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• W2911330337 abstract "To implement split liver transplantation (SLT) a mandatory-split policy has been adopted in Italy since August 2015: donors aged 18-50 years at standard risk are offered for SLT, resulting in a left-lateral segment (LLS) graft for children and an extended-right graft (ERG) for adults. We aim to analyze the impact of the new mandatory-split policy on liver transplantation (LT)-waiting list and SLT outcomes, compared to old allocation policy. Between August 2015 and December 2016 out of 413 potentially “splittable” donors, 252 (61%) were proposed for SLT, of whom 53 (21%) donors were accepted for SLT whereas 101 (40.1%) were excluded because of donor characteristics and 98 (38.9%) for absence of suitable pediatric recipients. The SLT rate augmented from 6% to 8.4%. Children undergoing SLT increased from 49.3% to 65.8% (P = .009) and the pediatric LT-waiting list time dropped (229 [10-2121] vs 80 [12-2503] days [P = .045]). The pediatric (4.5% vs 2.5% [P = .398]) and adult (9.7% to 5.2% [P < .001]) LT-waiting list mortality reduced; SLT outcomes remained stable. Retransplantation (HR = 2.641, P = .035) and recipient weight >20 kg (HR = 5.113, P = .048) in LLS, and ischemic time >8 hours (HR = 2.475, P = .048) in ERG were identified as predictors of graft failure. A national mandatory-split policy maximizes the SLT donor resources, whose selection criteria can be safely expanded, providing favorable impact on the pediatric LT-waiting list and priority for adult sick LT candidates. To implement split liver transplantation (SLT) a mandatory-split policy has been adopted in Italy since August 2015: donors aged 18-50 years at standard risk are offered for SLT, resulting in a left-lateral segment (LLS) graft for children and an extended-right graft (ERG) for adults. We aim to analyze the impact of the new mandatory-split policy on liver transplantation (LT)-waiting list and SLT outcomes, compared to old allocation policy. Between August 2015 and December 2016 out of 413 potentially “splittable” donors, 252 (61%) were proposed for SLT, of whom 53 (21%) donors were accepted for SLT whereas 101 (40.1%) were excluded because of donor characteristics and 98 (38.9%) for absence of suitable pediatric recipients. The SLT rate augmented from 6% to 8.4%. Children undergoing SLT increased from 49.3% to 65.8% (P = .009) and the pediatric LT-waiting list time dropped (229 [10-2121] vs 80 [12-2503] days [P = .045]). The pediatric (4.5% vs 2.5% [P = .398]) and adult (9.7% to 5.2% [P < .001]) LT-waiting list mortality reduced; SLT outcomes remained stable. Retransplantation (HR = 2.641, P = .035) and recipient weight >20 kg (HR = 5.113, P = .048) in LLS, and ischemic time >8 hours (HR = 2.475, P = .048) in ERG were identified as predictors of graft failure. A national mandatory-split policy maximizes the SLT donor resources, whose selection criteria can be safely expanded, providing favorable impact on the pediatric LT-waiting list and priority for adult sick LT candidates. Over the past few years, the transplant community has made great efforts to increase the pediatric priority in liver organ allocation; however, the mortality of children candidates for liver transplantation (LT), who are disadvantaged because of the lack of size-matched donors, has been steady at approximately 10% every year.1Kim WR Lake JR Smith JM et al.Liver.Am J Transplant. 2016; 16: 69-98Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar,2Hsu EK Shaffer ML Gao L et al.Analysis of liver graft offers to pediatric candidates on the transplant waiting list.Gastroenterology. 