Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Outcomes of Living Donor Transplantation: The Western Perspective
The benefit of liver transplantation among patients with end-stage liver disease cannot be disputed in the modern era. However, access to a deceased donor liver allograft remains an extremely challenging problem that has prevented expansion of this medical advance to all patients in need. The persistent disparity between patients in need and the availability of deceased donor livers has forced the transplant community to expand the use of living liver donors.
The first successful liver transplant from a living donor to a child was performed by Raia et al in 1989 in Brazil. Following this initial success, other centers expanded both the use of additional liver segments and the recipient population ( Table 58-1 ). Early in the experience, living donor liver transplantation (LDLT) was pioneered in children, given the size disparity and the high mortality among children awaiting liver transplantation at the time. As experience with liver reduction techniques and living donor transplantation grew, however, the transplantation of a right lobe into an adult was ultimately successfully attempted. Right lobe adult-to-adult liver transplantation is now performed throughout the world.
TABLE 58-1
Historical Milestones in Living Donor Liver Transplantation
| Group | Year | Graft Type | Recipient |
|---|---|---|---|
| Strong et al | 1989 | Left lobe | Pediatric |
| Yamaoka et al | 1994 | Right lobe | Pediatric |
| Hachikura et al | 1993 | Left lobe | Adult |
| Lo et al | 1997 | Extended right lobe | Adult |
| Wachs et al | 1998 | Right lobe | Adult |
Although LDLT has been adopted all around the globe, it has been particularly well embraced by Asian countries given the lack of infrastructure or cultural limitations for the use of deceased donors in these areas. Given the much greater availability of deceased donors in Western countries compared to Asia, LDLT has constituted only 2% to 9% of total liver transplants in both Europe and the United States over the last decade (Organ Procurement and Transplantation Network [OPTN] data, 1998-2011). Similar to the evolution of LDLT in Asia, children were the first recipients of LDLT in Western centers. In the early 2000s, LDLT expanded to a greater degree in both Europe and the United States, representing up to 11% of all liver transplants in Germany and 9.3% of U.S. liver transplants in 2001 (OPTN data). However, the annual number of LDLTs performed both in the United States ( Fig. 58-1 ) and Europe has fallen since that time, because of changes in liver allocation, as well as concerns regarding donor safety, particularly among right lobe donors.
Living donor liver transplants in the United States (1998-2007).
Recipient Outcomes of Living Donor Liver Transplantation in the West
Pediatric Recipient Outcomes
Contemporary data suggest that graft and patient outcomes are excellent in pediatric recipients of living donors in Western centers. One year after transplantation, patient and graft survival is well above 90% and 85%, respectively, and later outcomes remain comparably high ( Table 58-2 ). These recipient outcomes are comparable to those for whole-organ deceased donor recipients and those observed in Eastern series (5-year patient survival is 84% in Japan, 5-year patient survival is 86% in Korea ). These outcomes also demonstrate stability when compared with older data. Such transplant success in a patient population with historically high waiting list mortality because of limited graft availability has consequently encouraged the ongoing use of living donors in pediatric patients, especially in the youngest recipients. Overall, LDLT is currently performed in approximately 16% of recipients under 1 year of age in the United States (OPTN data, 2009-2011).
TABLE 58-2
Outcomes of Pediatric Living Donor Liver Transplantation in Western Countries
| Center | Early Outcome (1 yr) | Late Outcome (3, 4, or 5 yr) | Graft Type | ||
|---|---|---|---|---|---|
| PS (%) | GS (%) | PS (%) | GS (%) | ||
| Madrid | 96 | 85 | 96 (5 yr) | 85 (5 yr) | LLS: 85% |
| Toronto | 100 | 100 | NR | NR | LLS: 77% |
| New York | 91 | 91 | NR | NR | LLS: 91% |
| UNOS | NR | NR | 82 (3 yr) | 77 (3 yr) | NS |
| SRTR | 90% ∗ | 85% ∗ | NR | NR | NS |
| SPLIT | 90 | 85 | 89 (4 yr) | 78 (4 yr) | NS |
GS , Graft survival; LLS , left lateral segment; NR , not reported; NS , not specified; PS , patient survival; SPLIT , Studies in Pediatric Liver Transplantation; SRTR , Scientific Registry of Transplant Recipients; UNOS , United Network for Organ Sharing.
The excellent graft and patient survival outcomes associated with LDLT in pediatric recipients, however, are balanced by a higher frequency of complications when compared to whole-organ cadaveric transplantation. In a recent report from the Studies in Pediatric Liver Transplantation (SPLIT) multicenter registry, more complications were observed in living donor recipients than in recipients of whole-organ cadaveric grafts. As shown in Table 58-3 , biliary and vascular complications were more frequent in recipients of living donor allografts, and this trend was noted at both early (30 days) and late (24 months) time points after transplantation. Despite the fact that these complications contribute to a higher risk for graft loss in this population (relative risk [RR], 1.32; P < .05), overall patient survival at 4 years is similar between pediatric recipients of either a deceased donor whole-organ allograft or a living donor allograft (RR, 1.36; P = .08).
TABLE 58-3
Complications Among Pediatric Recipients ∗ in the SPLIT Registry
Modified from Diamond IR, Fecteau A, Millis JM, et al. Impact of graft type on outcome in pediatric liver transplantation: a report from Studies of Pediatric Liver Transplantation (SPLIT). Ann Surg . 2007;246(2):301.
| Complication | Whole Liver (n = 672) | Living Donor (n = 197) |
|---|---|---|
| Biliary complications (%) † Leak † Intrahepatic stricture † Anastomotic stricture † |
17.3 5.8 3.6 7.7 |
40.1 21.8 10.2 21.3 |
| Vascular complications (%) † Hepatic artery thrombosis Portal vein thrombosis † |
16.5 8.6 5.2 |
24.4 6.1 13.7 |
SPLIT , Studies in Pediatric Liver Transplantation.
∗ Among patients surviving to 24 months after transplantation.
Taken altogether, current data demonstrate an overall benefit of LDLT in pediatric recipients, mostly by supplying small grafts for these recipients. Although these technically complex surgical procedures have higher complication rates than whole-organ transplantation, both single-center and registry data demonstrate that patient and graft survival can be maintained at the highest level. LDLT is most beneficial in the youngest children, in whom outcomes are equivalent if not superior to whole-organ transplantation. Thanks to these results, LDLT in pediatric recipients has endured the test of time and remained popular throughout the West for over 20 years, and it is expected to remain a critical component of U.S. and European pediatric programs into the distant future.
Adult Recipient Outcomes
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here