Living Donor Liver Transplant: Pulling down the wall to

LivingDonorLiverTransplant:Pullingdownthewalltotransplant

indisadvantagedpatientsColleenJay,MD,MS

UniversityTransplantCenter

TheScopeoftheProblem…..OPTN/SRTR2015AnnualDataReport:Liver

Percentageofadultswhounderwentdeceaseddonorlivertransplantwithin5

yearsoflistingin2009,byDSA

Pretransplant mortalityratesamongadultswaitlistedforlivertransplant

in2014–2015,byDSA

DT• 46yo malewithPSCandUC• UCquiescent,nosurgery• FrequentERCPandstents• Stillworkingfulltimeascountyclerk• Labs• Current:TB1.6,AP756,INR1.1,Cr

0.5,MELD8• Prior:TB4.9,AP1118,INR1.1,Cr

0.5,MELD14• Bloodtype:B-

• Meds:propranolol,Imuran

365dayprobabilityoftransplantinSouthTexas

Allbloodtypes

Bloodtype:B

https://www.srtr.org/reports-tools/tools/

LivingDonation

Donorcriteria• Age21-55• BMI<28• Healthy• Stablepsychosocialsituation• Anatomicalevaluation• Fullcardiaceval ifage>50

AndresMuniz(stepfather,recipient)&KatieGarcia(stepdaughter,donor)2016

Katieshared,“hehasbeenafathertomesinceIwas5-years-old.Mykidslovehim,Ilovehim,andIdon’twanttobewithouthim.”AlthoughAndresinitially

wasagainstKatiedonating,shewasnotgoingtotakenoforananswer.

• 50yo male– coworker• PMH:elevatedcholesterol• MEDS:fishoil,niacin• BMI:27• Multidisciplinaryevaluation:surgery,hepatology,SW+/- psych,ILDA,nutrition.

• CTA+/- MRimaging

PotentialDonor:BO

LivingDonorLiverTransplant

Reynolds, MarkReynolds, Mark21143874211438742/25/19652/25/196550 YEAR50 YEARMM

Page: 85 of 299Page: 85 of 299

Acq no: 6Acq no: 6KVp: 120KVp: 120mA: 392mA: 392Tilt: 0Tilt: 0RD: 350RD: 350

University Hosp CT2 University Hosp CT2CT ABDOMEN 3 PHASE LIVER WOW CONTRAST 74170CT ABDOMEN 3 PHASE LIVER WOW CONTRAST 74170

THINS, iDose (3)THINS, iDose (3) 5/19/2015 1:26:29 PM 5/19/2015 1:26:29 PM

3256960532569605LOC: 157.50LOC: 157.50

THK: 2THK: 2FFSFFS------

Contrast: IVContrast: IVCV: 0CV: 0

IM:85IM:85 SE:602 SE:602

DFOV:35DFOV:35x35cmx35cmW: 400W: 400

C: 60C: 60Z: 1Z: 1

CFR:---CFR:---CC: 0CC: 0

RR LL

AA

PP

Reynolds, MarkReynolds, Mark21143874211438742/25/19652/25/196550 YEAR50 YEARMM

Page: 1 of 1Page: 1 of 1

University Hosp CT2 University Hosp CT2CT ABDOMEN 3 PHASE LIVER WOW CONTRAST 74170CT ABDOMEN 3 PHASE LIVER WOW CONTRAST 74170

L & R liver volumes (Dup)L & R liver volumes (Dup) 5/20/2015 7:30:02 AM 5/20/2015 7:30:02 AM

3256960532569605IodineIodine

------FFSFFS

IM: 1IM: 1

W: 256W: 256C: 128C: 128

Z: 1Z: 1

Totalvolume:1590ml,rightlobe:1050ml,leftlobe540ml:remnant=34%(threshold:30%)GraftWeighttoRecipientWeightratio:1.3%(threshold0.8%)

Reynolds, MarkReynolds, Mark21143874211438742/25/19652/25/196550 YEAR50 YEARMM

Page: 35 of 99Page: 35 of 99

Acq no: 5Acq no: 5KVp: 120KVp: 120mA: 471mA: 471Tilt: 0Tilt: 0RD: 350RD: 350

University Hosp CT2 University Hosp CT2CT ABDOMEN 3 PHASE LIVER WOW CONTRAST 74170CT ABDOMEN 3 PHASE LIVER WOW CONTRAST 74170

CORONAL, iDose (3)CORONAL, iDose (3) 5/19/2015 1:25:39 PM 5/19/2015 1:25:39 PM

3256960532569605------

THK: 3THK: 3FFSFFS------

Contrast: IVContrast: IVCV: 100CV: 100

IM:35IM:35 SE:503 SE:503

DFOV:35DFOV:35x30cmx30cmW: 400W: 400

C: 60C: 60Z: 1Z: 1

CFR:4CFR:4CC: 300CC: 300

RR LL

HH

FF

Vascularanatomy:1.Arterial:inthiscase,accessoryleft

hepaticartery

Vascularanatomy:1.Arterial2.Portal3.HepaticVeins

BiliaryConsiderationsReynolds, MarkReynolds, Mark21143874211438742/25/19652/25/196550 YEAR50 YEARMM

Page: 9 of 10Page: 9 of 10

--- ---XR CHOLANGIOGRAM OPERATIVE 74300XR CHOLANGIOGRAM OPERATIVE 74300

------ 6/16/2015 9:24:39 AM 6/16/2015 9:24:39 AM

3262334832623348------------------

IM: 9IM: 9

W: 65535W: 65535C: 32767C: 32767

Z: 1Z: 1

Internationaltransplant- India

• Major• PerioperativeMortality(US):0.1-0.2%• A2ALL(2007)– NorthAmerican

multicenterconsortium• Aborteddonation:earlyexperience~3%• Biliary:9%• Hernia:5%• Psych:4%• >95%ofcomplications=Grade1-2(nolong-

termdisability)

DonorOutcomes

• Hepaticregenerationwasassessedat3monthsafterdonorhepatectomy.• Pre-operativeMRIvolumetry wascomparedto3-monthvolumetry.• Regenerationreachedmean:73.4-86.8%.

DonorRegeneration

Joseph(uncle,recipient)&James(nephew,donor)

Steffanic,2009

• Relativecontraindications:• HighMELD• Priorityonlist• Renalfailure• Advancedportalhypertension,significantascites–

toosmallforsizeissues• Technicallycomplicated• Priorlivertransplant• Portal/mesentericthrombus

RecipientConsiderations

Tammy(mother,recipient)&Miranda(daughter,donor)

Green,2014

RecipientOutcomesPatientSurvival

GraftSurvival

RecipientComplications

~1/3withbiliary/infectiouscomplicationsearly,majorityresolvedwithin90days.

HannahParker(daughter,donor)&LoriHenk (mother,recipient)2014

ThankYou

Roundtable/Q&ADrs.Speeg andJay

MeetingSummaryTurninyourcompletedpost-teststoregistration

deskorstaffmember