Low Preoperative Platelet Count Predicts Risk of Subclinical Posthepatectomy Liver Failure in Right Lobe Donors for Liver Transplantation

Abstract

Living donor right hepatectomy (LDRH) is a common procedure in adult-to-adult living donor liver transplantation, but it is associated with a higher risk of posthepatectomy liver failure (PHLF) compared with left hepatectomy because of a smaller remnant. We identified risk factors for PHLF and other complications in LDRH, verified the appropriateness of the criteria, and explored the possibility of adjusting the minimum remnant liver volume (RLV) based on individual risk. Between October 2005 and November 2017, 254 donors undergoing LDRH at Kyoto University Hospital were enrolled. Clinical data were collected retrospectively. All complications were graded according to the Clavien-Dindo classification. No donors had grade 4 or 5 complications or clinically significant grade B or C PHLF. Grade A PHLF occurred in 30 donors (11.8%). Male sex (P = 0.01), lower preoperative platelet count (PLT; P = 0.01), higher prothrombin time-international normalized ratio (P = 0.03), higher total bilirubin (P = 0.01), smaller RLV (P = 0.03), and greater blood loss (P = 0.04) were associated with increased risk of PHLF in the univariate analysis, whereas PLT, RLV, and blood loss remained significant in the multivariate analysis. Grade 2 or 3 complications were observed in 32 (12.6%) donors. Higher body mass index (BMI; P = 0.002) and larger blood loss (P = 0.02) were identified as risk factors for complications (Clavien-Dindo grade ≥ 2) in univariate analysis. Only BMI remained significant in the multivariate analysis. In conclusion, LDRH is performed safely with acceptable morbidity under the current criteria. Minimum RLV may be marginally adjusted by PLT and reducing intraoperative blood loss minimizes PHLF risk. Liver Transplantation 00 000-000 2018 AASLD.

Long-term impact and clinical significance of living donor liver transplantation with respect to donor liver restoration and spleen size: A prospective study

“…These results suggest that splenomegaly after donor surgery is not only a phenomenon of mere splenic enlargement, but indicates signs of portal hypertension while being subclinical. Predictably, PLT decrease was significantly greater in the right lobe donors than in the left lobe/lateral segment donors, reaffirming that living donor right hepatectomy in individuals with lower PLT levels should be carefully considered not only in terms of short‐term morbidity but also in terms of long‐term consequence. This supports our current policy to use left lobe grafts with priority …”

Optimizing pre‐donation physiologic evaluation for enhanced recovery after living liver donation – Systematic review and multidisciplinary expert panel recommendations

“…Screening of 1386 records and 43 full texts as well as addition of three articles identified from other sources led to three articles matching eligibility criteria (Figure 1). These three articles described retrospective cohort studies 8,14,15 . In these studies, a total of 1193 living donors underwent partial hepatectomy.…”

“…However, our review demonstrates that donor age does not confer an increased risk for postoperative complications, increased length of stay, or biochemical hepatic recovery. It is important to note that donor selection was exclusive to donors who age ≤ 65 years (with no comorbidity) in one study 14 with well-controlled hypertension without end-organ damage or other cardiovascular abnormalities were allowed to donate; an approach that is in line with the opinion of our expert panel. The findings of these studies are also in line with the recent observations in general population.…”

“…The results of our systematic review about BMI are conflicting, which affected the judgment for QOE of this recommendation, yet they are thought‐provoking. While Knaak et al 15 showed, in a study conducted in North America, that donor BMI of 30‐35 kg/m 2 does not confer a risk for postoperative complications compared to BMI of < 30 kg/m 2 , Yoshino et al 14 showed, in a study conducted in Asia, that donors with postoperative complications had a median BMI of 23.8 kg/m 2 compared to 21.7 kg/m 2 in those without complications (OR 1.67). These results need to be interpreted with the understanding that the BMI cut‐offs for Asian and Pacific populations tend to be lower than that of other populations (overweight cut‐off is 23 kg/m 2 vs 25 kg/m 2 and obesity cut‐off is 25 kg/m 2 vs 30 kg/m 2 ) given the difference in the body frame, body relative composition (i.e., proportion of fat, muscle, and bone), and metabolic risks 21 .…”

Dualistic role of platelets in living donor liver transplantation: Are they harmful?

“…The remnant liver volume ratio, which was recommended to exceed the minimum of 30% to 35% for donor safety[ 54 ], is closely related to postoperative morbidity such as liver failure, and platelets have been highlighted as playing an important role in this condition. Yoshino et al [ 55 ] retrospectively collected data from 254 donors undergoing LDLT and showed that a lower preoperative platelet count was an independent risk factor for postoperative complications, such as bile leakage, subphrenic effusion, infectious ascites, postoperative anemia, and liver failure, after living donor hepatectomy. Emond et al [ 56 ] demonstrated that even in healthy donors, the fluctuation of platelet count within the normal range was negatively associated with potential portal hypertension and subclinical liver dysfunction, indicating that platelet count might serve as a surrogate marker to predict potential liver failure in healthy donors.…”