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.