http://www.medscape.com/viewarticle/834746?src=rssLiving Donor Transplants No Longer 'Last Resort'
Neil Osterweil
Transplant patients who receive livers from living donors have outcomes "as good as, if not better" than patients who receive livers from deceased donors, report investigators.
It might be time to rethink the notion that living-donor liver transplant should be a last resort, said David Goldberg, MD, from the Penn Transplant Institute and the Perelman School of Medicine in Philadelphia.
Recent guidelines from the American Association for the Study of Liver Diseases note that living donor transplantation is controversial. "These data suggest that the issue of living-donor transplantation,
at least from the recipient's side, is less controversial," Dr Goldberg said here at The Liver Meeting 2014.
In the late 1990s, transplant centers in the United States began to use live donors for liver transplantation to bridge the gap between organ supply and demand, he explained. In recent years, outcomes have improved because technical challenges have been overcome and because perioperative management and donor and recipient assessment have gotten better.
Still, just 3% to 4% of all adult liver transplants in the United States are living-donor procedures.
Dr Goldberg and colleagues decided to delve into the data to see whether the earlier reservations about the safety and efficacy of living-donor transplants are still warranted.
They searched the Organ Procurement and Transplantation Network and the United Network for Organ Sharing from 2002 to 2012 and identified 2103 living-donor and 46,674 deceased-donor transplants.
Unadjusted 3-year graft survival improved steadily during the study period for patients who underwent living-donor liver transplants.
Table. Three-Year Living-Donor Outcomes
Year of Transplant Unadjusted Graft Survival, % 95% Confidence Interval
1999 63.4 54.1–71.3
2000–2001 71.4 67.5–74.9
2002–2004 75.4 72.0–78.4
2008 82.2 75.3–87.4
A similar pattern of steady improvement over time in graft survival was seen after adjustment for center experience, hospitalization status at the time of transplant, lobe (right vs left), recipient and donor age, cold ischemic time, recipient diagnosis, and recipient race. In fact, survival was significantly better for living-donor liver transplants in 2008 than in 1998 (P < .001), Dr Goldberg reported.
Model for End-stage Liver Disease (MELD) scores demonstrated that graft survival was better in living-donor than in deceased-donor recipients when the procedure was performed at a center that had done more than 15 living-donor liver transplants (P < .001). Experience made a difference; within a center, graft survival was better after 15 of the procedures had been performed than before (P = .006).
However, even after 15 living-donor procedures had been performed at a center, patient survival was significantly worse in living-donor recipients than in deceased-donor recipients. "And there was a numerical but not statistically significant increase in patient survival in experienced versus less experienced centers," Dr Goldberg said.
In multivariable models that controlled for age, sex, race and ethnicity, laboratory MELD score, status prior to transplant, year of surgery, and interaction between diagnosis and center experience, graft survival at experienced centers was significantly better for patients with cholestatic liver disease (hazard ratio
, 0.75; P = .004) and autoimmune liver disease (HR, 0.56; P = .004).
The investigators developed a risk score to predict graft outcomes after living-donor transplantation, with an eye to identifying optimal donor and recipient matches and providing estimates of risk for donors and for patients on waiting lists. They used clinical and demographic data to stratify patients into low-, intermediate-, and high-risk groups.
With the risk score, predicted rates of 3-year graft survival were 87.8% for low-risk patients, 79.4% for intermediate-risk patients, and 71.0% for high-risk patients.
Liver Donation Safer Than Kidney
These findings are reassuring for both patients and potential donors, said David Mulliagan, MD, from the Yale School of Medicine in New Haven, Connecticut, who attended the presentation.
"Nobody can be dissatisfied with these survival data, and I think we heard that a lot today at the meeting," he told Medscape Medical News.
Dr Mulliagan explained that living-donor liver transplantation has been slow to catch on in the United States, largely because of the doctrine of first do no harm.
"The issues that we have been facing with living-donor liver transplant are more focused on donors — what it takes for them to go through the operation and what risks they have to assume," he explained.
When stories of
living-donor deaths in New York in 2002 and in Colorado in 2012 made headlines, some centers paused or scaled back their use of living donors, he reported.
Many people
routinely donate kidneys to a relative, or even a stranger, Dr Mulliagan said.
Although the risks associated with kidney donation are not as high as those associated with liver donation, they are not negligible."There's just something about this operation that makes people ask, 'Are we really pushing things too far?'," he said.
This study was supported by Penn Transplant. Dr Goldberg reports receiving grant and research support from Bayer Healthcare. Dr Mulligan has disclosed no relevant financial relationships.
The Liver Meeting 2014: American Association for the Study of Liver Diseases (AASLD). Abstract 3. Presented November 9, 2014.
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