Our initial experience suggests that this technique is a safe and reliable option for adults with chronic end-stage liver disease. A conservative application of this procedure in the adult population could significantly reduce the mortality on the adult waiting list.

No abstract

Living donor liver transplantation (LDLT) for adults is now a practical alternative to cadaveric liver transplantation. Use of right-lobe grafts has become the preferred donor procedure. Because of the complexity of this operation, a learning curve is to be expected. We report the outcome of our first 41 LDLTs at the University of Colorado Health Sciences Center (Denver, CO). We also discuss the lessons learned and the resultant modifications in the procedure that evolved during our series. L iving donor liver transplantation (LDLT) has undergone an evolution from its beginnings in pediatric transplantation using left lateral segments to adult-to-adult left-lobe transplantation to the now fairly well-accepted standard of adult-to-adult rightlobe transplantation. [1][2][3][4][5] We published a report of our first 2 cases using this technique and the rationale for our approach. 6 Since these initial cases, we have accumulated to date a series of 41 adult-to-adult right-lobe LDLTs. The results of this series and the lessons learned from these cases are presented to show that this can be a safe and effective procedure.Justification for the use of adult-to-adult liver transplantation is based on the critical shortage of adult organs available for cadaveric transplantation. A growing number of people are being listed for transplantation, whereas the availability of cadaveric donor organs is remaining fairly constant. The increasing use of marginal donor organs may increase this number, but what cost this will have on short-and long-term survival of the organs is yet to be determined. Waiting-list mortality remains a problem and is approximately 10% per year. 7 Using LDLT has been shown to decrease waiting time on the list for the transplant recipients while freeing organs for the remainder of the recipient pool who may not have potential living donors. 8 When introduced for the pediatric population, LDLT reduced mortality and waiting times for pediatric liver recipients. 9 Applying this concept to adults remained difficult because left lateral segments would not provide sufficient liver mass to meet an adult transplant recipient's needs. Left-lobe grafting in the adult-to-adult setting was initiated with mixed results, with concerns of inadequate hepatic mass. 10 The right-lobe graft has several advantages over the left lobe. These include increased hepatic mass, better anatomic position for anastomoses, and less concern for hepatic venous outflow obstruction.Of utmost importance in the use of this procedure is donor safety. Adequate liver volume must be left in place to avoid hepatic dysfunction. Technical resection of the right lobe of the liver has to be performed in a setting in which donor morbidity and mortality are minimal. Based on large surgical series of major hepatic resections, this donor operation should be able to be performed with a quoted mortality risk of less than 1% in experienced centers. 11 Several reports document the safety of living donor surgery in liver transplantation. 12,13 Realistic expect...

Primary sclerosing cholangitis (PSC) is the fourth leading diagnosis in liver transplant recipients in the UnitedStates. The disease is known to recur in 15% to 30% of liver transplant recipients. We set out to investigate how different immunosuppression regimens affected natural history of PSC after liver transplantation at our center. We reviewed records of all patients who underwent a liver transplantation at our institution in between 1988 and 2000 and had a diagnosis of PSC at the time of liver transplantation. Primary sclerosing cholangitis recurred in 15 of 71 patients (21.1%) who had complete records and survived more than 30 days after liver transplantation. Although recurrence of primary sclerosing cholangitis was most often seen (but not statistically significantly so) in patients who received maintenance corticosteroids, the time to recurrence was not significantly different between those who were treated with maintenance, those who were not successfully weaned, and those who successfully weaned off corticosteroids within 3 months after liver transplantation. Orthoclone (OKT3) therapy (Ortho-Biotech, Inc., Raritan, NJ) was associated with a higher risk of primary sclerosing cholangitis recurrence (29% versus 10%, P < .05). Recurrence was not influenced by immunosuppression with either cyclosporine or tacrolimus. Coexistent inflammatory bowel disease was a cause of failure to wean off corticosteroids, was associated with a shorter time to recurrence of sclerosing cholangitis, and was responsible for significant comorbidity (colon cancer in 7.3%). Primary sclerosing cholangitis recurrence is commonly seen after liver transplantation. More immunosuppression seems to be detrimental to the outcome of our patients with sclerosing cholangitis: use of OKT3 was associated with a greater incidence of recurrence. Length of corticosteroid use did not affect timing or risk of recurrence, and because it has been proven that early corticosteroid withdrawal after liver transplantation is beneficial, we continue to recommend this practice. (Liver Transpl 2003;9:727-732.)

MMF in combination with either TAC or CsA allows withdrawal of PRED 14 days after liver transplantation with a moderate rejection rate and no immunologic graft losses. Early PRED withdrawal decreases posttransplant diabetes, hypercholesterolemia, and hypertension, but patients maintained on TAC have lower serum cholesterol levels and a lower incidence of hypertension than CsA-treated patients.