2017; 153: 988-995Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar Split liver transplantation (SLT) was introduced to expand the pool of grafts available for pediatric recipients, providing a left lateral segment (LLS) to a child and an extended-right graft (ERG) to an adult recipient.3Pichlmayr R Ringe B Gubernatis G et al.Transplantation of a donor liver to 2 recipients (splitting transplantation)–a new method in the further development of segmental liver transplantation.Langenbecks Arch Chir. 1988; 373: 127-130Crossref PubMed Scopus (453) Google Scholar After the initial splitting experience, advances in surgical techniques and a better understanding of recipient/donor matching led to excellent SLT outcomes both in pediatric and adult recipients.4Otte JB de Ville de Goyet J Alberti D et al.The concept and technique of the split liver in clinical transplantation.Surgery. 1990; 107: 605-612PubMed Google Scholar, 5Azoulay D Astarcioglu I Bismuth H et al.Split-liver transplantation. The Paul Brousse policy.Ann Surg. 1996; 224: 737-746Crossref PubMed Scopus (160) Google Scholar, 6Mirza DF Achilleos O Pirenne J et al.Encouraging results of split-liver transplantation.Br J Surg. 1998; 85: 494-497Crossref PubMed Scopus (49) Google Scholar, 7de Ville de Goyet J Split liver transplantation in Europe—1988 to 1993.Transplantation. 1995; 59: 1371-1376Crossref PubMed Scopus (154) Google Scholar, 8Wan P Li Q Zhang J et al.Right lobe split liver transplantation versus whole liver transplantation in adult recipients: a systematic review and meta-analysis.Liver Transpl. 2015; 21: 928-943Crossref PubMed Scopus (38) Google Scholar, 9Ross MW Cescon M Angelico R et al.A matched pair analysis of multicenter long-term follow-up after split liver transplantation with extended right grafts.Liver Transpl. 2017; 23: 1384-1395Crossref PubMed Scopus (18) Google Scholar Different organ allocation systems encouraged the implementation of SLT to expand the graft availability from deceased donors for children, without disadvantaging adult LT candidates.10Hsu EK Mazariegos GV Global lessons in graft type and pediatric liver allocation: a path toward improving outcomes and eliminating wait-list mortality.Liver Transpl. 2017; 23: 86-95Crossref PubMed Scopus (39) Google Scholar The SLT rate varies worldwide: in Europe, SLT represents approximately 6% of all LT.11Adam R Karam V Delvart V et al.Evolution of indications and results of liver transplantation in Europe. A report from the European Liver Transplant Registry (ELTR).J Hepatol. 2012; 57: 675-688Abstract Full Text Full Text PDF PubMed Scopus (625) Google Scholar In the United States, SLT comprises approximately 1% of all LT, despite the fact that it is estimated that 20% of deceased donors meet United Network of Organ Sharing (UNOS) guidelines for split livers.12Superina R To split or not to split: that is the question.Liver Transpl. 2012; 18: 389-390Crossref PubMed Scopus (18) Google Scholar In Italy, after the encouraging results of the initial SLT experience of the North Italian Transplant programme,13Cardillo M De Fazio N Pedotti P et al.Split and whole liver transplantation outcomes: a comparative cohort study.Liver Transpl. 2006; 12: 402-410Crossref PubMed Scopus (94) Google Scholar since 2015 the National Transplantation Centre (CNT) in collaboration with the Italian College of Liver Transplantation Programmes defined a mandatory-split liver policy (SLP) in order to increase the number of splitting procedures nationwide and to reduce pediatric LT-waiting list mortality. This study aims to analyze liver allocation in Italy after the introduction of the new SLP and its impact on the pediatric/adult LT-waiting list and on SLT outcomes. In Italy there are 21 LT centers divided into 13 regions governed by the