Leading article

Living donor liver transplantationS. A. White and S. G. PollardDepartment of Organ Transplantation, St James University Hospital, Beckett Street, Leeds LS9, 7TF, UK(e-mail: steve islets@hotmail.com)

Published online in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.4939

Liver transplantation, though costly,resource intensive and technicallydemanding, is the single most effec-tive therapy for end stage liver fail-ure with 5-year survival rates nowin excess of 70 per cent. This suc-cess has occurred during an era ofdeclining numbers of organ donors,and the disproportion is now critical.In 2003 in the USA, 17 853 patientswere placed on a liver transplant wait-ing list; 1756 of them died beforereceiving a graft1. This unacceptablesituation has led to some innovativestrategies, including marginal grafts,reduction hepatectomy and split livertransplantation. Split liver transplan-tation has reduced paediatric waitinglist mortality to almost zero and nowaccounts for 30% of all paediatric livertransplants world-wide. While thishas not advanced the adult situation,despite some use of the right lobe,the observation nevertheless providesa compelling argument for increasingthe use of split liver transplantation inadults.

Living donor liver transplantation(LDLT) has several advantages overcadaver transplantation. It not onlyreduces waiting list mortality andincreases the rate of transplanta-tion, but also permits pre-emptiveoperation before the development ofserious complications associated withcirrhosis and portal hypertension,thereby making liver transplantationmore cost-effective. These advantageshave allowed LDLT to become estab-lished through much of the worldbut, sadly, not in the United King-dom where it is not currently fundedby the government. This may not besurprising given that early results were

poor. Nevertheless, while safety andefficacy are still debated by some, per-sistence with the technique in Japan,where brain stem death criteria arenot accepted for organ donation, andin the USA, where there has beena significant number of waiting listdeaths, has resulted in acceptablerates of morbidity and mortality forLDLT.

The ethics of LDLT do not dif-fer from those of living donor renaltransplantation. Donors must acceptthe risks of surgery and shouldagree to donation voluntarily with-out coercion. A significant feature ofLDLT is that nearly 80 per cent ofpotential donors are unsuitable andmany discover they have a hithertounrecognised co-morbidity that needsinvestigation. The cost of assess-ment of unsuitable donors is of someconsequence5. In the early days ofLDLT, anticipating hepatic anatom-ical anomalies in the donor was diffi-cult; pre-operative imaging is impor-tant to preserve arterial and por-tal inflow, and biliary and venousdrainage. Today new generation mag-netic resonance imaging and com-puter tomography (CT) can detailarterial, portal and biliary struc-tures. Multi-slice helical CT and 3-dimensional reconstruction can beused for volumetric analysis to ensurepreservation of sufficient volume inthe remnant liver while ensuring anadequate sized graft. Different formu-las have been devised to predict saferemnant volumes but one predictingfunctional volume accurately remainsproblematic. Grafts are classified aseither segmental, or multi-segmental.The commonest grafts used are left

lateral segments (II and III), usuallyreserved for paediatric recipients, andlarger left (II-IV) or right lobe grafts(IV-VIII) for adults; posterior sec-toral grafts (VI-VII) are rarely used.Laparoscopic left lateral segmentec-tomy has recently been introduced byenthusiasts6.

Complications affect both donorand recipient. There have been at leastnine reported donor deaths2,3; thetrue total can only be guessed at andit cannot be denied that such deathshave an extraordinary negative impacton donation rates. The magnitude ofdonor risk is difficult to assess, butmost centres quote mortality ratesbetween 0·1 and 1 per cent4. Surgicalrisk is highly dependent on the extentof resection. The risk of death isassumed to be greater than thatfor kidney donation (0·03 per cent)5

and segmental living donor pancreasdonation, for which no death hasbeen reported6. A recent UK surveysuggests that 42 per cent of potentialdonors would accept a 0·5 per centrisk of death7.

Experience of liver resection comesmostly from non-cirrhotic patientswith colorectal metastasis. It is dif-ficult to compare this cohort withliving donors as the former aregenerally older, undernourished andhave already compensated for defi-cient hepatic function by regener-ation. In a recent series of 1001such patients the surgical mortalitywas 2·8 per cent8. For living relateddonors the outcomes from 11 cen-tres in Europe suggest an 18 per centrate for major adverse events and a14 per cent rate for minor events14. Amore recent report from Asian centres

Copyright 2005 British Journal of Surgery Society Ltd British Journal of Surgery 2005; 92: 262–263Published by John Wiley & Sons Ltd

Living donor liver transplantation 263

describes outcome for 1,508 donors.All types of resection were evaluated,with an overall donor complicationrate of 16 per cent and a 1 per centre-operation rate. Biliary complica-tions predominate, with cholestasis(7 per cent), bile leak (6 per cent) andbiliary strictures (1 per cent)10. For-tunately most of these can be man-aged conservatively or radiologicallywithout the need for surgical inter-vention. Important adverse events forthe recipient, other than death, arehepatic artery and portal vein throm-bosis; initial reports suggested anoverall incidence of 6 per cent butthis has now fallen to 2 per cent.The commonest recipient compli-cations are again biliary, but theseare often transient. European reg-istry data on 796 recipients show a75 per cent graft survival at 3 years9,while a Japanese survey of 950 paedi-atric and 614 adult recipients reported5 year cumulative graft survival ratesof 82 and 70 per cent respectively11.Patient survival is highly depen-dent on the recipients’ status. Forexample, those with fulminant hep-atic failure have a 34 per cent riskof death within the first year9;LDLT for this indication is contro-versial.

LDLT for hepatocellular carci-noma also needs consideration. Mostpatients with this disease also havecirrhosis and their only real chanceof cure is liver transplantation. Timespent on the waiting list often makes

prognosis worse, and LDLT is attrac-tive as it can reduce waiting time by afactor of seven. In Japan overall 3-yearpatient survival is now 69 per cent,and for those not achieving Milancriteria after cadaver liver transplanta-tion it is 53 per cent12. Many patientswho are not accepted for cadaverliver transplantation as judged by theMilan criteria are being consideredfor LDLT as there is a good chanceof long-term survival.

In the Far East and the USA,LDLT has expanded the treatmentoptions for those with end stage liverfailure. The greatest and most obvi-ous benefit has been the reductionin mortality among potential paedi-atric recipients. For now it remainsunder careful scrutiny from the pub-lic, media and health care profession-als but the living related donor isundoubtedly a vital organ source inthe present era of decline in cadavericorgan donation. This is so despite itscost and risk of donor mortality.

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Copyright 2005 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2005; 92: 262–263Published by John Wiley & Sons Ltd