Many centers require a minimal graft to body weight ratio (GBWR) Ն 0.8 as an arbitrary threshold to proceed with right-lobe living donor liver transplantation (RL-LDLT), and there is often hesitancy about transplanting lower volume living donor (LD) liver grafts into sicker patients. The data supporting this dogma, based on the early experience with RL-LDLT at Asian centers, are weak. To determine the effect of LD liver volume in the modern era, we investigated the impact of GBWR on the outcome of RL-LDLT with a GBWR as low as 0.6 at the University of Toronto. Between April 2000 and September 2008, 271 adult-to-adult RL-LDLT procedures and 614 deceased donor liver transplants were performed. Twenty-two living donor liver transplantation (LDLT) cases with a GBWR of 0.59 to 0.79 (group A) were compared with 249 LDLT cases with a GBWR Ն 0.8 (group B) and with 66 full-graft deceased donor liver transplants (group C), who were matched 3:1 according to donor and recipient age, Model for End-Stage Liver Disease score, and presence of hepatitis C and hepatocellular carcinoma with the low-GBWR group. Portal vein shunts were not used. Markers of reperfusion injury [aspartate aminotransferase (AST) and alanine aminotransferase (ALT)], graft function (international normalized ratio and bilirubin), complications graded by the Clavien score, and graft and patient survival were compared. As expected, LD recipients had a significantly shorter cold ischemia time (94 Ϯ 43 minutes for A, 96 Ϯ 57 minutes for B, and 453 Ϯ 152 minutes for C, P ϭ 0.0001). However, the peak AST, peak ALT, absolute decrease in the international normalized ratio, day 7 bilirubin level, postoperative creatinine clearance, complication rate graded by the Clavien score, and median hospital stay were similar in all groups. The rate of biliary complications was higher with LD grafts than deceased donor grafts (19% for A versus 10% for B and 0% for C, P ϭ 0.2). Patient survival was similar in all groups at 1, 3, and 5 years (91% for A versus 89% for B and 93% for C at 1 year, 87% for A versus 81% for B and 89% for C at 3 years, and 83% for A versus 81% for B and 87% for C at 5 years, P ϭ 0.63). A Cox proportional regression analysis revealed only hepatitis C virus as a risk factor for poorer graft survival and not GBWR as a continuous or categorical variable. In conclusion, we found no evidence of inferior outcomes with smaller size grafts versus larger size LD grafts or full-size deceased donor grafts. Further studies are warranted to examine the factors affecting the function of smaller grafts for living liver donation and thereby define the safe lower limits for transplantation. Liver Transpl 15: 1776Transpl 15: -1782Transpl 15: , 2009 Adult-to adult right-lobe living donor liver transplantation (RL-LDLT) has gained widespread acceptance during the last 10 years as an alternative to deceased donor liver transplantation. Although living donor (LD) grafts are always from high-quality donors and are less likely to suffer from reperfusion injury, there is ...

To refine selection criteria for adult living liver donors and improve donor quality of care, risk factors for poor postdonation health-related quality of life (HRQOL) must be identified. This cross-sectional study examined donors who underwent a right hepatectomy at the University of Toronto between 2000 and 2007 (n = 143), and investigated predictors of (1) physical and mental health postdonation, as well as (2) willingness to participate in the donor process again. Participants completed a standardized HRQOL measure (SF-36) and measures of the pre-and postdonation process. Donor scores on the SF-36 physical and mental health indices were equivalent to, or greater than, population norms. Greater predonation concerns, a psychiatric diagnosis and a graduate degree were associated with lower mental health postdonation whereas older donors reported better mental health. The majority of donors (80%) stated they would donate again but those who perceived that their recipient engaged in risky health behaviors were more hesitant. Prospective donors with risk factors for lower postdonation satisfaction and mental health may require more extensive predonation counseling and postdonation psychosocial follow-up. Risk factors identified in this study should be prospectively evaluated in future research. participate (n = 204). Procedures used by our center to determine donor suitability for right hepatectomy have been reported elsewhere (1). Eleven donors who had been either lost to follow-up (n = 9) or who informed our program that they were doing well and no longer required follow-up (n = 2) were not contacted. Study designThis is a cross-sectional study in which donors who were at least 3 months postdonation were mailed a package of materials that contained a cover letter explaining the study objectives, a consent form and a written questionnaire. Only those measures that were analyzed in this report will be described here. Postdonation questionnaireLiving liver donors completed a one-time comprehensive questionnaire assessing demographics (sex, age, marital status, ethnicity, education, income and employment