CNT network and grouped into two macro-areas (Figure 1). Since the CNT’s establishment, liver allocation policies have seen several modifications. The first national SLT allocation program was approved in 2006; transplant centers could voluntary decide whether or not to participate. At that time, donors aged ≤14 years were preferentially allocated to pediatric recipients (<18 years), whereas donors ≥15 years were allocated to adults. Donors aged 10-50 years with stable hemodynamics, intensive therapy unit (ITU)-stay ≤5 days, transaminases ≤3 times normal, and absence of steatosis on the ultrasound scan were defined as “splittable.” The decision of whether or not to perform the splitting procedure was the choice of the LT center to which the graft was assigned. In 2015, a consensus redefined the Italian criteria for LT candidate stratification not only based on urgency but also on the principles of utility and transplant benefit. The current liver allocation system is based on the Model for End-Stage Liver Disease (MELD)/Italian Score for Organ Allocation (ISO), which is defined by biochemical MELD and exceptions.14Cillo U Burra P Mazzaferro V et al.A multistep, consensus-based approach to organ allocation in liver transplantation: toward a “Blended Principle Model”.Am J Transplant. 2015; 15: 2552-2561Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar At present, liver grafts are shared according to the following principles: (1) nationwide, for (a) UNOS status 1 patients; (b) pediatric candidates according to the pediatric LT allocation system15http://www.trapianti.salute.gov.it/ Accessed September 13, 2018Google Scholar; (2) macro-areas for adult LT candidates with MELD ≥30; and (3) regionally for adult patients with MELD <30.14Cillo U Burra P Mazzaferro V et al.A multistep, consensus-based approach to organ allocation in liver transplantation: toward a “Blended Principle Model”.Am J Transplant. 2015; 15: 2552-2561Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar Additionally, the age of the donors preferentially assigned to pediatric recipients increased from 14 to 17 years and a national mandatory SLP was adopted. In the new SLP, all deceased donors aged 18-50 years with standard risk (defined as the absence of potential transmissible infections or neoplastic diseases) are mandatorily offered to pediatric transplant centers according to the pediatric national LT-waiting list15http://www.trapianti.salute.gov.it/ Accessed September 13, 2018Google Scholar unless a UNOS 1 status or MELD ≥30 adult candidate is on the waiting list. If the deceased donor is “splittable,” the LLS graft is allocated to a pediatric recipient. According to the adult rules, the ERG is then allocated to a recipient not only on the basis of the MELD/ISO score14Cillo U Burra P Mazzaferro V et al.A multistep, consensus-based approach to organ allocation in liver transplantation: toward a “Blended Principle Model”.Am J Transplant. 2015; 15: 2552-2561Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar but also taking into account clinical parameters and donor-to-recipient size matching (Figure 2). This study analyzed all deceased donors used in Italy for LT after the introduction of the new SLP and all recipients transplanted with LLSs and ERGs derived from split procedures. For the outcome analysis, the same number of SLTs performed consecutively before the introduction of the new SLP was used as a control group. To evaluate the impact of the new SLP, data from adult and pediatric LT-waiting lists as well as data on living donor liver transplantation (LDLT) activity were considered. Organ allocation, donor, recipient, and surgical data were recovered from the CNT prospective databases and