HPi: A Novel Parameter to Predict Graft-related Outcome in Adult Living Donor Liver Transplant

Singh, Akanand; Singhal, Saurabh; Venuthurimilli, Arun; Pareek, Shishir; Maung, Pyone Maung; Aung, Thet Htoo; Garg, Hitendra; Vohra, Sandeep; Sahni, Reeti; Goyal, Neerav

doi:10.1097/tp.0000000000003890

Cited by 9 publications

(11 citation statements)

References 46 publications

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“…With so few SFSS events in the current study, we chose to use EAD as the endpoint of analysis. EAD has been reported to occur in 16% to 31% of LDLT series using mainly RLG (H5678) 5,12,15,46. Our EAD rate was 13.8% overall and 19.7% in LLG (H1234-MHV), which is still much lower than the previously reported rates of up to 50.8% in LLG (H1234-MHV) 5.…”

Section: Discussioncontrasting

confidence: 78%

Living Donor Liver Transplantation With Augmented Venous Outflow and Splenectomy

et al. 2022

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Objective: Living donor liver transplantation (LDLT) using small grafts, especially left lobe grafts (H1234-MHV) (LLG), continues to be a challenge due to small-for-size syndrome (SFSS). We herein demonstrate that with surgical modifications, outcomes with small grafts can be improved. Methods: Between 2012 and 2020, we performed 130 adult LDLT using 61 (47%) LLG (H1234-MHV) in a single Enterprise. The median graftto-recipient weight ratio was 0.84%, with graft-to-recipient weight ratio <0.7% accounting for 22%. Splenectomy was performed in 72 (56%) patients for inflow modulation before (n = 50) or after (n = 22) graft reperfusion. In LLG-LDLT, venous outflow was achieved using all three recipient hepatic veins. In right lobe graft (H5678) (RLG)-LDLT, the augmented graft right hepatic vein was anastomosed to the recipient's cava with a large cavotomy. Outcome measures include SFSS, early allograft dysfunction (EAD), and survival. Results: Graft survival rates at 1, 3, and 5 years were 94%, 90%, and 83%, respectively, with no differences between LLG (H1234-MHV) and RLG (H5678). Splenectomy significantly reduced portal flow without increasing the complication rate. Despite the aggressive use of small grafts, SFSS and EAD developed in only 1 (0.8%) and 18 (13.8%) patients, respectively. Multivariable logistic regression revealed model for end-stage liver disease score and LLG (H1234-MHV) as independent risk factors for EAD and splenectomy as a protective factor (odds ratio: 0.09; P = 0.03). For LLG (H1234-MHV)-LDLT, patients who underwent prereperfusion splenectomy tended to have better 1-year graft survival than those receiving postreperfusion splenectomy. Conclusions: LLG (H1234-MHV) are feasible in adult LDLT with excellent outcomes comparable to RLG (H5678). Venous outflow augmentation and splenectomy help lower the threshold of using small-forsize grafts without compromising graft survival.

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Section: Discussioncontrasting

confidence: 78%

Living Donor Liver Transplantation With Augmented Venous Outflow and Splenectomy

et al. 2022

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“…Previous studies reported EAD occurred in 16% to 31% of LDLT series using mainly RLG, but it can be up to 50% in LLG. 10,12,42,43 Augmentation of venous outflow along with preplanned aggressive measures to lower excessive PV flow or pressure, such as pre or postreperfusion splenectomy, has allowed our program to have outstanding outcomes despite the high utilization of smaller LLG. 7 Interestingly, this study showed that the risk of EAD in LLG can be lowered by using a laparoscopic approach (21.1% for open and 10.4% for laparoscopic) with an OR of 0.36 (P = 0.05).…”