Venous congestion of segments V and VIII is observed frequently in living-donor right lobe liver transplants without middle hepatic vein (MHV) drainage, and can be a cause of graft dysfunction and failure. Inclusion of the MHV with the graft is controversial, however, because of the perceived potential for increased donor morbidity.We compared the outcome of living liver donors in whom the MHV was either left intact in the donor (group 1; n = 28) or was removed with the graft (group 2; n = 28). All prospective donors completed an extensive multidisciplinary evaluation to determine suitability for surgery and to ensure that the MHV could be removed safely without compromising venous outflow from the remaining liver. Patient demographics including age, weight, body-mass index, and liver volumetry as determined by computerized tomography were similar in both groups. Operative time in group 2 was significantly shorter than in group 1. There was no difference in estimated blood loss, transfusion requirements, peak serum liver tests, time interval from surgery to complete normalization of liver tests, complications, and length of hospitalization. We conclude that including the MHV with livingdonor right lobe grafts can be performed safely in most donors. Key words: Liver transplantation, living donor Received 30 October 2003, revised and accepted for publication 18 December 2003Over the past 5 years, living-donor liver transplantation (LDLT) of right lobe grafts has become increasingly common, with further growth anticipated as the gap between the need and availability of cadaver livers expands (1). A critical determinant of recipient outcome after LDLT is the quantity of functional liver mass transplanted. In addition to the actual size of the graft, apparent functional mass can be affected by several factors including venous congestion, portal hypertension, and recipient clinical status (2,3). Venous congestion of Couinaud's segments V and VIII of right lobe grafts is observed frequently when middle hepatic vein (MHV) tributaries from these segments are ligated. Although venous congestion usually resolves as intrahepatic venous collaterals to the right hepatic vein enlarge, it may persist and contribute to the development of graft dysfunction and failure. Reported solutions to mitigate this problem include revascularization of large segment V and VIII veins, revascularization of the entire MHV, retention of a segment of the MHV with the graft to promote development of venous collaterals, and splenic artery ligation or splenectomy to reduce portal venous inflow (4-11). Currently there is no consensus as to which approach is optimal.Since the inception of our right lobe LDLT program, the surgical management of venous drainage from segments V and VIII has evolved from routine ligation to selective revascularization of MHV tributaries from segments V and VIII, and most recently to routine MHV revascularization. Inclusion of the MHV with the graft is controversial, however, because of the perceived potential of increasin...

Right lobe living donor liver transplantation is an effective treatment for selected individuals with end-stage liver disease. Although 1 year donor morbidity and mortality have been reported, little is known about outcomes beyond 1 year. Our objective was to analyze the outcomes of the first 202 consecutive donors performed at our center with a minimum follow-up of 12 months (range 12-96 months). All physical complications were prospectively recorded and categorized according to the modified Clavien classification system. Donors were seen by a dedicated family physician at 2 weeks, 1, 3 and 12 months postoperatively and yearly thereafter. The cohort included 108 males and 94 females (mean age 37.3 ± 11.5 years). Donor survival was 100%. A total of 39.6% of donors experienced a medical complication during the first year after surgery (21 Grade 1, 27 Grade 2, 32 Grade 3). After 1 year, three donors experienced a medical complication (1 Grade 1, 1 Grade 2, 1 Grade 3). All donors returned to predonation employment or studies although four donors (2%) experienced a psychiatric complication. This prospective study suggests that living liver donation can be performed safely without any serious late medical complications and suggests that long-term follow-up may contribute to favorable donor outcomes.

There are no published series of the assessment process, profiles and outcomes of anonymous, directed or nondirected live liver donation. The outcomes of 29 consecutive potential anonymous liver donors at our center were assessed. We used our standard live liver assessment process, augmented with the following additional acceptance criteria: a logical rationale for donation, a history of social altruism, strong social supports and a willingness to maintain confidentiality of patient information. Seventeen potential donors were rejected and 12 donors were ultimately accepted (six male, six female). All donors were strongly motivated by a desire and sense of responsibility to help others. Four donations were directed toward recipients who undertook media appeals. The donor operations included five left lateral segmentectomies and seven right hepatectomies. The overall donor morbidity was 40% with one patient having a transient Clavien level 3 complication (a pneumothorax). All donors are currently well. None expressed regret about their decision to donate, and all volunteered the opinion that donation had improved their lives. The standard live liver donor assessment process plus our additional requirements appears to provide a robust assessment process for the selection of anonymous live liver donors. Acceptance of anonymous donors enlarges the donor liver pool.

