=0.778). Aorta after endarterectomy showed 3-month patency rate of 91.6% and 1-year patency rate of 63.5%. Mean patency time of MHV with AoE 21.4AE1.9 months. When compared to iliac vein group, which demonstrated 3-month and 1year patency rate as 90.0% and 37.3%, respectively, AoE proved superior patency outcome (p=0.001). Mean patency time of iliac vein was 19.6AE2.2 months. Conclusion: In this study, AoE showed an acceptable outcome and even better patency compared to iliac vein. Clinically significant complication of stenosis or obstruction of MHV was fairly low. Larger diameter with well-matched thickness to MHV branches, not requiring iliac artery patch, is of great advantage in AoE as interposition graft.

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