Section: Discussionmentioning

confidence: 99%

Left Lobe First with Purely Laparoscopic Approach

et al. 2023

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Objective: A left-lobe graft (LLG) first approach and a purely laparoscopic donor hemihepatectomy (PLDH) are two methods to reduce surgical stress for donors in adult living donor liver transplantation (LDLT). We herein report our strategy to minimize donor risk by applying LLG first combined with PLDH. Methods: From 2012-2023, 186 adult LDLTs were performed with hemiliver grafts, procured by open surgery in 95 and PLDH in 91 cases. LLGs were considered first when graft-to-recipient weight ratio ≥0.6%. Following a four-month adoption process, all donor hepatectomies since December 2019 were performed laparoscopically. Results: There was one intra-operative conversion to open (1%). Mean operative times were similar in laparoscopic and open cases (366 vs. 371 minutes). PLDH provided shorter hospital stay, lower blood loss, and lower peak AST. Peak bilirubin was lower in LLG donors compared to RLG donors (1.4 mg/dL vs. 2.4 mg/dL, P<0.01), and PLDH further improved the bilirubin levels in LLG donors (1.2 vs. 1.6 mg/dL, P<0.01). PLDH also afforded a low rate of early complications (Clavien-Dindo grade ≥ II, 8% vs. 22%, P=0.007) and late complications including incisional hernia (0% vs. 13.7%, P<0.001) compared to open cases. LLG was more likely to have a single duct than RLG (89% vs. 60%, P<0.01). Importantly, with the aggressive use of LLG in 47% of adult LDLT, favorable graft survival was achieved without any differences between type of graft or surgical approach. Conclusions: The LLG first with PLDH approach minimizes surgical stress for donors in adult LDLT without compromising recipient outcomes. This strategy can lighten the burden for living donors, which could help expand the donor pool.

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“…The hyperperfusion index of ≥ 9.97 mm Hg.cc/g predicted early graft outcomes and recipient mortality. [43] Besides portal hemodynamics, a non-mechanical impediment to free hepatic venous outflow from a high caval pressure may potentially jeopardize graft function. In a prospective observational study including 61 LDLT recipients, a post-LDLT high CVP of > 11 mm Hg led to functional HVO obstruction, thereby leading to elevated portal vein pressure by 45% and delayed recovery of graft function.…”

Section: Graft Hemodynamicsmentioning

confidence: 99%

“…[57] Table 3 summarizes the early predictive markers of EAD in LDLT. [43,48,[59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76] Although the clinical use of these predictive biomarkers is not proven, we hypothesize that molecular biomarkers, combined with conventional clinical parameters, could lead to a more precise prediction of EAD after LDLT.…”

Section: Predictive Biomarkers Of Ead After Ldltmentioning

confidence: 99%

“…A recent systematic review demonstrated a low quality of evidence supporting the use of 10 biomarkers in predicting early EAD 57 Table 3. summarizes the early predictive markers of EAD in LDLT 43,48,59–76 . Although the clinical use of these predictive biomarkers is not proven, we hypothesize that molecular biomarkers, combined with conventional clinical parameters, could lead to a more precise prediction of EAD after LDLT.…”

Section: Introductionmentioning

confidence: 97%

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Early allograft dysfunction after living donor liver transplantation—current concepts and future directions

Agrawal¹,

Saigal

2023

Liver Transplantation

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Early allograft dysfunction (EAD) after liver transplantation is a significant clinical problem that negatively impacts graft and patient outcomes. The rising incidence of EAD and what it means concerning living donor liver transplantation (LDLT) is an area of great interest. However, EAD after LDLT is a complex research topic yet to be reviewed comprehensively. Most of the literature on EAD is based on experience in deceased donor liver transplantation, and limited information is available in the context of LDLT. Thus, in this review, we present an overview of EAD after LDLT and have attempted to present balanced points of view on all its aspects, such as definitions, pathogenesis, risk factors, predictive markers, and management. The review aims to broadly overview the nature and extent of ongoing research evidence on this complex topic and inform practice in the field by identifying key concepts and knowledge gaps and highlighting areas that require further inquiry.

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HPi: A Novel Parameter to Predict Graft-related Outcome in Adult Living Donor Liver Transplant

Cited by 9 publications

References 46 publications

Living Donor Liver Transplantation With Augmented Venous Outflow and Splenectomy

Living Donor Liver Transplantation With Augmented Venous Outflow and Splenectomy

Left Lobe First with Purely Laparoscopic Approach

Early allograft dysfunction after living donor liver transplantation—current concepts and future directions

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