Living Donor Liver Transplantation for Acute Liver Failure: Donor Safety and Recipient Outcome

Abstract

In countries where deceased organ donation is sparse, emergency living donor liver transplantation (LDLT) is the only lifesaving option in select patients with acute liver failure (ALF). The aim of the current study is living liver donor safety and recipient outcomes following LDLT for ALF. A total of 410 patients underwent LDLT between March 2011 and February 2018, out of which 61 (14.9%) were for ALF. All satisfied the King’s College criteria (KCC). Median admission to transplant time was 48 hours (range, 24‐80.5 hours), and median living donor evaluation time was 18 hours (14‐20 hours). Median Model for End‐Stage Liver Disease score was 37 (32‐40) with more than two‐thirds having grade 3 or 4 encephalopathy and 70% being on mechanical ventilation. The most common etiology was viral (37%). Median jaundice‐to‐encephalopathy time was 15 (9‐29) days. Preoperative culture was positive in 47.5%. There was no difference in the complication rate among emergency and elective living liver donors (13.1% versus 21.2%; P = 0.19). There was no donor mortality. For patients who met the KCC but did not undergo LT, survival was 22.8% (29/127). The 5‐year post‐LT actuarial survival was 65.57% with a median follow‐up of 35 months. On multivariate analysis, postoperative worsening of cerebral edema (CE; hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.01‐6.31), systemic inflammatory response syndrome (SIRS; HR, 16.7; 95% CI, 2.05‐136.7), preoperative culture positivity (HR, 6.54; 95% CI, 2.24‐19.07), and a longer anhepatic phase duration (HR, 1.01; 95% CI, 1.00‐1.02) predicted poor outcomes. In conclusion, emergency LDLT is lifesaving in selected patients with ALF. Outcomes of emergency living liver donation were comparable to that of elective donors. Postoperative worsening of CE, preoperative SIRS, and sepsis predicted outcome after LDLT for ALF.

Indian National Association for the Study of Liver Consensus Statement on Acute Liver Failure (Part-2): Management of Acute Liver Failure

“…211 Several other studies including 2 Indian reports have shown good outcomes of LDLT for ALF. [212][213][214][215][216] Yamashiki et al 214 reported survival rates of 79%, 74%, and 73% at 1, 5, and 10 years, respectively, in a nationwide survey from Japan. Outcomes of ALF with LDLT and DDLT are similar.…”

Biliary Reconstruction in Adult Living Donor Liver Transplantation: The All‐Knots‐Outside Technique

“…With this donor safety policy, we recently reported only 1 major (grade 3a) BC in 410 living donor hepatectomies. (10) The incidence of multiple bile ducts will always be there because it is also associated with biliary anatomy, and almost half of the patients will have a variation. (8,18) With growing experience and the modified technique, the rate of BCs in our series decreased even in the subgroup of patients with multiple ducts.…”

“…The posttransplant immunosuppression protocol followed the procedures that have been previously published. (7,9,10) Briefly, it consisted of steroids (100 mg methylprednisolone) in the anhepatic phase, tapered over the next 5 days. Maintenance immunosuppression consisted of tacrolimus plus mycophenolate mofetil plus steroids (prednisolone).…”

Indian National Association for the Study of the Liver Consensus Statement on Acute Liver Failure (Part 1): Epidemiology, Pathogenesis, Presentation and Prognosis

“…A summary of recent publications from tertiary care centers in India is shown in Table 4. [31][32][33][34][35][36][37][38][39][40][41][42][43][44][45] During epidemics of viral hepatitis,~1% of clinical cases may develop ALF. The various etiologies of ALF include hepatitis virus infections (the most common cause in India), drugs such as anti-TB therapy (ATT) drugs, metabolic causes, ischemia, and toxins.…”