Paired Exchange Living Donor Liver Transplantation: A Nine-year Experience From North India

Abstract

Background. Paired exchange liver transplantation is an evolving strategy to overcome ABO blood group incompatibility and other barriers such as inadequate graft-to-recipient weight ratio and low remnant liver volume in donors. However, for the transplant team to carry 4 major operations simultaneously is a Herculean effort. We analyzed our experience with liver paired exchange (LPE) program over the past 9 y. Methods. This prospective study included 34 of 2340 (1.45%) living donor liver transplantations performed between May 2012 and April 2021. The reason for LPE was ABO incompatibility in all (n = 34) patients included in the study. After donor reassignment through 2-by-2 paired exchange with directed donors, the ABO matching status changed from A to A (n = 17) and B to B (n = 17), which made all matches ABO-identical. Recipients (R) and donors (D) of each swap pair were prospectively divided into R1/D1 and R2/D2 groups for comparative and survival analyses. Results. The recipients (n = 34) had a median age of 45.5 y (11–59 y), and 31 were men. LPEs were performed in 4 operating rooms running simultaneously by 2 independent surgical teams. Donor survival was 100%. Baseline clinical and perioperative parameters, postoperative complications, median intensive care unit/hospital stay, and early deaths were comparable (P > 0.1) between the R1 and R2 groups. The median follow-up period was 27 mo (1–108 mo). The 30-d and 1-y survivals were 88.2% (n = 30) and 85.3% (n = 29), respectively. Conclusions. Our experience suggests that with careful attention to ethical and logistical issues, the LPE program can expand the living donor liver pool and facilitate a greater number of living donor liver transplantations.

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation

“…However, before donation, the parents should undergo close examinations, including liver biopsy and genetic analysis [425]. When it was difficult to perform LDLT between family members due to problems such as ABO incompatibility and graft volume, sometimes LDLT has been performed as paired exchange programs [426][427][428].…”

Increasing Living Liver Donor Pools: Liver Paired Exchange Versus ABO-incompatible Living Donor Liver Transplantation

“…In this issue of Transplantation, Agrawal et al 6 report their experience with an LPE program in India. Two to eight LPEs were performed most years from 2012 to 2021 (with the exception of 2013 and 2015).…”

“…8,9 ABOi LDLTs enable LLD pool expansion, increasing LDLT cases in our center by 20%-30% annually (Figure 1). Agrawal et al 6 noted that LPE was performed based predominantly on the donor's anatomical factors, such as the size of partial liver graft (ie, graft-to-recipient weight ratio and percent of future remnant liver volume)‚ and anatomical variations‚ such as arterial, portal, and biliary variants. Although donations were limited by small remnant liver volume in this study, 32 LLDs underwent right hepatectomy‚ and 1 donor underwent extended right hepatectomy.…”