Liver Transplantation in Children From Living Related Donors

Abstract

Pediatric liver transplantation with reduced size donor organs (RLT) has evolved into a standard clinical procedure increasing the choices of recipients for their treatment. Nevertheless organ availability remains a major problem. The authors therefore have proposed to study the use of hepatic segments from living related donors (LRT) in a group of 20 children less than 2 years of age or weighing less than 15 kg, in whom standard indications for transplantation existed. Volunteer related donors were selected after medical and psychiatric evaluations, and the suitability of the donor's liver was established by functional and radiologic criteria. A two-stage informed consent process assured appropriate "volunteerism." Nineteen infants received LRT as first grafts and one as a second graft. Seventeen of the recipients are alive 3 to 18 months after LRT. Fifteen of 20 patients are currently at home with the original graft and normal liver function (bilirubin less than 1.5 mg/dl) after a median hospital stay of 27 days (range, 14-93 days). Four patients underwent retransplantation, in all cases due to arterial thrombosis. The overall graft survival for 20 primary LRTs is 75%, with follow-up between 3 and 18 months. A number of technical problems occurred during our initial trial, the most aggravating being vascular thrombosis. Refined approaches to vascular reconstruction should reduce the incidence of thrombosis and improve the rate of survival in future cases. The donor group for the initial 20 LRT procedures comprised 12 mothers, 7 fathers, and 1 grandmother. In addition one father and one uncle, who was an identical twin of the recipient's father, who did not qualify for anatomic reasons, were used in repeat LRT. All donors survived and are now in normal health between 3 and 18 months after LRT, having returned to all activities enjoyed before donation. The median hospital stay was 6 days (range, 5-14). Complications were minimal, and all were limited to the first three procedures, in which a full left hepatectomy was performed. After alteration of the procedure into a left lateral segmentectomy, no complications were encountered. The left lateral segmentectomy presents minimal surgical trauma to the liver and should remain the primary approach for obtaining a liver graft from a living donor. For children, transplantation of a left lateral segment from a live donor provides a new way of providing a transplant of appropriate size and with good function. The success of this program has led to the acceptance of LRT for general clinical application in the authors' institution.

Death of a living liver donor: Opening Pandora's box

“…2 The benefit to the recipient, who would otherwise die waiting for a cadaveric organ, is undisputed. 3 Although a period of 23 years has passed since the first case of LDLT was reported, 4 the LDLT/deceased donor liver transplantation debate continues and is focused heavily on 2 aspects of LDLT: donor mortality and the ethics of LDLT (specifically issues related to donor autonomy and transplant commercialism). Both, sadly, have been underreported.…”

Split-Liver Transplantation: A Review

“…These techniques could be applied to cadaver donors in the performance of SLT (11,12) or to live volunteers to create living-donor liver transplantation (13,14).…”

Cigarette smoking is associated with an increased incidence of vascular complications after liver transplantation

“…Such changes have been known and studied in animals and humans for more than 30 years. 1,2 In particular, hepatic artery thrombosis (HAT) and other vascular complications (hepatic artery stenosis [HAS], portal vein thrombosis [PVT] and deep vein thrombosis [DVT]) remain devastating complications after LT. 2,3 The reported incidence of HAT is estimated to be 25% in living related allografts, 4 10% to 25% in pediatric cadaver liver recipients, [5][6][7][8] 2.6% to 20% in adult cadaver liver recipients, 9 and as high as 30% in children younger than 1 year old. 10 Early onset HAT usually develops within the first 2 months, 11,12 especially the first 5 days after LT. 13 Clinical presentations include acute, massive hepatic necrosis leading to fulminant hepatic failure, relapsing bacteremia with recurrent biliary sepsis from cholangitis, biliary tract ischemia leading to bile duct necrosis and leaks, and asymptomatic presentation with normal liver function tests.…”