retrospectively analyzed. To define the impact of the split liver procuring centers, the pediatric centers, which performed all split procedures, were stratified according to the number of split procurements performed/year (high-volume, ≥15 procedures; low-volume, <15 procedures). Since the beginning of the Italian SLT experience dating back to the mid-1990s, split liver has been performed in situ by a surgical team composed of a pediatric and an adult transplant surgeon. Ex situ split is carried out only if the in situ procedure might compromise the recovery of other organs (ie, donor hemodynamic instability) or for intraoperative technical issues, which did not allow the in situ technique. Before 2015, parenchymal transection was preferentially performed using the transumbilical technique16Broelsch CE Whitington PF Emond JC et al.Liver transplantation in children from living related donors surgical techniques and results.Ann Surg. 1991; 214: 428-437Crossref PubMed Scopus (645) Google Scholar and the celiac tripod was kept in continuity with the left hepatic artery. According to the new SLP, parenchymal transection (transumbilical or transhilar17Emond JC Whitington PF Thistlethwaite JR et al.Transplantation of two patients with one liver. Analysis of a preliminary experience with “split liver” grafting.Ann Surg. 1990; 21: 14-22Crossref Scopus (264) Google Scholar) and vessels’ division are decided in agreement between pediatric and adult surgeons intraoperatively. The celiac tripod can be assigned either to the LLS or the ERG according to (1) donor-to-recipient size matching, (2) donors’ vascular anatomy (vessels’ sizes, number of branches, segment IV branches’ origin), and (3) recipients’ vascular anatomy and clinical status (urgency, retransplantation, hepatic artery thrombosis). The main portal vein is assigned to the ERG and the left portal vein to the LLS. Only in case of disagreement regarding vessels’ division, the final decision is taken by the adult center for donor ≥18 years, whereas by the pediatric centers for donor <18 years. Intraoperative cholangiography is not routinely performed. Statistical analyses were performed using IBM SPSS Statistics, version 22.0 (IBM, Chicago, IL). Donor/recipient characteristics and clinical data are shown (wherever applicable) as either median with range or mean ± standard deviation. Univariate data were analyzed using the Mann-Whitney test and Fisher’s exact test. A P value of <.05 was considered significant. Normal distribution continuous data were analyzed by parametric test (Student’s t test). Survival rates were calculated using the Kaplan-Meier method for univariate analysis and Cox-regression for multivariate analysis. Between August 2015 and December 2016, 1537 cadaveric donors were used for LT, including 58 (3.8%) pediatric donors (<18 years), 1066 (69.4%) adults >50 years and/or nonstandard risk, and 413 (26.8%) adults aged 18-50 years with standard risk. In the latter group, 161 (39%) donors were allocated to UNOS status 1 or MELD ≥30 patients; the remaining 252 (61%) were proposed for SLT, of whom 53 (21%) were accepted. One hundred and one (40.1%) were excluded from split because of the clinical characteristics of the donor at the time of offer (n = 85) or at laparotomy (n = 16). In 88 cases (34.9%), the split procedure was not performed for absence of suitable pediatric recipient, and in 10 cases (4%) due to logistic issues (Table 1). All donors refused for SLT were allocated to adult recipients as a whole graft. The donors accepted for SLT were significantly younger, had lower body weights, and received less vasopressor compared to those not split (Table 2).TABLE 1Causes of nonsplitting in adult donors offered