Utilization of elderly donors in living donor liver transplantation: When more is less?

Abstract

An accepted definition of donor exclusion criteria has not been established for living donor liver transplantation (LDLT). The use of elderly donors to expand the living donor pool raises ethical concerns about donor safety. The aims of this study were (1) the comparison of the postoperative outcomes of living liver donors by age (!50 versus <50 years) and (2) the evaluation of the impact of the extent of right hepatectomy on donor outcomes. The study group included 150 donors who underwent donor right hepatectomy between October 2004 and April 2009. Extended criteria surgery (ECS) was defined as right hepatectomy with middle hepatic vein (MHV) harvesting or right hepatectomy resulting in an estimated remnant liver volume (RLV) less than 35%. The primary endpoints were donor outcomes in terms of donor complications graded according to the Clavien classification. Group 1 consisted of donors who were 50 years old or older (n ¼ 28), and group 2 consisted of donors who were less than 50 years old (n ¼ 122). At least 1 ECS criterion was present in 74% of donors: 57% had 1 criterion, and 17% had 2 criteria. None of the donors had grade 4 complications or died. The overall and major complication rates were similar in the 2 donor age groups [28.6% and 14.3% in group 1 and 32% and 8.2% in group 2 for the overall complication rates (P ¼ 0.8) and the major complication rates (P ¼ 0.2), respectively]. However, there was a significant correlation between the rate of major complications and the type of surgery in donors who were 50 years old or older. In LDLT, extending the limits of surgery comes at the price of more complications in elderly donors. Right hepatectomy with MHV harvesting and any procedure causing an RLV less than 35% should be avoided in living liver donors who are 50 years old or older.

A Donor Age-Based and Graft Volume–Based Analysis for Living Donor Liver Transplantation in Elderly Recipients

“…A small liver remnant is the best predictor of hepatic dysfunction after liver resection. 22 Dayangac et al 11 reported that liver donation resulting in a remnant liver volume less than 35% should be avoided in donors 50 years or older to ensure their safety. Despite the conflicts inherent in ensuring both a sufficient GV for the recipient and a sufficient remnant liver volume for the donor, the safety of living donors should take priority in LDLT for elderly recipients.…”

“…We used a cutoff of 50 years for the donor age because recipients of grafts from donors 50 years or older have a higher mortality rate and a lower 1-year survival rate than recipients of grafts from younger donors. 11 …”

Differences in Perioperative Outcomes Between Right and Left Hepatic Lobectomy

“…Furthermore, it is known that morbidity and mortality after hepatic resection for malignancy is strongly associated with volume of the future liver remnant [18]. It is likely that the smaller future liver remnant following right hepatic lobectomy contributes to the worse perioperative outcomes as echoed by many other studies involving living donors undergoing right hepatectomies [13,19,20]. Given the limitations of the ACS-NSQIP database we could not factor in the details on the size of future liver remnant or rates of post-hepatectomy liver failure.…”

Mathematical Model of Liver Regeneration in Human Live Donors

“…Our model only takes into consideration the donor, and not the recipient. There are factors such as age which affect the risks and complications, at least in a size dependent resection (Dayangac et al, 2011). We do not consider age given the few subjects we had, nor do we consider gender or ethnicity.…”