Live Donor Liver Transplantation: A Valid Alternative for Critically Ill Patients Suffering From Acute Liver Failure

N. Goldaracena; V. N. Spetzler; M. Marquez; N. Selzner; M. S. Cattral; P. D. Greig; L. Lilly; I. D. McGilvray; G. A. Levy; A. Ghanekar; E. L. Renner; D. R. Grant; M. Selzner

Disclosures

American Journal of Transplantation. 2015;15(6):1591-1597. 

In This Article

Abstract and Introduction

Abstract

We report the outcome of live donor liver transplantation (LDLT) for patients suffering from acute liver failure (ALF). From 2006 to 2013, all patients with ALF who received a LDLT (n = 7) at our institution were compared to all ALF patients receiving a deceased donor liver transplantation (DDLT = 26). Groups were comparable regarding pretransplant ICU stay (DDLT: 1 [0–7] vs. LDLT: 1 days [0–10]; p = 0.38), mechanical ventilation support (DDLT: 69% vs. LDLT: 57%; p = 0.66), inotropic drug requirement (DDLT: 27% vs. LDLT: 43%; p = 0.64) and dialysis (DDLT: 2 vs. LDLT: 0 patients; p = 1). Median evaluation time for live donors was 24 h (18–72 h). LDLT versus DDLT had similar incidence of overall postoperative complications (31% vs. 43%; p = 0.66). No difference was detected between LDLT and DDLT patients regarding 1- (DDLT: 92% vs. LDLT: 86%), 3- (DDLT: 92% vs. LDLT: 86%), and 5- (DDLT: 92% vs. LDLT: 86%) year graft and patient survival (p = 0.63). No severe donor complication (Dindo–Clavien ≥3 b) occurred after live liver donation. ALF is a severe disease with high mortality on liver transplant waiting lists worldwide. Therefore, LDLT is an attractive option since live donor work-up can be expedited and liver transplantation can be performed within 24 h with excellent short- and long-term outcomes.

Introduction

Acute liver failure (ALF) is a critical condition, which is characterized by rapid deterioration of liver function.[1] If untreated, it results in coma and death in over 80% of cases.[1] The only effective therapy is liver transplantation (LT), which offers a 1-year survival of 60–70%.[2,3] The success of LT for patients with ALF is largely dependent on the availability of a life saving graft and proceeding with LT in time before the liver failure has resulted in irreversible secondary organ damage or brain death.

In 2011, 394 patients with ALF were registered in the LT waiting list in the United States,[4] of whom only 234 patients received a LT. It has been estimated that almost 17% of patients with ALF die on the waiting list before a liver graft becomes available.[5] In addition, in many cases, the liver graft is only offered after the liver failure has progressed to an advanced stage, which is associated with decreased chances of successful LT and increased risk of permanent extrahepatic organ (in particular brain) damage. This indicates an important need for new strategies to increase the donor pool, in particular for patients with an urgent need for LT. Live donor liver transplantation (LDLT) is an attractive option to overcome this problem.[2] LDLT can be performed with a short waiting time minimizing mortality for patients with ALF on the waiting list, and improving the survival chances with LT. However, considering the increased postoperative mortality rate for patients receiving a LT for ALF together with the ethical concerns for an urgent live donor work-up, it is unclear if LDLT should be used to treat patients with ALF.[6] For example, the New York State Health Department Guidelines list ALF as a contraindication for LDLT.[7] Unfortunately, this policy is not based on data, but rather on anecdotal cases and might not be in the best interest of our patients and their families. The lack of data in this field limits transplant physicians, our patients and their potential live donors to make an informed decision about LDLT as an option for treating ALF.

To the best of our knowledge, evidence supporting the use of LDLT to treat ALF in adult patients is scarce in the Western Hemisphere,[8] while few reports are available from Asian centers.[1,9–14] Herein, we report a single center experience of adult patients suffering from ALF who were treated at our institution with LDLT. In addition, we analyzed whether the usage of LDLT in patients suffering from ALF is comparable to the outcome of patients receiving a deceased donor liver transplantation (DDLT).

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