for split liver transplantationNumber (%)At the time of donor offer171 (85.9)DonorAbnormal LFTs30 (15.1)Steatosis on US scan20 (10.1)Hemodynamic instability20 (10.1)Hepatic lesions on US scan7 (3.5)Comorbidities4 (2)Prolonged ITU stay4 (2)RecipientInadequate donor/recipient size matching65 (32.7)No suitable recipients on the waiting list13 (6.5)Logistic issue8 (4)At donor laparotomy28 (14.1)DonorSteatosis at liver biopsy6 (3)Intraoperative vascular anomalies6 (3)Intraoperative hemodynamic instability4 (2)RecipientInadequate donor/recipient size matching10 (5)Intraoperative logistic issue2 (1)ITU, intensive therapy unit; LFTs, liver function tests; US scan, ultrasound scan. Open table in a new tab TABLE 2Characteristics of donors offered for split liver transplantation under the new split liver policyVariablesTotal donor offered for SLTDonor refused for donor characteristicsaLiver graft from donor refused for SLT due to donor or recipient characteristics was used as whole liver graft.Donor refused for absence of suitable recipientsaLiver graft from donor refused for SLT due to donor or recipient characteristics was used as whole liver graft.Donors accepted for SLTP valueNumber (%)252101 (40.1%)98 (38.9%)53 (21%)-Age (years)41 (18-50)43.5 (18-50)41 (18-50)38 (18-50).044Gender (female)88 (34.9%)38 (37.6%)29 (29.6%)21 (39.6%).366BMI25 (16-46)25 (18-46)26 (18-46)24 (18-32)<.0001Weight (kg)75 (30-150)75 (42-120)80 (30-150)70 (50-90)<.0001Height (cm)170 (130-192)170 (146-190)175 (130-192)170 (150-190).158Blood group094 (37.3%)45 (44.6%)22 (22.4%)27 (50.9%)A103 (40.9%)37 (36.7%)50 (51.0%)16 (30.2%)AB14 (5.6%)5 (4.9%)9 (9.2%)0 (%).002B41 (16.3%)14 (13.9%)17 (17.3%)10 (18.9%)Use of vasopressors (yes)198 (78.6%)76 (75.2%)69 (70.4%)42 (86.8%)<.0001Use >1 vasopressors49 (19.4%)25 (24.8%)13 (13.3%)11 (20.8%).088ITU stay (days)3 (0-37)2 (0-37)3 (0-16)3 (0-19).648AST (U/L)45 (7-15285)55 (9-15285)40 (7-497)42 (9-628).023ALT (U/L)41 (5-5575)56 (6-5575)32 (5-971)34 (9-530).035Total bilirubin (mg/dL)0.4 (0.1-7.8)0.4 (0.1-7.8)0.4 (0.1-3.04)0.3 (0.1-2.6).038GGT (U/L)39 (5-988)42 (5-988)33 (8-537)33 (5-624).378Serum sodium (mmL/L)150 (130-187)150 (131-183)151 (130-187)148 (131-173).438Cause of deathCerebrovascular accident112 (44.4%)40 (39.6%)46 (46.9%)26 (49.1%)Trauma93 (36.9%)38 (37.6%)37 (37.8%)18 (34%).248Anoxia38 (15.1%)20 (19.8%)12 (12.2%)6 (11.3%)Others9 (3.6%)3 (3%)3 (3.1%)3 (5.7%)ALT, alaninoaminotransferase; AST, aspartatoaminotransferase; GGT, gamma-glutamyltransferase; BMI, body mass index; ITU, intensive therapy unit; LFTs, liver function tests; US scan, ultrasound scan.a Liver graft from donor refused for SLT due to donor or recipient characteristics was used as whole liver graft. Open table in a new tab ITU, intensive therapy unit; LFTs, liver function tests; US scan, ultrasound scan. ALT, alaninoaminotransferase; AST, aspartatoaminotransferase; GGT, gamma-glutamyltransferase; BMI, body mass index; ITU, intensive therapy unit; LFTs, liver function tests; US scan, ultrasound scan. In the pediatric donor group (n = 58), 45 (78%) livers were transplanted as whole grafts into 26 (58%) pediatric and 19 (42%) adult recipients. In the other 11 (19%) cases, livers were split generating 10 LLSs, 10 ERGs, one left and one right lobes. Two (3%) pediatric grafts were reduced on the back table. In 4 cases, split liver procurements were performed in donors >50 years. The clinical characteristics of split liver donors <18 and >50 years are summarized in Table S1. In summary, 68 split liver procedures were performed after the introduction of the new SLP, generating one left lobe, one right lobe, 66 LLSs (one LLS was discarded because of vascular injury), and 67 ERGs. For outcomes evaluation, the