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Hepatocellular carcinoma (HCC) represents an increasing fraction of liver transplant indications; the role of living donor liver transplant (LDLT) remains unclear. Recurrence and post-transplant mortality rates were compared in LDLT and deceased donor liver transplant (DDLT) patients with at least one potential living donor evaluated. HCC recurrence and post-transplant mortality were evaluated among 100 LDLT and 97 DDLT recipients in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study. Mortality from date of evaluation of each recipient’s first potential living donor was analyzed. LDLT recipients had shorter time to transplant, were more likely to have tumors exceeding Milan criteria, higher alpha-fetoprotein levels, and less likely to have received pre-operative loco-regional therapy than DDLT recipients. Unadjusted 5-year HCC recurrence was significantly higher after LDLT (38%) than DDLT (11%), (p=0.0004). After adjustment for tumor characteristics, HCC recurrence remained significantly different between LDLT and DDLT recipients (hazard ratio (HR) = 2.35; p=0.04) for the overall cohort but not for recipients transplanted following the introduction of MELD prioritization. Five-year post-transplant survival was similar in LDLT and DDLT recipients from time of transplant (HR=1.32; p=0.27) and from date of LDLT evaluation (HR=0.73; p=0.36). We conclude that the higher recurrence observed after LDLT is likely due to differences in tumor characteristics, pre-transplant HCC management, and waiting time.

Background & Aims Adult-to-adult living donors and recipients were studied to characterize patterns of liver growth and identify associated factors in a multicenter study. Methods 350 donors and 353 recipients in A2ALL (Adult to Adult Living Donor Liver Transplantation Cohort Study) transplanted between March 2003 and February 2010 were included. Potential predictors of 3-month liver volume included total and standard liver volumes (TLV, SLV), the model for end-stage liver disease (MELD) score (in recipients), remnant and graft size, remnant to donor and graft to recipient weight ratio (RDWR, GRWR), remnant/TLV, and graft/SLV. Results Among donors, 3-month absolute growth was 676±251g (mean± SD) and percent reconstitution was 80%±13%. Among recipients, GRWR was 1.3%±0.4% (8<0.8%). Graft weight was 60%±13% of SLV. Three-month absolute growth was 549±267g and percent reconstitution was 93%±18%. Predictors of greater 3-month liver volume included larger patient size (donors, recipients), larger graft volume (recipients), and larger TLV (donors). Donors with the smallest remnant/TLV ratios had larger than expected growth, but also had higher postoperative bilirubin and international normalized ratio at 7 and 30 days. In a combined donor-recipient analysis, donors had smaller 3-month liver volumes than recipients adjusted for patient size, remnant or graft volume, and TLV or SLV (p=0.004). Recipient graft failure in the first 90 days was predicted by poor graft function at day 7 (HR=4.50, p=0.001), but not by GRWR or graft fraction (p>0.90 for each). Conclusions Both donors and recipients had rapid yet incomplete restoration of tissue mass in the first 3 months, confirming previous reports. Recipients achieved a greater percentage of expected total volume. Patient size and recipient graft volume significantly influenced 3 month volumes. Importantly, donor liver volume is a critical predictor of the rate of regeneration, and donor remnant fraction impacts post-resection function.

Endoscopic stenting of the gallbladder may be a potential treatment for symptomatic gallbladder disease in patients with cirrhosis awaiting liver transplantation, considered to be high-risk for cholecystectomy.

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