Three liver transplants after a single cadaveric procurement: Split liver transplantation plus domino liver transplantation, an infrequent but valid alternative for maximizing transplant sharing and applicability-report of the first Latin American case

Abstract

TO THE EDITORS:The development of liver surgery and the need to overcome the shortage of cadaveric grafts have stimulated the creativity of surgeons in describing different options for using segmental liver grafts. Reduced size liver transplantation, ex vivo and in situ split liver transplantation, and living related donor liver transplantation are options that have spread since their original descriptions. 1 In the setting of these accepted strategies, the option of performing sequential or domino liver transplantation with livers from patients with familial amyloidotic polyneuropathy (FAP) has become possible, and these patients have started to be used worldwide as whole living donors for patients who otherwise would not benefit from the current allocation system and cannot apply for a segmental adult living donor graft. The success of some of the aforementioned techniques can be currently followed via Web-based registries such as the Familial Amyloidotic Polyneuropathy World Transplant Registry, which includes 62 centers in 21 countries performing orthotopic liver transplantation with FAP donors. 2 The need to foster maximal sharing has led to surgical innovations for further splitting FAP livers or performing split liver transplants for a pediatric recipient and an adult recipient with FAP followed by sequential or domino liver transplantation; however, only a small number of cases of this kind have been described. 3-5 Therefore, we report here our experience with the first case of split transplantation plus domino transplantation in Latin America at 2 Argentinean institutions. PATIENTS AND METHODSThe liver of a 19-year-old cadaveric donor with a donor risk index of 1.97 who died from head trauma was nationally distributed and allocated to a 13-month-old patient (12 kg) with acute liver failure of an unknown etiology. The left lateral segment was accepted, and the surgical team proposed splitting the organ and giving the right lobe plus segments I and IV to an adult recipient. In accordance with the Argentinean organ allocation policy, the right section of the liver was distributed nationally and was accepted by our program for a 41-year-old male patient (61.4 kg) with FAP and a Model for End-Stage Liver Disease score of 17; he was 30th on the national list. After the right split had been accepted, his FAP liver was offered to the same national list, and it was accepted for a second adult, a 63-year-old female (81 kg) with cryptogenic cirrhosis and encephalopathy (also from our program) who had a Model for End-Stage Liver Disease score of 20; she was 19th on the national list.The logistics were arranged for performing an ex vivo split at the pediatric hospital while the 3 recipients were prepared for engraftment: the pediatric recipient at a public pediatric hospital and the 2 adult recipients at our private institution.

Surgical technique and the long‐term outcomes of pediatric living donor domino liver transplantation from patients with maple syrup urine disease

“…SLT in deceased donor LT can effectively increase the chances of obtaining liver grafts for pediatric LT. Split‐liver policies have been deployed based on the same concept, that “a good‐quality liver” can be split 21 . DLT with split livers from patients with FAP was reported as a solution for the organ shortage and to maximize organ sharing 22,23 . Our experience provides precious evidence on the development of SLT using a split graft from an MSUD liver.…”

“…21 DLT with split livers from patients with FAP was reported as a solution for the organ shortage and to maximize organ sharing. 22,23 Our experience provides precious evidence on the development of SLT using a split graft from an MSUD liver.…”

Measuring Long-term Outcomes of Pediatric Liver Transplantation: The Japanese Exemplar

“…[3][4][5] To provide sufficient liver transplants for their children in need, the Japanese Organ Transplant Network could evaluate the possibility not only of performing domino liver transplants but also stimulating the use of ex vivo or in situ split liver donations, which has become a major source of pediatric deceased liver donation in countries with far fewer resources than Japan, highly recognized for having extremely well-developed surgical technics and skills. 6,7 Splitting the liver brings additional advantages through optimizing the use of a single donor for 2 recipients, reducing the need for ABO-incompatible transplants, and avoiding the need for a living donor. The disadvantage of the practice of splitting deceased donor livers is that it requires the commitment of the surgical team to provide senior experienced surgeons for the procedure both to reduce operating times and improve results for both transplant recipients.…”