left and right lobes and two ERGs that were part of multiorgan transplantations were excluded, resulting in 66 LLSs and 65 ERGs enrolled in the study. All LLSs were transplanted into pediatric recipients. In 57 (87.7%) cases, the ERG was transplanted into adults, and in 8 (12.3%) cases into a child (Table 3). Two children, with UNOS 1 status, received ERGs from donors >18 years.TABLE 3Liver donor allocation during the new and old split liver policyNew split liver policyWhole liver transplantationSplit liver transplantationType of deceased donorsTotalLLSERGLeft lobeRight lobeTotalPediatric recipientAdult recipientPediatric recipientAdult recipientPediatric recipientAdult recipientPediatric recipientAdult recipientPediatric recipientAdult recipientPediatric (<18 y)58 (3.8%)4728aTwo liver grafts from pediatric donor were reduced on backtable.192210-641--1Adult 18-50 y, standard risk413 (26.8%)360-36010552-251b2 ERGs combined with kidney transplantation were excluded from the outcome analysis.----Adult >50 y, non-standard risk1066 (69.4%)10626105684--4----Total1537146934143513566-8591--1Enrolled in the outcome analysis---6665---Old split liver policyWhole liver transplantationSplit liver transplantationLLSERGLeft lobeRight lobeType of deceased donorsTotalPediatric recipientAdult recipientTotalPediatric RecipientAdult recipientPediatric recipientAdult recipientPediatric recipientAdult recipientPediatric recipientAdult recipientPediatric (<18 y)96 (4.4%)8541442211-47----Adult 18-50 y, standard risk574 (26.2%)52565199746-344c1 ERG combined with pancreas transplantation was excluded from the outcome analysis.11-2Adult >50 y, nonstandard risk1518 (69.4%)151041506168-17----Total2188212051206913565-85811-2Enrolled in the outcome analysis6565ERG, extended right graft; LLS, left-lateral segment; y, years.a Two liver grafts from pediatric donor were reduced on backtable.b 2 ERGs combined with kidney transplantation were excluded from the outcome analysis.c 1 ERG combined with pancreas transplantation was excluded from the outcome analysis. Open table in a new tab ERG, extended right graft; LLS, left-lateral segment; y, years. The 68 consecutive split liver procedures chosen as the control group were performed between June 2013 and August 2015. In the control group, 49 (72%) split procedures were performed in donors aged 18-50 years, 11 (16.2%) in donors <18 years, and 8 (11.8%) in donors >50 years (Table 3). These were standard split liver procedures in 66 (97.1%) cases and full-left/full-right split in 2 (2.9%) cases. One LLS graft was not transplanted because of vascular injury. Similar to the study group, left and right lobes and one ERG used for combined liver-pancreas transplantation were excluded, resulting in 65 LLSs and 65 ERGs enrolled in the study. The clinical characteristics of the donors who underwent split liver procurement in the new and old SLP were similar except for the ITU-stay, which was longer in the study period (3 [0-19] vs 2 [0-11] days, P = .039) (Table 4).TABLE 4Split liver donor characteristics under the new and old split liver policyDonor variablesNew split liver policyOld split liver policyP valueNumber6665Age (years)36 (5-66)33 (8-58).836<18 years10 (15.4%)11 (16.7%)18-50 years52 (80%)46 (70.8%)>50 years4 (6.2%)8 (12.3%)Gender (female)25 (51%)24 (49%)1.000BMI23 (16-32)23 (19-33).692Weight (kg)68 (25-90)70 (42-101).421Height (cm)170 (125-190)170 (145-194).245Blood group034 (51.5%)30 (46.2%)A22 (33.3%)30 (46.2%).211B10 (15.2%)5 (7.7%)Use of vasopressors45 (66.7%)35 (53.8%).155Use of >1 vasopressors12 (18.2%)11 (16.9%).291ITU stay (days)3 (0-19)2 (0-11).039*AST (U/L)40 (9-628)42 (8-357).639ALT (U/L)29 (9-530)34 (8-269).978Total bilirubin (mg/dL)0.5 (0.1-3)0.4 (0.1-8).078GGT (U/L)30 (5-624)28 (5-545).712Serum sodium (mmL/L)148 (131-173)148 (124-193).363Cause of deathCerebrovascular31 (46.9%)33 (50.8%)Trauma24 (36.4%)21 (32.3%).632Anoxia7 (10.6%)10 (15.4%)Others4 (6.1%)1 (1.5%)ALT, alaninoaminotransferase; AST, aspartatoaminotransferase; GGT, gamma-glutamyltransferase; BMI, body mass index; ITU, intensive therapy unit. Open table in a new tab ALT, alaninoaminotransferase; AST, aspartatoaminotransferase; GGT, gamma-glutamyltransferase; BMI, body mass index; ITU, intensive therapy unit. Table 5 shows the surgical and recipient characteristics of LLS transplantation. During the study period, the LLS recipients were significantly younger compared to those transplanted in the control period, including 77.3% vs 58.5% children <24 months of age (P = .025).TABLE 5Surgical and recipient characteristics of left-lateral segment transplantationVariablesNew split liver policy (n = 66)Old split liver policy (n = 65)P valueSurgical variablesIn situ/ex situ split64 (97%) / 2 (3%)63 (96.9%) / 2 (3.1%)1.000Cold ischemic time (hours)6 (3-10)5 (1-8).108Warm ischemic time (minutes)47 (24-110)40 (30-121).238Recipient variablesAge (years)1.1 (0.1-11.2)2.1 (0.1-12.1).043Gender (female)33 (50%)36 (55.4%).601BMI16.4 (13 -23.8)16.5 (11.3-22.3).848Weight (kg)8.7 (4-35)12 (6-30).020Height (cm)70.1 (53-135)84 (58-152).014Blood group028 (42.4%)22 (33.8%)A23 (34.8%)33 (50.8%).271B12 (18.2%)7 (10.8%)AB3 (4.5%)3 (4.6%)PELD score22 (10-43)22 (12-39)1.000UNOS status18 (12.1%)7 (10.8%)1B1 (1.5%)6 (9.2%)2A5 (7.6%)7 (10.8%).3442B10 (15.2%)10 (15.4%)342 (63.6%)35 (53.8%)Indication for transplantationAcute liver failure6 (9.1%)3 (4.6%)Autoimmune liver disease2 (3%)1 (1.5%)Cholestatic liver disease43 (65.2%)36 (55.4%)Tumor2 (3%)9 (13.8%).074Metabolic liver disease7 (10.6%)6 (9.2%)Retransplantation (early/late)4 (2/2) (6.1%)10 (1/9) (15.4%)Other disease2 (3%)-Time on waiting list to transplant (days)36 (1-530)35 (1-571).634ALT, alaninoaminotransferase; AST, aspartatoaminotransferase; GGT, gamma-glutamyltransferase; BMI, body mass index; PELD, pediatric end-stage liver disease; UNOS, United Network of Organ Sharing. Open table in a new tab ALT, alaninoaminotransferase; AST, aspartatoaminotransferase; GGT, gamma-glutamyltransferase; BMI, body mass index; PELD, pediatric end-stage liver disease; UNOS, United Network of Organ Sharing. The overall 1-year patient survivals were 84.8% and 87.7% in the study and control period respectively (P = .408); the overall 1-year graft survival was 78.8% for the new SLP and 80% for the old SLP (P = .610) (Figure 3). In the study group, 10 (15.2%) patients died within 1 year from SLT, of whom 5 (50%) were urgent SLT. Of 7 (10.8%) children who died during the old SLP, only one (14.2%) had urgent transplantation. The retransplantation rate was similar in the two groups (4 [6.1%] vs 5 [7.7%] [P = .712]) (Table 6). The characteristics of the deceased and retransplanted LLS recipients are detailed in Table S2.TABLE 6Causes of death and retransplantation after left-lateral segment transplantationVariablesNew split liver policy (n = 66)Old split liver policy (n = 65)P valueTotal number of death10 (15.2%)7 (10.8%).456Cause of deathPNF1 (1.5%)2 (3.1%).619Sepsis2 (3.0%)1 (1.5%).568MOF5 (7.6%)2 (3.1%).077Tumor recurrence0 (0%)1 (1.5%)1.000Pulmonary embolism1 (1.5%)0 (1.5%).496Biliary complication0 (0%)1 (1.5%)1.000Cerebrovascular accident1 (1.5%)0 (0%).496Retransplantation4 (6.1%)5 (7.7%).712Cause of retransplantationPNF/DNF1 (1.5%)3 (4.6%).302Hepatic artery thrombosis2 (3%)0 (0%).496Portal vein thrombosis1 (1.5%)1 (1.5%).991Chronic rejection0 (0%)1 (1.5%).312DNF, delayed nonfunction; LLS, left-lateral segment; MOF, multiorgan failure; PNF, primary