Living liver donation is a successful treatment for patients with end-stage liver disease. Most adults are provided with a right lobe graft to ensure a generous recipient liver volume. Some centers are re-exploring the use of smaller left lobe grafts to potentially reduce the donor risk. However, the evidence showing that the donor risk is lower with left lobe donation is inconsistent, and most previous studies have been limited by potential learning curve effects, small sample sizes, or poorly matched comparison groups. To address these deficiencies, we conducted a case-control study. Forty-five consecutive patients who underwent left hepatectomy (LH; n ¼ 4) or left lateral segmentectomy (LLS; n ¼ 41) were compared with matched controls who underwent right hepatectomy (RH) or extended right hepatectomy (ERH). The overall complication rates of the 3 groups were similar (31%-37%). There were no grade 4 or 5 complications. There were more grade 3 complications for the RH patients (13.3%) and the ERH patients (15.6%) versus the LH/LLS patients (2.2%). The extent of the liver resection significantly correlated with the peak international normalized ratio (INR), the days to INR normalization, and the peak bilirubin level. A univariate analysis demonstrated that hepatectomy, the spared volume percentage, and the peak bilirubin level were strongly associated with grade 3 complications. A higher peak bilirubin level, which correlated with a lower residual liver volume, was associated with grade 3 complications in a multivariate analysis (P ¼ 0.005). RH and grade 3 complications were associated with an increased length of stay (>7 days) in a multivariate analysis. In conclusion, this analysis demonstrates a significant correlation between the residual liver volume and liver dysfunction, serious adverse postoperative events, and longer hospital stays. Donor safety should be the first priority of all living liver donor programs. We propose that the surgical procedure removing the smallest amount of the liver required to provide adequate recipient graft function should become the standard of care for living liver donation. Liver Transpl 17:1404-1411, 2011. V C 2011 AASLD.Received December 31, 2010; accepted August 1, 2011.Living donor liver transplantation (LDLT) is a successful procedure with patient survival rates that are equivalent to those with deceased donor liver transplantation. [1][2][3][4] In regions in which donor rates are low, LDLT reduces wait-list death rates and improves survival from the time of listing in comparison with deceased donor liver transplantation. 5 Currently, right lobe liver grafts are procured for most adult recipients of living donor organs in North America, whereas left lobe grafts or left lateral segment grafts, which typically provide less liver mass, are reserved for infants and children. Recipient outcomes are excellent with right lobe LDLT, but donor morbidity rates range from 20% to 40%. 6 The drive to identify safer alternatives has stimulated renewed interest in the use of left late...

We studied the role of donor and recipient age in transplantation/ischemia-reperfusion injury (TIRI) and short-and long-term graft and patient survival. Eight hundred twenty-two patients underwent deceased donor liver transplantation, with 197 donors being Ն60 years old. We evaluated markers of reperfusion injury, graft function, and clinical outcomes as well as short-and long-term graft and patient survival. Increased donor age was associated with more severe TIRI and decreased 3-and 5-year graft survival (73% versus 85% and 72% versus 81%, P Ͻ 0.001) and patient survival (77% versus 88% and 77% versus 82%, P Ͻ 0.003). Hepatitis C virus (HCV) infection and recipient age were the only independent risk factors for graft and patient survival in patients receiving an older graft. In the HCV(ϩ) cohort (297 patients), patients Ն 50 years old who were transplanted with an older graft versus a younger graft had significantly decreased 3-and 5-year graft survival (68% versus 83% and 64% versus 83%, P Ͻ 0.009). In contrast, HCV(ϩ) patients Ͻ 50 years old had similar 3-and 5-year graft survival if transplanted with either a young graft or an old graft (81% versus 82% and 81% versus 82%, P ϭ 0.9). In conclusion, recipient age and HCV status affect the graft and patient survival of older livers. Combining older grafts with older recipients should be avoided, particularly in HCV(ϩ) patients, whereas the effects of donor age can be minimized in younger recipients. Liver Transpl 15: 1288Transpl 15: -1295Transpl 15: , 2009 Liver transplantation is the only chance of cure for patients with end-stage liver disease and results in a 5-year survival rate of 70% to 85% in most centers. Although demand for the operation has increased, rates of deceased organ donation have not kept pace, and this had led to a marked shortage of organs available for transplantation. 1 One response to this shortage has been to accept increasingly older donors. In 1988, only 28% of all donors were older than 50 years, and 0.05% were older than 65. By 1995, these percentages had increased to 42% and 5%, and by 2007, they had increased even further to 65% and 10%, respectively.

Objective: To determine the outcomes in solid organ transplant recipients following inpatient rehabilitation, as a result of a unique partnership between the rehabilitation hospital and the multiorgan transplant program in an acute hospital. Design: Retrospective observational study. Setting: Community rehabilitation hospital affiliated with a university. Participants: A cohort of 173 organ transplant patients admitted consecutively over a four-year period (2004-2008) was compared to a cohort of all rehabilitation patients (n = 9762) admitted to the same inpatient rehab facility during the same period. Interventions: Inpatient rehab program to all participants. Main Outcome Measures: Length of hospital stay, Functional Independence Measure (FIM ™) change (admission-discharge), and rate of discharges to home. Results: Outcomes were measured using components of the FIM ™ instrument, admission and discharge data. Chi-square and independent two-sample t-tests were used for statistical analysis. Compared to a general rehabilitation inpatient population, transplant rehabilitation inpatients had: more immediate (<3 days) transfers to an acute hospital (5.2% vs. 1.9%, p < 0.001); a higher rate of readmission to an acute hospital after the first 3 days (19.1% vs. 1.9%, p < 0.001); a longer mean length of stay (27 ± 19 vs. 20 ± 18 days, p < 0.001); a lower total FIM ™ change (8.9 vs. 20.9, p < 0.001); a lower FIM ™ efficiency (1.1 vs. 1.4, p < 0.001); and a higher rate of discharges to home in patients not readmitted to acute care (98.5% vs. 94.5% p < 0.001). Conclusion: Outcomes of rehabilitation in solid organ transplant patients are comparable but not identical to those in other patient groups. Inpatient rehabilitation for transplant patients is therefore fully justifiable and necessary. The ten times higher rate of transplant patient readmission to acute hospital must be communicated, facilitated, accepted and managed within a partnership strategy.