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• W47258085 abstract "Live-donor liver transplantation for acute-on-chronic hepatitis B liver failure. Transplantation 2003; 76: 1174. Chi-Leung Liu,Sheung-Tat Fan, Chung-Mau Lo, William Ignace Wei, Boon-Hun Yong, Ching-Lung Lai, John Wong Primum Nil Nocere Living-donor transplantation for adults has received widespread media attention in recent months. This is attributed to the recognition that complications are relatively common and occasional deaths have been observed among the previously healthy donors (1). Transplantation is now publishing a timely article on the results of living-donor liver transplantation for patients with acutely decompensated chronic liver disease caused by hepatitis B virus infection (2). These authors suggest that this therapeutic option should no longer be considered inappropriate for treatment of “acute-on-chronic liver failure.” Previous reports emphasized that the already inferior survival observed after liver transplantation in these recipients is compromised even further if a partial liver allograft is used (3,4). Therefore, the general consensus has been that exposure of a living donor to the risks of partial hepatectomy in the face of an anticipated recipient mortality of 50% or greater could not be justified. Now, Liu et al. (2) have reopened the discussion. Patient and graft survival in their cohort after a 23-month follow-up was 88%, which compares favorably with reported survival after cadaveric orthotopic liver transplantation for similar indications. The reasons for the improved survival rates achieved by the Hong Kong team are multifactorial and undoubtedly include the technical skills of an experienced surgical team; recipient selection with hepatitis B virus infection, which is unlikely to recur in the allograft with available prophylactic treatment; and timely transplantation when acute hepatic decompensation develops. The most important factor is probably transplantation of the extended right hepatic lobe including the middle hepatic vein, which provided not only improved venous outflow but also up to 87% of the estimated liver weight of the recipients. Although such a technical approach can be expected to result in reduced morbidity in the recipient, a strong note of caution must be exerted. A remnant liver volume in the donor of 23.6% to 43.2% is marginal even by the authors’ published recommendations (5). In fact, in the current series, there are harbingers of the potential for a disastrous outcome with more widespread application of the approach. One donor with mildly fatty liver developed prolonged cholestasis, a serious wound infection with methicillin-resistant Staphylococcus aureus, and an incisional hernia. Another developed bile duct stricture requiring surgical intervention. In addition, the unusual wound infection rate (6/32, 18.7%) in these previously healthy individuals possibly indicates some degree of immunocompromise as a result of impaired liver function. As emphasized by the aftermath of the report of a donor death in New York in January 2002, such events adversely impact not only the individual families involved but also the efforts of transplantation in general (6). Living-donor liver transplants performed in the United States decreased to 358 in the 12 months after January 2002 from 518 in the 12 months before (Fig. 1a). Fortunately, cadaveric donation did not decrease in the same time frame (Fig. 1b), but it is evident that a single catastrophic event can disadvantage many potential recipients awaiting transplantation. Figure 1: (a) Living-donor liver transplants performed in the United States from January 1998 to December 2002. All types of living donation are included. The steep decline caused by September 11, 2001 (arrowhead) was short-lived. However, donation has steadily declined since January 2002, with a possible recovery since December 2002. Total number of liver transplants in 2002 was 358, decreased from 518 in 2001 (−31%). (b) Cadaveric donor liver transplants performed in the United States from January 1998 to December 2002. The number of transplants performed monthly has not changed significantly during this 5-year period. The total number of cadaveric organ transplants performed in 2002 was 4,968, compared with 4,640 in 2001 (+6%). The increase is within the range observed since 1988 (not shown).Of course, it is laudable to explore innovative approaches for the management of acutely decompensated chronic liver disease, particularly in regions where there is little likelihood of identifying a cadaveric donor in time. The urgency of such circumstances might be compared with those encountered in children before the introduction of living-donor left lateral lobe transplantation by Broelsch et al. (7). At that time, more than 25% of children typically expired while waiting for a suitably sized cadaveric liver allograft. The successful development of living-donor left lateral lobe transplantation has now essentially eliminated waiting-list mortality for children. Nevertheless, even with this much more limited donor surgery, several deaths have been reported. This serves to emphasize again that living-donor transplant surgeons cannot lose sight of their special dual responsibility: to their own patients, for whom they are understandably pressured to provide a suitable allograft in a timely fashion, and perhaps even greater to the donors, who altruistically step forward out of affection for the recipient only because they trust the medical community’s commitment to “primum nil nocere” to protect them from exposure to unsuitable risks. Transplant physicians also have an obligation to all allograft recipient candidates, whose likelihood of receiving a donor organ might be compromised by society’s perception that overly aggressive medical practices have resulted in unacceptable morbidity or mortality in living donors. It is safe to say that the negative publicity related to the death in New York (6) has already contributed to reluctance by potential donors to pursue this option. In addition, it is our observation that referring physicians, transplant psychiatrists, hepatologists, and many surgeons have become more conservative in defining the indications for living-donor liver transplantation, the limits of acceptable comorbidities in potential donors, and the type of experience and resources that should be in place in institutions providing this service. This assessment is, of course, typical of the evolution that any previously untried technology must undergo as new complications are encountered and the appropriate role for that therapy in the medical armamentarium is more precisely defined. In this context, more widespread use of extended right hepatectomy allografts from living donors, as recommended by Liu et al., (2) for treatment of high-risk acute-on-chronic liver failure must be approached with caution and only under carefully defined circumstances. Significant donor morbidity or mortality will be difficult to justify simply by the arguments that the extended donor procedure is technically possible and that it improves recipient outcome. Finally, it is important not to lose focus of the more important issue currently limiting clinical transplantation, namely, the unavailability of cadaveric organs. The multiorgan donor rate worldwide ranges from a low of 1 to 3 per million population in many Eastern societies to a high of more than 30 per million habitants in some Western countries (8). Thus, there seems to be significant potential for improvement in the likelihood of identifying a cadaveric donor organ in urgent situations in Eastern countries if societal objections to organ donation could be addressed. In addition, more frequent use of split-liver transplantation could provide a 10% to 15% increase in the number of cadaveric allografts, again reducing the need for living donation (9,10)." @default.
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• W47258085 title "Live-donor liver transplantation for acute-on-chronic hepatitis B liver failure." @default.
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