nonfunction. Open table in a new tab DNF, delayed nonfunction; LLS, left-lateral segment; MOF, multiorgan failure; PNF, primary nonfunction. Within the first year of SLT, postoperative technical complications were comparable in the two periods (20 [30.3%] vs 24 [36.9%], [P = .529]) (Table S3). The technical and recipient characteristics of ERG transplantation were comparable in the two periods (Table 7). The 1-year patient survival was 93.8% in both groups (P = .538), whereas 1-year graft survival was 86.2% after the introduction of the new SLP and 83.1% in the control period (P = .753) (Figure 4).TABLE 7Surgical and recipient characteristics of extended right graft transplantationVariablesNew split liver policy (n = 65)Old split liver policy (n = 65)P valueSurgical variablesIn situ/ex situ split58 (89.2%)/7 (10.8%)59 (90.8%)/6 (9.2%).778Cold ischemic time (hours)7 (4-11)6 (3-15).125Warm ischemic time (minutes)42 (22-165)35 (22-80).207Recipient variablesAge (years)53 (2-71)53 (8-69).714Gender (female)29 (44.6%)38 (58.5%).160BMI23.2 (13.4-32)23.5 (14.3-43.3).257Weight (kg)64 (11-103)65 (22-109).782Height (cm)168 (88-183)165 (86-180).279Blood group030 (46.2%)21 (32.3%)A22 (33.8%)37 (56.1%)B12 (18.5%)6 (9.2%).040AB1 (1.5%)1 (1.5%)Biochemical MELD/PELD18 (10-35)20 (9-42)1.000UNOS status12 (3.1%)3 (4.6%)2A5 (7.7%)8 (12.3%).8242B38 (58.5%)35 (53.8%)320 (30.8%)19 (29.2%)Indication for SLTAlcoholic liver disease10 (15.4%)8 (12.3%)Autoimmune liver disease12 (18.5%)9 (13.8%)Cholestatic liver disease4 (6.2%)2 (3.1%)Tumor16 (24.6%)24 (36.9%).109Viral-related cirrhosis16 (24.6%)7 (10.8%)Cryptogenic cirrhosis1 (1.5%)5 (7.7%)Metabolic liver disease5 (7.7%)4 (6.2%)Retransplantation0 (0%)1 (1.5%)Others1 (1.5%)5 (7.7%)Time on waiting list to transplant (days)91 (1-1682)74 (1-1479).764ALT, alaninoaminotransferase; AST, aspartatoaminotransferase; GGT, gamma-glutamyltransferase; BMI, body mass index; MELD, model for end-stage liver disease; LFTs, liver function tests; PELD, pediatric end-stage liver disease; UNOS, United Network of Organ Sharing. Open table in a new tab ALT, alaninoaminotransferase; AST, aspartatoaminotransferase; GGT, gamma-glutamyltransferase; BMI, body mass index; MELD, model for end-stage liver disease; LFTs, liver function tests; PELD, pediatric end-stage liver disease; UNOS, United Network of Organ Sharing. In the study group, 4 (6.2%) patients died within 1 year of SLT, of whom 1 (25%) was transplanted with UNOS 1 status; of 4 (6.2%) deceased patients in the control group, none received urgent transplantation. The retransplantation rate was similar in the two groups (5 [7.7%] vs 7 [10.8%] [P = .638]) (Table 8). The characteristics of the deceased and retransplanted ERG recipients are reported in Table S4.TABLE 8Causes of death and retransplantation after extended right graft transplantationVariablesNew split liver policy (n = 65)Old split liver policy (n = 65)P valueTotal number of death4 (6.2%)4 (6.2%)1.000Cause of deathSepsis2 (3.1%)1 (1.5%).559Myocardial infarction1 (1.5%)0 (0%).315Tumor recurrence1 (1.5%)1 (1.5%)1.000MOF0 (0%)2 (3%).496Retransplantation5 (7.7%)7 (10.8%).638Cause of retransplantationPNF/DNF3 (4.6%)3 (4.6%)1.000Hepatic artery thrombosis2 (3.1%)2 (3.1%)1.000Biliary complications0 (0%)2 (3.1%).154DNF, delayed nonfunction; ERG, extended right graft; MOF, multiorgan failure; PNF, primary nonfunction. Open table in a new tab DNF, del" @default.
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• W2911330337 date "2019-07-01" @default.
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• W2911330337 title "A national mandatory-split liver policy: A report from the Italian experience" @default.
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