Elsevier

Journal of Hepatology

Volume 51, Issue 4, October 2009, Pages 715-724
Journal of Hepatology

Complications of right lobe living donor liver transplantation

https://doi.org/10.1016/j.jhep.2009.04.023Get rights and content

Background/Aims

Right lobar living donor liver transplantation (LDLT) has been controversial because of donor deaths and widely variable reports of recipient and donor morbidity. Our aims were to ensure full disclosure to donors and recipients of the risks and benefits of this procedure in a large University center and to help explain reporting inconsistencies.

Methods

The Clavien 5-tier grading system was applied retrospectively in 121 consecutive adult right lobe recipients and their donors. The incidence was determined of potentially (Grade III), actually (Grade IV), or ultimately fatal (Grade V) complications during the first post-transplant year. When patients had more than one complication, only the seminal one was counted, or the most serious one if complications occurred contemporaneously.

Results

One year recipient/graft survival was 91%/84%. Within the year, 80 (66%) of the 121 recipients had Grade III (n = 54) Grade IV (n = 16), or Grade V (n = 10) complications. The complications involved the graft’s biliary tract (42% incidence), graft vasculature (15%), or non-graft locations (9%). Complications during the first year did not decline with increased team experience, and adversely affected survival out to 5 years. All 121 donors survive. However, 13 donors (10.7%) had Grade III (n = 9) or IV (n = 4) complications of which five were graft-related.

Conclusions

Despite the satisfactory recipient and graft survival at our and selected other institutions, and although we have not had a donor mortality to date, the role of right lobar LDLT is not clear because of the recipient morbidity and risk to the donors.

Introduction

Successful transplantation to pediatric recipients of small portions of the left hepatic lobe of living adult donors was first reported in 1990 [1], [2]. By the mid 1990s, removal began of larger hepatic fragments for adult-to-adult transplantation [3], [4], [5], [6]. It was soon recognized that the risk of donor death with living donor liver transplantation (LDLT) exceeded that of live kidney donation and that the highest mortality was with right lobar LDLT [7], [8]. Because of concern about the donor deaths, and uncertainty about recipient outcomes, a group of stakeholders agreed in 2005 that all LDLT cases should be entered into an international registry [9].

It was further agreed that the rate and severity of recipient and donor complications would be determined with the multi-tier grading system developed by Clavien et al. [10], [11] (Table 1). One of the high priorities was definitive assessment of the right lobar LDLT that had become the most commonly used living donor procedure for adult recipients in Western (non-Asian) countries. Instead, there have been striking disparities in the reported incidence and severity of complications in both right lobar donors and their recipients [12].

To help explain these inconsistencies and allow full disclosure to all interested parties of the risks and benefits of right lobar LDLT, we analyzed our nearly 4-year experience with 121 consecutive cases. The parallel purpose of this quality assurance study was to identify factors that potentially could be modified to improve results.

Section snippets

Patient population(s), procedures, and immunosuppression

We retrospectively identified and analyzed the complications during the first post-transplant year of 121 right liver lobe recipients whose operations and follow-up were carried out at the Montefiore Hospital of the University of Pittsburgh Medical Center (UPMC) between March 2003 and November 2006. Recipient disease severity scores (model for end-stage liver disease, MELD) were calculated as of the time of transplantation with a UNOS formula based on the individual’s bilirubin, creatinine, and

Recipient and donor population characteristics

The 94 consanguineous (genetically related) donations (Table 2) were offspring to parent (n = 53[44%]), sibling to sibling (n = 29[24%]), parent to offspring (n = 6[5%]), and other (n = 6[5%]). Non-related donors were spouses (n = 8), friends (n = 12), in-laws (n = 5), or altruistic volunteers (n = 2). All donors were ABO identical with their recipients. There were only three examples of HLA identity, all siblings. Fourteen of the organs were transplanted to recipients with antidonor cytotoxic antibodies

Discussion

The Ethics Committee of the Transplantation Society recently recommended that transplantation of non-renal organs from living donors should be done only when “…the aggregate benefits to the donor–recipient pair (survival, quality of life, psychological, and social well being) outweigh the risks to the donor–recipient pair (death, medical, psychological, and social morbidities)” [20].

Although the psychosocial components of the aggregate equation were not readily measurable in our right lobar

Acknowledgements

J.W.M. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. We thank Ms. Debra Bass for her data analysis and Ms. Terry Mangan for her assistance in manuscript preparation.

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    The authors who have taken part in this study declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.

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