Study Supports Living-Donor Liver Transplants

[Clark]

http://www.generalsurgerynews.com/ViewArticle.aspx?d=Breaking+News&d_id=552&i=June+2015&i_id=1197&a_id=32792
Study Supports Living-Donor Liver Transplants
by Kate O'Rourke

Patients who receive a liver transplant from a living donor experience outcomes as good as—if not better than—those of individuals who receive an organ from a deceased donor, researchers have found.
The findings mark a shift from studies in the 1990s and early 2000s, when three-year survival rates for live-donor liver grafts were not much above 60%. Now they are over 80% and appear to be climbing, according to the researchers, who presented their findings at the 2014 Liver Meeting of the American Association for the Study of Liver Diseases (AASLD; abstract 3). Experts said the results indicate that live-donor livers can help ease shortage of the organs available for transplant.
“As a community, we should consider increased use of living-donor liver transplantation to help bridge the organ-supply demand gap, as long as it can be done without compromising donor safety,” said David Goldberg, MD, medical director for living-donor liver transplantation at the Hospital of the University of Pennsylvania, in Philadelphia, who led the study. “Recent AASLD guidelines for transplantation suggest that living-donor transplantation is controversial. These data suggest that the issue, at least from the recipient side, is less controversial.”
In the new study, researchers examined national transplant data from the Organ Procurement and Transplant Network/United Network for Organ Sharing between 1999 and 2012, to compare outcomes of liver transplant recipients when living versus deceased donors were used. Patients receiving a second liver and recipients of multiple organs were excluded from the analysis.
The three-year unadjusted graft survival from living-donor liver transplants steadily rose over time, from 63.4% in 1999 to 82.2% in 2008. By 2008, outcomes were similar in terms of patient survival and graft survival whether a deceased or living donor was used.
Center experience was clearly associated with transplant outcomes. Patients with autoimmune hepatitis or cholestatic liver disease were more likely to survive a live-donor transplant if they received care at an experienced center, defined as one that had performed at least 15 adult living-donor procedures.

Novel Risk Assessment
The researchers calculated a living-donor risk index score to identify donor–recipient combinations to achieve the best outcomes. The formula included factors such as recipient age, weight, diagnosis and serum albumin, as well as donor age, weight and graft type.
The researchers said they were surprised that the Model for End-Stage Liver Disease (MELD) score was not significantly associated with outcomes among living-donor recipients, but that may reflect the fact that there was a narrow range of MELD scores and few living-donor recipients with a score greater than 25 at transplantation. At one, three and five years, the risk index score was moderately accurate at predicting graft survival.
“This score, when validated in a separate cohort, which we are currently doing, may help to identify donor–recipient combinations to achieve best living-donor transplant outcomes. This could potentially work under several different scenarios,” Dr. Goldberg said.
First, he said, when a recipient has several potential donors, the score might help to objectively measure the best donor for that given recipient. Currently, there is no quantitative way to do that. Second, the score could be used in the future if paired liver exchanges become a reality. Finally, by having data on predicted graft outcomes, clinicians may be able to counsel patients on predicted outcomes. Dr. Goldberg cautioned that the score was not yet ready to use for clinical purposes and requires further validation.
Julie Heimbach, MD, surgical director of Liver Transplantation at Mayo Clinic, in Rochester, Minn., said the study highlights patient populations that may do quite well following living-donor liver transplant. But Dr. Heimbach said she was not convinced it would translate into a change in clinical practice.
“We would all much prefer not to operate on healthy people who are undergoing a major procedure for the benefit of someone else, thus having two people at risk for complications related to the surgery instead of one. If the deceased-donor volume could meet the extreme shortage, that would be much better,” said Dr. Heimbach, who was not involved in the study. “I think decisions about whether to proceed to living-donor liver transplant have to be made with the individual patient in mind, considering the patient’s disease, organ availability and center expertise. This study supports that approach.”