Considering extended right lobe grafts as major extended donor criteria in liver transplantation is justified

Abstract

Summary The outcomes of split‐liver transplantation are controversial. This study compared outcomes and morbidity after extended right lobe liver transplantation (ERLT) and whole liver transplantation (WLT) in adults. MEDLINE and Web of Science databases were searched systematically and unrestrictedly for studies on ERLT and its impact on graft and patient survival, and postoperative complications. Graft loss and patient mortality odds ratios (OR) and 95% confidence intervals (CI) were assessed by meta‐analyses using Mantel–Haenszel tests with a random‐effects model. Vascular and biliary complications, primary nonfunction, 3‐month, 1‐, and 3‐year graft and patient survival, and retransplantation after ERLT and WLT were analyzed. The literature search yielded 10 594 articles. After exclusion, 22 studies (n = 75 799 adult transplant patients) were included in the analysis. ERLT was associated with lower 3‐month (OR = 1.43, 95% CI = 1.09–1.89, P = 0.01), 1‐year (OR = 1.46, 95% CI = 1.08–1.97, P = 0.01), and 3‐year (OR = 1.37, 95% CI = 1.01–1.84, P = 0.04) graft survival. WL grafts were less associated with retransplantation (OR = 0.57; 95% CI = 0.41–0.80; P < 0.01), vascular complications (OR = 0.53, 95% CI = 0.38–0.74, P < 0.01) and biliary complications (OR = 0.67; 95% CI = 0.47–0.95; P = 0.03). Considering ERLT as major Extended Donor Criteria is justified because ERL grafts are associated with vasculobiliary complications and the need for retransplantation, and have a negative influence on graft survival.

Outcome of Extended Right Lobe Liver Transplantations

“…Based on these findings, we suggested that ERLT livers be considered maEDC grafts. (11) We hypothesized that the labMELD score, which reflects the patient's clinical condition and acuity, may determine the ERLT outcome, but we were not able to confirm this hypothesis because the included studies did not report recipient data. This emphasized that recipient parameters are neglected when it comes to addressing issues of a highly technical procedure and allocating organs for ERLT.…”

“…One way to avoid this bias and to remain within the optimal CIT range would be to improve logistics and to allocate ex situ split grafts to pediatric and adult transplantation candidates at the center where the ex situ split‐liver procedure is performed and to allocate in situ split grafts to different centers. ( 11 ) Combined with machine perfusion, this may abrogate the negative physiological consequences of prolonged ischemia time especially in ex situ ERLT. ( 20 ) Although information on splitting technique was not available in this study, the analysis revealed a CIT cut‐off of 10 hours, beyond which the outcomes of ERLT are suboptimal.…”

“…(6,8,9) In a recent metaanalysis, ERL grafts were classified as major extended donor criteria (maEDC) organs because they had higher vasculobiliary complications and retransplantation rates and reduced graft survival in adult recipients. (11) However, the study could not address all aspects of the multifaceted ERLT because recipient data were not available.…”

Prognostic role of selection criteria for liver transplantation in patients with hepatocellular carcinoma: a network meta-analysis

“…Major extended donor criteria (maEDC) organs are a good alternative for patients with HCC who are in a better condition and have lower labMELD scores 9 , 96 . The studies included in the present analysis did not provide donor data, which means that an analysis of whether maEDC grafts or grafts with a higher donor risk index are suitable for patients who exceed the Milan criteria but meet the extended selection criteria was not possible 97 , 98 . This may be interesting, because while recurrence-free survival depends mostly on the recipient characteristics, overall survival may be also affected by donor and organ factors that are not considered by the selection models.…”

Prognostic role of the Donor Risk Index, the Eurotransplant Donor Risk Index, and the Balance of Risk score on graft loss after liver transplantation

“…In contrast to ideal grafts, EDC organs are heterogeneous and are associated with higher risk of graft failure, which will unlikely decrease unless organ preservation is improved [7,8,65]. As relative risks for a specific liver allograft and recipient, the DRI, the ET-DRI, and the BAR scores have helped in allocating organs to specific recipients, but clear cutoff values have not yet been defined.…”