Defining Long-term Outcomes With Living Donor Liver Transplantation in North America

Abstract

Objective To compare long-term survival of living donor liver transplant (LDLT) at experienced transplant centers to outcomes of deceased donor liver transplant (DDLT) and identify key variables impacting patient and graft survival. Summary Background Data The Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) is a prospective multicenter NIH study comparing outcomes of LDLT and DDLT and associated risks. Methods Mortality and graft failure for 1427 liver recipients (963 LDLT) enrolled in A2ALL transplanted between 1/1/1998 and 1/31/2014 at 12 North American centers with median follow-up 6.7 years were analyzed using Kaplan-Meier and multivariable Cox models. Results Survival probability at 10 years was 70% for LDLT and 64% for DDLT. Unadjusted survival was higher with LDLT (HR=0.76, p=0.02) but attenuated after adjustment (HR=0.98, p=0.90) as LDLT recipients had lower mean MELD (15.5 vs 20.4) and fewer were transplanted from ICU, inpatient, on dialysis, ventilated, or with ascites. Post-transplant ICU days were less for LDLT. For all recipients female gender and primary sclerosing cholangitis were associated with improved survival, while dialysis and older recipient/donor age were associated with worse survival. Higher MELD score was associated with increased graft failure. Era of transplantation and type of donated lobe did not impact survival in LDLT. Conclusions LDLT provides significant long-term transplant benefit resulting in transplantation at a lower MELD score, decreased death on waitlist, and excellent post-transplant outcomes. Recipient diagnosis, disease severity, renal failure, and ages of recipient and donor should be considered in decision-making regarding timing of transplant and donor options. Clinical Trials ID NCT00096733.

Acute Rejection Increases Risk of Graft Failure and Death in Recent Liver Transplant Recipients

“…These corroborative findings, which are consistent with results in other organs, may help to explain recent data demonstrating higher survival and less impact of donor specific antibodies in LDLT vs. DDLT recipients. 5, 6, 23 In regard to immune-mediated diseases, higher rejection rates in autoimmune hepatitis have led to recommendations for augmented immunosuppression. 7, 15, 22, 24 However, in A2ALL and SRTR cohorts, LT recipients with other immune-mediated liver disease (primary biliary cirrhosis, primary sclerosing cholangitis) had significantly increased risks, suggesting the need to maintain a higher level of immunosuppression in all immune-mediated diseases.…”

“…Furthermore, two recent publications have highlighted the superior long-term survival for select recipients of living-donor liver transplants (LDLT), although it is not clear if this improved survival is related to a lower incidence of rejection in LDLT compared to deceased donor liver transplantation (DDLT). 5, 6 …”

Liver Transplantation is a Preferable Alternative to Palliative Therapy for Selected Patients with Advanced Hepatocellular Carcinoma

“…Another alternative would be living donor LT. This does not affect the candidacy of others, and the outcomes are comparable to deceased donor LT [26,27]; therefore, would be a preferred option for selected patients with advanced HCC. The equivalence of HCC recurrence and patient survival between deceased donor and living donor LT of the present analysis further supports this notion.…”

Living donor liver transplantation in high Model for End‐Stage Liver Disease score patients

“…The sparse application of LDLT to high‐MELD candidates is evidenced by the fact that only 54 LDLTs were performed nationally for MELD ≥ 25 candidates between February 2002 and May 2008 . This is similarly iterated by a recent report from the 9‐center A2ALL consortium encompassing 963 LDLTs and 464 DDLTs performed between January 1, 1998 and August 31, 2010 . At the time of transplant, mean (standard deviation [SD]) MELD score was 15.5 (5.9) for LDLT compared with 20.4 (8.9) for DDLT recipients ( P < 0.001).…”