Expansion of the Liver Donor Supply Through Greater Use of Split‐Liver Transplantation: Identifying Optimal Recipients

Abstract

The increased use of split liver transplantation (SLT) represents one strategy to increase the supply of organs. Although outcomes after SLT and whole liver transplantation (WLT) are similar on average among pediatric recipients, we hypothesized that the relationship between graft type and outcomes may vary depending on patient, donor, and surgical characteristics. We evaluated graft survival among pediatric (<18 years), deceased-donor, liver-only transplant recipients from March, 2002, until December, 2015, using data from the the Scientific Registry of Transplant Recipients. Graft survival was assessed in a Cox proportional hazards model, with and without effect modification between graft type and donor, recipient, and surgical characteristics, to identify conditions where the risk of graft loss for SLT and WLT were similar. In a traditional multivariable model, characteristics associated with graft loss included donor age >50 years, recipient weight <10 kg, acute hepatic necrosis, autoimmune diseases, tumor, public insurance, and cold ischemia time (CIT) >8 hours. In an analysis that explored whether these characteristics modified the relationship between graft type and graft loss, many characteristics associated with loss actually had similar outcomes irrespective of graft type including weight <10 kg, acute hepatic necrosis, autoimmune diseases, and tumor. In contrast, several subgroups had worse outcomes when SLT was used, including recipient weight 10-35 kg, non-BA cholestasis, and metabolic disease. Allocation score, share type, or CIT did not modify risk of graft type and graft failure. Although one might anticipate that individuals with higher rates of graft loss would be worse candidates for SLT, data suggest that these patients actually have similar rates of graft loss. These findings can guide surgical decision-making and may support policy changes that promote the increased use of SLT for specific pediatric recipients. This article is protected by copyright. All rights reserved.

Application of pediatric donors in split liver transplantation: Is there an age limit?

“…Although a liver biopsy was not performed in recipients 11 and 12, one of the patients developed cholangitis after operation and the other patient had slow recovery of biliary function. These results supported a recent study showing that prolonged cold ischemia time was associated with inferior graft recovery in SLT . Thus, a more cautious evaluation should be given to assess potential “split‐able” liver grafts with a long cold ischemia time.…”

“…The 6 recipients receiving these liver grafts had a smooth recovery after transplant. Although the length of ICU stay is not considered in some transplant centers to determine potential “split‐able” liver grafts, we still take this factor into consideration because longer ICU stay may be related to nosocomial infection or hemodynamic disorder, and pediatric recipients are more vulnerable to this kind of injury.…”

“…These results supported a recent study showing that prolonged cold ischemia time was associated with inferior graft recovery in SLT. 17 Thus, a more cautious evaluation should be given to assess potential "split-able" liver grafts with a long cold ischemia time. In addition, 3 donors had a longer ICU stay before organ procurement than given in our criteria.…”

Split liver transplantation is utilized infrequently and concentrated at few transplant centers in the United States

“…While the slow adoption of SLT has historically been attributed to higher rates of postoperative biliary and vascular complications leading to lower survival, more recent studies have demonstrated similar rates of survival in recipients of SLT compared to whole liver transplantation . These improvements in posttransplant mortality, with continued waitlist mortality among children and adults, suggest that expanded use of SLT could benefit both children and adults …”

Liver graft rejection following immune checkpoint inhibitors treatment: a review

“…Immunotherapy using immune checkpoint inhibitors (ICIs), which can interrupt the cancer-immunity cycle and promote the tumor-specific immune cell activity without intrinsic cytotoxicity, has become the standard of care for a variety of tumors, including melanoma, lung cancer, urothelial cancer, kidney cancer, and hepatocellular carcinoma (HCC) [1][2][3][4][5][6][7][8][9][10][11][12]. For HCC patients, increasing importance has been attached to liver transplantation (LT) thanks to the advances in surgical techniques and immunosuppression regimens, resulting in the mean 1-year and 5-year survival rates of 85-90% and 70-75%, respectively [13][14][15][16][17][18]. However, about 16% HCC patients develop recurrence after LT [19][20][21][22][23][24][25][26]; besides, ICIs can activate the alloreactive T cells and give rise to acute rejection and graft loss, but its safety and efficacy for HCC patients undergoing LT remain a source of controversy.…”